Review Cheat Sheet (What we look for)

Transcription

1 Review Cheat Sheet (What we look for) Last Review: Was the last review POI completed within a timely manner? Anything that wasn t completed can be transferred into this section. TLogs: TLog: Search, Export to Detailed Excel (when searching for something specific) Are there TLogs written at least once daily during review period? Is there something that sticks out (ie positives, something against policy/protocols, not clarified, etc)? Is documentation person-centered? Is the summary line being used effectively? Appointments: Was a consultation form completed/attached for every appointment? If there were labs or tests, were they scanned/attached? If there was any data given to the provider (ie BDT, sleep tracking, I&E), is it scanned/attached or identified in the comment section? Are the results added via blue add button and staff comments in the appointment? Were all orders/recommendations followed? Did new orders get added to MAR, Protocols, IDF, etc in a timely manner (MAR as soon as possible, Protocols/IDF a couple weeks)? Were there any appointments with Scheduling still in the Type? Did any follow-up appointments get added into Therap? If there was a sedate given, was the monitoring log attached in the appointment? Has a balancing test been completed? If there was an immunization, did it get recorded in Therap? Are all evaluations available with Evaluation as the type? Were there any IDT/Treatment team meetings during review period - and were the notes attached? MAR: Are all medications/treatments signed for? Are medications/treatments marked as M/R, LOA, or OH have comments why? If a medication was not available, is there documentation showing you tried to get it? Does each order have an appropriate attachment? Does each order have an appropriate purpose? Are the purposes appropriate for current diagnoses? Have all medications been added/discontinued timely and appropriately? Are ICC orders being completed as written? Are all zz orders on bottom of the MAR? Are info onlys clearly labeled on MAR, not being signed for and current? Are the orders clear and concise? For PRNs, if there are two PRNs for the same reason are they clearly defined which to give when? If any medications were missed (ie PRN for no BM), was it clearly documented that it was missed?

2 PRN: MAR Report: PRN Follow-Up Were all PRNs given appropriately with clear comments in detail mode (ex applied TAO to right ankle for scratch)? Do all PRNs have appropriate follow-up? Do all PRNs have comments on how to administer the medication? Intake and Elimination (I&E): Was each protocol followed (ie were BMs tracked and PRNs given per Constipation Protocol, was intake/output amounts recorded per Dehydration Protocol, Are there comments for all staff awake hours for BMs (only if BMs are tracked), etc. GER: Are all fields filled out appropriately? Does the title match the BSP operational definition or list provided by PCL? Has the administrative review been completed and include a plan of prevention? Were all administrative review plans for future preventions completed and documented? Do PPIs have begin and end times? Are GERs being approved within appropriate timelines? Were all notifications documented? If a GER references an inservice - was it completed and attached? If there was monitoring needed (ie head injury, fall, temp, etc), was it scanned/attached? Did staff handle the situation appropriately and follow the BSP? Did they follow the appropriate procedure/protocol/plan? Skin/Wound: Are skin/wound tracking attached or being currently tracked for all injury GERs? If there is skin/wound attached - was it filled out appropriately/completely/daily until healed (ie no ditto marks)? If there was a PRN applied, was that documented in comments? Seizures: Seizures: Search, Export to Detailed Excel Was the protocol(s) followed? Were seizures recorded and documented per seizure protocol? If there was a description in the seizure record that wasn t on the description of the protocol, did staff follow the steps for an unusual seizure? Were PRNs given, if needed? Was VNS applied and documented? Vitals: Are vitals being taken per doctor s/nurse s orders? If vitals were out of range, was the order followed? If there is an associated protocol, was it followed?

3 Weights: Are weights being taken per ICC (at least monthly, per PCL policy)? If there was an unexplained weight loss/gain of 5+ pounds in one month, was the physician notified? If physician was notified, what was their response? Was a trend noted? Time Tracking: Was tracking completed for all staff awake hours? If there is an associated protocol, was it followed? Are there any trends noted? Behavior Data Tracking (BDT): Programmatic Report/Clinician Report Does the BDT contain all behaviors the BSP directs to track? Does the number of challenging behaviors in GERs match the number in BDT? Do the comments contain the same information from the GERs (doesn t contradict, doesn t have additional information). Is the information in there substantial (doesn t just say see GER? ) Is it being completed at least daily? Are staff completing functional alternatives? Any trends noted? Tapestry Goals: Does the ISP Program data match ISP? Are goals being completed as written in the ISP? ISP Data: Programmatic Report Are the desired outcomes being completed as written? Any trends noted? ISP Programs: Acknowledgement Report Are all ISP documents, change forms, protocols and plans attached in Therap? Do they match the protocols match the ones in the book? Do the ISP and support documents date match the dates in the tasks box, included updates? Have all staff (including relief) acknowledged the ISP and Support Document Acknowledgement Program? If there was a medication disposal of a controlled medication, did a leadership person observe and sign? Were old goals/isp Programs discontinued? Are goals written exactly as written in desired outcomes/action plans? ISP: Is there at least one growth goal (with an action plan)? Does the one page profile best reflect the person? Are there any change forms - if so, was the loop closed (If it

4 changed a document, was that document also trained, implemented and uploaded in Therap along with change form?) Is there an agenda and all loops closed? Person Centered Information (PCI): Did all appropriate people contribute, including the person and DSPs? Are there any blanks? Are there any places that say N/A, but can easily have more information added (especially employment/day support section)? Is the information current? Risk Identification Tool (RIT): Does each question have a yes/no/history answer? Do repeating questions have the same answer (1b&3a (34/35), 1c&8, 1h&2e&3d, 1i&2f, 1j&2g, 1k& 2h, 1l&2i, 1m&3b?) Have evaluations been completed? Are the evaluations listed and current? Are the dates accurate and found in the location identified in the RIT? Do the answers given match the person s needs? If in 24 hour services - are the new questions (safety and cleanliness, enters into contracts, lack of access, unsafe medication management, significant risk of exploitation) marked no or a reasonable explanation of why that risk if present? If there were any new risks throughout the year, was the RIT updated in a timely manner? Provider Risk Management Strategies (PRMS): Are all risks from RIT listed? Does it match the Risk Management Plan in ISP? Do all risks list the correct support document? Do all dates match protocols listed in Therap and book? Support Documents/Protocols: Are there supports in place as stated in the ISP? If there is a nursing relationship, did she sign all protocols she is following the person for? Are there any blanks? If there is an assessment, are the directives included in the protocol? Description: Does the description accurately state why this person is at risk? If it is for Aspiration/Choking, Dehydration, or Constipation - does the description match all risks identified from the RIT? Section 1/Preventions: Are all applicable orders listed as preventions? Are there any new preventions listed in administrative reviews that need to be added? Do the preventions match the person? Section 2/Signs & Symptoms: Does the temperature here match the PRN for fever? Is other filled out appropriately, with definitions for environment (hot weather) and fever? Does it state where to document missed/refused meals/fluids?

5 Section 3/What to do if signs & symptoms are observed: Is taking the temperature clarified - how many hours to take it for, what range to be concerned, who to call, and where to document? Do the signs/symptoms match the person? Section 4/When to call 911: Is the case manager listed? Is the nurse listed (including how to contact them after hours) if the nurse is following them for the protocol? If the physician is marked - would you really call them after 911? What documentation should be completed after calling 911? Were Protocols followed (ie were CBG s taken and recorded per Diabetes protocol, temperatures taken per Aspiration Protocol, etc?) If they self administer medications, is there clear documentation around it and how staff are monitoring? (For Supported Living - it is the expectation that people will self administer medications. If they are living in SL and they do not self administer there should be a documented ISP team conversation about why not.) Nursing Care Plan (NCP)/Physical Therapy (PT): CHAT is the Nursing Assessment. Health Care Management Plan is the Nursing Care Plan. Reviews are located in TLogs. Is the assessment current? What kind of nursing plan is in place (holistic or specific issue(s))? Are delegations/trainings current? Have reviews been completed per plan? Does the person have a PT relationship? Is the assessment current? Are all PT recommendations in place and documented accurately? Are PT follow-up visits and trainings being completed and documented per their plan? If there has been a health change, were the Nurse/PT notified, if needed? PT has it s own ISP Program Acknowledgement - is it current? Behavior Support Plan (BSP): Does the BSP address all risks as written in PRMS/RIT? Are environmental supports being followed? Is the BSP clear (ie give definitions to small, sharp, etc) Does the BSP identify functional alternatives, proactive strategies, and alteration criteria? Does the BSP identify how often and how it will be reviewed? Were reviews completed? Do supports make sense to the person? Does date match in Therap/PRMS? Are supervision comments, alarm checks, environmental sweeps available and being documented as written in BSP? Medication Cabinet: Was medication cabinet locked, if needed? Are all medications/treatments present in cabinet? Are all refrigerated medications in a locked box? Do all OTC medications have initials, SEE MAR stickers, and date opened? Are topicals stored separate from the oral

6 medications? Are there any expired medications or treatments? Do medication labels match the MAR? Are the bubble packs being punched for correct date and initialed? Are medications being disposed of in a timely manner after new medications arrive? Is the medication cabinet cleaned? Menus: Is there a current menu for anyone with a modified or special diet? If their texture is modified, is there a guide with how staff are to prepare the modified texture? If they have a special diet, does the menu reflect it (ie does it say lowfat yogurt instead of just yogurt in menu item or in a substitutions list)? Do they have each person s current diet order listed? Are planned meals well-balanced? Are leftovers being utilized? Do the snacks listed fit diet? Are beverages listed? Is there a menu for the current week? Environmental/Cleanliness: Are all environmental modifications from BSP/Plans/Protocols in place? Is the house clean and smell nice? Is the house cluttered? Are pests being controlled (no flies, ants, mice or mosquitoes?) Are there bugs in the window sills? Are there any holes in the walls? Is everything in good repair, inside and out? Are food items labeled, dated and stored properly? Are there any food items that are expired? Is the smoking area clean and being utilized correctly? If there is a pet, is it properly cleaned up after? Do toothbrushes have covers or stored in a clean, dry place? Does the house need deep cleaned (ie vents, baseboards, etc). Is the house decorated per each person s likes? IDF: Are all fields filled out, including: current picture, gender, marital status, religious preference, medical card number, guardianship status, characteristics, home address, adaptive equipment, mobility, communication, language, toileting status, emotional/physical outburst (from EP plan), no contact order, etc? Are all diet/eating guidelines listed under diet - are they current? Are personal contacts filled out appropriate for the person - do they have any others that should be added? Are all shared contacts up to date and include case manager, employment, PCP, on-call PCP, specialists, hospital and pharmacy? Are all diagnoses and allergies complete? Are all custom fields filled out appropriately? Does it list the current TL/AD? Do the behavior and supervision sections match current PCL policy? If they have a Health Care Rep, is the paperwork current? Have rights (PCL and DHS) been signed in the last year? Are they scanned into Consents? If they have a POLST/DNR/etc is it scanned/attached into Consents? Does it need reprinted? Book Review:

7 Does the book contain all needed information? Does it have the current forms used by PCL (ie Required Notifications, Index, etc). Does it need overflowed? Is the required notification for hospitalization accurate? Does it include the current TL, AD, area on-call, nurse, case manager? Have all telephone orders been followed up with (have physician signature and implemented)? Is there a current (every 3 years or when physicians change), signed medication error protocol for Primary (Psych and Neuro if applicable)? Safety POI: Was Safety inspection completed? Was the POI filled out within appropriate timelines (24 hours for urgent items, 2 weeks for the rest? Was anything noted on the inspection of concern? Was the fire drill completed and filled out correctly? Entry/Exit: Have they moved since last review? Was welcome home safety checklist completed and scanned/attached to TLog? Was move paperwork from PCL and county, if available, scanned/attached into Doc Storage? Were To Do s from move paperwork completed? Have the ISP/plans/protocols/etc been updated for current home (especially environmental (for person who moved and housemates), goals)? Is a 60 day ISP scheduled, if needed? Was all personal property present and accounted for? Was EP Plan and DHS form updated to ensure that it is current for house? Does backpack have all current supplies? Did all staff acknowledge ISP Programs before working with them? Other: Did you observe staff following protocols/plans and procedures? Is there a pet book for any household pets? Is pet current on all vaccinations and treatments? Anything else should be noted here. Are things going well? How did you feel about the house (ie staff are confident, home is inviting, etc). Yellow Highlights : This is something that could potentially cause a return visit from the state. The entire box should be highlighted yellow. Light Blue Highlights : These are things that were copied directly from Therap. Italics: A helpful way to look up the information in Therap.