Persons with HIV-AIDS RR Tool.pdf

Quality Assurance Review Tool – On-site Records Review

Case Management Agency Record Review Tool

Persons with HIV/AIDS Waiver Operating Agency: Division of Rehabilitation Services

Record #: _____________________ RIN: __________________________________________

Customer Name: ___________________________________ Phone: _____________________

Guardian Name: ___________________________________ Phone: _______________________

Level of Care (Appendix B)

Level of Care Assurance: The State demonstrates that it implements the processes and instrument(s) specified in its approved waiver for evaluating/reevaluating an applicant’s/waiver participant’s level of care consistent with care provided in a hospital, NF, or ICF/ID-DD.

Sub-Assurance B: The levels of care of enrolled participants are reevaluated at least annually or as specified in the approved waiver.

16B: The waiver participant is reassessed through the redetermination process of waiver eligibility every 12 months.

• Data Source: WebCM / Hard Chart

• Date of most recent LOC assessment:

• Date of previous LOC assessment:

• Recommendations for Remediation (if noncompliant):

• Comments:

Yes No

Sub-Assurance C: The processes and instruments described in the approved waiver are applied appropriately and according to the approved description to determine participant level of care.

17B: The waiver participant’s documentation supports LOC determination (minimum total DON score of 29).

• Data Source: DON / HSP Needs Assessment

• DON score:

• Recommendations for Remediation (if noncompliant):

Service Plan (Appendix D)

Service Plan Assurance: The State demonstrates it has designed and implemented an effective system for reviewing the adequacy of service plans for waiver participants.

Sub-Assurance A: Service plans address all participants’ assessed needs (including health and safety risk factors) and personal goals, either by the provision of waiver services or through other means.

29D: The waiver participant’s service plan addresses all personal goals identified by the assessment.

• Data Source(s): Service Plan, Assessment

• Explanation, if noncompliant:

• Recommendations for Remediation (if noncompliant):

30D: The waiver participant’s service plan addresses all of the participant’s needs identified by the assessment.

• Data Source(s): Service Plan, Assessment

• Explanation, if noncompliant:

• Recommendations for Remediation (if noncompliant):

• Comments:

31D: The waiver participant’s service plan addresses all health and safety risk factors identified in the assessment.

• Data Source(s): Service Plan, Assessment

• Explanation, if noncompliant:

• Recommendations for Remediation (if noncompliant):

Sub-Assurance B: The State monitors service plan development in accordance with its policies and procedures.

33D: The waiver participant’s service plan is signed and dated by the participant (or legally authorized representative) and the case manager (counselor).

• Data Source(s): Service Plan

• Participant or Representative Signature present?

• Date of Participant or Representative Signature:

• Case Manager (Counselor) Signature present?

• Date of Case Manager (Counselor) Signature:

• Explanation, if noncompliant:

Yes No

34D: The waiver participant received monthly contacts, with one face-to-face contact every other month (bi-monthly), by his/her case manager in an effort to monitor service provision and to address potential gaps in service delivery.

• Data Source(s): WebCM

• Month(s) missing face-to-face contact:

• Month(s) missing telephone contact:

• Explanation, if noncompliant:

Sub-Assurance C: Service plans are updated/revised at least annually or when warranted by changes in the waiver participant’s needs.

35D: The waiver participant has his/her service plan updated every 12 months.

• Data Source(s): Recent Assessment, Service Plan

• Date the current year service plan was updated/revised:

• Date the previous year service plan was updated/revised:

• Recommendations for Remediation (if noncompliant):

Sub-Assurance D: Services are delivered in accordance with the service plan, including the type, scope, amount, duration and frequency specified in the service plan.

37D: Were services delivered to the participant in the type, scope, amount, duration, and frequency as specified in the service plan?

• Data Source(s): Service Plan, Case Management notes, WebCM

• Recommendations for Remediation (if noncompliant):

Sub-Assurance E: Participants are afforded choice between/among waiver services and providers.

39D: The waiver participant’s records with a signed plan of care indicates participant had choice between waiver services and institutional care;

and between/among services and providers.

• Data Source(s): HSP Application and Eligibility Form, Consent Packet

• Explanation, if noncompliant:

• Recommendations for Remediation (if noncompliant):

Health and Welfare (Appendix G)

Health and Welfare Assurance: The State demonstrates it has designed and implemented an effective system for assuring waiver participant health and welfare.

Sub-Assurance A: The state demonstrates on an ongoing basis that it identifies, addresses and seeks to prevent instances of abuse, neglect, exploitation and unexplained death (A/N/E).

40G: The waiver participant received information about how and to whom to report A/N/E at the time of assessment/reassessment.

• Data Source(s): Consent Packet

• Date of assessment/reassessment:

• Date participant received A/N/E information:

• Explanation, if noncompliant:

• Recommendations for Remediation (if noncompliant):