ISC Quality Q1000I

REVISED 10/28/24

ISC Name:  Provider:

Individual Name: Individual's Address:

Sample #:  W#:  Provider Services: _ CDS _CILA _ SDA _ AHBS _ CSW _CRW

Date of Review  Reviewer(s):

Item Yes No N/A Remediation on / required by

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 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:

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

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)

Personal Plan:
Current date:
Prior date:

PMD7

Comments:

4. Are the Discovery Tool and Personal Plan completed on the current versions of each form? (DT and PP should be on the most current version of each form at the time of completion, but ALL DTs and PPs must at least be on the 10/2022 version or later.)

Comments:

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:

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

PMD1

Comments:

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

PMD2

Comments:

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

PMD3

Comments:

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

Comments:
10. In the current Discovery Tool/Personal Plan, is it documented that the individual has reported having a Primary Care Provider (PCP) and has reported having had a physical exam within the past 12 months?

PMG8

Comments:
11. (If #10 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)?

12. In the past year have there been any significant changes in the individual's medical, behavioral, or support needs?
(No Findings associated with this question)

PMD8d

Comments:

13. If #12 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:

14. (This is answered 'N/A' for CILA, CRW, 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:

15. (If #14 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:

16. 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:

17. 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)
    Visit 1 Date/Quarter: Visit 1 location:
    Visit 2 Date/Quarter: Visit 2 location:
    Visit 3 Date/Quarter: Visit 3 location:
    Visit 4 Date/Quarter: Visit 4 location:

IDHS: UPDATED - V.4 - ISC Remote Monitoring Activities (state.il.us) - effective 11/11/23, ISC agencies are required to conduct all ISSA visits in person, unless authorized as defined in this Bulletin.

PMD5

Comments:

18. 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
IDHS: UPDATED - V.3 - ISC Remote Monitoring Activities (state.il.us)

Comments:

19. Does the individual's record indicate that all identified CIRAS-reportable events in the past 12 months were reported to CIRAS?
IDHS: Critical Incident Reporting and Analysis System (CIRAS) Manual (state.il.us)

Comments:

20. Has the person received waiver services for more than 12 months (365 days)?
(No Findings associated with this question)

PMB2d

Comments:

21. (If #20 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

  1. DDPAS-10 Date:
  2. Indicate the name and associated agency of the qualified QIDP completing the
    DDPAS-10:
    QIDP Name:
    ISC Agency Name:

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

Comments:

22. (If #20 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: Prior Redetermination date:
    IL462-0952 (R-1-08)
  2. Indicate the name of the qualified QIDP completing the annual redetermination of individual's Waiver eligibility.
    QIDP Name:
    ISC Agency Name:

PMB2n

Comments:

23. Did the initial level of care determination (#21) or annual redetermination (#22) (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:

24. 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-03-23) Current Date:

PMD10

Comments:

25. 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 #20 is 'no', type 'N/A' for 'prior date'.)\
Current Date:
Prior Date:
(IL462-1201 R-03-23)

PMG1

Comments: