Exit Conference Guidelines (PC010)
These guidelines are used as an outline of information to be discussed during the Exit Conference.
Exit Conference Sign in Sheet (PC011)
This sheet is used when surveyors meet with the provider to brief on the completed provider compliance review.
Combined IO and Level One Waiver H/PC – Agency Review Tool (PC012)
This is a combination of IO Waiver HPC tool and Level One HPC tool created due to the implementation of the new IO HPC Rule 5123:2-13-04 in July 2005.
IO Waiver Transportation – Agency Review Tool (PC013)
Combined IO and Level One H/PC – Individual Review Tool (PC015)
This is a combination of IO Waiver HPC tool and Level One HPC tool created due to the implementation of the new IO HPC Rule 5123:2-13-04 in July 2005.
IO Waiver Social Work – Agency & Individual Review Tool (PC017)
IO Waiver Interpreter- Agency & Individual Review Tool (PC018)
IO Waiver Home Delivered Meals – Agency & Individual Review Tool (PC019)
IO Waiver Environmental Modifications –Agency & Individual Review Tool (PC020)
IO Waiver Adaptive & Assistive Equipment– Agency & Individual Review Tool (PC021)
IO Waiver Nutrition Services – Agency & Individual Review Tool (PC022)
IO Waiver Incidents Adversely Affecting Health & Safety (Appendix A) Review Tool Addendum (PC024)
This form is used when IO waiver HPC and transportation services are being reviewed.
IO Waiver Behavior Support Checklist (Appendix B) Review Tool Addendum (PC025)
This form is only used when a provider is delivering services to an individual who has an approved behavioral program indicated in their ISP.
IO Waiver Medication Checklist (Appendix C) Review Tool Addendum (PC026)
This form is used for individual providers and agencies that administer medications.
IO Waiver Personnel Information for Selected Employees (Agency Only) Review Tool Addendum (PC027)
This form is used for the review of agency provider employee records. A form is completed for each sample staff and the information from these individual forms is used to address the questions on the respective tools as well as documenting information that will be needed to specify details for the POC such as “which staff did not have a BCII based on hire date, which staff did not receive initial MUI Training” based on hire date.
Sample Key (PC065)
This key is to be used whenever sample names need to be identified. Using this key will maintain the privacy of individuals. In any reports, correspondence or forms, the “Key Number” is used instead of the individual’s name, DODD # or initials. This document cannot be shared or copied even if requested through a “Public Records Request”. NOTE: Suggested sample numbers of records needed in a PC review can be referenced on form PC066 on the Provider Compliance Pre-review Documents page.