ADULT DAY SERVICE - REVIEW WORKSHEET

Agency:

Agreement:

Reviewers: Carrie Long

Date:

Address:
SAFE ENVIRONMENT & FACILITY ISSUES:
CRITERIA

YES

NO

COMMENTS

N/
A

Room Temperature(s):
between 70 - 85 Fahrenheit?

Rule/PIM reference

Refer to
Corrective
action #

240.1550
X

Temperature(s): 75

240.1550(b)(5)

Restroom temperature(s):

240.1550

hot water temperature(s) between 100 119 Fahrenheit?

Space availability:

Temperature(s): 108/111

240.1550(b)(9)

separate identifiable area designated for

sole use by the Adult Day Service (ADS)?
adequate space available (minimum 40 sq.
ft. of activity area per participant)?
dining area with sufficient space (chairs)?

240.1550(b)(6)

space for office equipment and supplies?

240.1550(b)(8)

one (1) quiet place with chair, cot or bed?

240.1550
240.1550(b)(1)

80*40=3200 SF

240.1550(b)(2)

Recliner in nurses office

Restroom(s):

240.1550(b)(11)
240.1550

handicapped-accessible restroom?

240.1550(b)(7)

one (1) bathroom for up to 12

participants?
two (2) bathrooms for 13+ participants?

240.1550(b)(7)

240.1550(b)(7)

Common Area(s):

240.1550

barrier-free (exit areas clear of equipment

and debris safe environment)?
equipped with monitoring/signaling devices
to alert staff to participants leaving the
facility?
Telephone:

240.1550(b)(12)

at least one (1) land-line telephone

available in the participant activity area?
emergency numbers posted by telephone?

240.1550(b)(13)

240.1550(b)(13)

Need buzzer on
entrance of ADS

front

240.1550(b)(12)

240.1550

1.

CRITERIA

YES

NO

COMMENTS

N/
A

Meals:
mid-day meal and snacks provided
menus approved and documented by the
Registered Dietician (RD)
portion sizes reflected on menu

Rule/PIM reference

240.1550
X

240.1550(c)(1)
X

No RD

240.1550(c)(2)(A)

240.1550(c)(2)(A)

menus posted in a location visible to the

participant
menus planned for a minimum of 4 weeks

240.1550(c)(2)(B)

240.1550(c)(2)(C)

Catered Meals transported in equipment

240.1550(c)(2)(G)

-copy of caterers inspection certificate

240.1550(c)(2)(J)

-hot foods = 140 Fahrenheit or above

-cold foods = 41 Fahrenheit or below

Hot
Temperature(s):
160/146
Cold Temperature(s): 40

240.1550(c)(2)(G)
240.1550(c)(2)(G)

On-Site Meal Preparation:

N/A

current health inspection

certificates/letters on file and/or posted in
facility?
-hot foods = 140 Fahrenheit or above?

N/A

240.1550(c)(2)(J)

Hot Temperature(s):

N/A

240.1550(c)(2)(I)

-cold foods = 41 Fahrenheit or below?

Cold Temperature(s):

N/A

240.1550(c)(2)(I)

Written procedures for receiving and

storing food and portion control:
verification of food quantities

Refer to
Corrective
action #

240.1550
X

240.1550(c)(2)(F)(i)

checking and documentation of food

temperatures @ delivery and serving
equipment to be utilized

240.1550(c)(2)(F)(ii)

240.1550(c)(2)(F)(iii)

procedures for foods that arrive above

and/or below required temperature(s)
procedures for deteriorated foods

240.1550(c)(2)(F)(iv)

240.1550(c)(2)(F)(iv)

procedures for food shortages

240.1550(c)(2)(F)(iv)

control portion sizes/meet dietary

allowances

240.1550(c)(2)(D)

Revised 9-2011

2.

CRITERIA

YES

NO

COMMENTS

N/
A

Emergency Plan:

Rule/PIM reference

240.1550

evacuation plan posted

240.1550(b)(4)

fire drills conducted and documented

240.1550(b)(4)

state fire marshal inspection on file

REQUESTED 10/12/16

240.1550(b)(3)(A)(iii)

emergency first aid supplies immediately

accessible to client activity areas
Transportation (TR):

240.1550(b)(14)

two (2)-way communication devices

CELL PHONES

240.1550(d)(1)

provided by agency vehicles; procedures to

ensure safe transportation is provided

1-Mini Van- N/A

240.1550(d)(2)

current safety inspection stickers

240.1550

Cargo Exp. 04/17

240.1550(b)(3)(A)(iv)

transportation subcontracted; agency has

copy of service agreement/procedures to
ensure safe transportation is provided
Insurance:
General Liability/Insurance Coverage
Procedures Regarding Emergency
Situations:
All hazards disaster operations plan

240.1550(d)(3)

240.1520
X

240.1520(b)-(d)
240.1510

240.1510(q)

Participant emergency plan (e.g.: late

pickup of a participant; participant
elopement)
Medical emergency plan

240.1510(q)

240.1510(q)

Agency vehicle emergency plan

Procedures Regarding Medication

Management:
stored, locked & labeled?

240.1510(q)
240.1550

Location: Nurses Office

240.1550(a)(1)(2)

administered by the appropriate licensed

professional?
documentation if participant able to selfadminister
meds. administered by staff are recorded

240.1550(a)(3)(A)

240.1550(a)(3)(B)

240.1550(a)(3)(C)

recorded procedures & physicians orders?

240.1550(a)(3)(D)

Refer to
Corrective
action #

CRITERIA

Summary of employee file review with

documents to be maintained in file:
Qualifications
Application
24 hrs Pre-service hours

YES

NO

N/
A

X
X
X

12 hrs In-Service/calendar year (1 hr a

month beginning after month of hire)
Annual performance evaluations

criminal background checks

HHS & HFS OIG checks

Summary of participant file review:

Timeframes/TSI/Interim/Re-des/etc.
Reporting Changes to CCU
Evidence of health monitoring
Requests/Complaints/follow-up

COMMENTS

X
X
X

5 OF 7 FILES- MISSING
2 OF 7 FILES- N/A
CURRENT- OK, PREVIOUSOUTDATED
1 OF 7 MISSING, 6 OF 7
NEED DUPDATED
1 OF 7 MISSING

Rule/PIM reference

240.1510(d)(5)(E)
240.1560
240.1510(d)(5)(A)
240.1510(d)(5)(C)
240.1555(d)(1)(A-V)
240.1510(d)(5)(C)
240.1555(d)(2)(A-X)
240.1510(d)(5)(B)

TA 1
TA 2

240.1510(d)(5)(G)
240.1520(p)(1-2)

TA 3

TA 4

240.1520(h)
240.230(a)(4)
240.1520(i)
240.1510(p)
240.1550(e)

Participant emergency records on file

2 OF 5 MISSING, 3 OF 5
OUTDATED

Recent photograph of the participant

3 OF 5 MISSING

Service follows POC

Individualized Plan of Care (IPOC)

developed
CCU POC and IPOC match
IPOC timeframes met/updated
HOSC completed correctly for ADS and TR
HOSC match VRFP

4 OF 5 FILES, 2 MISSING
C/A
1 OF 5 FILES

240.1510(b)
240.1520(g)
240.230(a)(1)(A)

X
X
X
X

5
4
3
2

240.230(a)(1)(C)
240.230(a)(1)(B)&(F)
PIM 10/2/91
240.1520(j)
240.1520(p)(1)(C)(iv)

3.

240.1510(d)(5)(H)

ISSUES WITH C/A- 3 OF 5

OF 5 FILES
OF 5 FILES
OF 5 FILES
MISSING C/A

Refer to
Corrective
action #

240.1550(e)

Staffing:

CRITERIA

Required Staff:
Administrator
Program Coordinator/Director
Program Nurse (RN / LPN circle one)
RD

YES

NO

X
X
X
X
X
X

Food Service Sanitation Handler

X
X

COMMENTS

N/
A

240.1560
240.1560(a)(1)(A-B)
240.1560(a)(2)(A-B)
240.1560(a)(3)(A-C)
(a)(5)(A)(ii)

Name:
Name:
Name:
Name: NONE
License #:
Expiration date:
Name:
License #: cert/no lic
Expiration date:

(a)(5)(A)(i)

TR Driver/Escort:
1
2
Optional staff:
Social Service Worker
Program Assistant(s)
Medical Consultant
Rehabilitation Consultant
Staff certification:
At least two (2) program staff are
certified in CPR and trained in Emergency
First Aid:
At least one (1) program staff who is
certified is on-site when participants are
present:
Substitute Staff/Volunteers:
Substitutes employee file
w/qualifications and availability

Rule/PIM
reference

240.1560(a)(4)(AC)
X
X
X
X
X
X
X

5 OF 7 EXPIRED
1-DRIVER/ 1- NURSE
NURSE

240.1555(e)

240.1560(b)
240.1560(b)(1)(A-C)
240.1560(b)(2)
240.1560(b)(3)
240.1560(b)(4)
240.1555
240.1555(e)

240.1560
240.1560(c)(1)-(2)

Refer to
Corrective
action #

 Regularly scheduled volunteers/students

must have application on file
Substitutes and/or volunteers used in
ratios require pre-service and in-service
training

CRITERIA

Staff to client ratios:

Minimum ratio of full-time staff present
meets standards (circle one applicable):
2/01-12
5/29-35
3/13-20
6/36-45
4/21-28
7/46-52
Written policies/procedures:

YES

NO

COMMENTS

240.1560(c)(3)-(5)

240.1560(c)(6)

N/
A

Rule/PIM
reference

240.1555
240.1555(c)(1-3)

Policy on Promotion and Evaluation

Criteria
Job descriptions for each job category
Review agencys employee handbook
Wage Range for each job category
Policy on Benefits and Grievance
Procedures
Mandated reporting of ANE

240.1510&240.152
5
240.1510(d)

X
X
X
X

240.1510(d)(1)
240.1510(d)(2)
240.1510(d)(3)
240.1510(d)(4)

Seclusion/Restraint Practices
Marketing Standards

X
X

240.1510(s)&Memo
dated 11/3/03
240.1510(t)
240.1510(v)(1-5)

ADS Respiratory Service

Universal Precautions/ Control of
Infectious Disease Policy
Non-discrimination/ Civil Rights Policy

PIM 10-6-09

240.1510(m)

240.1510(n)

Refer to
Corrective
action #

Confidentiality Policy
Are records kept in a confidential
location?
Files kept in a locked cabinet?

X
X

240.1510(a)(1)
240.1510(a)(1)
240.1510(a)(2)
240.1525(a)(1)
240.1510(p)
240.1510(d)(5)(I)
240.1510

Complaint Procedure Policy

Employee Influenza Policy
On-Going Annual Quality
Improvement:
Policy on participant/family satisfaction
surveys (voluntary)

240.1510(f) &
Annual Quality
Assurance Surveys
policy 1/26/11
240.1510(f)(1)
240.1510(f)(2)
240.1510(f)(3)
240.230
240.230(a)(2)(A)(C)
240.230(a)(2)(D)

Staff and community agency surveys

Program and service reviews
Implementation of changes
Activities:
Planned therapeutic activities
Activities posted
Activities observed during the review

Correctiv
e Action
#
1

Corrective action

Due
within

Description

2
3

TECHNICAL ASSISTANCE AND RECOMMENDATIONS:

FOLLOW-UP:

Failure to complete the required corrective action may result in contract action.

Provider Agency:
Agreement:
Employee
Required
Name and
Staff
Date of Hire
Structure
(DOH)
Title

Adult Day Service Review-Employee File Review

Qualifications:
Type of Qualifications:
Application:

Pre-Service
24 hours required rule
effective
3-23-2009

In-Service
12 hours per calendar year rule
effective
3-23-2009

Copy of qualifications in file:

Required Hours Provided:

Required Hours Provided:

Yes

No

Qualifications:

Yes

Application in file: Yes No

Yes

No

Qualifications:

Yes

N/A

Yes

No

N/A

No

N/A

Required Documentation in file:

Application in file: Yes No
Yes

No

Qualifications:

Yes

No

N/A

Required Hours Provided:

Yes

No

N/A

Required Topics Provided:

Yes

No

N/A

Required Documentation in file:

Application in file: Yes No
Copy of qualifications in file:
Yes

No

Qualifications:

Yes

No

N/A

Required Hours Provided:

Yes

No

N/A

Required Topics Provided:

Yes

No

N/A

Required Documentation in file:

Application in file: Yes No
Copy of qualifications in file:
Yes

No

Qualifications:

Yes

No

N/A

Required Hours Provided:

Yes

No

N/A

Required Topics Provided:

Yes

DOH:

No

Required Topics Provided:

Copy of qualifications in file:

DOH:

N/A

Required Hours Provided:

Yes

DOH:

No

Required Documentation in file:

Copy of qualifications in file:

DOH:

N/A

Required Topics Provided:

Yes

DOH:

No

No

N/A

Required Documentation in file:

Application in file: Yes No

Yes

No

N/A

Yes

No

N/A

Required Topics Provided:

Yes

No

N/A

Required Documentation in file:

Yes

No

N/A

Required Hours Provided:

Yes

No

N/A

Required Topics Provided:

Yes

No

N/A

Required Documentation in file:

Yes

No

N/A

Required Hours Provided:

Yes

No

N/A

Required Topics Provided:

Yes

No

N/A

Required Documentation in file:

Yes

No

N/A

Required Hours Provided:

Yes

No

N/A

Required Topics Provided:

Yes

No

N/A

Required Documentation in file:

Yes

No

N/A

Required Hours Provided:

Yes

No

N/A

Required Topics Provided:

Yes

No

N/A

Required Documentation in file:

Yes

No

N/A

Adult Day Service Review-Employee File Review (continued)

Provider Agency:
Agreement:
Employee
Required Staff
Name
Structure Title

Annual
Performance

[ ]CPR | Exp. Date:

[ ]Emergency First Aid

Evaluations

Criminal Background Checks:

[ ]On file [ ]Requested [ ]Missing
Waiver (if needed):
[ ]On file [ ]Requested [ ]N/A
Federal HHS [ ]On file [ ]N/A (efft. 3-23-09)

Current:
Previous:

CPR | Exp. Date:

Illinois HFS OIG[ ]On file [ ]N/A (efft. 3-23-09)

Criminal Background Checks: Yes No Missing

Emergency First Aid

Waiver (if needed): Yes No Requested N/A

Federal HHS: Yes Missing

DOH:

Illinois HFS OIG: Yes Missing

Current:
Previous:

CPR | Exp. Date:

Criminal Background Checks: Yes No Missing

Emergency First Aid

Waiver (if needed): Yes No Requested N/A

Federal HHS: Yes Missing

DOH:
Current:
Previous:

CPR | Exp. Date:

Illinois HFS OIG: Yes Missing

Criminal Background Checks: Yes No Missing

Emergency First Aid

Waiver (if needed): Yes No Requested N/A

Federal HHS: Yes Missing

DOH:
Current:
Previous:

CPR | Exp. Date:

Illinois HFS OIG: Yes Missing

Criminal Background Checks: Yes No Missing

Emergency First Aid

Waiver (if needed): Yes No Requested N/A

Federal HHS: Yes Missing

DOH:
Current:
Previous:

CPR | Exp. Date:

Illinois HFS OIG: Yes Missing

Criminal Background Checks: Yes No Missing

Emergency First Aid

Waiver (if needed): Yes No Requested N/A

Federal HHS: Yes Missing

DOH:

Illinois HFS OIG: Yes Missing

Adult Day Service Review-Participant File Review

10

Provider Agency:
Agreement:
Participant
Name

Time Frames:
Does the
providers date on
the CA match the
date ranges on
the POCNF?

Provider
documents and
reports changes
to the CCU

Evidence of
Health
Monitoring

TSI
Interim
Initial
Re-De
TSI
Interim
Initial
Re-De
TSI
Interim
Initial
Re-De
TSI
Interim
Initial
Re-De
TSI
Interim
Initial
Re-De

Requests/
Complaints
Follow-up?
(15 calendar
days from date
of request)

[ ]Emergency records up-to-date

[ ]Updated picture on file

Emergency records up-to-date

Updated picture on file
Emergency records up-to-date
Updated picture on file
Emergency records up-to-date
Updated picture on file
Emergency records up-to-date
Updated picture on file
Emergency records up-to-date
Updated picture on file

11

pant
me

Adult Day Service Review-Participant File Review (continued)

Provider Agency:
Agreement:
Plan of Care:
1. Units on POC followed?
2. Deviations noted?
3. Justification for dev?

HOSC:
1. Completed correctly?
2. Beg/ending times?
3. Sign/dated @ end of
month?

HOSC match t
VRFP?
TR=transport

4. CCU notified of Dev?

1. IPOC developed?
2. All tasks on
CCU POC are on IPOC?
3. IPOC timeframes met?
4. Most recent IPOC date?

1.
2.
3.
4.

1.
2.
3.
4.

1.
2.
3.

HOSC:
VRFP:

1.
2.
3.
4.

1.
2.
3.
4.

1.
2.
3.

1.
2.
3.
4.

1.
2.
3.
4.

1.
2.
3.

1.
2.
3.
4.

1.
2.
3.
4.

1.
2.
3.

1.
2.
3.
4.

1.
2.
3.
4.

1.
2.
3.

12

TR HOSC:
TR VRFP:
HOSC:
VRFP:
TR HOSC:
TR VRFP:
HOSC:
VRFP:
TR HOSC:
TR VRFP:
HOSC:
VRFP:
TR HOSC:
TR VRFP:
HOSC:
VRFP:
TR HOSC:
TR VRFP: