Supportive Day Care

I. General Policies and Procedures

Describe the time span between referral and assessment.

Describe the time span between assessment and consumer participation.

What is your proposed rate for Supportive Day Care? Describe any additional charges.

Describe the following assessment procedures and who is responsible for the procedures:

Intake/Screening

Physician Report

Plan of Care (including activity plan)

Enrollment Agreement

Reassessment of Care Plan Timetable

Discharge criteria and notification

Describe your participant orientation procedure

Describe your record keeping method for each consumer including quarterly progress notes

Describe your policy and training for reporting suspected abuse or neglect of a participant

Describe your consumer grievance procedure

Attach a copy of your participant bill of rights and responsibilities that is posted and distributed to all participants6

Describe your procedure for handling participant medical emergencies.

Describe your emergency plan that includes plans for evacuation and relocation of participants in the event of an emergency such as fire, loss of power (lights and/or heat), and hurricanes/snowstorms:

Describe your nutrition services including how often and who provides the meals.

Attach a monthly schedule of participant activities.

Describe your arrangements or contract for transportation to your facility.

II. Program Administration

Do you have a governing body responsible for operation of your program?

Do you have an advisory committee?

Is your written plan of operation reviewed and updated annually?

Do you have an updated organizational chart?

Do you have a formally established fee schedule?

III. Personnel Procedure

Describe policy/procedure and frequency for:

Tuberculosis Screening

Describe procedure and frequency for the following trainings, if applicable:

CPR First Aid

C. Describe procedure for staff and volunteer orientation.

D. Describe procedure and frequency for supervision and in-service training, including the use of standard protocols for communicable diseases and infection control

E. Do you perform evaluations for employees? How often?

F. Describe how you achieve the mandatory minimum staff to consumer ratio.

Provider employee who completed this form

Name: __________________________________	Date: ____________________

Supportive Day Care

Please note the documents and records which will be required for the Consumer files and/or Employee files to be reviewed at the time of On Site Evaluation

EMPLOYEE Records Review
Provider Date Monitor
Start Date & Termination Date, if applicable
Number of reference checks
CORI Check
Orientation: Date
Job Description(s)
Licenses/Certificate of Training Current/expired?
Ongoing training: dates Communicable Diseases and Infection Control: Dates
CPR: latest dates First Aid: latest dates Current/expired?
Physical: latest date (if applicable)
Performance Appraisal Date:
OIG monthly check
TB: latest date
Comments

Supportive Day Care

Please note the documents and records which will be required for the Consumer files and/or Employee files to be reviewed at the time of On Site Evaluation

Consumer Records Review
Provider Date Monitor
ASAP Authorization
Service start date & termination date, if applicable
ID Info – name; address; phone; DOB
Emergency contact(s) and phone
Physician(s) report including medical
Plan of Care
Enrollment agreement
Semi-annual reassessment
Quarterly progress notes
Name of current CM
Comments
NOTE: Shaded data elements are only required in the Consumer File if provider is not on Provider Direct. Otherwise the PD Demonstrator will be asked to illustrate “on screen”.
Name and Position of Provider Direct Demonstrator