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Attachment A

Employment Information Form: Complete and submit with application.

 Agency Self Assessment (optional)

1. Using the PROS Standards of Care and the Agency Self Assessment Form, evaluate your program by determining the rating for each Standard of Care.
2. Determine one or more areas to address.
3. Develop a quality improvement plan to address the identified deficits prior to the survey.

Private Office Space should be designated for use by the Surveyors.

Any or all of the following will be part of the survey process:

1. On-site opening conference regarding the purpose of and plan for the visit
2. Review of the course of care of at least four (4) individuals currently receiving services at the program. This will entail:
   1. Case record reviews
   2. Interviews with program recipients and others
   3. Interviews with program clinical, professional and administrative staff and collateral service providers
   4. Observation of groups
   5. Review of clinic policies, procedures, meeting minutes, administrative materials, data, etc.
3. Review of four (4) closed records
4. Tour of the premises including any medication storage areas
5. Exit conference and summation of findings

At the time of the survey visit, it is necessary for the following materials/information to be available:

1. List of expected participant attendance for the days of the visit
2. Log or process for identifying recipients at-risk
3. Referral/screening/admission process and logs
4. Referred-but-not admitted/screened-out log
5. Staffing patterns/waivers/staff development, supervision, and training documentation
6. After-hours services plan
7. Meeting minutes of the Special Review Committee and access to information about all incidents
8. Grievances/complaint documentation
9. Mechanism for recipient input into program operations
10. Completed ‘Employment Services Information’ form (General and aggregate information about employment services offered at the PROS program.)
11. Quality improvement process/outcome data
12. Selected personnel files
13. Program policy and procedure manual

June 26, 2013

Comments or questions about the information on this page can be directed to the Rehabilitation Services Unit.