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Page 1: Bay Area Quality Management System Quality Service … · 207 Bay Area Quality Management System Quality Service Review (QSR) Interpretive Guidelines, Technical Assistance, and Resources

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What’s the purpose of the Service Coordinator Review? Service Coordinators/Case Managers provide critical health, safety, and life quality information about individuals on a regular basis. This information is an important part of the Quality Management System. It’s used as an ongoing service review, follow-up tracking system, and as an element in the certification of service providers.

When is it used? This review is used as the quarterly report for all individuals who have transitioned from Agnews Developmental Center into the community. The intervals for completion are within the first month of living in a home and quarterly thereafter (or more frequently as needed).

Does it need to be completely filled out each time? Yes, it’s important that the service coordinator completes the entire form initially (within the first 30 days) and quarterly thereafter. For other visits (e.g., monthly, unannounced), please complete the first section (basic information about the individual, type of visit) and any applicable sections (e.g., follow-up items, health and wellness for 962 homes).

Information provided from Quality Management Information System

Individual’s Name: DOB: UCI#: Service Provider: (name of home or program): Street address: City, ZIP: Date individual entered this home/service (mm/dd/yy):/ / / /

When the review form is generated from an individual record in the Quality Management Information System, the information in this section will automatically be printed on the form.

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Sample Questions The Review includes questions about health, safety, community participation, well-being, life quality, documentation, and progress on the Individual Program Plan. In addition to a simple yes/no rating system, there is also space to indicate a need for follow-up by the Service Coordinator, Resource Developer, Nurse, QMS Specialist, Psychologist or Behavior Analyst, or Other.

Please answer all of the following questions at each quarterly visit. Follow-up can be suggested for any indicator, but is required for any answer that indicates a negative outcome for the individual.

CHOICE AND COMMUNITY PARTICIPATIONQ5. Have there been any contact or visits with family or friends? (13a,b) If no, recommended follow-up?

Family has expressed an interest to visit their son more often. Follow-up with service provider to arrange twice monthly home visits by 11/31/06.

Familyx Yes o No o N/AFriends x Yes o NoFollow-Up by:x SC o QMS o Other

Q6. Do community activities observed or reported, reflect individual choice and preferences? (12a-c) If no, recommended follow-up?

Individual does not use words to communicate, so it’s difficult to tell. Need to use alternative ways to assess preferences; follow-up by 12/31/06.

o Yes x No Follow-Up by:x SC o QMS o Other

HEALTH AND WELLNESS11. Have there been changes that place the individual at increased risk? (22f) If yes, please check the appropriate boxes below.x weight change of more than 5 pounds: -15 lbs. o illness o psychotropic medication o sleep patterns o behavior o other:Recommended follow-up?

Referred to nurse for follow-up on rapid weight loss by 10/31/06.

x Yes o NoFollow-Up by:o SC o QMS o Otherx Nurse

It’s the Service Coordinator’s responsibility to make the referral to the Nurse. It’s the Quality Management Specialist’s responsibility to ensure the completion of follow-up activities and to assist with technical assistance and training as needed.

Follow-up can be recommended even if an answer indicates a positive outcome.

These numbers refer to Expectations and Measures on the Quality Service Review (QSR).

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SERVICE PLANNING AND DELIVERY

20. Has progress on all ISP objectives occurred? (2c,3d)If no, recommended follow-up?

x Yes o NoFollow-Up by:o SC o QMS o Other

21. Does the ISP effectively implement the goals and objectives in the IPP? (2a)If no, recommended follow-up?

x Yes o NoFollow-Up by:o SC o QMS o Other

24. Quarterly and other reports (such as progress reports and logs) documenting progress on the ISP are complete and current? (3a,c) If no, recommended follow-up?

Service Coordinator will work with provider to develop a better format for documenting ISP progress by 10/31/06.

o Yes x NoFollow-Up by:x SC o QMS o Other

On the last page of the Service Coordinator Review, you’ll find space for narrative information. In the electronic version of the review (embedded in the Quality Management Information System), each of these fields will hold 70,000 characters.

Is there anything that you became aware of that is or is not working well? (Note: You can also use this space to describe examples of best practices that are reported or observed.)

1. The home is nicely kept and the individual seems to be happy and comfortable there. However, it seems like this individual needs more activities to be involved in. Service Coordinator will follow up.

2. Several new objectives were added to the annual IPP. This individual has demonstrated terrific progress in these targeted areas in the past 3 months.

3. It is evident that there has been increased choice and variety of community integration.

Additional Comments (also used to report additional information on IPP progress for both residen-tial and nonresidential goals; or additional details regarding ‘Other’ follow-up):

The IPP was mailed 12/20/06 to conservator, however, it has not been returned signed. Service Coordinator will contact conservator for follow-up.

It’s the Service Coordinator’s responsibility to check an individual’s record to ensure quarterly reports are current, P & I funds are reported in the ISP, the P & I log is accurate, and other pertinent documents are current (e.g., consents are current and signed by the appropriate individual).

Please make sure to date all follow-up items.

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I concur with assessment of progress towards achievement of the IPP objectives as described in the ISP, and have reviewed this information with the consumer and/or ID Team or conservator. __________________________(signature).

Sign off by the service coordinatorThe Service Coordinator Review needs to be signed by the service coordinator. The signature block below is found at the bottom of the fourth (final) page of the report.

What happens with the information? Service Coordinators can use it as a basis for follow-up work with the Service Provider; and as the basis for a referral to a specialist (e.g., Nurse). It is also used as an important resource for the QSR Review. Reviews become a part of the electronic, Quality Management Information System (QMIS). The QMIS will generate aggregate reports that will be reviewed by the QMS Specialist and the Service Provider as a part of the process in preparing for certification.

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Follow-UpIt’s the Service Coordinator’s responsibility to make referrals for follow-up activities as noted in the review. Once the review is entered into the QMIS, the Quality Management Specialist can develop a report which summarizes needed follow-up and projected dates of completion. The QMS Specialist monitors the status of follow-up activities and ensures their completion. When the Service Coordinator is completing a follow-up activity, the Service Coordinator Review tool can be used to focus on only those areas (it would not have to be completed in its entirety). This information should also be entered into the QMIS.

This is the responsibility of the QMS Specialist.

This is the responsibility of the Service Coordinator.

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Other notes about the tool

(1) Use additional sheets as needed to report progress on individual IPP objectives.

(2) All items requiring follow-up should be documented in the format used by the service coordinator’s regional center.

(3) At this time, Title 19 case notes need to be written up in the format required by your regional center.

(3) When completed and signed, it’s recommended that a copy of the review be mailed to the Service Provider.

(4) The QMIS can generate custom reports for the by the Service Coordinator, Service Provider, and other professionals.

(5) The term psychotropic medication refers to drugs that have an effect upon an individual patient’s mental state including mind, emotions, and behavior. For the purposes of this pilot project, psychotropic medication includes antipsychotic, antidepressant, antimanic, anxiolytic and hypnotic drugs.