Q1000I ISC Quality

1. Were the following available at the ISC agency during the review (check all that apply):

Must have all applicable forms in file in order to be answered 'Yes'.

Reviewers must save a copy of the current Personal Plan and current Provider Signature Page(s) to the ISC agency review folder in the BQM G: drive.

(If current IS and/or current PSP from all providers are not available, document any supporting communication/documentation to explain the reason for delay, and record the Provider agency name in the comments.)

____ Discovery Tool 

____ Personal Plan

____ Implementation Strategy/EOR

____ Provider Signature Page (from all applicable providers)

Comments:

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2. Was a Discovery Tool completed within the 6 months prior to the date of the current Personal Plan?

(date of the DT is the date of ISC signature / date of the PP is the last date on the PP signature page)

Discovery Tool date: ___________________ 

Current Personal Plan date: ___________________

Comments:

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3. Was the Personal Plan updated annually (365 days)? (Date of PP is the last date among the signatures on the Personal Plan signature page. Verbal/email approvals are not acceptable.)

Personal Plan:

• Current date: ___________________
• Prior date: ___________________

PMD7

Comments:

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4. Are the Discovery Tool and Personal Plan completed on the most current versions of each form? (The most current version of the Discovery Tool for FY26 is dated 3/2023. The most current version of the Personal Plan for FY26 is dated 7/2023.)

Comments:

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5. Was the Personal Plan signed either by pen/ink or via authenticated electronic signature for all signatures? (Rule 120.95)

Informational Finding ONLY for FY25

Comments:

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6. Does the Personal Plan address all the personal goals (outcomes) identified during the assessment/discovery process?

PMD1

Comments:

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7. Does the Personal Plan address all the support needs identified during the assessment/discovery process?

PMD2

Comments:

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8. Does the Personal Plan address all of the health and safety risk factors identified during the assessment/discovery process?

PMD3

Comments:

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9. Does the Personal Plan identify and provide justification for all rights restrictions and Settings modifications identified during the assessment/discovery process?

Comments:

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10. Are all of the identified rights restrictions/Settings modifications contained within the correct HCBS Settings section under "Important Things To Know" on the Personal Plan? (Informational Finding Only for FY26)

Comments:

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11. In the current Discovery Tool/Personal Plan, is it documented that the individual has reported having had a physical exam within the past 12 months (from the date of the Discovery Meeting/date of report)?

PMG8

Comments:

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12. (If #11 is answered 'yes', this is answered 'N/A'.) If the individual's record does not reflect that the individual has reported having had a physical exam in the past year, has the ISC documented working with the individual/guardian to identify and address barriers to accessing a Primary Care Provider (PCP) or to having a physical exam completed?

Comments:

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13. Does the individual's record indicate that there have been any significant changes in their medical, behavioral, or support needs in the past year? 

(No Findings associated with this question)

PMD8d

Comments:

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14. (If #13 is 'No', this is answered N/A.) 

Was the Personal Plan updated when there was a significant change in the individual's medical, behavioral, or support needs?

PMD8n

Comments:

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15. (This is answered 'N/A' for CILA, CRW, CLF, or CDS-Only services)

Does the Personal Plan Summary of Services & Supports indicate services to be provided by a Personal Support Worker? (No Findings associated with this question)

PMD4d

Comments:

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16. (If #15 is 'No' or 'N/A', this is answered 'N/A'.)

Did the person's Personal Plan include a PSW back up plan? (Effective 7/1/22)

IL462-4125 (N-06-22)

IDHS: Individualized Back Up Plan (state.il.us)

PMD4n

Comments:

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17. Do the ISC Individual Monitoring and Interview Notes (IL462-4465) indicate that the individual has received services in the type, scope, amount, duration, and frequency as specified in the Personal Plan?

PMD9

Comments:

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18. Does the record indicate that the individual received 4 visits from the ISC during the past 12 months?

• One visit must be conducted to complete the Discovery Process (shown on the Discovery Tool under 'Date(s) of the Discovery Process'). The ISC Individual Monitoring and Interview Notes (IL462-4465) serve as the official documentation for the other three quarterly visits.
• Quarterly visits are based on state FY and defined as:
  Q1 (7/1 - 9/30), Q2 (10/1 - 12/31), Q3 (1/1 - 3/31), Q4 (4/1 - 6/30)
• Note with 'DT' next to the date of the Discovery Tool Meeting

ISC Remote Monitoring Activities - effective 11/11/23, ISC agencies are required to conduct all ISSA visits in person, unless authorized as defined in this Bulletin.

PMD5

Comments:

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19. Were all of the ISC Monitoring Visits conducted in person? If not, is there documentation present explaining why any remote visits were not conducted in person (individual/guardian choice, individual/guardian time conflict, etc.)?

DD.22.011 ISSA Monitoring Visits

ISC Remote Monitoring Activities

Comments:

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20. Does the individual's record indicate that all identified CIRAS-reportable events in the past 12 months were reported to CIRAS? (If there are no identifiable CIRAS-reportable events in the individual's record in the past 12 months, mark 'N/A'.)

IDHS: Critical Incident Reporting and Analysis System (CIRAS) Manual

Comments:

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21. Has the person received waiver services for more than 12 months (365 days)?

 (No Findings associated with this question)

PMB2d

Comments:

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22. (If #21 is 'Yes', this is answered 'N/A'.)

For individuals who have received Waiver services for less than 12 months, was the Initial Level of Care of Waiver Eligibility completed as required?

Initial Date

• DDPAS-5 Signature Date: ______________________________
• Indicate the name and associated agency of the qualified QIDP completing the
  • DDPAS-5: _________________________________________________________________
  • QIDP Name: ______________________________________________________________
  • ISC Agency Name: ________________________________________________________

Clear documentation of the failure to transfer documentation from the original ISC should be marked as N/A.

Comments:

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23. (If #21 is 'No', this is answered 'N/A')

For individuals who have received Waiver services for more than 12 months, was the individual reassessed through the redetermination process annually (365 days) as required?

(both a and b must be compliant to answer 'Yes')

1. Current Redetermination date: ______________________________
2. Prior Redetermination date: IL462-0952 (R-1-08): ______________________________
3. Indicate the name of the qualified QIDP completing the annual redetermination of individual's Waiver eligibility.
   1. QIDP Name: ______________________________________________________________
   2. ISC Agency Name: ________________________________________________________

PMB2n

Comments:

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24. Did the initial level of care determination (#22) or annual redetermination (#23) (if required) use processes and forms as required by the state? Were all of the forms completed correctly and signed annually (when required)?

PMB3

Comments:

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25. Does the record indicate an individual's choice between waiver services and institutional care and between/among services and providers? (check form used)

______ IL462-1201 (R-03-23) OR  ______ IL462-1238 (R-11-23)

Current Date: ______________________________

PMD10

Comments:

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26. At the time of each assessment, is there documentation that the individual and/or guardian received initial/annual information/education about how and to whom to report unexplained deaths and abuse, neglect, and exploitation incidents? (If #21 is 'no', type 'N/A' for 'prior date'. When #21 is 'no', as long as a current 1201 is present, this is answered 'yes'.)

Current Date: ______________________________

Prior Date: _________________________________

(IL462-1201 (R-03-23))

PMG1

Comments:

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