Medical
Documentation
Site Requirements
Provider Requirements
Individual Requirements
100

When should new prescriptions be turned into CCSS?

Prior to starting the medication.

100

What should be the formula for your daily notes?

What the individual does, what you do to support, and the individual's response?

100

How often are emergency drills due?

Every 3 months (quarterly).

100

How long do you have to notify your program manager in the case of a reportable incident?

Within 4 hours.

100

If an individual chokes and you use back blows to resolve it, who do you need to call and when?

Call 911, the guardian, and the program manager within 4 hours.

200

What is the deadline for turning in MARs at the beginning of the month?

by 5pm on the 3rd.

200

Which routine supports/risks need to be documented on in your weekly note?

All of them. If a support/risk did not apply, document that it did not apply (e.g., “No scheduled medical appointments occurred”).

200

How often are water tests due?

Yearly.

200

Should the refrigerator and pantry be accessible to individuals (for access to food)?

Yes, unless specific restrictions are approved by Local Human Rights Committee (LHRC). 

200

If the individual you support is diagnosed with a pressure injury at the dermatologist, who do you call that day and what paperwork is needed?

Call the guardian, program manager, and nurse within 4 hours. Submit a medical form and prescription orders.

300

What are the five rights of medication administration?

Person, route, drug, dose, time.

300

Name some types of supports that can be used in documentation to illustrate how you supported an individual.

Physical assistance, modeling, verbal reminders, step-by-step instructions, gesturing.


300

What is the highest allowed water temperature?

120°F.

300

What areas of the home can an individual access?

Any room except the provider’s personal bedroom.

300

Who should have a key to the bedroom of the individual you support?

The staff providing support and the individual.

400

Can you administer a medication written as "Give 1-2 tablets every 2-4 hours"?

No. The prescription must be specific and not open-ended.

400

If you document something like a bruise, scratch, or skin irritation, how long should you keep documenting the issue?

Document progression daily until the issue is healed.

400

What must be on all food and drinks in the freezer, refrigerator, and cabinets?

Expiration dates and labels with contents.

400

When are DMV driving records due for Providers and DSPs?

February of each year.

400

If you have a keypad lock on your front door, who should have the access code?

Staff providing supports and the individual.

500

What are the only injections medication aides are allowed to give?

EpiPen, Glucagon, and Insulin.

500

How do you document if an individual chose not to participate in an activity?

Indicate “declined” or “chose not to.”

500

What documents should be posted in the home?

Human rights poster, emergency numbers, copy of the most recent license, evacuation routes (with egress routes posted by each exit).

500

Who is responsible for hiring, firing, training, and ensuring compliance for all backup DSPs working in the home?

The provider(s)

500

Name one HCBS right other than having a key to their bedroom.

Decorating their room, accessing the community when desired, painting their room any color, or choosing what TV programs to watch.

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