Core Competencies and Evaluation Protocols

The Code of Ethics is a guide developed by the National Alliance for Direct Support Professionals (NADSP) to help Direct Support Professionals in resolving daily ethical dilemmas while meeting the highest standards of the direct support profession. The Code of Ethics presents ethical statements that represent the beliefs, attitudes, and expectations that should be incorporated into daily practice in the field of intellectual and developmental disabilities. The Code of Ethics was created in 2000, and then updated in 2016.

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Goal 1: Putting People First

Goal 1: Competency Area A: Supporting A Person's Unique Capacities, Personality, and Potential

1-1 The individual was provided written notice of their right to a person-centered planning process.
1-2 The individual’s planning process/planning meetings include people chosen by and important to the individual.
1-3 The individual’s planning process/planning meetings include participation and input from required parties.
1-4 The individual’s planning meetings are scheduled at the times and locations convenient to the individual.
1-5 The individual is supported to direct the planning process to the maximum extent possible and desired.
1-6 Conflicts, disagreements, and conflict-of-interest are appropriately addressed during the individual’s planning process.
1-7 The individual is provided information and education to make informed choices related to services and supports; the settings for those services, and service providers.
1-11 The individual’s goals and desired outcomes are documented in the person-centered service plan.
1-12 The individual’s strengths and preferences are documented in the service plan.
1-13 The individual’s identified needs for clinical and/or functional support are documented in the service plan.
1-14 The individual’s cultural/religious and other personalized associational interests/preferences are included in person centered planning/plan.
1-15 The individual’s priorities/interests regarding meaningful community based activities, including the desired frequency and the supports needed are identified in the person-centered plan.
1-16 The individual’s goals and priorities regarding meaningful relationships are identified in the person-centered plan.
1-17 The individual’s goals, priorities, and interests regarding meaningful work, volunteer and recreational activities are identified in the person-centered plan.
1-18 The individual’s goals and priorities related to health concerns and medical needs are identified in the person-centered plan.
1-23 The individual’s written plan documents each specific service and support to be provided to address his/her needs and achieve his/her identified desired outcomes, short term and long term goals.
1-26 The person-centered plan evidences that informed choice is made regarding self-direction; and if chosen identifies the services that the individual elects to self-direct.
1-30 The individual’s person centered service plan is agreed to by services providers and/or members of the team as required.
1-34 The individual has been informed that they can request a change to the plan and understands how to do so.
1-35 The Individual’s written person centered service plan is reviewed with regular required frequency.
1-36 Review of the plan includes the individual’s status/progress towards the achievement of his/her goals, priorities and outcomes.
1-37 The individual’s person centered service plan is revised whenever changes are necessary and warranted and/or as directed/preferred by the individual.
1-40 The SC/CM/CC competently assures person centered planning as evidence by the individual’s written plan for services and supports and interview.
2-9 Services and supports are delivered in the most integrated setting appropriate to the individual’s needs, preferences, and desired outcomes.
2-10 Services and supports are delivered in a manner that optimizes and fosters the individual’s initiative, autonomy, independence, and dignity.
2-11 The person’s services are delivered by competent staff/supports that understand their role, the service/service plan and the person’s needs, preferences and goals related to the service.
2-12 The individuals’ service and/or plan is reviewed to determine whether the services/supports delivered are effective in achievement of advancement of his/her goals, priorities, needed safeguards and outcomes.
2-14 The individual’s services/supports and/or delivery modalities are modified as needed/desired in conjunction with the person to foster the advancement/achievement of his/her goals/outcomes.
2-15 The person is satisfied with the specific service.
2a-1 The individual was provided a choice of service/care manager/coordinator.
2a-9 The individual and designees, as applicable are given required contact information.
2a-10 The individual can reach the service coordinator when needed in a timely manner.
2a-12 Meetings for the review of the person centered service plan must be face to face as required by the service type.
2a-20 The SC/CM/CC monitors that the individual is linked to and receiving the service she/she wants and that the services are helping the individual to attain his/her valued outcomes and life goals.
2a-21 The WCS Coordinator or WSC assists the QIDP, treatment coordinator and/or IDT members in linking to services and/or in support during crisis intervention, as needed.
2a-27 The person is satisfied with the coordinator/case management services he/she receives.
2b-1 The individual is supported to exercise budget authority over how his or her resources are budgeted and managed within the Personal Resources Account (PRA).
2e-1 The Support Broker assists the individual with developing a comprehensive self-direction budget within the person’s Personal Resource Account (PRA) amount.
3-1 The individual is informed of their rights according to Part 633.4
3-2 The individual is informed of rights as a FIDA-IDD member and availability of the FIDA-IDD Ombudsman
3-3 The individual is informed of their right to objections of services/service plan and process to do so
3-4 The individual is informed of their HCBS rights
3-5 The individual is provided with information about their rights in plain language and in a way that is accessible to them
3-7 The individual is supported to express themselves through personal choices/decisions on style of dress and grooming preferences
3-8 The individual is supported to participate in cultural/religious associational practices, education, celebrations and experiences per their interests and preferences
3-9 The individual is supported to have visitors of their choosing according to their preferences
3-10 The individual has privacy in his/her home, bedroom or other service environments and per their needs for support
3-11 The individual is aware that he/she is not required to follow a particular schedule for waking up, going to bed, eating, leisure activities, etc.
3-12 The individual is encouraged and supported to make their own scheduling choices and changes according to their preferences and needs
3-13 The individual can choose to eat meals when they want to, even if mealtimes occur at routine or scheduled times
3-14 The individual has access/is supported to have access to food at any time and to store their own food and snack choices for their use at any time as desired, similar to people without disabilities
3-15 The individual is supported to have independent access to the site/service setting with freedom to come and go as desired, similar to people without disabilities
3-16 The individual has full/unrestricted access to typical spaces and facilities in the home or day setting and are supported to use them
3-17 The setting reflects the individual’s needs and preferences including the presence of any necessary physical modifications, if applicable
3-20 The individual may view their service record upon request
3-21 The individual controls their personal resources and decides how to spend their personal discretionary funds
3-22 The individual is encouraged and supported to advocate for themselves and to increase their self-advocacy skills
3-23 The individual is not subjected to coercion (includes subtle coercion)
3a-5 The individual has given informed consent to the rights limitations/restrictions in place
4-1 The individual is encouraged and supported to have full access to the community based on their interests/preferences/priorities for meaningful activities to the same degree as others in the community.
4-3 The individual is satisfied with their level of access to the broader community as well as the support provided the pursue activities that are meaningful to them for the period of time desired
5-1 The individual is encouraged and supported to foster and/or maintain relationships that are important and meaningful to them
6-1 The individual is satisfied with their living situation and does not express a desire (when questioned) to move to another living setting and/or with another roommate
6-2 If the individual is NOT satisfied with living situation, there is evidence that the staff is proactively working to find an alternate arrangement based on the person’s needs, choices and preferences in a timely manner
6-3 The individual’s personal living space(s) reflect their individualized interests and tastes
11-2 The individual is living as independently as able in the home/living environment they choose
11-4 The person is employed, doing volunteer work or participating in other integrated meaningful activities, per their desires/life goals
11-5 The person is maintaining their desired role in their community
11-7 The person lives safely in their community per their informed choices
11-8 The person is satisfied with the supports they receive intended to achieve their outcomes
11-9 The person’s service(s) in total, contribute to advancing toward or achieving their specified goals and personal outcomes

Goal 1: Competency Area B: Getting To Know the Person Through Assessment/Discovery

1-1 The individual was provided written notice of their right to a person-centered planning process.
1-2 The individual’s planning process/planning meetings include people chosen by and important to the individual.
1-3 The individual’s planning process/planning meetings include participation and input from required parties.
1-5 The individual is supported to direct the planning process to the maximum extent possible and desired.
1-6 Conflicts, disagreements, and conflict-of-interest are appropriately addressed during the individual’s planning process.
1-10 Assessments needed by the individual or required by program regulation were completed to inform the individual’s plan development.
1-12 The individual’s strengths and preferences are documented in the service plan.
1-13 The individual’s identified needs for clinical and/or functional support are documented in the service plan.
1-14 The individual’s cultural/religious and other personalized associational interests/preferences are included in person centered planning/plan.
1-15 The individual’s priorities/interests regarding meaningful community based activities, including the desired frequency and the supports needed are identified in the person-centered plan.
1-16 The individual’s goals and priorities regarding meaningful relationships are identified in the person-centered plan.
1-17 The individual’s goals, priorities, and interests regarding meaningful work, volunteer and recreational activities are identified in the person-centered plan.
1-18 The individual’s goals and priorities related to health concerns and medical needs are identified in the person-centered plan.
1-19 The individual’s known food, medication, and/or environmental allergies and the corresponding precautions are identified in the person-centered plan.
1-23 The individual’s written plan documents each specific service and support to be provided to address his/her needs and achieve his/her identified desired outcomes, short term and long term goals.
1-26 The person-centered plan evidences that informed choice is made regarding self-direction; and if chosen identifies the services that the individual elects to self-direct.
1-36 Review of the plan includes the individual’s status/progress towards the achievement of his/her goals, priorities and outcomes.
2-6 The service plan/provided services clearly evidence the intent to facilitate advancement of the individual towards achievement of outcomes.
2-9 Services and supports are delivered in the most integrated setting appropriate to the individual’s needs, preferences, and desired outcomes.
2-10 Services and supports are delivered in a manner that optimizes and fosters the individual’s initiative, autonomy, independence, and dignity.
2-11 The person’s services are delivered by competent staff/supports that understand their role, the service/service plan and the person’s needs, preferences and goals related to the service.
2-12 The individuals’ service and/or plan is reviewed to determine whether the services/supports delivered are effective in achievement of advancement of his/her goals, priorities, needed safeguards and outcomes.
2-14 The individual’s services/supports and/or delivery modalities are modified as needed/desired in conjunction with the person to foster the advancement/achievement of his/her goals/outcomes.
2a-20 The SC/CM/CC monitors that the individual is linked to and receiving the service she/she wants and that the services are helping the individual to attain his/her valued outcomes and life goals.
2a-24 Care/Case/Service Coordinator/Manager advocates for the rights and entitlements of the individual in the home, day and work environments and in all spheres of his/her life.
QQ-2b Does the individual Self-Direct by exercising Budget authority?
2l-1 A functional behavior assessment meeting content requirements is completed prior to the development of the individual’s behavior support plan.
3-16 The individual has full/unrestricted access to typical spaces and facilities in the home or day setting and are supported to use them
3-17 The setting reflects the individual’s needs and preferences including the presence of any necessary physical modifications, if applicable
3-21 The individual controls their personal resources and decides how to spend their personal discretionary funds
3-22 The individual is encouraged and supported to advocate for themselves and to increase their self-advocacy skills
6-1 The individual is satisfied with their living situation and does not express a desire (when questioned) to move to another living setting and/or with another roommate
6-2 If the individual is NOT satisfied with living situation, there is evidence that the staff is proactively working to find an alternate arrangement based on the person’s needs, choices and preferences in a timely manner
8a-7 The individual receives diagnostic evaluation/testing per his/her health care professionals’ recommendations and standard safe practice (e.g. Lab work, x-rays, scans, MRIs, etc.)
9-1 A Functional Behavioral Assessment is completed for the individual prior to the development of the Behavior Support Plan
9-2 The Individual’s Functional Behavioral Assessment identifies the challenging behaviors and all contextual factors as required
9-3 The Individual’s Functional Behavioral Assessment includes an evaluation of possible social and environmental alterations, any additional factors and reinforcers that may serve to reduce or eliminate behaviors
9-4 The Individual’s Functional Behavioral Assessment provides a baseline description of their challenging behaviors
9-7 The Individual’s Behavior Support Plan was developed from their Functional Behavioral Assessment.
9a-1 A Functional Behavioral Assessment is completed for the individual prior to the development of the Behavior Support Plan
9a-2 The Individual’s Behavior Support Plan includes a description of all approaches that have been tried but have been unsuccessful, leading to inclusion of the current interventions
11-6 The individual is living safely/receiving supports to live safely in their home/living environment, according to informed choices and responsible consideration
11-8 The person is satisfied with the supports they receive intended to achieve their outcomes
11-9 The person’s service(s) in total, contribute to advancing toward or achieving their specified goals and personal outcomes

Goal 1: Competency Area C: Promoting Advocacy with the Individual

1-1 The individual was provided written notice of their right to a person-centered planning process.
1-5 The individual is supported to direct the planning process to the maximum extent possible and desired.
1-7 The individual is provided information and education to make informed choices related to services and supports; the settings for those services, and service providers.
1-25 The person-centered plan identifies the provider(s) of the individual’s supports and services.
1-26 The person-centered plan evidences that informed choice is made regarding self-direction; and if chosen identifies the services that the individual elects to self-direct.
1-30 The individual’s person centered service plan is agreed to by services providers and/or members of the team as required.
1-34 The individual has been informed that they can request a change to the plan and understands how to do so.
2-11 The person’s services are delivered by competent staff/supports that understand their role, the service/service plan and the person’s needs, preferences and goals related to the service.
2a-5 The Willowbrook class member’s Notice of Rights is placed in the SC/CM/CC service record.
2a-6 The SC/CM/CC advocates/ensures that rights limitations occur only with required protections, justifications and approvals in place.
2a-8 The individual enrolled in FIDA-IDD is provided a set of guidelines and care responsibilities of the entire IDT.
2a-9 The individual and designees, as applicable are given required contact information.
2a-10 The individual can reach the service coordinator when needed in a timely manner.
2a-11 The SC/CM/CC solicits input from/among members of the person’s ‘circle’/team as part of the review of the person’s services and status as needed.
2a-12 Meetings for the review of the person centered service plan must be face to face as required by the service type.
2a-14 The SC/CM/CC notes indicate that the service coordinator/case manager has contact with the individual in the frequency and manner required by the service and when needed.
2a-15 The service coordinator/case manager meets with the individual in his/her home at least quarterly with a Willowbrook Class Member, annually with a non-class member, and when needed.
2a-20 The SC/CM/CC monitors that the individual is linked to and receiving the service she/she wants and that the services are helping the individual to attain his/her valued outcomes and life goals.
2a-21 The WCS Coordinator or WSC assists the QIDP, treatment coordinator and/or IDT members in linking to services and/or in support during crisis intervention, as needed.
2a-24 Care/Case/Service Coordinator/Manager advocates for the rights and entitlements of the individual in the home, day and work environments and in all spheres of his/her life.
2a-25 The Care/Case/Service Coordinator/Manager ensures that procedural and substantive due process requirements are met.
3-1 The individual is informed of their rights according to Part 633.4
3-2 The individual is informed of rights as a FIDA-IDD member and availability of the FIDA-IDD Ombudsman
3-3 The individual is informed of their right to objections of services/service plan and process to do so
3-4 The individual is informed of their HCBS rights
3-5 The individual is provided with information about their rights in plain language and in a way that is accessible to them
3-6 The individual knows who to contact/how to make a complaint including anonymous complaints if desired
3-7 The individual is supported to express themselves through personal choices/decisions on style of dress and grooming preferences
3-10 The individual has privacy in his/her home, bedroom or other service environments and per their needs for support
3-20 The individual may view their service record upon request
3-22 The individual is encouraged and supported to advocate for themselves and to increase their self-advocacy skills
3-24 The individual’s rights are respected and staff support/advocate for the individual’s rights as needed.
QQ-3a The individual is subjected to restrictions or limitations to their rights not associated with a Behavior Support Plan.
3a-1 When interventions that restrict or modify the individual’s rights are used (not part of a behavior support plan), the individual’s service plan includes a description of the positive and less intrusive approaches that have been tried but have not been successful.
3a-2 When interventions are used that restrict or modify the individual’s rights (but not part of a behavior support plan), the individual’s service plan includes a description of the individualized assessed need and/or behavior that justifies the rights restriction or rights modification (clinical justification)
3a-3 When interventions restrict or modify the individual’s rights (not part of a behavior support plan), the service plan includes time limits for imposition and review of continued necessity.
3a-4 The individual’s service plan identifies specific actions/supports, collection/review of data related to effectiveness, and actions to ensure the interventions cause no harm.
3a-5 The individual has given informed consent to the rights limitations/restrictions in place
9a-8 Written informed consent was obtained from an appropriate consent giver prior to implementation of a Behavior Support Plan that includes restrictive/intrusive interventions
9a-9 Written informed consent is obtained annually for a plan that includes a limitation on the individual’s rights and/or a restrictive/intrusive intervention
9a-10 Rights Limitations were implemented in accordance with Behavior Support Plans.
9a-11 Clinical justification for use of rights limitations in an emergency is documented in the individual’s record
9a-12 Repeated use of emergency or unplanned rights limitations in a 30-day period resulted in a comprehensive review
9e-2 Written Informed Consent for use of medication by the individuals has been obtained and is current
11-2 The individual is living as independently as able in the home/living environment they choose
11-6 The individual is living safely/receiving supports to live safely in their home/living environment, according to informed choices and responsible consideration
11-7 The person lives safely in their community per their informed choices

Goal 1: Competency Area D: Facilitating Personal Growth and Development

1-5 The individual is supported to direct the planning process to the maximum extent possible and desired.
1-7 The individual is provided information and education to make informed choices related to services and supports; the settings for those services, and service providers.

Goal 1: Competency Area E: Facilitation of Supports and Services

1-2 The individual’s planning process/planning meetings include people chosen by and important to the individual.
1-3 The individual’s planning process/planning meetings include participation and input from required parties.
1-5 The individual is supported to direct the planning process to the maximum extent possible and desired.
1-7 The individual is provided information and education to make informed choices related to services and supports; the settings for those services, and service providers.
1-10 Assessments needed by the individual or required by program regulation were completed to inform the individual’s plan development.
1-12 The individual’s strengths and preferences are documented in the service plan.
1-13 The individual’s identified needs for clinical and/or functional support are documented in the service plan.
1-14 The individual’s cultural/religious and other personalized associational interests/preferences are included in person centered planning/plan.
1-15 The individual’s priorities/interests regarding meaningful community based activities, including the desired frequency and the supports needed are identified in the person-centered plan.
1-17 The individual’s goals, priorities, and interests regarding meaningful work, volunteer and recreational activities are identified in the person-centered plan
1-18 The individual’s goals and priorities related to health concerns and medical needs are identified in the person-centered plan.
1-19 The individual’s known food, medication, and/or environmental allergies and the corresponding precautions are identified in the person-centered plan.
1-20 Individualized considerations and safeguards regarding fire safety are identified in the person-centered service plan.
1-21 The person-centered planning and plan allow for acceptance of risk in support of the individual’s desired outcomes when balanced with the conscientious discussion, and proportionate safeguards and risk mitigation strategies.
1-22 Risks to the individual and the strategies, supports, and safeguards to minimize risk, including specific back-up plans, are identified in the person-centered plan.
1-23 The individual’s written plan documents each specific service and support to be provided to address his/her needs and achieve his/her identified desired outcomes, short term and long term goals.
1-24 The individual’s written plan identifies the amount, frequency and duration of each HCBS waiver service he/she receives, as applicable.
1-25 The person-centered plan identifies the provider(s) of the individual’s supports and services.
1-26 The person-centered plan evidences that informed choice is made regarding self-direction; and if chosen identifies the services that the individual elects to self-direct.
1-27 For FIDA-IDD, the Life Plan identifies the services the individual is responsible to schedule and the support needed to do so.
1-28 The plan is written in plain language, in a manner that is accessible to the individual and parties responsible for the implementation of the plan.
1-29 The person-centered service plan is signed by the individual as indicator of written informed consent or approval.
1-30 The individual’s person centered service plan is agreed to by services providers and/or members of the team as required.
1-31 The individual’s FIDA-IDD Life Plan is authorized as required per the services in the plan.
1-32 The person-centered plan is distributed to the individual and service providers. The person-centered service plan includes all relevant and applicable attachments.
1-34 The individual has been informed that they can request a change to the plan and understands how to do so.
1-35 The Individual’s written person centered service plan is reviewed with regular required frequency.
1-36 Review of the plan includes the individual’s status/progress towards the achievement of his/her goals, priorities and outcomes.
1-37 The individual’s person centered service plan is revised whenever changes are necessary and warranted and/or as directed/preferred by the individual.
1-38 Revisions to the individual’s written plan are documented in the form and format required.
1-40 The SC/CM/CC competently assures person centered planning as evidence by the individual’s written plan for services and supports and interview.
1-41 CAS findings were reviewed with the individual within 30 days.
2-2 The service record contains the current service plan(s) required for the service/service setting.
2-3 The individual’s written service plan is developed within time frames required for the specific service.
2-4 The person’s service specific written plan meets the content requirements for the specific service, and describes action expected by service provider and the individual.
2-5 The individual is provided the service(s) and activities identified/described in the written plan and/or required by the service type.
2-7 Documentation of the delivery of services, supports, interventions, and therapies to the individual meets quality expectations specific to the service type.
2-11 The person’s services are delivered by competent staff/supports that understand their role, the service/service plan and the person’s needs, preferences and goals related to the service.
2-12 The individuals’ service and/or plan is reviewed to determine whether the services/supports delivered are effective in achievement of advancement of his/her goals, priorities, needed safeguards and outcomes.
2-13 There is a review summary note reporting on the service delivery, actions taken, evaluation of effectiveness and recommendations.
2-14 The individual’s services/supports and/or delivery modalities are modified as needed/desired in conjunction with the person to foster the advancement/achievement of his/her goals/outcomes.
2a-1 An initial Level of Care determination (LCED) was completed indicating OPWDD determination that the individual is eligible for services (when individuals receive HCBS Waiver Services).
2a-11 The SC/CM/CC solicits input from/among members of the person’s ‘circle’/team as part of the review of the person’s services and status as needed.
2a-12 Meetings for the review of the person centered service plan must be face to face as required by the service type.
2a-20 The SC/CM/CC monitors that the individual is linked to and receiving the service she/she wants and that the services are helping the individual to attain his/her valued outcomes and life goals.
2a-21 The WCS Coordinator or WSC assists the QIDP, treatment coordinator and/or IDT members in linking to services and/or in support during crisis intervention, as needed.
2a-22 The SC/CM/CC monitors that the fire safety safeguard identified in the Person Centered plan are in place/provided.
2a-23 The SC/CM/CC monitors that individuals receive the health care services identified in their service plan.
7-1 The individual’s specific safeguarding needs and related interventions (including supervision) are identified and documented in their service specific plan or attachment according to service/setting requirements
7-2 The individual is provided necessary safeguards/supports per his/her written plan and as needed (excludes supervision, mobility and dining supports)
7-3 The individual is provided supervision per his/her written plan and as needed
7-4 The individual is provided mobility supports per his/her written plan and as needed
7-5 The individual is provided dining supports for consistency, assistance, and monitoring per his/her written plan and as needed
8a-3 The individual’s service plan identifies the services and supports necessary to access to and receipt of routine professional medical care and evaluation
8d-3 The individual’s service record/service plan is maintained to reflect current status of the individual’s health needs being addressed
9g-2 The Individual’s Monitoring Plan clearly identifies target symptoms associated with each medication prescribed for a psychiatric disorder
9g-3 The Individual’s Monitoring Plan includes the method to measure and document symptom reduction and functional improvement
9g-4 The Individual’s Monitoring Plan includes alternative interventions (other than medication)
9g-5 The Individual’s Monitoring Plan is developed by a qualified clinician
9g-6 The effectiveness of the individual’s Monitoring Plan in improving the quality of his/her life is reviewed as identified in the plan

Goal 2: Positive Relationships

Goal 2: Competency Area F: Building and Maintaining Relationships

1-2 The individual’s planning process/planning meetings include people chosen by and important to the individual.
1-3 The individual’s planning process/planning meetings include participation and input from required parties.
1-16 The individual’s goals and priorities regarding meaningful relationships are identified in the person-centered plan.
1-17 The individual’s goals, priorities, and interests regarding meaningful work, volunteer and recreational activities are identified in the person-centered plan.
2a-11 The SC/CM/CC solicits input from/among members of the person’s ‘circle’/team as part of the review of the person’s services and status as needed.
3-9 The individual is supported to have visitors of their choosing according to their preferences
5-1 The individual is encouraged and supported to foster and/or maintain relationships that are important and meaningful to them
11-3 The person is maintaining/improving and/or developing meaningful relationship(s)
11-5 The person is maintaining their desired role in their community
11-7 The person lives safely in their community per their informed choices

Goal 2: Competency Area G: Creating Meaningful Communication

1-5 The individual is supported to direct the planning process to the maximum extent possible and desired.
1-6 Conflicts, disagreements, and conflict-of-interest are appropriately addressed during the individual’s planning process.
1-7 The individual is provided information and education to make informed choices related to services and supports; the settings for those services, and service providers.
1-11 The individual’s goals and desired outcomes are documented in the person-centered service plan.
1-12 The individual’s strengths and preferences are documented in the service plan.
1-14 The individual’s cultural/religious and other personalized associational interests/preferences are included in person centered planning/plan.
1-15 The individual’s priorities/interests regarding meaningful community based activities, including the desired frequency and the supports needed are identified in the person-centered plan.
1-16 The individual’s goals and priorities regarding meaningful relationships are identified in the person-centered plan.
1-17 The individual’s goals, priorities, and interests regarding meaningful work, volunteer and recreational activities are identified in the person-centered plan.
1-18 The individual’s goals and priorities related to health concerns and medical needs are identified in the person-centered plan.
1-19 The individual’s known food, medication, and/or environmental allergies and the corresponding precautions are identified in the person-centered plan.
1-23 The individual’s written plan documents each specific service and support to be provided to address his/her needs and achieve his/her identified desired outcomes, short term and long term goals.
1-26 The person-centered plan evidences that informed choice is made regarding self-direction; and if chosen identifies the services that the individual elects to self-direct.
1-28 The plan is written in plain language, in a manner that is accessible to the individual and parties responsible for the implementation of the plan.
1-34 The individual has been informed that they can request a change to the plan and understands how to do so.
1-36 Review of the plan includes the individual’s status/progress towards the achievement of his/her goals, priorities and outcomes.
1-37 The individual’s person centered service plan is revised whenever changes are necessary and warranted and/or as directed/preferred by the individual.
2-6 The service plan/provided services clearly evidence the intent to facilitate advancement of the individual towards achievement of outcomes.
2-9 Services and supports are delivered in the most integrated setting appropriate to the individual’s needs, preferences, and desired outcomes.
2-10 Services and supports are delivered in a manner that optimizes and fosters the individual’s initiative, autonomy, independence, and dignity.
2-11 The person’s services are delivered by competent staff/supports that understand their role, the service/service plan and the person’s needs, preferences and goals related to the service.
2-12 The individuals’ service and/or plan is reviewed to determine whether the services/supports delivered are effective in achievement or advancement of his/her goals, priorities, needed safeguards and outcomes.
2-14 The individual’s services/supports and/or delivery modalities are modified as needed/desired in conjunction with the person to foster the advancement/achievement of his/her goals/outcomes.
2-15 The person is satisfied with the specific service.
2a-10 The individual can reach the service coordinator when needed in a timely manner.
2a-11 The SC/CM/CC solicits input from/among members of the person’s ‘circle’/team as part of the review of the person’s services and status as needed.
2a-12 Meetings for the review of the person centered service plan must be face to face as required by the service type.
2a-14 The SC/CM/CC notes indicate that the service coordinator/case manager has contact with the individual in the frequency and manner required by the service and when needed.
2a-15 The service coordinator/case manager meets with the individual in his/her home at least quarterly with a Willowbrook Class Member, annually with a non-class member, and when needed.
2a-20 The SC/CM/CC monitors that the individual is linked to and receiving the service she/she wants and that the services are helping the individual to attain his/her valued outcomes and life goals.
2a-25 Care/Case/Service Coordinator/Manager advocates for the rights and entitlements of the individual in the home, day and work environments and in all spheres of his/her life.
2a-27 The person is satisfied with the coordinator/case management services he/she receives.
QQ-2b Does the individual Self-Direct by exercising Budget authority?
2b-1 The individual is supported to exercise budget authority over how his or her resources are budgeted and managed within the Personal Resources Account (PRA).
2e-1 The Support Broker assists the individual with developing a comprehensive self-direction budget within the person’s Personal Resource Account (PRA) amount.
2f-1 The Individual Directed Goods and Services (IDGS) a person receives address an identified need in a person’s ISP, to promote his/her inclusion in the community, and/or increase the person’s safety and independence in the home environment, and/or decrease the need for other Medicaid services.
2h-1 SEMP services are directed toward achieving sustained self-employment or competitive integrated employment in the general workforce, in a job that meets the individual’s personal and career goals.
2h-3 Services provided without the individual present are documented and serve to benefit the individual in attaining his/her employment goals.
3-6 The individual knows who to contact/how to make a complaint including anonymous complaints if desired
3-7 The individual is supported to express themselves through personal choices/decisions on style of dress and grooming preferences
3-8 The individual is supported to participate in cultural/religious associational practices, education, celebrations and experiences per their interests and preferences
3-9 The individual is supported to have visitors of their choosing according to their preferences
3-10 The individual has privacy in his/her home, bedroom or other service environments and per their needs for support
3-11 The individual is aware that he/she is not required to follow a particular schedule for waking up, going to bed, eating, leisure activities, etc.
3-12 The individual is encouraged and supported to make their own scheduling choices and changes according to their preferences and needs
3-13 The individual can choose to eat meals when they want to, even if mealtimes occur at routine or scheduled times
3-14 The individual has access/is supported to have access to food at any time and to store their own food and snack choices for their use at any time as desired, similar to people without disabilities
3-17 The setting reflects the individual’s needs and preferences including the presence of any necessary physical modifications, if applicable
3-21 The individual controls their personal resources and decides how to spend their personal discretionary funds
3-22 The individual is encouraged and supported to advocate for themselves and to increase their self-advocacy skills
4-1 The individual is encouraged and supported to have full access to the community based on their interests/preferences/priorities for meaningful activities to the same degree as others in the community.
4-3 The individual is satisfied with their level of access to the broader community as well as the support provided the pursue activities that are meaningful to them for the period of time desired
5-1 The individual is encouraged and supported to foster and/or maintain relationships that are important and meaningful to them
6-3 The individual’s personal living space(s) reflect their individualized interests and tastes
8a-22 The individual is supported to advocate and is included in informed decision-making related to medical care and treatment
8a-29 The individual and his/her guardian, family member, or advocate is satisfied overall with the medical care that the individual receives
11-2 The individual is living as independently as able in the home/living environment they choose
11-3 The person is maintaining/improving and/or developing meaningful relationship(s)
11-5 The person is maintaining their desired role in their community
11-6 The individual is living safely/receiving supports to live safely in their home/living environment, according to informed choices and responsible consideration
11-7 The person lives safely in their community per their informed choices
11-8 The person is satisfied with the supports they receive intended to achieve their outcomes
11-9 The person’s service(s) in total, contribute to advancing toward or achieving their specified goals and personal outcomes

Goal 3: Be a Professional

Goal 3: Competency Area H: Developing Professional Relationships

1-2 The individual’s planning process/planning meetings include people chosen by and important to the individual.
1-3 The individual’s planning process/planning meetings include participation and input from required parties.
1-6 Conflicts, disagreements, and conflict-of-interest are appropriately addressed during the individual’s planning process.
1-16 The individual’s goals and priorities regarding meaningful relationships are identified in the person-centered plan.
1-30 The individual’s person centered service plan is agreed to by services providers and/or members of the team as required.
2-4 The person’s service specific written plan meets the content requirements for the specific service, and describes action expected by service provider and the individual.
2-11 The person’s services are delivered by competent staff/supports that understand their role, the service/service plan and the person’s needs, preferences and goals related to the service.
2a-1 The individual was provided a choice of service/care manager/coordinator.
2a-9 The individual and designees, as applicable are given required contact information.
2a-10 The individual can reach the service coordinator when needed in a timely manner.
2a-11 The SC/CM/CC solicits input from/among members of the person’s ‘circle’/team as part of the review of the person’s services and status as needed.
2a-12 Meetings for the review of the person centered service plan must be face to face as required by the service type.
2a-14 The SC/CM/CC notes indicate that the service coordinator/case manager has contact with the individual in the frequency and manner required by the service and when needed.
2a-15 The service coordinator/case manager meets with the individual in his/her home at least quarterly with a Willowbrook Class Member, annually with a non-class member, and when needed.
2a-21 The WCS Coordinator or WSC assists the QIDP, treatment coordinator and/or IDT members in linking to services and/or in support during crisis intervention, as needed.
2o-2 Documentation evidences that training was provided to the individual’s family regarding the nature and impact of the person’s disability and/or the service options
2o-3 Training provided to the individual’s family was at least two (2) hours duration and provided by someone other than the person’s MSC.
2q-2 Coordination with the individual’s residential provider is evident
8a-29 The individual and his/her guardian, family member, or advocate is satisfied overall with the medical care that the individual receives
9-5 The Individual’s Behavior Support Plan was developed by a BIS, a licensed psychologist or a licensed clinical social worker with training in behavioral intervention techniques; and supervised by appropriate clinician as determined by the interventions in the plan

Goal 3: Competency Area I: Exhibiting Professional Behavior

1-2 The individual’s planning process/planning meetings include people chosen by and important to the individual.
1-3 The individual’s planning process/planning meetings include participation and input from required parties.
1-4 The individual’s planning meetings are scheduled at the times and locations convenient to the individual.
1-6 Conflicts, disagreements, and conflict-of-interest are appropriately addressed during the individual’s planning process.
1-30 The individual’s person centered service plan is agreed to by services providers and/or members of the team as required.
2-4 The person’s service specific written plan meets the content requirements for the specific service, and describes action expected by service provider and the individual.
2-11 The person’s services are delivered by competent staff/supports that understand their role, the service/service plan and the person’s needs, preferences and goals related to the service.
2a-2 An initial Level of Care determination (LCED) was completed indicating OPWDD determination that the individual is eligible for services (when individuals receive HCBS Waiver Services).
2a-3 The level of care is reevaluated at least annually (within 365 days) as evidenced by a current LCED in the SC/CC record.
2a-4 The service plan record contains a correctly completed Documentation of Choices form.
2a-5 The Willowbrook class member’s Notice of Rights is placed in the SC/CM/CC service record.
2a-7 The individual has a signed Service Coordination Agreement, which is reviewed annually
2a-10 The individual can reach the service coordinator when needed in a timely manner.
2a-11 The SC/CM/CC solicits input from/among members of the person’s ‘circle’/team as part of the review of the person’s services and status as needed
2a-14 The SC/CM/CC notes indicate that the service coordinator/case manager has contact with the individual in the frequency and manner required by the service and when needed.
2a-16 A Service Coordination Observation Report (SCOR) was completed at least twice yearly for Willowbrook Class Members and as needed.
2a-20 The SC/CM/CC monitors that the individual is linked to and receiving the service she/she wants and that the services are helping the individual to attain his/her valued outcomes and life goals.
2a-21 The WCS Coordinator or WSC assists the QIDP, treatment coordinator and/or IDT members in linking to services and/or in support during crisis intervention, as needed.
2e-1 The Support Broker assists the individual with developing a comprehensive self-direction budget within the person’s Personal Resource Account (PRA) amount.
8a-12 The individual’s health care services are competently overseen by an RN, to ensure receipt of needed health care services and the competent delivery of delegated nursing services

Goal 3: Competency Area J: Showing Respect for Diversity and Inclusion

1-14 The individual’s cultural/religious and other personalized associational interests/preferences are included in person centered planning/plan.
3-8 The individual is supported to participate in cultural/religious associational practices, education, celebrations and experiences per their interests and preferences

Goal 3: Competency Area K: Creating Meaningful Documentation Records

1-12 The individual’s strengths and preferences are documented in the service plan.
1-13 The individual’s identified needs for clinical and/or functional support are documented in the service plan.
1-38 Revisions to the individual’s written plan are documented in the form and format required.
2-7 Documentation of the delivery of services, supports, interventions, and therapies to the individual meets quality expectations specific to the service type.
3-20 The individual may view their service record upon request
8a-15 The individual’s current medications are correctly documented as prescribed when support for administration is needed/provided

Goal 3: Competency Area L: Education, Training and Self-Development

1-3 The individual’s planning process/planning meetings include participation and input from required parties.
1-7 The individual is provided information and education to make informed choices related to services and supports; the settings for those services, and service providers.
1-28 The plan is written in plain language, in a manner that is accessible to the individual and parties responsible for the implementation of the plan.
1-37 The individual’s person centered service plan is revised whenever changes are necessary and warranted and/or as directed/preferred by the individual.
2-6 The service plan/provided services clearly evidence the intent to facilitate advancement of the individual towards achievement of outcomes.
2-7 Documentation of the delivery of services, supports, interventions, and therapies to the individual meets quality expectations specific to the service type.
2-9 Services and supports are delivered in the most integrated setting appropriate to the individual’s needs, preferences, and desired outcomes.
2-11 The person’s services are delivered by competent staff/supports that understand their role, the service/service plan and the person’s needs, preferences and goals related to the service.
2-12 The individuals’ service and/or plan is reviewed to determine whether the services/supports delivered are effective in achievement of advancement of his/her goals, priorities, needed safeguards and outcomes.
2l-1 A functional behavior assessment meeting content requirements is completed prior to the development of the individual’s behavior support plan.
3-24 The individual’s rights are respected and staff support/advocate for the individual’s rights as needed.
7-6 The individual’s needs for support and assistance related to fire safety and evacuation are documented according to service/setting requirements
8a-12 (8d-4) The individual’s health care services are competently overseen by an RN, to ensure receipt of needed health care services and the competent delivery of delegated nursing services
8a-19 The individual’s medication regimen is reviewed on a regular basis by a designated professional
QQ-8d The individual receives supports related to health care, delivered by the site/program staff
8d-1 There is a written plan/instruction to address routine care/monitoring to be provided related to the individual’s specific medical condition(s) addressed during services at the site
9-5 The Individual’s Behavior Support Plan was developed by a BIS, a licensed psychologist or a licensed clinical social worker with training in behavioral intervention techniques; and supervised by appropriate clinician as determined by the interventions in the plan
9-16 The individual’s support staff has completed and is annually recertified in an OPWDD-approved training course in positive behavioral strategies and physical intervention techniques (if applicable)

Goal 3: Competency Area M: Organizational Participation

1-1 The individual was provided written notice of their right to a person-centered planning process.
1-6 Conflicts, disagreements, and conflict-of-interest are appropriately addressed during the individual’s planning process.
1-7 The individual is provided information and education to make informed choices related to services and supports; the settings for those services, and service providers.
1-11 The individual’s goals and desired outcomes are documented in the person-centered service plan.
1-16 The individual’s goals and priorities regarding meaningful relationships are identified in the person-centered plan.
1-17 The individual’s goals, priorities, and interests regarding meaningful work, volunteer and recreational activities are identified in the person-centered plan.
2a-1 The individual was provided a choice of service/care manager/coordinator.
2a-2 An initial Level of Care determination (LCED) was completed indicating OPWDD determination that the individual is eligible for services (when individuals receive HCBS Waiver Services).
2a-3 The level of care is reevaluated at least annually (within 365 days) as evidenced by a current LCED in the SC/CC record.
2a-4 The service plan record contains a correctly completed Documentation of Choices form.
2a-5 The Willowbrook class member’s Notice of Rights is placed in the SC/CM/CC service record.
2a-15 The service coordinator/case manager meets with the individual in his/her home at least quarterly with a Willowbrook Class Member, annually with a non-class member, and when needed.
2a-16 A Service Coordination Observation Report (SCOR) was completed at least twice yearly for Willowbrook Class Members and as needed.
2a-20 The SC/CM/CC monitors that the individual is linked to and receiving the service she/she wants and that the services are helping the individual to attain his/her valued outcomes and life goals.
2a-22 The SC/CM/CC monitors that the fire safety safeguard identified in the Person Centered plan are in place/provided.
2a-23 The SC/CM/CC monitors that individuals receive the health care services identified in their service plan.
2a-24 Care/Case/Service Coordinator/Manager advocates for the rights and entitlements of the individual in the home, day and work environments and in all spheres of his/her life.
2a-25 The Care/Case/Service Coordinator/Manager ensures that procedural and substantive due process requirements are met.
2a-26 The WCS Coordinator or WCS ensures active representation, either by the class member, the correspondent or Consumer Advisory Board (CAB)
2a-27 The person is satisfied with the coordinator/case management services he/she receives.
2l-2 The individual has a behavior support plan (BSP) which meets content requirements.
2m-1 The person’s need for the adaptive device is documented in his/her ISP
QQ-2n The individual receives/received HCBS Waiver Environmental Modifications (Emod)
2p-1 When the individual’s services include vocational services, services must be in compliance with federal and state laws regarding labor wages and safety
2q-3 When the individual’s services include therapeutic prevocational services, he/she must be compensated compliance with New York wage and hour laws.
2r-1 If the individual is engaged in pre-vocational training, it is in accordance with applicable federal and state labor and wage laws, including periodic review of pre-vocational task to deem if they require compensation.
2r-2 When the individual’s services include vocational services, compliance with federal and state laws regarding labor wages and safety is evidenced.
3-1 The individual is informed of their rights according to Part 633.4
3-2 The individual is informed of rights as a FIDA-IDD member and availability of the FIDA-IDD Ombudsman
3-3 The individual is informed of their right to objections of services/service plan and process to do so
3-4 The individual is informed of their HCBS rights
3-5 The individual is provided with information about their rights in plain language and in a way that is accessible to them
3-10 The individual has privacy in his/her home, bedroom or other service environments and per their needs for support
3-23 The individual is not subjected to coercion (includes subtle coercion)
3-24 The individual’s rights are respected and staff support/advocate for the individual’s rights as needed.
3a-1 When interventions that restrict or modify the individual’s rights are used (not part of a behavior support plan), the individual’s service plan includes a description of the positive and less intrusive approaches that have been tried but have not been successful.
5-1 The individual is encouraged and supported to foster and/or maintain relationships that are important and meaningful to them
9e-6 The Individual ‘service record includes evidence that the effectiveness of the medication has been re-evaluated at least semi-annually at the program review with required service attendees
9e-7 Medications were administered in accordance with requirements

Goal 3: Competency Area N: Exhibiting Ethical Behavior on the Job

1-1 The individual was provided written notice of their right to a person-centered planning process.
1-17 The individual’s goals, priorities, and interests regarding meaningful work, volunteer and recreational activities are identified in the person-centered plan.
1-18 The individual’s goals and priorities related to health concerns and medical needs are identified in the person-centered plan.
1-19 The individual’s known food, medication, and/or environmental allergies and the corresponding precautions are identified in the person-centered plan.
1-34 The individual has been informed that they can request a change to the plan and understands how to do so.
1-36 Review of the plan includes the individual’s status/progress towards the achievement of his/her goals, priorities and outcomes.
2-6 The service plan/provided services clearly evidence the intent to facilitate advancement of the individual towards achievement of outcomes.
2-9 Services and supports are delivered in the most integrated setting appropriate to the individual’s needs, preferences, and desired outcomes.
2-10 Services and supports are delivered in a manner that optimizes and fosters the individual’s initiative, autonomy, independence, and dignity.
2-11 The person’s services are delivered by competent staff/supports that understand their role, the service/service plan and the person’s needs, preferences and goals related to the service.
2-12 The individuals’ service and/or plan is reviewed to determine whether the services/supports delivered are effective in achievement of advancement of his/her goals, priorities, needed safeguards and outcomes.
2-14 The individual’s services/supports and/or delivery modalities are modified as needed/desired in conjunction with the person to foster the advancement/achievement of his/her goals/outcomes.
2-15 The person is satisfied with the specific service.
2a-20 The SC/CM/CC monitors that the individual is linked to and receiving the service she/she wants and that the services are helping the individual to attain his/her valued outcomes and life goals.
QQ-2b Does the individual Self-Direct by exercising Budget authority?
2f-1 The Individual Directed Goods and Services (IDGS) a person receives address an identified need in a person’s ISP, to promote his/her inclusion in the community, and/or increase the person’s safety and independence in the home environment, and/or decrease the need for other Medicaid services.
2h-1 SEMP services are directed toward achieving sustained self-employment or competitive integrated employment in the general workforce, in a job that meets the individual’s personal and career goals.
2h-3 Services provided without the individual present are documented and serve to benefit the individual in attaining his/her employment goals.
3-1 The individual is informed of their rights according to Part 633.4
3-2 The individual is informed of rights as a FIDA-IDD member and availability of the FIDA-IDD Ombudsman
3-3 The individual is informed of their right to objections of services/service plan and process to do so
3-4 The individual is informed of their HCBS rights
3-5 The individual is provided with information about their rights in plain language and in a way that is accessible to them
3-10 The individual has privacy in his/her home, bedroom or other service environments and per their needs for support
3-21 The individual controls their personal resources and decides how to spend their personal discretionary funds
3-24 The individual’s rights are respected and staff support/advocate for the individual’s rights as needed.
QQ-3a The individual is subjected to restrictions or limitations to their rights not associated with a Behavior Support Plan.
3a-1 When interventions that restrict or modify the individual’s rights are used (not part of a behavior support plan), the individual’s service plan includes a description of the positive and less intrusive approaches that have been tried but have not been successful.
3a-2 When interventions are used that restrict or modify the individual’s rights (but not part of a behavior support plan), the individual’s service plan includes a description of the individualized assessed need and/or behavior that justifies the rights restriction or rights modification (clinical justification)
3a-3 When interventions restrict or modify the individual’s rights (not part of a behavior support plan), the service plan includes time limits for imposition and review of continued necessity.
3a-5 The individual has given informed consent to the rights limitations/restrictions in place
4-1 The individual is encouraged and supported to have full access to the community based on their interests/preferences/priorities for meaningful activities to the same degree as others in the community.
4-2 The individual regularly participates in unscheduled and scheduled community activities to the same degree as individuals not receiving HCBS
4-3 The individual is satisfied with their level of access to the broader community as well as the support provided the pursue activities that are meaningful to them for the period of time desired
5-1 The individual is encouraged and supported to foster and/or maintain relationships that are important and meaningful to them
6-2 If the individual is NOT satisfied with living situation, there is evidence that the staff is proactively working to find an alternate arrangement based on the person’s needs, choices and preferences in a timely manner
6-3 The individual’s personal living space(s) reflect their individualized interests and tastes
8a-22 The individual is supported to advocate and is included in informed decision-making related to medical care and treatment
8a-23 Individuals have been given the opportunity to have advanced directives in place (DNR order, healthcare proxy, or living will)
8a-24 For those that have advanced directives, they are completed properly in accordance with the Healthcare Decisions Act
8a-28 The individual has all necessary medical services and supports in place that allow him/her to live as independently as possible in the least restrictive setting
8a-29 The individual and his/her guardian, family member, or advocate is satisfied overall with the medical care that the individual receives
10b-1 Immediate care and treatment identified and needed was provided to the individual
10b-2 Initial measures to protect the individuals from harm and abuse, were implemented immediately
11-6 The individual is living safely/receiving supports to live safely in their home/living environment, according to informed choices and responsible consideration
11-7 The person lives safely in their community per their informed choices
11-8 The person is satisfied with the supports they receive intended to achieve their outcomes
11-9 The person’s service(s) in total, contribute to advancing toward or achieving their specified goals and personal outcomes

Goal 4: Health

Goal 4: Competency Area O: Promoting Positive Behavior and Supports

3-7 The individual is supported to express themselves through personal choices/decisions on style of dress and grooming preferences
3-8 The individual is supported to participate in cultural/religious associational practices, education, celebrations and experiences per their interests and preferences
3-9 The individual is supported to have visitors of their choosing according to their preferences
3-10 The individual has privacy in his/her home, bedroom or other service environments and per their needs for support
3-11 The individual is aware that he/she is not required to follow a particular schedule for waking up, going to bed, eating, leisure activities, etc.
3-12 The individual is encouraged and supported to make their own scheduling choices and changes according to their preferences and needs
3-13 The individual can choose to eat meals when they want to, even if mealtimes occur at routine or scheduled times
3-14 The individual has access/is supported to have access to food at any time and to store their own food and snack choices for their use at any time as desired, similar to people without disabilities
3-15 The individual is supported to have independent access to the site/service setting with freedom to come and go as desired, similar to people without disabilities
3-21 The individual controls their personal resources and decides how to spend their personal discretionary funds
4-1 The individual is encouraged and supported to have full access to the community based on their interests/preferences/priorities for meaningful activities to the same degree as others in the community.
4-2 The individual regularly participates in unscheduled and scheduled community activities to the same degree as individuals not receiving HCBS
4-3 The individual is satisfied with their level of access to the broader community as well as the support provided the pursue activities that are meaningful to them for the period of time desired
5-1 The individual is encouraged and supported to foster and/or maintain relationships that are important and meaningful to them
6-3 The individual’s personal living space(s) reflect their individualized interests and tastes
11-3 The person is maintaining/improving and/or developing meaningful relationship(s)
11-5 The person is maintaining their desired role in their community

Goal 4: Competency Area P: Supporting Health and Wellness

1-3 The individual’s identified needs for clinical and/or functional support are documented in the service plan.
1-18 The individual’s goals and priorities related to health concerns and medical needs are identified in the person-centered plan.
1-19 The individual’s known food, medication, and/or environmental allergies and the corresponding precautions are identified in the person-centered plan.
2a-23 The SC/CM/CC monitors that individuals receive the health care services identified in their service plan.
2s-1 The service plan (IPP) identifies whether the individual has a health care problem that requires more than three (3) hours of daily individualized care by health care staff.
3-13 The individual can choose to eat meals when they want to, even if mealtimes occur at routine or scheduled times
3-14 The individual has access/is supported to have access to food at any time and to store their own food and snack choices for their use at any time as desired, similar to people without disabilities
7-5 The individual is provided dining supports for consistency, assistance, and monitoring per his/her written plan and as needed
8a-1 A health assessment which identifies the individual’s health care needs has been completed by a physician, PA, NP, or RN
8a-2 The individual has someone chosen/delegated to support them in coordinating their health care
8a-3 The individual’s service plan identifies the services and supports necessary to access to and receipt of routine professional medical care and evaluation
8a-4 The individual’s routine health care providers are identified and known to the person and/or their supports
8a-5 The individual and/or their support(s) knows how to access emergency medical care
8a-6 The individual receives routine medical exams/medical appointments per his/her health care professionals’ recommendations
8a-7 The individual receives diagnostic evaluation/testing per his/her health care professionals’ recommendations and standard safe practice (e.g. Lab work, x-rays, scans, MRIs, etc.)
8a-8 The individual receives necessary dental exams and treatments
8a-9 The individual receives preventative testing and/or care based on recommended professional guidelines for medical conditions, gender, and age
8a-10 There is a written plan/ instruction to address routine care/monitoring to be provided related to the individual’s specific medical condition(s)
8a-11 The individual receives needed care/support/interventions, through arranged supports or independent delivery. DOES NOT APPLY TO MEDICATION
8a-12 The individual’s health care services are competently overseen by an RN, to ensure receipt of needed health care services and the competent delivery of delegated nursing services
8a-13 The individual and/or their support(s) report the individual’s health concerns/symptoms to appropriate parties as needed or directed
8a-14 The individual’s emerging signs/symptoms are reported to a health care professional, and monitored and addressed appropriately
8a-15 The individual’s current medications are correctly documented as prescribed when support for administration is needed/provided
8a-16 The individual is assessed regarding ability to self-administer medications, when medication administration is associated with the service or service environment
8a-17 The individual receives or self-administers medications and treatments safely as prescribed
8a-18 Problems or errors with administration of the individual’s medication are reported and remediated per agency processes
8a-20 The individual exhibits a healthy lifestyle and/or receives support(s) to replace the unhealthy behaviors with healthier actions
8a-21 The individual is provided choice in health care providers
8a-22 The individual is supported to advocate and is included in informed decision-making related to medical care and treatment
8a-23 Individuals have been given the opportunity to have advanced directives in place (DNR order, healthcare proxy, or living will)
8a-24 For those that have advanced directives, they are completed properly in accordance with the Healthcare Decisions Act
8a-26 The individual is supported to obtain a second opinion or submit a grievance when the medical service is considered unsatisfactory
8a-28 The individual has all necessary medical services and supports in place that allow him/her to live as independently as possible in the least restrictive setting
8a-29 The individual and his/her guardian, family member, or advocate is satisfied overall with the medical care that the individual receives
QQ-8b The agency’s waiver certification includes approval to provide delegated nursing services per the NPA expansion to selected community based HCBS services, and is providing such services to the individual in the course of community based waiver services delivery
8b-1 A medical assessment which identifies the individual’s health care needs has been completed by a physician, PA, NP, or RN
8b-2 There is a written plan/instruction to address routine care/monitoring to be provided related to the individual’s specific medical condition(s)
8b-2 The individual receives needed care/support/interventions, through arranged supports or independent delivery. DOES NOT APPLY TO MEDICATION
8b-4 The individual’s health care services are competently overseen by an RN, to ensure receipt of needed health care services and the competent delivery of delegated nursing services
8b-5 The individual and/or their support(s) report the individual’s health concerns/symptoms to appropriate parties as needed or directed
8b-6 The individual’s service record/service plan is maintained to reflect current status of the individual’s health
QQ-8c Does the person receive support for medication administration during delivery of this service?
8c-1 The individual’s current medications are correctly documented as prescribed when support for administration is needed/provided
8c-2 The individual is assessed regarding ability to self-administer medications, when medication administration is associated with the service or service environment
8c-3 The individual receives or self-administers medications and treatments safely as prescribed
8c-4 Problems or errors with administration of the individual’s medication are reported and remediated per agency processes
8c-5 The individual’s medication regimen is reviewed on a regular basis by a designated professional
QQ-8d The individual receives supports related to health care, delivered by the site/program staff
8d-1 There is a written plan/instruction to address routine care/monitoring to be provided related to the individual’s specific medical condition(s) addressed during services at the site
8d-2 The individual receives the needed care/support/interventions, through arranged supports or independent delivery. DOES NOT APPLY TO MEDICATION
8d-3 The individual’s service record/service plan is maintained to reflect current status of the individual’s health needs being addressed
8d-4 The individual’s health care services are competently overseen by an RN, to ensure receipt of needed health care services and the competent delivery of delegated nursing services
8d-5 The individual and/or their support(s) report the individual’s health concern/symptoms to appropriate parties as needed or directed
QQ-8e Does the person receive support for medication administration during delivery of this service?
8e-2 The individual is assessed regarding ability to self-administer medications, when medication administration is associated with the service or service environment
8e-3 The individual receives medications and treatments safely as prescribed
8e-4 Problems or errors with administration of the individual’s medication are reported and remediated per agency processes
QQ-9e Medication is used as a behavior support
9e-1 Medication to address the individual’s challenging behavior or a symptom of a diagnosed co-occurring psychiatric disorder is administered only as a part of a BSP or Monitoring Plan which includes additional interventions
9e-2 Written Informed Consent for use of medication by the individuals has been obtained and is current
9e-3 When the plan includes the medication the Individual’s service record includes a semi-annual medication regimen review that is used to evaluate the benefits/risk of continuation
9e-4 The Individual’s service record includes evidence that the prescriber was consulted regarding administration and continued effectiveness of the medication
9e-5 The Individual’s service record includes evidence that the use of medication is having a positive effect on his/her behavior or target symptoms
9e-6 The Individual ‘service record includes evidence that the effectiveness of the medication has been re-evaluated at least semi-annually at the program review with required service attendees
9e-7 Medications were administered in accordance with requirements
QQ-9f The individual is either prescribed PRN MEDICATIONS for behavior or co-occurring symptoms AND/OR medications was ordered in an emergency situation
9f-1 When prn medication is prescribed to address behavior or symptoms of a psychiatric disorder, this strategy is included in the Individual’s Behavioral Support or Monitoring Plan
9f-2 The Individual’s service record includes evidence of the display of the behavior(s) or symptom(s) for which the PRN medication is being prescribed in the past 12 months
9f-3 The Individual’s Behavioral Support or Monitoring Plan provides instruction and guidance for administration of the PRN medication, consistent with the prescriber’s order
9f-4 The Individual’s service record must include a summary, in behavioral terms, of the results of PRN medication administration
9f-5 The Individual’s service record includes evidence that any adverse or unexpected side effects were reported to the PRN prescriber immediately and the planning team by the next business day
9f-6 Use of the PRN Medications on more than four (4) separate days in a 14-day period resulted in consideration of a recommendation for incorporation into a regular drug regimen
9f-7 Lack of use of a PRN medication during a six-month period resulted in a review of the BSP and a recommendation to the prescriber
9f-8 Effectiveness of the medication ordered in an emergency is documented in the Individual’s record
9f-9 Emergency use of medication in more than 4 instances in a 14-day period resulted in a comprehensive review
9f-10 Use of PRN medications in conjunction with a restrictive physical intervention technique were reported electronically to OPWDD
QQ-9g The individual has a monitoring plan only, as medications are prescribed to treat only the co-occurring diagnosed psychiatric disorders as diagnosed by a physician, psychiatrist, or psychiatric nurse practitioner
9g-1 The Individual’s record identifies the symptoms he/she exhibits and each co-occurring psychiatric disorder diagnosis
9g-2 The Individual’s Monitoring Plan clearly identifies target symptoms associated with each medication prescribed for a psychiatric disorder
9g-3 The Individual’s Monitoring Plan includes the method to measure and document symptom reduction and functional improvement
9g-4 The Individual’s Monitoring Plan includes alternative interventions (other than medication)
9g-5 The Individual’s Monitoring Plan is developed by a qualified clinician

Goal 4: Competency Area Q: Preventing, Recognizing and Reporting Abuse

2a-19 If abuse was substantiated, SC/CM/CC advocates for the safety and protection of the individual.
2a-20 The SC/CM/CC monitors that the individual is linked to and receiving the service she/she wants and that the services are helping the individual to attain his/her valued outcomes and life goals.

Goal 5: Safety

Goal 5: Competency Area R: Supporting Crisis Prevention, Intervention, and Resolution

1-2 The individual’s planning process/planning meetings include people chosen by and important to the individual.
1-3 The individual’s planning process/planning meetings include participation and input from required parties.
1-12 The individual’s strengths and preferences are documented in the service plan.
1-15 The individual’s priorities/interests regarding meaningful community based activities, including the desired frequency and the supports needed are identified in the person-centered plan.
1-16 The individual’s goals and priorities regarding meaningful relationships are identified in the person-centered plan.
1-17 The individual’s goals, priorities, and interests regarding meaningful work, volunteer and recreational activities are identified in the person-centered plan.
1-19 The individual’s known food, medication, and/or environmental allergies and the corresponding precautions are identified in the person-centered plan.
1-20 Individualized considerations and safeguards regarding fire safety are identified in the person-centered service plan.
1-21 The person-centered planning and plan allow for acceptance of risk in support of the individual’s desired outcomes when balanced with the conscientious discussion, and proportionate safeguards and risk mitigation strategies.
1-22 Risks to the individual and the strategies, supports, and safeguards to minimize risk, including specific back-up plans, are identified in the person-centered plan.
2a-22 The SC/CM/CC monitors that the fire safety safeguard identified in the Person Centered plan are in place/provided.
2r-1 If the individual is engaged in pre-vocational training, it is in accordance with applicable federal and state labor and wage laws, including periodic review of pre-vocational task to deem if they require compensation.
2r-2 When the individual’s services include vocational services, compliance with federal and state laws regarding labor wages and safety is evidenced.
4-1 The individual is encouraged and supported to have full access to the community based on their interests/preferences/priorities for meaningful activities to the same degree as others in the community.
4-2 The individual regularly participates in unscheduled and scheduled community activities to the same degree as individuals not receiving HCBS
4-3 The individual is satisfied with their level of access to the broader community as well as the support provided the pursue activities that are meaningful to them for the period of time desired
5-1 The individual is encouraged and supported to foster and/or maintain relationships that are important and meaningful to them
6-1 The individual is satisfied with their living situation and does not express a desire (when questioned) to move to another living setting and/or with another roommate
6-2 If the individual is NOT satisfied with living situation, there is evidence that the staff is proactively working to find an alternate arrangement based on the person’s needs, choices and preferences in a timely manner
6-3 The individual’s personal living space(s) reflect their individualized interests and tastes
7-2 The individual is provided necessary safeguards/supports per his/her written plan and as needed (excludes supervision, mobility and dining supports)

Goal 5: Competency Area S: Supporting Safety

9b-1 The Individual’s Behavior Support Plan that includes a Mechanical Restraining device specifies the facts justifying the use of the device
9b-7 The Individual’s service record includes a written physicians order for the use of immobilization of the extremities or total immobilization
9b-14 Immobilizing devices were only applied under the supervision of a senior member of the staff
9b-16 Helmets with chin straps are used only when Individuals are awake and in a safe position
9c-4 Use of intermediate or restrictive physical intervention techniques in an emergency resulted in notification to appropriate parties within two business days
9c-5 Repeated emergency use of physical interventions in a 30-day period of six-month period resulted in a comprehensive review
9e-7 Medications were administered in accordance with requirements
10b-2 Initial measures to protect the individuals from harm and abuse, were implemented immediately

Goal 5: Competency Area T: Ensuring Safety of Individuals During Environmental Emergencies

1-19 The individual’s known food, medication, and/or environmental allergies and the corresponding precautions are identified in the person-centered plan.
1-20 Individualized considerations and safeguards regarding fire safety are identified in the person-centered service plan.
2a-22 The SC/CM/CC monitors that the fire safety safeguard identified in the Person Centered plan are in place/provided.
QQ-2n The individual receives/received HCBS Waiver Environmental Modifications (Emod)
7-6 The individual’s needs for support and assistance related to fire safety and evacuation are documented according to service/setting requirements
7-7 The individual is provided the necessary supports and assistance related to fire safety and evacuation

Goal 6: Home Life

Goal 6: Competency Area U: Supporting People to Live in the Home of Their Choice

1-9 The individual has made informed choice of residential setting and alternative options considered by the individual are recorded in his/her written plan.
2d-2 There is evidence that the person is responsible for his/her own living expenses in the home.
2g-1 The individual receiving Live-in Caregiver services resides in his/her own home or a leased residence where he/she is responsible for the residence.
3-10 The individual has privacy in his/her home, bedroom or other service environments and per their needs for support
3-11 The individual is aware that he/she is not required to follow a particular schedule for waking up, going to bed, eating, leisure activities, etc.
3-12 The individual is encouraged and supported to make their own scheduling choices and changes according to their preferences and needs
3-13 The individual can choose to eat meals when they want to, even if mealtimes occur at routine or scheduled times
3-14 The individual has access/is supported to have access to food at any time and to store their own food and snack choices for their use at any time as desired, similar to people without disabilities
3-15 The individual is supported to have independent access to the site/service setting with freedom to come and go as desired, similar to people without disabilities
3-16 The individual has full/unrestricted access to typical spaces and facilities in the home or day setting and are supported to use them
3-17 The setting reflects the individual’s needs and preferences including the presence of any necessary physical modifications, if applicable
3-18 The individual has a lease or other written occupancy agreement that provides eviction protections and due process/appeals and specifies the circumstances when he/she could be required to relocate
3-19 There is evidence that the individual and/or their representative knows/understands their right to due process/appeals and when he/she could be required to relocate
6-1 The individual is satisfied with their living situation and does not express a desire (when questioned) to move to another living setting and/or with another roommate
6-2 If the individual is NOT satisfied with living situation, there is evidence that the staff is proactively working to find an alternate arrangement based on the person’s needs, choices and preferences in a timely manner
6-3 The individual’s personal living space(s) reflect their individualized interests and tastes
11-2 The individual is living as independently as able in the home/living environment they choose
11-6 The individual is living safely/receiving supports to live safely in their home/living environment, according to informed choices and responsible consideration

Goal 7: Get Into the Community

Goal 7: Competency Area V: Supporting Active Participation in the Community

1-15 The individual’s priorities/interests regarding meaningful community based activities, including the desired frequency and the supports needed are identified in the person-centered plan.
1-17 The individual’s goals, priorities, and interests regarding meaningful work, volunteer and recreational activities are identified in the person-centered plan.
2f-1 The Individual Directed Goods and Services (IDGS) a person receives address an identified need in a person’s ISP, to promote his/her inclusion in the community, and/or increase the person’s safety and independence in the home environment, and/or decrease the need for other Medicaid services.
4-2 The individual regularly participates in unscheduled and scheduled community activities to the same degree as individuals not receiving HCBS
4-3 The individual is satisfied with their level of access to the broader community as well as the support provided the pursue activities that are meaningful to them for the period of time desired
11-5 The person is maintaining their desired role in their community

Goal 7: Competency Area W: Supporting Employment, Educational and Career Goal Attainment

2h-1 SEMP services are directed toward achieving sustained self-employment or competitive integrated employment in the general workforce, in a job that meets the individual’s personal and career goals.
2h-2 Individuals receiving SEMP who are earning a wage must be compensated at or above the minimum wage.
2h-3 Services provided without the individual present are documented and serve to benefit the individual in attaining his/her employment goals.
2k-1 When the individual’s services include site-based prevocational services, the individual must have a demonstrated or assessed earning capacity relative to the prevocational task(s) involved, of less than 50 percent of the current State minimum wage, Federal minimum wage or prevailing wage, whichever is greatest, and be expected to have such an earning capacity while participating in the services.
2r-2 When the individual’s services include vocational services, services must be in compliance with federal and state laws regarding labor wages and safety
2q-3 When the individual’s services include therapeutic prevocational services, he/she must be compensated compliance with New York wage and hour laws.
2r-1 If the individual is engaged in pre-vocational training, it is in accordance with applicable federal and state labor and wage laws, including periodic review of pre-vocational task to deem if they require compensation.
2r-2 When the individual’s services include vocational services, compliance with federal and state laws regarding labor wages and safety is evidenced.