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Check list sample

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POST-TRANSITION QUALITY ASSURANCE CHECKLIST
State Form 51681 (R / 3-06) / BQIS 0005

INSTRUCTIONS:

1. Prior to conducting the survey, check to see if any incidents have been reported; attach a copy of those incidents and follow up to this survey form. Note in question 45 if any incident
reports do not have appropriate follow up submitted.
2. For the 7-day post-move visit, the existing ISP should still be in place regardless of type of placement setting. For the 30-day post-move visit, at a minimum, a meeting should be scheduled
to review the existing ISP for individuals moving into supported living setting, and an IPP should be in place for individuals moving into group homes.
3. All questions below are to be scored using the current support plan (supported living) or individual program plan (group home) for the resident:
“Yes” = compliance with plan, “No” = not in compliance with plan, “N/A” = not a need in plan.
Note: All “No” responses must include a narrative explaining the deficit.

Name of individual

Telephone number

(

)

Address of home (number and street, city, state, and ZIP code)

Date resident moved into home (month, day, year)

Setting

Date of individual support plan used for this checklist (month, day, year)

SL

SGL

Other (please describe)

New residential provider

Previous residential provider / SOF

Printed name(s) of BQIS / BDDS staff performing this checklist

Signature of BQIS / BDDS representative completing this form

Type of visit

Date of visit for transition QA checklist (month, day, year)

7-day

30-day

60-day

90-day

Other

Name of case manager (SL) / QMRP (SGL)

Telephone number

(

Name of residential provider contact person

)

Telephone number

(

)

QUESTIONS
YES
1.

Personal belongings in the home and available to individual?

2.

Home adaptations in place? (list adaptations per PCP / ISP)

3.

Is an emergency telephone list present? (N/A for nursing home placement)

4.

Medical equipment present (ex: G-tube, C-pap, Oxygen)? (list equipment per PCP / ISP)

5.

Adaptive equipment present (mealtime equipment, communicative devices, braces etc.)? (list equipment per PCP / ISP)

6.

Home clean and hygienic?

7.

Safe storage of medications, cleaning supplies, knives and other potential hazards? (N/A for nursing home placement)

8.

House, lot, yard, garage, walks, driveway, etc. free of environmental hazards? (N/A for nursing home placement)
Page 1

NO

N/A

State Form 51681 (R / 3-06) / BQIS 0005

Name of individual w...
POST-TRANSITION QUALITY ASSURANCE CHECKLIST
State Form 51681 (R / 3-06) / BQIS 0005
INSTRUCTIONS: 1. Prior to conducting the survey, check to see if any incidents have been reported; attach a copy of those incidents and follow up to this survey form. Note in question 45 if any incident
reports do not have appropriate follow up submitted.
2. For the 7-day post-move visit, the existing ISP should still be in place regardless of type of placement setting. For the 30-day post-move visit, at a minimum, a meeting should be scheduled
to review the existing ISP for individuals moving into supported living setting, and an IPP should be in place for individuals moving into group homes.
3. All questions below are to be scored using the current support plan (supported living) or individual program plan (group home) for the resident:
Yes = compliance with plan, No = not in compliance with plan, N/A = not a need in plan.
Note: All No responses must include a narrative explaining the deficit.
Name of individual
Date resident moved into home (month, day, year)
Address of home (number and street, city, state, and ZIP code)
Setting
SL SGL Other (please describe)
Previous residential provider / SOFNew residential provider
Telephone number
( )
Printed name(s) of BQIS / BDDS staff performing this checklist Signature of BQIS / BDDS representative completing this form
Type of visit
7-day 30-day 60-day 90-day Other
Date of visit for transition QA checklist (month, day, year)
Name of case manager (SL) / QMRP (SGL) Telephone number
( )
Name of residential provider contact person Telephone number
( )
Date of individual support plan used for this checklist (month, day, year)
QUESTIONS
1. Personal belongings in the home and available to individual?
2. Home adaptations in place? (list adaptations per PCP / ISP)
3. Is an emergency telephone list present? (N/A for nursing home placement)
4. Medical equipment present (ex: G-tube, C-pap, Oxygen)? (list equipment per PCP / ISP)
5. Adaptive equipment present (mealtime equipment, communicative devices, braces etc.)? (list equipment per PCP / ISP)
6. Home clean and hygienic?
7. Safe storage of medications, cleaning supplies, knives and other potential hazards? (N/A for nursing home placement)
8. House, lot, yard, garage, walks, driveway, etc. free of environmental hazards? (N/A for nursing home placement)
YES NO N/A
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