OPWDD QUALITY ASSURANCE-INTERNAL AUDIT TRACKING SHEET NEEDED.
QUALITY ASSURANCE AUDIT
OPWDD Internal Audit Criteria
NAME OF INDIVIDUAL:
Reviewer: Date of Review:
OPWDD Audit Criteria | Acceptable
(Yes/No) |
Missing Document | Comments |
A1. Level of Care Eligibility Determination (LCED) Form | |||
Name of Individual | |||
Address of Individual | |||
Individual’s Date of Birth | |||
Date of Psychological Evaluation | |||
Date of Social Evaluation | |||
Date of Physical Evaluation | |||
Medicaid No. (CIN) and Tabs ID | |||
Review Date and Signature of Qualified Person | |||
A2. Individual Plan of Protective Oversight and Safeguards | |||
Date of IPOP Review | |||
Date and Signature of Qualified Personnel
Safe guards in place to protect the recipient’s health and safety. |
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A3. Individualized Service Plan (ISP) | |||
Date of Annual ISP Review | |||
Date and Signature of Qualified Personnel | |||
Summary of Fire Safety | |||
Type of waiver (residential habilitation), frequency of service, duration of service and effective date service began. ISP designates the agency (Edwin Gould) as the provider service. | |||
Identification of personal goals, preferences, capabilities and capacities relative to the need stated in outcomes | |||
Safe guards in place to protect the recipient’s health and safety. | |||
Valued Outcomes | |||
Date of ISP Six Month Review | |||
Date and Signature of Qualified Personnel | |||
Valued Outcomes | |||
Summary of Fire Safety | |||
Safe guards in place to protect the recipient’s health and safety. | |||
A5. IRA Residential Habilitation Plan | |||
Name of Individual | |||
Identification of category of waiver service provided | |||
Date the habilitation plan was last reviewed | |||
Medicaid No. (CIN) | |||
Safeguards identified in the Individual’s Plan of Protective Oversight that will be provided by the Habilitation Service Provider | |||
Valued Outcomes | |||
Description of services and support being provided to the individual | |||
Sign-in sheet that proves that IRA Residential Habilitation Plan was reviewed and/or revised. | |||
The initial habilitation plan is written within 60days of the start date of the habilitation service and forwarded to the service coordinator. | |||
Date and Signature and Title of Qualified Personnel | |||
IRA Residential Habilitation Billing | |||
A.9 | |||
B1. | |||
B2. | |||
B3. | |||
B4. | |||
B5. | |||
B6. | |||
B7. | |||
B8. | |||
B9. | |||
B10. | |||
C1. | |||
C2. | |||
D1. | |||
D2. |