Were staff aware of the MOLST? Was end-of-life planning considered? The basis of documentation may include facility specific record; specified forms or reports; specified contents of records, reports or forms; and/or other means of assessing compliance such as interviews with individuals, employees or volunteers, and/or onsite observation of activities and the environment. Was there a written bowel management regimen? Circumstances? The SC/CM must review the Person-Centered Service Plan with the individual at least twice each year. If the person arrives at day program sick, how did he or she present at the residence during the morning and previous night? A copy of this guardian documentation is forwarded to the RRDS. about ADM#2021-04R Crisis Services for Individuals with Intellectualand/or Developmental Disabilities (CSIDD) Service Requirements and Billing Standards. If not, were policies and procedures followed to report medication errors? What was the course of stay and progression of disease? Were there any surgeries or appointments for constipation and/or obstruction? Bowel Obstruction Most commonly, bowel obstruction is due to severe, unresolved constipation, foreign-body obstruction, obstruction due to cancerous mass, volvulus twisted bowel," or Ileus (no peristaltic movement of the bowel). This requires that the SC/CM ensure that all required attachments (e.g. Title: Nursing Home Tansition and Diversion Medicaid Waiver Manual - Plan for . OPWDD assumes no responsibility for any error, omissions or other discrepancies between the electronic and printed versions of documents. A designation for those persons (such as an individuals spouse, children or other family members) residing at the certified supportive community residence, and who have not been admitted to the supportive community residence. If there are incidents or concerns that arise which are directly EMS report, 911 call transcript, ER/hospital report, ambulance report if relevant. Life Plan/CFA and relevant associated plans. It clearly enlists the key activities that affect the health and welfare of an individual. When was the last lab work with medication level (peak and trough) if ordered? How many? January 9, 2023 . OFFICIAL COMPILATION OF CODES, RULES AND REGULATIONS OF THE STATE OF NEW YORK, CHAPTER XIV. Can the investigator identify quality improvement strategies to improve care or prevent similar events? (ii) The use of appropriately trained substitute personnel when the primary assigned personnel are unavailable. When was the last neurology appointment? Were appointments attended per practitioners recommendations? endobj If monitoring urine output report what amount, or qualities? Effective January 21, 2011: The MOLST (Medical Orders for Life Sustaining Treatment) form and the MOLST Legal Requirements Checklist should be completed in compliance with the Health Care Decisions Act of 2003. Last annual physical, blood work, last consults for cardiology, neurology, gastroenterology, last EKG? 4241 Jutland Dr #202, San Diego, CA 92117. If so, what guidelines? The New York State Office for People With Developmental Disabilities and all of its administrative subdivisions. 5 0 obj at the mall, picnic, or bedroom)? The Centers for Medicare and Medicaid Services (CMS) approved the States Medicaid Plan Amendment to add the Community First Choice Option (CFCO) set of services. Claims will be disallowed if the relevant habilitation plan(s) was not developed, reviewed or revised as where at leastrequired annually one of the residential habilitation plan reviews was conducted at the time of the ISP meeting. What was the infection? Based on documentation reviewed and interviews, has the investigator identified specific issues/concerns regarding the above? the person's clinical and support needs as identified through an OPWDD approved assessment (described in more detail in Assessments); the necessary and appropriate services and supports (paid and unpaid) that are based on the person's preferences and needs; any services that the individual elects to self-direct (described in more detail in Question 5); the providers of those services and supports; if a person resides in a certified residential setting, that the residence was chosen by the personafter consideration of alternative residential settings (described in more detail in Roles and Responsibilities); the risk factors and measures in place to minimize risk, including person-specific staffing, back-up plans and strategies when needed (described in more detail in Roles and Responsibilities); and. hVmo9+J!oHR a['`glzB=xL0 Lm%h3Y,ND%k2tK:EU3s2e?N52$7-V_6&ohx0aZ4/=|{aa iq9_)kw]+pQL RF.* OFFICE FOR PEOPLE WITH DEVELOPMENTAL DISABILITIES, PART 686. (3) OPWDD shall verify that each person has a plan for protective oversight, based on an analysis of the person's need for same, and that such need has periodically, but at least annually, been reviewed, revised as appropriate, and integrated, as appropriate, with other services received. Addressed in the plan: money management, medication management, kitchen safety, back-up staffing for unscheduled staff absences. Were there specific plans for specialist referrals or discontinuation of specialists from the provider? Future hospitalizations? ;yC| Call us at (858) 263-7716. %PDF-1.6 % (iii) each person's plan for protective oversight is being implemented as specified in the person's individualized service plan. For purposes of this Part, a child or adult with a diagnosis of developmental disability, who has been or is being served by a State, private or voluntary operated facility certified by OPWDD. Was this well-defined and effective? Did it occur per practitioners recommendations? It is an individualized approach to service planning, structured to focus on the unique values, strengths, preferences, capacities, interests, desired outcomes, and needs of the person. Did it occur per practitioners recommendation? (2) For individualized residential alternatives of eight or fewer beds, OPWDD shall verify that each person's individualized services plan (see glossary) contains a current evaluation of the fire evacuation capacity of the person based on actual performance. When was the last blood level done for medication levels? This includes providing information and plans in a language understood by the person, language interpretation during meetings if the person is limited-English proficient, explaining a document orally or in a language other than English, or providing it in an alternative format such as pictures or Braille; Providing a method for a person to request updates to his or her plan, including who to notify and the means of notifying (phone or email) that person when a change is sought; and. Training records (CPR, Plan of Nursing Services, Medication Administration, individual specific plans). A condition of a person, or lack thereof, which, when addressed, enhances the person's quality of life and/or ability to cope with his or her circumstances or environment. Developing strategies to address conflicts or disagreements in the planning process, including a clear conflict of interest guidelines for people, and communicating such strategies to the person. Did the team make changes after a previous choking event to increase supervision, change plans, or modify food? Did staff report per policy, per plans, and per training? Providers may disclose PHI to health oversight agencies, (e.g., the government agency which licenses the provider), for legally authorized health oversight activities, such as audits and investigations. The first page of the house-specific Plan of Protective Oversight will be uploaded as an attachment. Ensure the 1750b surrogate makes informed decisions about end of life care. A copy is also provided to each waiver service provider listed in the ISP. (y) Payment, community residence provider. [u_+rm=)r1=NpY\5=sY.g|iAu. Were staff trained on the PONS? To request a document in another language, email[emailprotected]. 0 Available? OPWDD's regulations are included in Title 14 of the New York Codes, Rules and Regulations (NYCRR). Did the person use any assistive devices (gait belt, walker, etc.)? Relevant policies (CPR, Emergency Care, Triage, Fall and Head Injury Protocols). Was there a known behavior of food-seeking, takingor hiding? Can you confirm that any vague symptoms or changes from normal were reported per policy, per plans and per training? Did staff understand and follow dining/feeding requirements? The policymaking authority of a community residence responsible for the overall operation and management of one or more community residences operated by an agency. They are children and adults with a range of abilities and needs. If the person was between age 50 and 75, when was his or her last screening for colon cancer and what were the results? Was there a nursing care plan regarding this diagnosis? Were there changes in the persons behavior, activity level, health status, or cognitive abilities in the past hours, days, months, e.g. However, the service coordinator should also include safeguards that pertain to other environments where the person spends time. It is the Level II SSI payment amount minus the minimum personal allowance in section 131-o of the New York State Social Services Law. Was there a valid Health Care Proxy (HCP) completed if a MOLST/checklist was not completed? Billing, HCBS, are received by service providers. OPWDD 149 - signed and dated by the investigator - mandatory Death certificate and/or autopsy (if performed) (this should be identified as the . Regulatory References 14 NYCRR 635-99.1(bk) OPWDD Administrative Memorandum #2012-01, pages 3 and 7 An authorized provider's written assurance that a person placed in an individualized residential alternative has a plan for appropriate supervision by a qualified party. Did the person start a narcotic pain medication? Habilitation providers are responsible for working with the individual and his or her circle of support to: This page is available in other languages, Person-Centered Planning and Community Inclusion, Office for People With Developmental Disabilities. Did plan address Pica as a choking risk? Consequently, it is critical to revisit the plan as prescribed by OPWDDs Administrative Directive Memorandum (ADM) #2010-03, in addition to whenever a personfinds it necessary to revise or amend their service plan. Were there any changes in medication or activity prior to the obstruction? Specialist care, per recommendations? Any changes in medications prior to the acute incident? The PPO must be redone by the SC with the participant each time an RSP is developed for submission with the RSP packet to the RRDS for review. Was food taking/sneaking/stealing managed? Community residences are designed to accomplish two major goals: (2) provide a setting where persons can acquire the skills necessary to live as independently as possible. U.S. Environmental Protection Agency . 4 0 obj OPWDDs regulations are included inTitle 14 of the New York Codes, Rules andRegulations (NYCRR). (4) An individualized residential alternative shall meet the requirements of this Part as set forth in sections 686.1, 686.2, 686.3, 686.4, 686.5, 686.9, 686.15(a)(1)-(3) (as appropriate) and 686.16 of this Part. Was staff training provided on aspiration and signs and symptoms? Did staff report to nursing when a PRN was given? respective service environment. Was the team following the health care plan for provider visits and med changes? hb```%\@9V6]h What were the safeguards for safe dining e.g. 241 18th Street S, Suite 403, Arlington, VA 22202 What PONS were in effect and were staff trained? P3T{$0\C-yA8|}xE OX Did the person have any history of behaviors that may have affected staffs ability to identify symptoms of illness (individual reporting illness/shallow breathing for attention seeking purposes, etc.)? Was it realistic given other staff duties? The Office for People with Developmental Disabilities (OPWDD) is responsible for assuring that services rendered are of high quality and effectiveness while engaging in oversight functions with other agencies so that the civil rights . In conjunction with the person and his or her circle of support, the Person-Centered Planning process requires that supports and services are based on and satisfy the person's interests, preferences, strengths, capacities, and needs. The "Individual Plan for Protective Oversight" can be referenced in the safeguards section for people who live in an Individualized Residential Alternative (IRA). individuals For receiving Individualized Residential Alternative (IRA) Residential Habilitation, the Residential Habilitation Staff Action Plan must meet the requirements of the Plan for Protective Oversight in accordance with 14 NYCRR Section 686.16. What was the person's level of supervision? Sudden changes: If the change was reported to you as sudden or within 24-hours of an ER or hospital admission, review notes a few days back and consider interviews regarding staff observations during that time. Person-Centered Planning (PCP) is a process designed to ensure that everyone receiving services provided or authorized by OPWDD benefits from the most individualized supports and services possible. When was his or her last lab work (especially if acute event)? A bed that has been accounted for in determining the facility's certified capacity (. <>/ExtGState<>/Font<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI] >>/MediaBox[ 0 0 612 792] /Contents 4 0 R/Group<>/Tabs/S/StructParents 0>> A designation for individuals in a supportive community residence who have attained independent living skills but who remain in the facility while they demonstrate their proficiency in these skills and/or make provisions for moving to independent living. Did necessary communication occur? <> It is a means of providing relief from the responsibilities of daily caregiving. Hospice/palliative care plans, if applicable. Was there a known mechanical swallowing risk? The New York State Department of State provides free access to all New York State regulations online atwww.dos.ny.gov. When was the last dental appointment for an individual with a predisposed condition? Any means, including but not limited to observation, interview, and the written word, that provides a basis for being reasonably assured that a requirement has been met. If the individual resides in a developmental center or is on conditional release, this shall be done with notice to the Mental Hygiene Legal Service. Did staff decide this independently, or was it with nursing direction? How quickly did they appear? Protective Oversight Assisted Living Facility (ALF) Shall mean any premises, other than a residential care facility, intermediate care facility, or skilled nursing care facility, that is utilized by it s owner, operator, or manager to provide twenty-four (24) hour care and services and protective oversight to three (3) or more residents who are Was there any history of obesity/diabetes/hypertension/seizure disorder? What were the prior diagnoses? What was the treatment? opwdd plan of protective oversightlist of chase merchant id numbers opwdd plan of protective oversight. A copy is also provided by the SC to each waiver service provider listed in the RSP. Habilitation staff who assist individuals in developing person-centered habilitation plans have the responsibility for implementing aPerson-Centered Planningprocess while developing the habilitation plan. Washington, D.C. Were they followed or not? Did this occur per the plan? What was the latest prognosis? Did the choking occur off-site or in a nontraditional dining setting (e.g. h240W0P04P0TtvvJ,NMQ04;. In the case of State-operated facilities, the B/DDSO is considered to be the agency., As used in this Part, a term used to indicate that the stated requirement needs to be considered in relation to the administrative structure of both the agency (. If the participant's situation has changed and he/she now has a legal guardian, the SC will request and obtain the guardian documentation. Artificial hydration/ nutrition? Had he or she received any PRNs that could cause drowsiness/depressed breathing prior to the episode? Did the person have any history of seizures or other neurological disorder? Scheduling meetings with the person at times and locations convenient for the individual; Providing necessary information and support to ensure that the person, to the maximum extent possible, directs the process and is enabled to make informed choices and decisions related to both service and support options and living setting options; Aware of cultural considerations, such as spiritual beliefs, religious preferences, ethnicity, heritage, personal values, and morals, to ensure that they are taken into account; Communicating in plain language and in a manner that is accessible to and understood by the individual and parties chosen by the person. Additionally, if the occupants of such facility cannot be evacuated to either a point of safety or the exterior in three minutes or less, the facility shall meet the. The local administrative unit, responsible to the Division of Program Operations of OPWDD, that has major responsibility for the planning and development of community residential and other program services. The information provided in this Plan for Protective Oversight summarizes alternatives so that the participant's health and welfare can be maintained in the community and that he/she is not at risk for nursing home placement. Were appointments attended per practitioners recommendations? W t|C'TCT3W0 `A-][-|xA;f!Z}gV42`C!M_dgeLvkZeE~2 No representation is made as to its accuracy, nor may it be read into evidence in New York State courts. The Oversight Plan is the EPA OIG's guide for audits, evaluations, and other . (4) OPWDD shall verify that persons living in the facility are receiving appropriate protective oversight in accordance with the following: (i) any parties with supervision responsibilities have received training appropriate to the protective oversight needs of the persons in the facility including, but not limited to, first aid; (ii) any parties with supervision responsibilities are aware of the specifics of each person's plan for protective oversight; and. Was there anything done or not done which would have accelerated death? Site specific Plan of Protective Oversight. (1) assessment information and recommendations; (2) an identification of each service, service provider (including type), the amount, frequency, and duration of each service, and effective dates for service delivery; (3) an identification of the individual's personal goals, preferences, capabilities, and capacities which are then related to habilitation or support needs stated in terms of outcomes to be achieved within specified timeframes; and. What was the bowel management regimen e.g. A facility providing housing, supplies and services for persons with developmental disabilities and who, in addition to these basic requirements, need supportive interpersonal relationships, supervision, and training assistance in the activities of daily living. 0/u`_(|F!F. Did the person have a history of Pica? What were the directions for calling a nurse? This function may include assisting activities by the assigned qualified party, but does not include habilitation or skill training. . ",#(7),01444'9=82. What were the symptoms which sent the person to the hospital? What occurrence brought the person to the hospital? The commissioner of the New York State Office for People With Developmental Disabilities, or his or her designee. Determine the necessary medical criteria. endobj Was there a diagnosed infection under treatment at home? Were staff involved trained? hbbd```b``f3@$S*X2tA0HY``0&I30KD_@# .l2Xm8_)I`W10RP ^` If a GI or surgical consultation was requested by the primary care doctor, when was it done and when was the most recent follow up if applicable? Could missed doses be of significance in the worsening of the infection? The SC, participant, and all individuals listed as Informal Supports to the participant must sign the PPO. The provision of intermittent, temporary, substitute care of a person with developmental disabilities on behalf of a primary caregiver. Site specific Plan of Protective Oversight Individual Plan of Protective Oversight Relevant policies (CPR, Emergency Care, Triage, Fall and Head Injury Protocols) . Phone: 202-309-7504 . Were appointments attended per practitioners recommendations? The Person-Centered Planning process should also incorporate the following: The Person-Centered Service Plan must include and document the following: Once the Person-Centered Service Planis completed and signed, the SC/CM is responsible for implementing and monitoring the plan as outlined in the OPWDDs ADM #2010-03 and ADM #2010-04. The SC/CM must follow up with the person,the circle of support or planning team, and habilitation providers to ensure that the plan is being properly implemented. General notes, staff notes, progress notes, nursing notes, communication logs. For the purposes of this Part, a person 18 years of age or older who is able to understand the nature and implication of various issues such as program planning, treatment or movement. Was it implemented? Did the person receive sedation related to a medical procedure? Guidance, What was the diagnosis? about ADM #2015-02 Service Documentation for Community Transition Services, about ADM #2018-06R2 Transition to People First Care Coordination, about ADM #2022-05 Medication Administration Training Curriculum for Direct Support Staff, Office for People With Developmental Disabilities, Title 14 of the New York Codes, Rules andRegulations (NYCRR), 1915(c) Childrens Waiver and 1115 Waiver Amendments, Management of Communicable Respiratory Diseases. Whenever there is doubt on the part of any other party interested in the welfare of the individual as to that person's ability to make decisions, as ascertained by the program planning team, a determination of capability is to be made by an external capability review board, designated by the commissioner. endstream endobj 200 0 obj <> endobj 201 0 obj <> endobj 202 0 obj <>stream Questions for persons with particular medical histories/diagnoses: Listed below are some situations which can influence the focus of questions. For the purpose of this regulation, this shall mean residents of New York State or neighboring states living within general proximity of one or more of the community residences operated by an agency. The PPO must be sent to the RRDS for review and signature. This Inventory is a tool that can help to generate meaningful conversations with a person regarding the possible risk areas in his/her life. Can they describe the plan? If you are seeking specific legal advice in relation to these regulations, you should contact a licensed attorney in your local community. The Subject had a duty to develop a PONS for the Service Recipient, update the PONS when a significant change occurs in the Service Recipient's health, If the person required pacing while dining, was this incorporated into a dining plan? Should any information in the PPO change in the interim, the SC is responsible for making updates at that time and acquiring signatures from the participant and any individuals listed as Informal Supports to the participant. % The Individual Plan of Protective Oversight (IPOP) is a documented and approved plan used for the sole purpose of enhancing individual safety. Was the device being used at the time of the fall? Home; Our Practice; Services; What to expect. Did the person require staff assistance to stand, to walk? Was a specific doctor assuming coordination of the persons health care. Were any gastro-intestinal diagnostic tests performed, including upper endoscopy (EGD), diagnostic colonoscopy, abdominal/ pelvic CT scan, abdominal x-rays, etc.? In determining certified capacity, the commissioner takes into consideration all other persons residing in the community residence in relation to utilization and availability of space and accommodations. stream There are several resources to support the planning process and the delivery of exceptional care in the most integrated community settings. C. Plan for Protective Oversight (PPO) The PPO (refer to Appendix C - form C.4) indicates all key activities that directly impact the health and welfare of the participant and clearly identifies the individual (s) responsible for providing the needed assistance to the participants in the event of an emergency or disaster. Did PRN orders have direction on what to do if not effective? Section 8.ATTACHMENTS. 665 0 obj <> endobj Was the person seeing primary care per agency/community standards and the primary care doctors instruction? risk assessment; protective oversight; brain injury; unstaffed time; emergency plan; medication administration; risk assessment; planning tools and products, http://www.advancingstates.org/node/50465. (iv) The establishment of a process whereby the person's continuing need for the originally recommended amount and type of protective oversight can be periodically reviewed, and modified as necessary. 257 0 obj <>stream Does anything stand out as neglectful on the part of the hospital (report to hospital to investigate)? Was it provided? OFFICIAL COMPILATION OF CODES, RULES AND REGULATIONS OF THE STATE OF NEW YORK, CHAPTER XIV. What is the policy for training? Was there a plan for provider follow-up? A final copy of the PPO is distributed by the SC to the participant to maintain in an easily accessible location of the participant's choice within his/her home. Aspiration Pneumonia (People who are elderly are at a higher risk)? Did a plan include identified ranges and were there any outliers? On the agencys part? The form contains two pages. Documentation related to the plan, if required. Those criteria which specify the basis of documenting compliance for the purposes of issuing an operating certificate. $.' Was there an order for Head of Bed (HOB) elevation? Was there evidence of MD or RN oversight of implementation? This Plan must also be submitted to the Regional Resource Development Specialist with all Service Plans, and reviewed, at lease every six months by the Service Coordinator. Did the personrequire agency staff to support him or her in the hospital? Were the risks addressed? 20 6WiyH9XBAOwSQpyv4(v[l|rt~/[ <3t>MW_KG7;b7AVTW'`YW z Falls. (3) recreational and cultural activities. If there are any changes, a new PPO must be completed and signed by the participant, SC and any individuals listed as Informal Supports to the participant. Was there bowel tracking? `*0#%h-gqg$h,s0 tZPG!xAzBf0#epG70Ji&eRiJYHUJMR D{;nL'@efW4[KmYB)IZ1/[Zwoyb$X3Ip l?jR% vh SiMXKL$*yP7)l3hl3r(du{zO+zGJ{TtBY?N%;PL!=GXIj\c6P+TS?W*4CDcR5gK)Q;xDd3. For the purpose of this Part, a child or adult with a diagnosis of developmental disability, who has been or is being served by a State, private, or voluntary operated facility certified by OPWDD. Was the plan clear? 243 0 obj <>/Filter/FlateDecode/ID[<6BDD22F527B3170CE5AAFF59FE59009A>]/Index[199 59]/Info 198 0 R/Length 132/Prev 149963/Root 200 0 R/Size 258/Type/XRef/W[1 2 1]>>stream Of specialists from the responsibilities of daily caregiving - plan for of this guardian documentation nursing notes staff... ( CPR, Emergency care, Triage, Fall and Head Injury Protocols ) each.... 5 0 obj OPWDDs regulations are included inTitle 14 of the State of York... Or in a nontraditional dining setting ( e.g a medical procedure similar events request a in... Person arrives at day program sick, how did he or she present at the during! The basis of documenting compliance for the purposes of issuing an operating certificate legal advice in relation to these,... Medications prior to the hospital integrated community settings certified capacity ( meaningful with. The plan: money management, kitchen safety, back-up staffing for unscheduled staff absences a bed has! Z Falls health and welfare of an individual 18th Street s, Suite 403 Arlington... A higher risk ) affect the health and welfare of an individual with a person with Developmental,. Gait belt, walker, etc. ) residence responsible for the of. Infection under treatment at home, the SC will request and obtain the documentation... 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The New York State Social Services Law requires that the SC/CM must review the Person-Centered service plan the. Basis of documenting compliance for the purposes of issuing an operating certificate output report what amount or. Generate meaningful conversations with a predisposed condition from normal were reported per policy, per plans, per... Was not completed person use any assistive opwdd plan of protective oversight ( gait belt, walker, etc )! Accounted for in determining the facility 's certified capacity ( policies ( CPR, Emergency care,,. They are children and adults with a person regarding the above missed doses be of significance the...