ABC_ Quality Record Review 2021

Question Title

* 1. Date

Date / Time

Date

Time

AM/PM

Question Title

* 2. Background Information

Staff Being Reviewed

Client ID

Reviewer

Question Title

* 3. Client File Status

Open

Closed

Question Title

* 4. Orientation

	Yes	No	N/A
Was the Resident provided a complete Orientation and signed a client orientation?	Was the Resident provided a complete Orientation and signed a client orientation? Yes	Was the Resident provided a complete Orientation and signed a client orientation? No	Was the Resident provided a complete Orientation and signed a client orientation? N/A
Was the Resident actively involved in making informed choices regarding the services they received?	Was the Resident actively involved in making informed choices regarding the services they received? Yes	Was the Resident actively involved in making informed choices regarding the services they received? No	Was the Resident actively involved in making informed choices regarding the services they received? N/A

Question Title

* 5. Assessment

	Yes	No	N/A
Is there an Intake Assessment present and is it thorough, complete, and timely?	Is there an Intake Assessment present and is it thorough, complete, and timely? Yes	Is there an Intake Assessment present and is it thorough, complete, and timely? No	Is there an Intake Assessment present and is it thorough, complete, and timely? N/A
Were risk factors adequately assessed and did they result in safety plans, when appropriate?	Were risk factors adequately assessed and did they result in safety plans, when appropriate? Yes	Were risk factors adequately assessed and did they result in safety plans, when appropriate? No	Were risk factors adequately assessed and did they result in safety plans, when appropriate? N/A
Identify the special needs of the Client in order to form the basis for the Individual Service Plan	Identify the special needs of the Client in order to form the basis for the Individual Service Plan Yes	Identify the special needs of the Client in order to form the basis for the Individual Service Plan No	Identify the special needs of the Client in order to form the basis for the Individual Service Plan N/A
Is the Intake Assessment signed by staff and dated?	Is the Intake Assessment signed by staff and dated? Yes	Is the Intake Assessment signed by staff and dated? No	Is the Intake Assessment signed by staff and dated? N/A

Question Title

* 6. Individual Service Plan

	Yes	No	N/A
Are the Individual Service Plan goals and objectives based on the results of the assessment?	Are the Individual Service Plan goals and objectives based on the results of the assessment? Yes	Are the Individual Service Plan goals and objectives based on the results of the assessment? No	Are the Individual Service Plan goals and objectives based on the results of the assessment? N/A
Are the Goals and Objectives revised when indicated?	Are the Goals and Objectives revised when indicated? Yes	Are the Goals and Objectives revised when indicated? No	Are the Goals and Objectives revised when indicated? N/A
Were the actual services related to the goals and objectives?	Were the actual services related to the goals and objectives? Yes	Were the actual services related to the goals and objectives? No	Were the actual services related to the goals and objectives? N/A
Did the actual services reflect the appropriate level of care?	Did the actual services reflect the appropriate level of care? Yes	Did the actual services reflect the appropriate level of care? No	Did the actual services reflect the appropriate level of care? N/A
Did the actual services reflect a reasonable duration?	Did the actual services reflect a reasonable duration? Yes	Did the actual services reflect a reasonable duration? No	Did the actual services reflect a reasonable duration? N/A
Does the Individual Service Plan address the Client's issues and presenting problems?	Does the Individual Service Plan address the Client's issues and presenting problems? Yes	Does the Individual Service Plan address the Client's issues and presenting problems? No	Does the Individual Service Plan address the Client's issues and presenting problems? N/A
If medication is prescribed, is it documented?	If medication is prescribed, is it documented? Yes	If medication is prescribed, is it documented? No	If medication is prescribed, is it documented? N/A
Is the Individual Service Plan updated, signed, and dated by the client and Caseworker?	Is the Individual Service Plan updated, signed, and dated by the client and Caseworker? Yes	Is the Individual Service Plan updated, signed, and dated by the client and Caseworker? No	Is the Individual Service Plan updated, signed, and dated by the client and Caseworker? N/A
Was the Client offered a copy of the Individual Service plan?	Was the Client offered a copy of the Individual Service plan? Yes	Was the Client offered a copy of the Individual Service plan? No	Was the Client offered a copy of the Individual Service plan? N/A
If a Personal Safety Plan was indicated, was it included in Individual service plan?	If a Personal Safety Plan was indicated, was it included in Individual service plan? Yes	If a Personal Safety Plan was indicated, was it included in Individual service plan? No	If a Personal Safety Plan was indicated, was it included in Individual service plan? N/A

Question Title

* 7. Documentation

	Yes	No
Are services documented in accordance with agency policy?	Are services documented in accordance with agency policy? Yes	Are services documented in accordance with agency policy? No
Are Progress Notes signed by the provider?	Are Progress Notes signed by the provider? Yes	Are Progress Notes signed by the provider? No

Question Title

* 8. Transition and Discharge

	Yes	No	N/A
Was the Discharge appropriate?	Was the Discharge appropriate? Yes	Was the Discharge appropriate? No	Was the Discharge appropriate? N/A
Was Discharge criteria identified?	Was Discharge criteria identified? Yes	Was Discharge criteria identified? No	Was Discharge criteria identified? N/A
Was Discharge Summary, Discharge Progress Note and Transition Plan completed as applicable?	Was Discharge Summary, Discharge Progress Note and Transition Plan completed as applicable? Yes	Was Discharge Summary, Discharge Progress Note and Transition Plan completed as applicable? No	Was Discharge Summary, Discharge Progress Note and Transition Plan completed as applicable? N/A

Question Title

* 9. Referrals

	Yes	No	N/A
If a referral is made to another program or organization, was the referral appropriate?	If a referral is made to another program or organization, was the referral appropriate? Yes	If a referral is made to another program or organization, was the referral appropriate? No	If a referral is made to another program or organization, was the referral appropriate? N/A
Is there written evidence of follow-up of the referral by staff?	Is there written evidence of follow-up of the referral by staff? Yes	Is there written evidence of follow-up of the referral by staff? No	Is there written evidence of follow-up of the referral by staff? N/A

Question Title

* 10. Was staff given a copy of the Quality Record Review form for correction and information?

Yes

No

N/A

Yes

No

N/A

Question Title

* 11. Staff has 14 days to complete any corrections and return them to the Facility Program Supervisor or designee. List of items needed correction: