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OPWDD QUALITY ASSURANCE-INTERNAL AUDIT TRACKING SHEET NEEDED.

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On January 8, 2024

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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




A.9





B1.







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B3.





B4.







B5.



B6.






B7.



B8.


B9.





B10.







C1.




C2.


D1.

D2.

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