Agency Protocol Manual - Office for People With ...

1 Table of Contents Page 1 of 362 Agency Protocol Manual 2/8/2019 Table of Contents Page 2 of 362 Agency Review Overview The Agency Review is intended to verify that agencies have procedures and act to facilitate compliance withregulatory requirements, emphasize quality services, and prioritize both compliance and quality organizationally. opwdd -Division of Quality Improvement (DQI) staff activities will include discussion with Agency representativesregarding topics and standards included in the Protocol . Agency staff may be asked to describe the processesrelated to standards in the Agency Review Protocol . For some areas of review, the Agency will be asked to demonstrate implementation and effectiveness of theprocedures and/or activities.

2 For some standards related to regulatory requirements, surveyors will review documentation demonstratingimplementation for a specified sample. This will be identified in each Protocol section when applicable. Thefindings from the sample review will be used to make a reasoned determination of whether the Agency appears tohave adequate procedures to meet the regulatory requirement being reviewed. Other standards related to best practices for organizations are evaluated through interview and documentationreview. Using Protocol guidance, surveyors will determine if the Agency has mechanisms to address the qualitystandard. The Agency Review will be implemented with each provider Agency .

3 Agency Review activities will take place primarily at the Agency main Office where the required documentation andstaff necessary for interview can be available. Incident Review using IRMA information may occur off site as ableto lessen time on site and travel expenses when applicable. Additional off-site activities may occur as agreed uponwith the Agency and DQI, when the Agency is able to provide information electronically. The visit will be announced. Notice will be sufficient to ensure that staff knowledgeable of the Agency s systems isavailable and written materials needed can be gathered, but no greater than two weeks.

4 The findings of both the Site Review and Person Centered Review (PCR) activities conducted, will guidedecisions on whether certain sections of the Protocol should be implemented. Experience from the Site and PCRmay also assist DQI staff in directing their questions and review of the Agency processes as they are alreadyfamiliar with some Agency practices and outcomes. The Site Reviews and PCRs serve as additional verificationthat Agency procedures are implemented and effective. The findings of all three review types provide the bestoverall assessment of the Agency 's competence to deliver quality : oThe guidelines in this document cannot be inclusive of every scenario a surveyor may encounter and are notmeant to substitute the judgment and knowledge base of experienced DQI identified in this document do not restrict opwdd 's ability to assess any item determined to influencethe regulatory compliance of an Agency or the safety and welfare of individuals receiving of Contents Page 3 of 362 Table of Contents Information Gathering Overview.

5 8 Standards Table .. 12 Guidance & Reference Citations .. 37 Topic 1: Oversight of Services and Outcomes .. 37 Section 1: Service Delivery .. 37 Standard # .. 37 1 .. 37 2 .. 39 3 .. 41 Section 2: Family Care Sponsoring Agency Activities .. 42 Standard # .. 42 1 .. 42 2 .. 43 3 .. 44 4 .. 45 Section 3: Respite Services .. 46 Standard # .. 46 1 .. 46 Section 4: Self-advocacy & Personal 47 Standard # .. 47 1 .. 47 2 .. 49 3 .. 51 Topic 2: Satisfaction and Complaint Management .. 53 Section 1: Complaints and Objections Procedures .. 53 Standard # .. 53 1 .. 53 2 .. 55 3 .. 58 Section 2: Satisfaction .. 59 Standard # .. 59 1.

6 59 2 .. 60 Topic 3: Agency Procedures Regarding Rights Protections .. 61 Section 1: Rights Promotion .. 61 Standard # .. 61 1 .. 61 2 .. 62 Section 2: Rights Protections .. 64 Standard # .. 64 1 .. 64 Section 3: Human Rights Committee .. 66 Standard # .. 66 1 .. 66 2 .. 68 3 .. 70 Topic 4: Behavior Intervention Policy and Procedures .. 72 Section 1: Written Part Policy and Procedures .. 72 Standard # .. 72 1 .. 72 2 .. 74 3 .. 76 4 .. 78 5 .. 80 6 .. 82 7 .. 84 8 .. 86 9 .. 88 Topic 5: Oversight of Health Care Services .. 91 Table of Contents Page 4 of 362 Sample Guidance .. 91 Section 1: RN Oversight All Settings .. 91 Standard #.

7 91 1 .. 91 2 .. 93 3 .. 96 Section 2: Medication Administration .. 98 Standard # .. 98 1 .. 98 2 .. 100 3 .. 102 Section 3: Written Procedures: Delegated Nursing in non-certified settings for community-based waiver services .. 103 Standard # .. 103 1 .. 103 2 .. 106 Topic 6: Workforce .. 107 Sample Guidance .. 107 Section Worksheets .. 107 Section 1: Hiring Practices .. 108 Standard # .. 108 1 .. 108 2 .. 110 3 .. 114 4 .. 116 5 .. 118 6 .. 120 7 .. 122 8 .. 124 Section 2: Background Checks .. 126 Standard # .. 126 1 .. 126 2 .. 128 3 .. 131 4 .. 134 5 .. 137 6 .. 140 7 .. 142 8 .. 144 9 .. 146 10 .. 148 11 .. 150 Section 3: Initial Training.

8 152 Standard # .. 152 1 .. 152 2 .. 154 3 .. 156 4 .. 158 5 .. 160 6 .. 162 7 .. 164 8 .. 166 9 .. 168 Section 4: Annual Training and Other Training Activities .. 169 Standard # .. 169 1 .. 169 2 .. 171 3 .. 172 4 .. 174 5 .. 176 6 .. 177 7 .. 178 8 .. 180 9 .. 182 10 .. 184 11 .. 186 Table of Contents Page 5 of 362 12 .. 187 13 .. 189 14 .. 191 Section 5: Evaluation and Competency .. 192 Standard # .. 192 1 .. 192 2 .. 194 3 .. 197 4 .. 201 5 .. 204 6 .. 206 7 .. 208 8 .. 210 Section 6: Staff Management and Development .. 211 Standard # .. 211 1 .. 211 2 .. 213 3 .. 215 4 .. 217 5 .. 219 6 .. 221 Topic 7: Tuberculosis Control.

9 223 Sample Guidance .. 223 Section 1: TB Testing .. 223 Standard # .. 223 1 .. 223 Standard # .. 225 2 .. 225 3 .. 227 Section 2: TB Evaluation for Excluded Persons .. 229 Standard # .. 229 1 .. 229 Topic 8: Personal Allowance .. 230 Sample Guidance .. 230 Section 1: Personal Allowance Oversight .. 230 Standard # .. 230 1 .. 230 2 .. 232 3 .. 233 4 .. 234 Section 2: Personal Allowance Policy/Procedure .. 236 Standard # .. 236 1 .. 236 2 .. 238 3 .. 241 4 .. 244 5 .. 246 Topic 9: Safety and Maintenance .. 248 Section 1: Safety and Maintenance .. 248 Standard # .. 248 1 .. 248 2 .. 250 3 .. 252 4 .. 253 5 .. 254 6 .. 256 7 .. 258 8.

10 259 9 .. 260 10 .. 261 11 .. 263 Topic 10: Incident Management .. 264 Sample Guidance .. 264 Section 1: Notification of Policy and Procedures .. 264 Table of Contents Page 6 of 362 Standard # .. 264 1 .. 264 2 .. 265 Section 2: VPCR 267 Standard # .. 267 1 .. 267 Section 3: IRC General Requirements .. 268 Standard # .. 268 1 .. 268 2 .. 270 3 .. 272 4 .. 273 5 .. 274 Section 4: IRC Incident Review Requirements .. 276 Standard # .. 276 1 .. 276 2 .. 277 3 .. 278 4 .. 279 5 .. 280 6 .. 281 7 .. 282 8 .. 284 9 .. 285 Section 5: IRC Part 624 Reporting and Notification Requirements .. 286 Standard # .. 286 1 .. 286 2.