Tiered Certification Adult Community Residence

• Audit Title

• Document No.

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

Standard 1.1: Medications are stored and monitored in accordance with OMH approved policies and procedures. 595.6(d)(7)(v), 595.12(b)(5)

• * CR 1.11:​ Medications storage and monitoring assures resident safety.

  Yes

  No

  N/A

• CR 1.12:​ Residents are trained and assisted, as needed, in self-administration of medication.

  Yes

  No

  N/A

Standard 1.2: Program has an effective incident reporting, investigation, and management process. 595.6(d)(8)(iii) 595.13(a)(2), Part 524

• * CR 1.21: Incidents are reported and investigated in accordance with the program’s approved incident reporting plan.

  Yes

  No

  N/A

• *CR 1.22: ​Incident reviews result in appropriate changes to policies and practices.

  Yes

  No

  N/A

Standard 1.3: The program maintains a safe environment. 595.15(a)(1), (a)(2), (a)(4), 595.16

• * CR 1.31: ​Residents meet requirements for self-preservation.

  Yes

  No

  N/A

• CR 1.32: The building, its equipment and fixtures are free from fire and safety hazards.

  Yes

  No

  N/A

• *CR 1.33 Smoke detectors and firefighting equipment are located and maintains as required by regulation.

  Yes

  No

  N/A

Standard 1.4: Living spaces are adequately furnished and well maintained. 595.16(b)(1)(v)(vi)

• CR 1.41: Personal living spaces meet regulatory requirements for furniture and linen. The rooms are clean and properly maintained.

  Yes

  No

  N/A

•  CR 1.42: ​Common living spaces are appropriately furnished. Furniture and spaces are properly maintained.

  Yes

  No

  N/A

Standard 1.5 The program ensures residents has access to emergency and crisis services. 595.12(b)(4)(12), & (f)

• *CR 1.51 Emergency health care services are provided to residents as needed.

  Yes

  No

  N/A

• *CR 1.52 Crisis Intervention services are available to residents as needed.

  Yes

  No

  N/A

Standard 2.1: Program exhibits respect for I dividual rights, dignity, personal integrity and the various ethnic and cultural backgrounds of its residents.

• CR 2.11 Program is sensitive to the culture and ethnicity of the residents served.

  Yes

  No

  N/A

• *CR 2.12 Residents are informed of and aware of their rights, Resident rights are respected.

  Yes

  No

  N/A

Standard 2.2 Resident input is solicited and incorporated into policy decisions.

• CR 2.21 Resident input is incorporated into residence operation.

  Yes

  No

  N/A

• CR 2.22 Resident grievances are reviewed and resolved in a timely manner.

  Yes

  No

  N/A

Standard 2.3: Resident information is safeguarded for confidentiality.

• CR 2.31: The confidentiality of resident records is maintained.

  Yes

  No

  N/A

• CR 2.32: Resident consent is obtained prior to the release of identifying or clinical information regarding the resident.

  Yes

  No

  N/A

Standard 3.1: The service planning process identifies resident needs, goals and objectives. The service plan identifies services and interventions designed to address these needs and attain resident objectives. The plan is based upon resident input and reflects the priorities of the resident.

• CR 3.11: Assessments identify resident needs.

  Yes

  No

  N/A

• *CR 3.12: Service plans identify specific, measurable goals and objectives and discharge criteria. Methods and time frames for attaining objectives are explicit.

  Yes

  No

  N/A

• CR 3.13: With resident consent, families (when clinically appropriate) and/or collaterals are part of the service planning/review process.

  Yes

  No

  N/A

• *CR 3.14: Service plans are periodically reviewed and revised as needed.

  Yes

  No

  N/A

• CR 3.15: Progress notes are timely and reflect residents' progress toward attaining agreed upon objectives.

  Yes

  No

  N/A

Standard 3.2: Program ensures that there are systematic, independent, ongoing reviews of appropriateness of services for each resident.

• *CR 3.21: Residents shall be appropriately admitted and retained.

  Yes

  No

  N/A

• CR 3.22: The utilization review process is carried out by staff who do not have primary responsibility for the resident under review.

  Yes

  No

  N/A

Standard 3.3: The discharge planning process ensures that residents are discharged to appropriate settings.

• CR 3.31: Discharge planning shall be based upon resident preferences and shall include input from relevant staff, community service providers and, where clinically appropriate, family members.

  Yes

  No

  N/A

• CR 3.32: Discharges of residents who are not discharge ready adequately safeguard the rights of all residents of the program and the community.

  Yes

  No

  N/A

• *CR 3.33: Connections to necessary community support services are, with the resident's consent, made prior to discharge.

  Yes

  No

  N/A

Standard 4.1: The program's administration ensures that staffing is sufficient to carry out the mission of the program and to ensure that quality services are provided.

• *CR 4.11: Staffing is adequate to provide the program's stated services.

  Yes

  No

  N/A

• CR 4.12: Training is regularly provided to all program staff to enhance their ability to effectively provide program services.

  Yes

  No

  N/A

Standard 4.2: the governing body effectively oversees the operation of the program.

• *CR 4.21: Program operation is regularly monitored against the goals and objectives established by the program and approved by OMH.

  Yes

  No

  N/A

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