OPWDD QUALITY ASSURANCE-INTERNAL AUDIT TRACKING SHEET NEEDED.
G101929
AUDITSHEETFORIRAs.docQUALITY ASSURANCE AUDIT
OPWDD Internal Audit Criteria
NAME OF INDIVIDUAL:
Reviewer: Date of Review:
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OPWDD Audit Criteria |
Acceptable (Yes/No) |
Missing Document |
Comments |
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A1. Level of Care Eligibility Determination (LCED) Form |
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Name of Individual |
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Address of Individual |
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Individual’s Date of Birth |
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Date of Psychological Evaluation |
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Date of Social Evaluation |
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Date of Physical Evaluation |
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Medicaid No. (CIN) and Tabs ID |
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Review Date and Signature of Qualified Person |
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A2. Individual Plan of Protective Oversight and Safeguards |
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Date of IPOP Review |
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Date and Signature of Qualified Personnel Safe guards in place to protect the recipient’s health and safety. |
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A3. Individualized Service Plan (ISP) |
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Date of Annual ISP Review |
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Date and Signature of Qualified Personnel |
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Summary of Fire Safety |
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Type of waiver (residential habilitation), frequency of service, duration of service and effective date service began. ISP designates the agency (Edwin Gould) as the provider service. |
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Identification of personal goals, preferences, capabilities and capacities relative to the need stated in outcomes |
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Safe guards in place to protect the recipient’s health and safety. |
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Valued Outcomes |
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Date of ISP Six Month Review |
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Date and Signature of Qualified Personnel |
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Valued Outcomes |
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Summary of Fire Safety |
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Safe guards in place to protect the recipient’s health and safety. |
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A5. IRA Residential Habilitation Plan |
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Name of Individual |
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Identification of category of waiver service provided |
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Date the habilitation plan was last reviewed |
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Medicaid No. (CIN) |
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Safeguards identified in the Individual’s Plan of Protective Oversight that will be provided by the Habilitation Service Provider |
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Valued Outcomes |
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Description of services and support being provided to the individual |
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Sign-in sheet that proves that IRA Residential Habilitation Plan was reviewed and/or revised. |
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The initial habilitation plan is written within 60days of the start date of the habilitation service and forwarded to the service coordinator. |
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Date and Signature and Title of Qualified Personnel |
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IRA Residential Habilitation Billing |
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A.9 |
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B1. |
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B2. |
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B3. |
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B4. |
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B5. |
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B6. |
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B7. |
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B8. |
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B9. |
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B10. |
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C1. |
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C2. |
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D1. |
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D2. |
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