CRW Policy Review QR9201

1. Is the agency is currently licensed as a Child Welfare Agency?

(Usually a letter from DCFS with License number and license period.)
Agency License Expiration date:

2. Has each residential site been reviewed and approved by DCFS?

(Review DCFS licensing monitoring record/notes for each site that is occupied.)

3. Has the agency developed and implemented a written policy and process for handling and reporting incidents of alleged abuse or neglect, recipient death and certain other incidents to the DHS Office of the Inspector General (OIG), DHS, Illinois Department of Public Health (IDPH) and the Department of Children and Family Services (DCFS) in accordance with DHS Rule 59 Ill. Admin. Code 50, DCFS Rule 89 Ill. Adm Code 331, and other applicable standards, rules, and laws? Does the policy include definitions of abuse and neglect, screening prohibition, time frames for reporting, preservation of evidence, and notification of parents and guardians.

(Use QR6200 to evaluate policy compliance.)

4. Is there documentation of a process of this person/guardian receiving not only information; but also, EDUCATION upon admission and annually thereafter about how to report abuse, neglect, exploitation, and other critical incidents in a appropriate and understandable format?

(The QIDP should provide policy to determine if the person/guardian has received information and education from the provider about reporting allegations verbally and in writing.) PMG1

5. Has the provider designed a procedure to evaluate the degree to which there is movement toward the outcomes which are documented in the individual's personal plan; modifying implementation strategies that are not resulting in movement toward desired outcomes?

(Review procedure/policy/practice provider has in place (documentation, Q notes) Look for modifications when progress is not occurring or resulting in movement towards the outcomes.)

6. All restrictive interventions (including seclusion, restraint, restriction of access to personal property etc.) follow procedures specified in the Children's Residential Waiver

(Complete review of restrictive interventions worksheet (QR9500) for each sample person.)

7. Are all restrictive interventions and the justifications included in the individual's implementation strategy and/or behavior treatment plan?

(Review implementation strategies and/or behavior treatment plans to confirm restrictive interventions are included.)

8. Did the provider develop an overall Agency Behavior Treatment Plan that outlines all behavior treatment procedures that may be used at the agency?

(Review the Agency Behavior Treatment Plan to determine if it includes the following:

• description of all behavior treatment/procedures utilized by the agency
• description of personnel training/credentials
• quality assurance mechanisms
• overall approach to behavior management programming that follows current acceptable behavior practice)

9. Did the provider establish and maintain a Human Rights Committee (HRC) that is responsible for the periodic review (at least annually) of procedures and practices for intrusive or restrictive behavior interventions that are in the provider's behavior treatment plan?

(Review the agency's policy for HRC to assure the agency has established a process to review all rights restrictions. Should include informed consent, due process and grievances, least restrictive practices, appropriateness of fit to the population served. Review HRC minutes to determine if persons restrictive interventions have been approved by HRC.)

10. Has the provider ensured that functional assessments are completed as directed?

(Review files of individuals in the sample to locate the functional assessments. Assessment must be within the past calendar year. Examples: physical, dental, medical history, psycho-social, educational or vocational, psychological, vision, hearing, speech and language, physical therapy, occupational therapy, etc. This is met with any functional assessment geared towards children - needs may be defined by school district assessments.)

11. Does the provider have a Behavior Treatment Committee that meets at least quarterly and keeps minutes?

(Review BTC minutes to determine: Meets quarterly?
Keeps minutes?)

12. Does the provider have a formalized ongoing systemic review process at least quarterly for review of incident reports/critical incidents (CIRAS reports)?

(Review process to ensure the following:

1. Occurs quarterly
2. Evaluates all critical incidents to determine how and why the injury or incident occurred, including determining all related processes and systems;
3. Identify risk points and their potential contribution to the event, such as the appropriateness of the plan and level of supervision, identifying, communicating, documenting, implementing and evaluating improvements in processes, systems, or treatment to prevent future such incidents including:
   Staff responsible for implementation, when the actions will be implemented
4. How the effectiveness of the action will be evaluated.)

13. Does the provider have a formalized process/policy for Unusual Incident Reporting (UIR) including?

• Injuries (including those not attributed to abuse or neglect and specifically those resulting from discipline or behavior management)
• Deaths
• Adverse events (elopement, restraint, etc.)
• 5 or more restraints of a specific child within a 30-day period
• Any violation of 89Il. Admin Code 384 (unauthorized use of restraint, seclusion, or restrictive interventions)

(Review agency policy/process to determine if the agency complies with the UIR process
While reviewing records of persons in the sample, be alert for documentation of occurrences of critical events. Limit review of critical events to 2 per individual except when a pattern of multiple critical events of a similar nature are identified.
UIR needs to be in writing and postmarked within 2 business days after incident.)

14. Have all required reporting training and background checks been completed as required?

(Complete QR4300 Staff T/B. for 8 staff)

15. Does the provider ensure that all professional services such as, but not limited to, nursing, physical therapy, speech therapy, counseling etc. are be provided by individuals licensed or certified to provide those services by the Illinois Department of Financial and Professional Regulations in accordance with the applicable practice arts?

(Review 5 professional staff records for verification of professional license and certificates as applicable. Be sure to check nurse trainer license.)

16. Are professional behavioral services provided by certified individuals who are enrolled in IMPACT and approved by the division?

(Review 3 staff records for verification of checking professional license and certificates as applicable.)

17. Does the agency have policies and practices that reflect formal mechanisms which ensure the participation of individuals and their families in the planning, development, delivery, and evaluation of services?

(Review policy to assure direct involvement and participation - look for evidence of flexibility when individual or guardian cannot readily participate. See if there is documentation of trying by phone, alternate times, etc. as efforts to have participation.)