i have a good life - jacksoncommunityreview.org · i have a good life individual quality review...

CLASS MEMBER: _____________ REGION: __________ REVIEWER: ____________ CASE JUDGE: __________DATE(S) OF ONSITE OBSERVATION: __________________

I Have A Good LifeIndividual Quality Review

Section 1. Information Gathering - Document Review Before On-Site

Start:

__/__/__

End:

__/__/__

1S PBSP 1GG Nutrition Progress Reports

1T Crisis Plan 1HH ARST

1U Behavior Quarterly Progress Reports 1II CARMP

1V Equipment Table 1JJ Medical Assessments/Consultations

1W Physical Therapy Assessment 1KK ER, Urgent Care, Hospitalization, 00H and Incident Information Reports

1X Physical Therapy Plans 1LL Allergies

1Y Physical Therapy Quarterly Progress Reports 1MM HCP/MERP's

1Z Occupational Therapy Assessment 1NN Health Care Coordination/Nursing Documentation

1AA Occupational Therapy Plans 1OO Seizure Tracking

1BB Occupational Therapy Quarterly Progress Reports 1PP Abnormal Involuntary Movement Screens

1CC Speech/Language Therapy Assessment 1QQ Weight Tracking

1DD Speech/Language Therapy Plans 1RR Bowel Tracking

1EE Speech/Language Quarterly Progress Reports 1SS DNR/Health care Directives/Living Will

1FF Nutrition Assessments

#

1. 6a 6g

Guidance Comments

Residential

Agency/Type

e.g. LLCP – Supported

Living

Was the plan provided to the team by the time the ISP

was effective?

XX XX e.g. Metro e.g. Peake.g. Su Vida -

Community Access

Class Member Reviewer Review Period Region CM AgencyDay Program

Agency/Type

Related Scoring Questions

1S Positive Behavior Support Plan

N/A (This person does not receive Behavior Support Services)

Section 1b: Current 4.19.2017 2017 Individual Quality Review of 25


2. 6h

3. 8g 8k

#

1. 6h 7a

2. 6h 7a

3. 6h 7a

If the plan is to be implemented by direct care

professionals are the steps to be taken identified? Are

they clearly written?

Does the plan describe what to do once

a crisis has occurred?

Does the plan describe interventions

that the staff should employ to de-

escalate the situation?

Does the plan describe specific signals

that a crisis is impending, based on the

assessment?

The following behaviors are frequently cited as prompting a Crisis Prevention/Intervention Plan.

a. Severe aggression toward others

b. Severe self-injury

c. Repeated elopement leading to risk for harm, exploitation, and/or illegal activities

d. Sexual aggression including criminal perpetration

e. Illegal behavior ranging from misdemeanors to felonies

f. Drug and alcohol abuse

g. Acute mental health incident

h. Current or impending homelessness

i. Substantial property destruction, including fire starting

1U Behavior Quarterly Progress Reports

Examples:

Comments/Justifications

How do the plan and the ISP relate?

1T Crisis Plan

Related Scores Scoring Questions

N/A (This person does not require a Crisis Plan)



# Date

1. 11c 12c

2. 13a 14a

3. 13c 14a

4. 13e 15a 15c

5. 14a 15d

6. 13a 14a

Guidance Provider/Description/Discussion Related Scoring Questions

Note any evidence of plans to address

progress/regression (e.g. changes in strategies,

changes environments, and/or changes in target

behaviors and plan.

Compare the progress report with any data provided

for the same period, such internal incident reports,

data collection sheets or anecdotal records in the daily

notes. Determine of the progress report accurately

reflects the data. (The time period the data was

collected must corresponded to the time period

reflected in the Quarterly Report.)

Guidance: Wherever adaptive equipment or assistive technology is listed (e.g. equipment list, medical assessments, therapy evaluations, ISP) it should also be noted on this table.

Note any negative behaviors which have been

eliminated, or positive behaviors which have been

established.

Note any progress/regression in areas outside of the

target behaviors.

Note the date due and the date provided to the case

manager, if available. Quarterly should match the ISP

year.

Note any specific, measurable progress/regression

since the last report.

1V Equipment Table

Note this equipment to look for during visits and use the information from observation and interview to score 25g and 26a-f.

N/A (This person does not receive Behavior Support Services)

N/A (This person does not use equipment)



Related Scoring Questions: 25g 26a 26b 26c 26d 26e 26f

Listed in AT

Inventory?

Listed in

ISP?

Date Needs

@ Day

Has @

Day

Used @

Day

Needs

@ Res

Has @

Res

Used @

Res

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

# Date

1. 4b

Therapist/therapy Description/discussion

Equipment

Environment(s) where Needed/Available/Used

Contact Person

Equipment is defined as: any item needed to enable a person to be successful in his/her environment. Examples of equipment include: durable medical equipment such as wheelchairs of any type,

walkers, shower chairs, shower trolleys, hospital beds, eating and drinking equipment; also personal items such as glasses, dentures, hearing aids. Adaptive equipment should be included e.g.;

communication systems, switches, electronic devices (anything with an on/off switch) and/or simple non-electric items such as picture devices communication systems including communications rings.

Equipment identified as being needed must be available and used by the person in all relevant environments; it works as intended; and continues to be appropriate to the person. If the person refuses

to use the equipment identified, there is evidence that the appropriate specialist has been consulted and alternative devices/interventions assessed, sought and tried. Devices designed specifically for

use to support work tasks only, need not be used at home and vice versa.

Document

Does this assessment identify where

this person started (baseline) in each

area?

1W Physical Therapy Assessment (Adequacy)


Guidance: review the initial or annual therapy assessments, plans and progress report/s for the past year for each therapy received. As you review, be sure to enter any questions that arise into the

appropriate interview in Section 2.

N/A (This person does not receive Physical Therapy)



2. 4c

3. 4c

4. 4d

5. 4e

6. 5b

7. 6a

8. 13a

#

1. 12a

Does the assessment describe my

strengths in each area?

What recommendations are made to the

team regarding new skills and how to

teach them?

Does this assessment describe how the

person currently functions in this area?

Does this assessment identify what

skills the person needs to learn and how

do they relate to the plan?

Describe progress since the last report,

especially progress on outcomes and

action steps.

Guidance Comments

Did the team receive the assessments

at least 14 days prior to the ISP

meeting?

Cross-reference the assessment with

the ISP. How were the

recommendations included in the plan?

If not, why not?

1X Physical Therapy WSDIs and Plans


Was the WDSI/plan provided to the

team by the time the ISP was effective?




2. 6

3. 8k

# Date

1. 12c

2. 13b 14a

3. 13c 14c

4. 15c

5. 15a 15b

If the plan is to be implemented by direct

care professionals, are the steps to be

taken identified? Are they clearly

written?

Examples:

Guidance Provider/Description/Discussion

How do the WDSI/plan and the ISP

relate?

1Y Physical Therapy Quarterly Progress Reports



progress/regression (e.g. changes in

action plan, changes in outcome, and

changes in TS&S, development of new

outcome or action steps.)

Note any outcomes achieved.

Note any progress/regression in areas

outside of the ISP.

Note the date due and the date provided

to the case manager, if available.

Quarterly should match the ISP year.

Note any specific, measurable

progress/regression since the last

report.




6. 13b 14a

# Date

1. 4b

2. 4c

3. 4d

4. 4c

5. 4e

6. 5b

7. 5a

1Z Occupational Therapy Assessment




area?

Compare the progress report for the

period of data reviewed above. Note

whether or not the progress report

accurately reflects the data. (This is

applicable only to the one progress

report which represents the data

reviewed.)




they relate to the plan?



teach them?







meeting?

Cross-reference the assessment with



If not, why not?

N/A (This person does not receive Occupational Therapy)



8. 13a

#

1. 12a

2. 6

3. 8k

# Date

1. 12c

2. 13b 14a



action steps.

Guidance Comments Related Scoring Questions

1AA Occupational Therapy WSDIs and Plans


care professionals, have the steps to be

taken been identified? Are they clearly

written?





relate?

1BB Occupational Therapy Quarterly Reports







report.





3. 13c 14c

4. 15c

5. 14a 15c 15d

6. 13b 14a

# Date

1. 4b

2. 4c

3. 4d



outside of the ISP.

Guidance: Review the programmatic assessments, plans and progress report/s for the past year. For each therapy received, except behavioral support. Copy the table below

for each therapy reviewed.









area?





applicable only to the one progress

report which represents the data

reviewed.)


1CC Speech and Language Therapy Assessments





N/A (This person does not receive SLP Services)



4. 4c

5. 4e

6. 5b

7. 5a

8. 13a 14a

#

1. 5a

2. 6

3. 8k



they relate to the plan?



teach them?



action steps.

Guidance Comments



meeting?Cross-reference the assessment with



If not, why not?

1DD Speech and Language Therapy WDSIs and Plans



care professionals, have steps to be

taken been identified? Are they clearly

written?

Examples:




relate?

1EE Speech and Language Quarterly Progress Reports





# Date

1. 12c

2. 13b 14a

3. 13c 14c

4. 15c

5. 14a 15c 15d

6. 13b 14a

Guidance Provider/Description/Discussion Related Scoring Questions





applicable only to the progress report

which represents the data reviewed.)



outside of the ISP.






report.






1FF Nutrition Assessments

N/A (This person does not require Nutritional Services – is not at moderate or high risk of aspiration.)



# Date:

1.

2. 4e 5j

3. 5k

4. 6

5. 13b 14a

# Date

1. 12c



Note the date due and the date provided to the case

manager, if available.

Cross-reference the assessment with the ISP. How

were the recommendations included in the plan? If

not, why not? (For nutrition, recommendations may be

included in the CARMP or other dining plan.

Recommendations should also be reflected in menus.)

Describe progress since the last assessment.

1GG Nutrition Progress Reports


What recommendations are made to the team on how

to assist the person in maintaining a healthy weight?

Did the team receive the assessment at least 14 days

prior to the ISP meeting? Note: Reference the date on

the Assessment

Guidance: Review the nutritional assessment, noting recommendations for diet, progress or regression, and other techniques recommended to assist the person to maintain a

healthy weight. Add anything that needs to be checked at the home or other program areas to the appropriate sections. For example, if Ensure is recommended when the

person fails to eat the majority of a meal, be certain that it is present in any location where meals are consumed. If the person is at moderate or high risk of aspiration, the

nutritionist/Registered Dietitian should have completed an Annual Assessment/Plan which is to be revised as needed.

Guidance Description/discussion

What is the person’s ideal body weight or suggested

weight range as determined by the assessment?

Information

only

N/A (This person does not require Nutritional Services – is not at moderate or high risk of aspiration.)



2. 13 14a

3. 14c

4. 15a

5. 14a 17c

# Date

1. 19f

2.

#

Note any nutrition related progress/regression in

areas outside of the ISP.


progress/regression e.g. work with PCP/Nurse

resulting in diet changes, education with individual and

staff when changes are needed.

Note any specific, measurable progress/regression

since the last report.

Note any nutrition outcomes achieved.

Created By Final Risk Level Notes

Medical Information

1HH Aspiration Risk Screening Tool


Guidance Comments/Justification

1II CARMP

Guidance: Review the CARMP and complete read the guidance in the table below. Utilize the information to assure consistency with other documents, and to inform your observations and interviews.

If the person does not have a CARMP, but is in need of one, note that. If the person does not require a CARMP, skip this section. If you have noted a change in the person’s health status elsewhere in

the record, be sure that the CARMP and any MERP’s or HCP’s have been updated.


N/A (This person is at low risk of aspiration and does not have a CARMP.)



1. 22e 22f

2. 21 21e 22d 22f

26a 26b 26d

24e 26b 26d 26e 26f

5. 24f 26b 26d 26e 26f

6. 11f 22f 24e

Note any Review specific requirement listed in the

CARMP and make a note in the appropriate interview

or observation to follow up. For example, if the staff is

to monitor weight weekly, check for that on the MAR

during the home visit, and add an interview question.

Note any food restrictions and consider those when

you monitor food in the home. Note if the health care

record is promptly updated. Check on visits and

during interviews for assistnce in scoring

Note food and liquid consistency required.

View Home Visit View Day Visit

Go to the equipment table and add any adaptive

eating equipment identified. Add this information to the

tables for visits in the home/day program. Note if the

equipment is in good repair.

Date of the CARMP:

Do a general review (read through) and note any

information which conflicts with other reports, e.g.

therapy reports, e-Chat, medical assessments. You do

not have to reproduce the content of the CARMP

here.

3.

4.

Note oral care requirements. Add this information to

the tables for visits in the home/day program.

View the Equipment Table

Note required strategies for mealtime, including level

of supervision, pacing, position of person and staff.

Add this information to the tables for visits in the

home/day program.



20f 20i

Guidance:

equipment table.

(19a)

Related Scoring Questions: 19a 19b 19d 19e 19g 20a 20c 20d 20g 20j

20k 26b 26c 35f 35h 35i 35j

View Home Visit View Day Visit

7.

1. Note any diagnosis given and add it to the diagnoses table.

(Equipment is anything that the person uses to improve their function, e.g. Hospital beds, glasses, communication devices, hearing aids, picture cards, etc.)

2. Note any equipment recommended and added to the

Note medication delivery strategies to look for. Add

this information to the tables for visits in the home/day

program and or interviews.

13. Make note of any information provided regarding healthcare directives and end-of-life directives. (35h-j).

5. Note anything that needs follow-up, whether or not a specific recommendation was made. E.g., TD screen indicates abnormal movement, laboratory studies indicate very

high cholesterol, or new diagnosis is made. Check for follow-up, either in records or on visits. (20)6. Note any information/recommendations regarding needed equipment (26b, 26c)

7. Note whether or not the person has a current annual physical, and other assessments consistent with professional recommendation, eg. Hearing, dental vision.. (19b-e).

9. Note any acute medical issues and when treatment was received (19b) (20c).

8. Note whether or not all age and gender appropriate health screenings have been performed per Healthfinder.gov

10. Note evidence of regression and overall health and how it is being addressed (19d, 20d,).

4. If recommendations were not followed, add information regarding the Team Justification Form or Decision Consultation form, including the alternate plan to address the recommendation. (20j) (20k)

11. Note labs and TD screenings administered to monitor medication effectiveness and side effects and their results. (19g, 20g).

12. Note restraints (physical and chemical) utilized for medical or dental treatment and how the person responded to them (35f).

1JJ Medical Assessments/Consultations

(Prior to the onsite review, list assessments found in Therap and the results. Then review the original consultation forms to verify accuracy in Therap and to add any additional information. Request the

original consultation form if it has not been provided.

Review all medical assessments and include the information in the table. The list should include annual physical, dental, vision, nutrition, nursing assessments, specialty consults, labs, TD screens,

ARST, MAAT, etc. Check other information such as the ISP, case management documentation, the CARMP and other assessments and tables for evidence that recommendations were followed up.

In that column, be sure to indicate the date, the means and result of follow-up and your source of documentation/verification. Based on the guidance, identify and enter the related information and

corresponding questions. Refer back to the guidance frequently.

3. Note when recommendations were made and when they were completed (19a, 19b, 19d, 19g, 20a). NOTE: This section will be completed as you review the rest of the file.



# Date

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

11.

12.

13.

14.

15.

16.

17.

18.

1KK ER, Urgent Care, Hospitalization, OOH and Incident Information Reports

Guidance: Review all ER, Urgent Care, medical and psychiatric hospitalizations and incidents which require Heimlich maneuver. Determine if needs were addressed in a timely manner and that

recommendations were followed. Were HCP’s and MERP’s implemented correctly? Add any information from OOH reports. Be alert to physical or functional regression. Look at Section 5 of the

eCHAT.

Related Scoring QuestionsSpecialty Author, TitleInformation/

Recommendations

Evidence that Recommendations

were followed up.

See Above



Related Scoring Questions: 14 19 20 21 22 23 24 25 26 36

# Date

1.

2.

3.

# Date

1.

2.

3.

For each General Event Report (GER), DOH Incident Report, and Internal Incident report, list, type of document (GER, IIR, DOH) the date, a brief description of what happened. In the comment

section, note any actions to be implemented to prevent reoccurrence. Add anything that you need to question or watch for to the appropriate interview questions or observation list. Depending upon

the content of the report, these could be scored under Indicators 19-23 (My Medical Needs Are Met), Indicators 24-26 (I Am Safe and Comfortable) indicator 36 (I am Protected from Abuse, Neglect or

Exploitation) or Indicator 14., (If I am Having Problems, my Team has Addressed Them.) For incidents which were (or should have been) reported to the state, indicate the date of the team

meeting and the disposition of the allegation.

Note: Internal Incident Reports may need to be added during the visit to the home or other program areas. Also, listing and/or sorting so that you have your information in chronological order helps

you ‘see’ what happened before and after. It also helps you begin to see frequency and trends.


1LL Allergy Table

Guidance: Using information from e-chat first, identify allergies identified for this person. If additional allergies are identified in places other than in e-Chat, note the source of that information in the

table below.

Author/title

Type/Purpose of VisitDescription/

RecommendationsDate and Nature of Follow-up Comments

As Above

Allergy Effects of exposure, if known. Document

1MM Health Care Plans/MERPs

N/A (This person does not have allergies and there is no discrepancy with the e-Chat information.)



Note: if you have different providers, EACH of them need MERPS.

# Date R/C

1 21c

2

3

4

5

6

This person's acuity level is: (Check one)

Low

Moderate

High

MERP/HCP and Provider For: Basic Steps Comments/ Justifications

Guidance: From the e-Chat summary, list all HCP’s and MERP’s required or recommended as identified in the e-Chat summary report, or IST section of the ISP. Also list those which have been

created, even if not required. Under “Comments” indicate the source document (e-Chat, ISP), whether or not the instructions are clear, individualized and whether or not they contradict any other

assessments or plan, such as the CARMP. Plans marked with “R” are required. Plans marked with “C” should be considered, but are not required. Plans should be reviewed quarterly and each time

there is a change in status.


Guidance: From the Health Field Survey Tool-

·The aspiration risk level is found on the Aspiration Risk Screening Tool or the CARMP.

·The minimum frequency of nursing oversight is based on acuity level and level of aspiration risk as required by DDSD:

eCHAT Acuity

Low Moderate High

1NN Health Care Coordination/Nursing Documentation

· Evidence of communication with DSPs may include: telephone calls, written correspondence, answered DSP questions

· Corrective action by the nurse may include: retraining, clarification of orders, updated plans, provided written instructions

Aspiration Risk

Semi-annual Quarterly Monthly

Quarterly Quarterly Monthly

Monthly Monthly Monthly

· The number of nurse visits may be affected by hospitalizations and Out Of Home Placements. (E.g., if an individual is in OOH placement for an entire month, a home nursing visit is not

required.)

Low Moderate High



Review of Nursing Documentation

20

21

a. That the nurse visited as required;

b. WHAT the nurse is doing during visits;

Guidance: Read each nursing note/quarterly. Enter the date, a brief description and any comments you wish to make. Utilizing the list below, note the question number for any indicator described. For

example, if you find evidence that the nurse either has or has not responded in a timely manner to a medical issue, note question 19a under Related Questions. You are looking to see:

c. Are my chronic conditions treated appropriately and consistently?

d. If my health is regressing, do I receive appropriate and timely intervention?

e. Is my medication stored appropriately?

f. Am I receiving my medication as prescribed?

g. Is my medication assessed regularly to see that it is effective and monitor side effects? (e.g. laboratory studies, TD screenings.)

h. If I am taking psychotropic medication, does my PBSC work with my psychiatrist to assure that my medication is effective in managing my symptoms?

c. Based on what you have reviewed to this point, if you find notes/visits which highlight good or weak practice, note them so they can be referenced in your

findings. d. If you have questions for the nurse, add those to your interview questions for the nurse.

I receive the medical treatment I need in a timely manner.

a. Do I receive routine/scheduled medical treatment?

b. When I have an acute medical issue, do I receive appropriate and timely treatment?

Utilizing the list below, note the question number for any indicator described. For example, if you find evidence that the nurse either has or has not responded in a timely manner to a medical issue,

note question 20a under Related Questions.

b. Does my nurse provide oversight of my health needs (I.e. weight records, vitals, lab reports, PRN medication use, seizure records) in order to identify and

respond to new issues?)

c. Has my nurse developed individualized health care plans (HCP’s) and medical emergency plans (MERP’s) to address my significant health concerns?

d. Does my nurse evaluate the effectiveness of pain management strategies and record the effectiveness in nursing notes or on the MAR?

e. Does the nurse ensure my healthcare record is promptly updated?

i. Are the recommendations/orders/prescriptions given to me being followed?

j. If the team disagrees with a professional recommendation, , have they discussed and documented why that is so, and developed a plan that addresses the

reason for not following the recommendation?

Note: If there is no Decision Consultation Form for every recommendation not followed, the answer is “No”.

k. Am I supported appropriately to participate in the medical assessments and treatments that I need?

l. If I am receiving effective pain management the strategies are communicated to all of my treating healthcare professionals?

I have adequate nursing services.

a. Does my nurse respond to all of my routine and emergency needs, as appropriate?



22

# Date

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

My team is familiar with, and addresses, my health needs.

a. Has my team developed plans to address any barriers to good health care, such as refusal to wear glasses, dentures, or hearing aids?

b. Can my team members describe my health issues and/or diagnoses and how they impact me on a day-to-day basis?

Note: To answer this as a “yes”, the case manager, the direct support professionals from day, employment and residential must have been found to be able to c. Can my team members describe or locate symptoms and side effects of medication that would need to be addressed by medical personnel?

d. Can the people who work with me every day explain how to implement the CARMP, HCP’s and MERP’s?

e. Are my health indicators (such as seizure tracking records, weight records, bowel movements, etc.,) tracked as needed, accurate and reviewed regularly by the

healthcare coordinator?

f. My CARMP is consistently and accurately implemented. Note: if this person does not have a CARMP, this would be “N/A”.

Type Description Comments Related Scoring Questions

See above



Date Time

#

1. 20c 21b 21e

2. 22e

Use this form for seizure tracking. Also answer the questions which follow.

Location # of Seizures Duration Description

1OO Seizure Tracking

Guidance: Determine how the agency tracks seizure information. If there are multiple sources, be sure to reference all of them. NA can be noted if the person does not have a seizure diagnosis. If

the person has not had a seizure in years, identify where you received/saw that information and what it says. If the person has many seizures a day, cluster your information by week or month

so that you can see if there are months when seizures are low/high, shifts and locations where the person has more/less seizures. You are looking for trends that may have some significance. If

someone has many seizures and you see no apparent pattern, you may pick a 3 month period of time at random and record that information.

Comments

See nursing quarterlies

and seizure tracking in

record

How many seizures have

been documented over

the past year?

Guidance Source/s & Date Comments/Clarification

Is there evidence of

nursing review?


N/A (This person does not have a diagnosis of epilepsy.)



3. 14a 15a 20e

4. 14a 15a 20e

5. 15a 20e

6. 15a 15b 20a

Abilify (aripiprazole) Reglan (metoclopramide)

Clozaril (clozapine) Prolixin or Permitil (fluphenazine)

Compazine (prochlorperazine) Risperdal (risperidone)

Geodone (ziprasidone) Serentil (mesoridazine)

Haldol (haloperidol) Seroquel (quetiapine)

Loxitane (loxapine) Stelazine (trifluoperazine)

Mellaril (thioridazine) Thorazine (chlorpromazine)

Moban (molindone) Trilafon (perphenazine)

Navane (thiothixene) Zeldox (ziprasidone)

Orap (pimoxide) Zyprexa (olanzapine)

If there have been

changes, what was done

about them? And by

whom?

Is there evidence of a

dramatic increase or

decrease in the number

of seizures?


dramatic increase or

decrease in the severity

of seizures?


change in the type of

seizure experienced by

this person?

1PP Abnormal Involuntary Movement Screens

Guidance: Determine whether or not the person being reviewed needs screenings for abnormal involuntary movement, based on the medications they take. Consult the medication table, and cross

reference with the list provided by Continuum of Care here:

N/A (This person does not take medication that would cause Tardive Dyskinesia)



#

1. 19a

2. 19a 20a

3. 19a 20a 21a 30b 30c

#

2. 22e

Have screenings been

provided in accordance

with M.D.

recommendations?

Guidance Source/s & Date Comments/Clarification Related Scoring Questions

* Standardized tools include, but are not limited to, the Abnormal Involuntary Movement Scale (AIMS) and the Dyskinesia Identification System (DISCUS).

Check medical consultations and assessments to determine if the prescribing physician has identified how often the screenings are to take place. Typically they occur quarterly.

Lists dates of screenings

over the past year.

What is the person’s ideal

body weight as

determined by the


abnormal involuntary

movement? If so, identify

any follow-up provided.

1.

nutrition assessment?

1QQ Weight Tracking

Guidance:Weight can be a very important measure of overall health. Rapid loss of weight may signal an unidentified illness. People who are overweight are at higher risk of health issues such as

diabetes, heart conditions and some types of cancer. Review the nutrition assessment, annual physical and the e-Chat to determine whether or not weight has been identified as an issue for this

person. If not, check the box above and move to the next area.


Information

only


Do the records indicate

progress in obtaining ideal

body weight, as

applicable?

N/A (This person does not have weight issues and does not require weight tracking)



3. 21c 22e

4. 20b 22e 21b

Review the bowel tracking records for the past year.

#

1.

2. 20c 21e 22e

3. 19f 20g 21e 22e

4. 20b 21b 21e 22e


episodes of loose bowels,

which required PRN

medication?



rapid weight gain or loss?

If so, has this been

brought to the attention of

the nutritionist?


nursing review?

1RR Bowel Tracking


Does the person have a

diagnosis of constipation

or other digestive issues?

Information

only


episodes where bowel

movements have not

occurred for 3 more days?

(or as specified in a HCP,


nursing review?

1SS DNR/Health care Directives/Living Will

N/A (This person does not require bowel tracking)

N/A (This person does not have and has not requested DNR and/or advanced directives)



Related Scoring Questions: 35 35h 35i 35j 35k 35l

# Date

1.

2.

3.

4.

See Above

· Documentation that the family/guardian in the individual have received information about healthcare decision-making (35h.);

· Documentation that the family/guardian and the individual have received information about advanced care planning and palliative care if we have chosen that for

me? (35i.);· Those healthcare and end-of-life directives reflect the needs, values and informed decisions of the individual as well as the family/guardian (35j);

Type of Document Provision Discussion

Guidance: A DNR order, Living Will and/or Healthcare Directives may or may not be in place. If present, review and identify the specific measures which may or may not be taken. Assure that the

order/directive has been signed by the appropriate persons, (35) and make a note in the residential and day section to assure that staff is asked about the provisions of any applicable document. You

may or may not find information regarding how the directive/order/will was created, but if you do, note that in the table below. Specifically look for:



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Documents