Person Served
How does the program support the person served to move towards a greater sense of self-determination?
x.8.8
Describe practice and give examples of how this is done within the program
Describe how and when "time-outs" are used within the program?
x.18.3
Define:
1. "time-outs" for children under 12 years of age are limited to 1minute per year of age and
2. Aged 12 and older not to exceed 20 minutes
What types of restraints are used within the program? x.19.4
Define type of restraint used
What is the practice that is in place to monitor the involvement of staff with person’s served financial affairs?
2.1.6
To describe to practice around:
What is the time frame that you have to provide personnel who are new, with access to the most current policies and procedures?
8.2.4
24 hours
What do you have to consider when planning a recreational activity?
x.26.2
1. PS can understand and follow guidelines for safety
2. Functioning level
3. Health/capabilities
4. Fun and offers skill development
What would you document on a critical incident report? What happens to it after you write it? Who gets copy? Does anyone review them?
x.20.2, x.20.3
1. Define what a reportable incident is
2. Define process
a. Documentation
b. Follow-up
c. Timelines for reporting
Who is allowed to administer restraints? Who do you need to call and when?
x.19.5
Only trained staff (if used the program will have one trained staff available on each shift)
Conditions of use are clearly defined
Who can authorize a restraint
What is the procedure that is in place to monitor access to person served and personnel file?
3.1.2
1. Define persons who would have access & reasons for access
2. Describe process to monitor access
When you were hired how were your oriented to your position; to your duties; and to the individuals you work with?
8.2.3
Staff will be able to briefly describe the timeline and the process they went through
Explore if the practice is consistent between all staff
How the person is served re-informed of their rights? how often? x.8.2
Define:
1. Process to re-inform PS rights
2. Process to document
3. Timeline matches care planning
Are pets allowed within the program? If so, what needs to be considered before bringing a pet into the program? x.16.8
Describe the process to ensure the following is addressed:
1. Risk to the person served
2. Risk to the pet
3. Temperament of the pet is suitable
What kind of supports are put in place for the person served and others involved following the incident? How would you document it?
x.19.6, x.19.7
Monitoring behavior and/ or effect on PS
Timelines for notification
Incident report completed and sent
Debriefing with all individuals affected
Informed of rights
Incident report reviewing
How does the organization ensure the electronically stored data is protected and access is limited? Does the organization permit the use of devices to store personal information? If so, what safeguards are in place to monitor the use? 3.2.1
Technologies used – computers, cells, PDAs, flash drives etc.
Security measures in place
How is the uses monitored
How do you ensure the equality of professional?
8.1.7
1. Level of professional services required (e.g. LPN, RN, etc.)
2. Case load requirements
3. Verification of credentials
4. Standardized scope of practice
How do you support the persons served to pursue personal interest, hobbies, and activities?
x.8.10
Describe how they:
1. Encourage involvement
2. Support cultural involvement
3. Expose PS to new activities
4. Support PS to access interest and activities
Describe what the practice of isolation of person served within program would look like?
x.19.3
1. Removal for longer than 20 minutes
2. Documented supervision
3. Engages and supported to regain self-control
How does the program control the transmission of infections and infectious diseases?
x.22.21
1. Staff are aware of role and responsibility to prevent/control infection
2. Staff have up-to-date information a nd are trained to prevent/control infection
3. Use of disposable latex gloves
4. Containment and decontamination
5. Maintenance of medical records of exposure
6. Protocols for early and rapid detection
Are person served data ever use in research projects? If so, what needs to be considered prior to start of a research project?
3.2.2
1. Participation is completely voluntary
2. Continuation of service is not dependent on participation
3. Honorariums and financial incentives are addressed
4. Informed written consent of the person served is required and will include:
a. Nature and purpose of the research
b. Clear description of possible risks or discomfort
c. Guarantee of confidentiality
d. Participant’s (or legal guardian’s) signature
Have you involved practicum students within your programs? If so, what needs to be in place to support their placement?
8.1.9 Practicum Student Contracts
What types of positive methods are used to influence the behavior of persons served?
x.18.1
1. Describe various ways in which they engage PS in a positive manner
2. Describe methods used such as:
a. Capacity building
b. Relational response
c. Strength based
d. Rewards etc.
Are Restrictive Procedures used within the program? If so, please describe what restrictive procedures are used and how are they monitored?
x.19.1
Describe:
1. If response procedures are used
2. If used will:
a. Identify type used
b. Identify if they are planned or unplanned
c. Describe how they are monitored
d. Define the documentation used to track use
What safety precautions are in place around medications?
x.23.1
1. Safe transportation
2. Locked storage
3. Medications are labeled
4. Review of drug interactions
5. Review of instructions prior to administration
6. Medication records
7. Storage and retention of records
8. Disposal of medication
9. Define response to exceptional circumstances-refusal, medication error, adverse reaction etc.
What is included in the Organization's Risk Management plan?
1.2.3 Risk Management Plan
The plan will address:
1. The development of written policies and procedures to outline:
a. How risks are identified
b. How risks are reported
c. How risks are managed
d. How risks are acted on
e. How risks are acted on
f. Protocols defining response time
g. Protocols defining type of response provided
2. The identification of potential and actual risks, which are recorded in a risk register
3. An assessment of the probability of occurrence and/or severity of the risks recorded
4. Strategies used to mitigate identified risks, including but not limited to:
a. Prevention
b. Risk-reduction activities
c. Adequate insurance coverage to cover potential liabilities
How do you provide reasonable accommodations* for staff, respectful of the diversity of all people?
8.1.8 Duty to Accommodate
• Accommodations for religious, cultural, or ethnic differences
• Physical access to the program and facility
• Assistive technology (e.g., materials developed to accommodate difficulties with understanding written materials such as enlarged screens, dictatalk software, etc.)
• Specialized equipment (e.g., wheelchairs, ergonomically designed furniture)
• Access to Employment Assistance Program