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.

       
 
       
       
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      
       
       
       
 
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