Incidents & Complaints
Rights & Responsibilities
Policies and/or Procedures
Person Centered
Numbers
100

The person who learns about an SRI

Who is the discoverer

100

A request for a change in services (add, increase, decrease, discontinue at any time)

What is an addendum 

100

Receiving Service Coordination and ILST from the same agency without attestation

What is Conflict of Interest

100

The right to take risk and fail, the right to choose where to live, who to socialize with and choose goals 

What is the Waiver Philosophy

100

Number of days to write an ISP after SC Agency form signed

What is 60 days

200
Physical, Sexual, Psychological, Seclusion, Restraint, Mistreatment, Adverse Conditioning 

What are Types of Abuse

200
I not only have Rights but I have _____________

What are Responsibilities

200

Authorization

Denial of Waiver Program

Discontinuance

Increase or Addition of Waiver Service

Reduction or Discontinuation of Waiver Service

Death

What are types of NODs

200

Is developed and implemented by the individual waiver service provider to identify the specific tasks and activities to be provided by the waiver provider in support of the participants goals

What is a Detailed Goal Plan (DGP)

200

Days to submit a team meeting summary after a team meeting 

What is 14 days

300

Committee that reviews agency SRIs

SIRC Committee (Serious Incident Review Committee)


Rhona Johnson

Jane Dupree (Investigator)

Brandy Reynolds

Sara Rockwell Smith

Dana Hultz

Austinishia Driscoll

Anne Crozier 


300

True or False 

I have the right to choose my Provider Agency and my specific Provider Staff 

What is false.

300

Request when a ISP is not going to be submitted in time. 

What is an extension.


NHTD has a form. TBI requires an Email

300
Indicates all key activities and protective measures that impact the health and welfare of the participant and clearly identifies the individual responsible for providing the assistance to the participant in the event of an emergency or disaster

What is the Protective Plan of Oversight (PPO)

300

The amount of time an SRI should be closed

What is 90 days

400

Person with direct knowledge of an incident 

What is the Witness

400

Right to receive a list in writing a list of names, telephone numbers, hours of operation, and supervisors for all waiver service providers, the RRDS, and the Waiver Complaint line

What is the Waiver Contact List (WCL)
400

Includes benefits, programs, well being, physical and mental health, safety, financial security, and social support

What is Health and Welfare

400
These are used to review and develop the participant's Service Plan. The participant is the driver and the key decision maker. 

What are Team Meetings 

400
How many days does the Service Coordinator have to sign if Agency Selection Form is received from the RRDC. 
What is 5 days
500

A real or imagined wrong or other cause for complaint or protest, especially unfair treatment, or something believed to be wrong or unfair

What is grievance 

500

A formal appeal process where you challenge a decision by your state's Medicaid agency (like a denial, reduction, or termination or benefits) before an impartial administrative law judge or hearing officer. 

What is a Fair Hearing
500

Name, Social Security Number, Driver's License, DOB, 

What is PII (Personal Identifiable Information)
500

Specific

Measurable

Attainable

Relevant

Time-Anchored 

What are SMART Goals 

500
Medicaid CIN has how many letters? and how many numbers?

What are 3 letters and 5 numbers

M
e
n
u