{"text_format":"1","workbook":"xlsx","n_sheets":2,"sheets":["Sheet1","Sheet2"],"not_rendered":{"charts":0,"images":0,"macros":1,"external_links":0,"defined_names":6,"comments":0,"pivot_tables":0},"unopened":[],"bounds":{"document_bytes":16777216,"sheet_cells":100000,"rows_first":2000,"rows_last":500,"rows_between":2000,"halvings":0,"cell_chars":16384,"cell_head_chars":4096},"cells_cut":0,"cells_raw":0,"read":"whole","date_system":"1900"}

{"sheet":"Sheet1","index":0,"n_rows":290,"n_cols":3,"rows_kept":290,"cut":false,"hidden":false,"merged":[[263,0,263,2],[262,0,262,1],[260,0,260,1],[249,0,249,1],[250,0,250,1],[259,0,259,1],[275,0,275,2],[273,0,273,2],[268,0,268,2],[265,0,265,2],[264,0,264,1],[266,0,266,1],[267,0,267,2],[61,0,61,2],[0,0,0,2],[7,0,11,0],[16,0,21,0],[22,0,22,1],[1,0,1,2],[29,0,29,2],[130,0,130,2],[187,0,187,2],[200,0,200,2],[214,0,214,2],[245,0,245,1],[228,0,228,2],[242,0,242,2],[241,0,241,1],[237,0,237,1],[238,0,238,1],[239,0,239,1],[229,0,229,2],[232,0,232,1],[233,0,233,1],[240,0,240,1],[243,0,243,1],[88,0,88,2],[109,0,109,2],[279,0,279,2],[230,0,230,1],[231,0,231,1],[234,0,234,1],[236,0,236,2],[235,0,235,1],[248,0,248,1],[246,0,246,2],[251,0,251,2],[247,0,247,1],[270,0,270,2],[272,0,272,2],[277,0,277,2],[261,0,261,2],[290,0,290,2],[291,0,291,2],[281,0,281,2],[285,0,285,2],[287,0,287,2],[289,0,289,2],[283,0,283,2],[244,0,244,1],[252,0,252,1],[253,0,253,1],[254,0,254,1],[258,0,258,1],[255,0,255,1],[256,0,256,1],[257,0,257,1]]}
["DODD Medication Administration (MA) and Health Related Activities (HRA) RN Quality Assessment Review"]
["Site Review Information"]
["Site Address"," "]
["Site Phone Number"," "]
["Provider Name"," "]
["Provider Address"," "]
["Provider Phone Number "," ","MA/HRA Support  Provided "]
["Individual(s) at site OR            ADS Sample Individuals","(Name & DOB)                                                    "]
[null,"(Name & DOB)                                                    "]
[null,"(Name & DOB)                                                    "]
[null,"(Name & DOB)                                                    "]
[null,"(Name & DOB)                                                    "]
["Site Visit Date"]
["Last QA Review Completed at this Provider Location"]
["Other Providers at this Location NOT included in this RN QA","(Provider Name, contact name, and phone #)"]
["RN QA Reviewer","(Name & Credentials)","DATE "]
["Personnel Observed and/or Interviewed","(Name & Title)"]
[null,"(Name & Title)"]
[null,"(Name & Title)"]
[null,"(Name & Title)"]
[null,"(Name & Title)"]
[null,"(Name & Title)"]
[null,null,"DATE "]
["Date of Observational Visit"," "]
["Report Sent To:","(Name of Agency Contact or Private Provider Name) "]
["Report Sent To:","(Name of CBDD Representative)"]
["Name & Date Report Response received from Provider","(Plan of Improvement)"]
["Date Plan of Improvement and Initiation of Implementation affirmed by QA RN as Sufficient","(Comments optional)"]
["Date the Insufficient POI/Initiation and QA Form Sent to the County Board and DODD [optional] (OAC 5123:2-6-07(D)(11))","(Provide details of insufficiencies)"]
["Certification & Provider Supervision"]
["CPS 1","Were the certifications for all MA certified UDDP (Unlicensed DD Personnel) able to be verified on the DODD Medication Administration Certification Verification site at https://mais.prodapps.dodd.ohio.gov/MAIS_PublicAccess.aspx by the QA RN?"]
["CPS 1a","If no, state the reason in the box below."]
[null," "]
["CPS 1b","If UDDP were noted to have provided MA/HRA with an invalid/expired certification, please indicate steps taken to remove the UDDP(s) from duty in box below."]
[]
["CPS 2","Is there evidence of a process to ensure that MA certifications for UDDP are verified by the agency/supervisor prior to the start of MA/HRA using the DODD Medication Administration Certification Verification site (https://mais.prodapps.dodd.ohio.gov/MAIS_PublicAccess.aspx)?"]
["CPS 2a","Is there evidence that the process is effective?    "]
["CPS 2b","Briefly describe the process, including how individuals are identified; or if the process is missing/ineffective, please note area(s) of concern in box below.  Then, in blue drop down box to the right of the text box, please rate the process: 0 = No Process; 1 = Incomplete or Ineffective Process; 2 = Effective Process  "]
[]
["CPS 3","Is there evidence of a process used by the agency/supervisor to track expiration dates to ensure MA certifications are current? "]
["CPS 3a","Is there evidence that the process is effective?"]
["CPS 3b","Briefly describe the process. If the process is missing/ineffective, please note area(s) of concern in box below.  Then, in blue drop down box to the right of the text box, please rate the process: 0 = No Process; 1 = Incomplete or Ineffective Process; 2 = Effective Process  "]
[]
["CPS 4","Is there evidence of a process to ensure that UDDP receive Individual Specific Training after certification and prior to the initial performance of MA or HRA for each individual? "]
["CPS 4a","Is there evidence that the process is effective? "]
["CPS 4b","Briefly describe the process. If the process is missing/ineffective, please note area(s) of concern in box below.  Then, in blue drop down box to the right of the text box, please rate the process: 0 = No Process; 1 = Incomplete or Ineffective Process; 2 = Effective Process  "]
[]
["CPS 5","Is there evidence of a process for ensuring that UDDP have had annual skill checks for each skill currently being used? "]
["CPS 5a","Is there evidence that the process is effective? "]
["CPS 5b ","Briefly describe the process. If the process is missing/ineffective, please note area(s) of concern in box below.  Then, in blue drop down box to the right of the text box, please rate the process: 0 = No Process; 1 = Incomplete or Ineffective Process; 2 = Effective Process  "]
[]
["CPS 6","Is there evidence of a process for agency/supervisor's on-going monitoring of UDDP utilization of correct MA/HRA techniques and documentation?"]
["CPS 6a","Is there evidence that the process is effective? "]
["CPS 6b","Briefly describe the process. If the process is missing/ineffective, please note area(s) of concern in box below.  Then, in blue drop down box to the right of the text box, please rate the process: 0 = No Process; 1 = Incomplete or Ineffective Process; 2 = Effective Process  "]
[]
["CPS 7","Is anyone in the setting prescribed VNS or epinephrine auto-injector; or using OTC topical products without a prescription?  "]
["CPS 7a","Is there evidence of a process that ensures UDDPs have had the required DODD training for the medication(s)/task(s)? "]
["CPS 7b","Is there evidence of a process that ensures UDDPs have had IST related to the medication(s)/task(s)? "]
["CPS 7c","Is there evidence that the processes are effective? "]
["CPS 7d","Briefly describe the processes. If the processes are missing/ineffective, please note area(s) of concern in box below.  Then, in blue drop down box to the right of the text box, please rate the processes: 0 = No Process; 1 = Incomplete or Ineffective Process; 2 = Effective Process  "]
[]
["Preparation "]
["Prep 1","Is there evidence of a process that ensures a current DODD approved Self-Administration Assessment is completed, for individuals who are not able to self-administer or self-administer with assistance; that the outcome is specified in the ISP; and that the steps that individuals CAN do are specified in the ISP?  (OAC 5123:2-6-02)"]
["Prep 1a","Is there evidence that the UDDP are following the outcome recommendations as indicated in the ISP for each individual receiving MA/HRA?  Are the identified areas of independence/support implemented by the provider for individuals receiving MA/HRA?"]
["Prep 1b","Is there evidence of a process to ensure that a new Self-Administration Assessment is completed at least once every three (3) years, with review of the current assessment at least annually and/or when significant changes related to MA/HRA were noted for individual(s) receiving MA/HRA? "]
["Prep 1c","Briefly describe the process. If the process is missing/ineffective, please note area(s) of concern in box below.  Then, in blue drop down box to the right of the text box, please rate the process: 0 = No Process; 1 = Incomplete or Ineffective Process; 2 = Effective Process  "]
[]
["Prep 2","Is there evidence of a process for clean, secure storage and care of medications including disposal of expired, contaminated, and/or discontinued medications? "]
["Prep 2a","Is there evidence that UDDP act according to the process?"]
["Prep 2b","Were interviewed UDDP knowledgeable about the process?"]
["Prep 2c","Briefly describe the process.   If the process is missing/ineffective, please note area(s) of concern in box below.  Then, in blue drop down box to the right of the text box, please rate the process: 0 = No Process; 1 = Incomplete or Ineffective Process; 2 = Effective Process  "]
[]
["Prep 3","Is there evidence of a process for tracking and accounting for prescribed controlled substances?  "]
["Prep 3a","Is there evidence that UDDP follow the process? "]
["Prep 3b","Is there evidence that the process is monitored by the employer/agency?"]
["Prep 3c","Were interviewed UDDP knowledgeable about the process?"]
["Prep 3d","Briefly describe the process. If the process is missing/ineffective, please note area(s) of concern in box below.  Then, in blue drop down box to the right of the text box, please rate the process: 0 = No Process; 1 = Incomplete or Ineffective Process; 2 = Effective Process  "]
[]
["Prep 4","Is there evidence of a process to ensure UDDP follow Universal Precautions when performing medication administration or HRAs?"]
["Prep 4a","Is there evidence that UDDP have needed supplies and act according to the process? "]
["Prep 4b","Were interviewed UDDP knowledgeable about the process?"]
["Prep 4c","Briefly describe the process. If the process is missing/ineffective, please note area(s) of concern in box below.  Then, in blue drop down box to the right of the text box, please rate the process: 0 = No Process; 1 = Incomplete or Ineffective Process; 2 = Effective Process  "]
[]
["Prep 5","Is there evidence of a process that ensures that there are prescriber’s orders with clear objective parameters for OTC medications, PRN medications, prescribed HRAs and dosage changes?  "]
["Prep 5a","Is there evidence that prescribed OTC, PRN and HRAs are administered/completed and follow specified parameters? "]
["Prep 5b","Were interviewed UDDP knowledgeable about the process? "]
["Prep 5c","Briefly describe the process. If the process is missing/ineffective, please note area(s) of concern in box below.  Then, in blue drop down box to the right of the text box, please rate the process: 0 = No Process; 1 = Incomplete or Ineffective Process; 2 = Effective Process  "]
[]
["Observation"]
["Obs. 1","Is there evidence of a process to ensure proper steps, as directed by the curriculum, are followed when administering routine/scheduled/PRN medications to the individuals who are not able to self-administer?   "]
["Obs. 1a","Are step-by-step instructions available for UDDP for all methods of Routine MA utilized in the setting? "]
["Obs. 1b","Is there evidence that UDDP are adhering to assurance of the 6 Rights of medication administration?"]
["Obs. 1c","Were interviewed UDDP aware of step-by-step instructions (where, why, and when to use them)?"]
["Obs. 1d","Is there evidence that UDDP know why each medication is prescribed and how it should affect the individual?"]
["Obs. 1e","Is there evidence that UDDP have ready access to information regarding potential side effects of medications, and know how/whom to report potential side effects? "]
["Obs. 1f","Briefly describe the process. If the process is missing/ineffective, please note area(s) of concern in box below.  Then, in blue drop down box to the right of the text box, please rate the process: 0 = No Process; 1 = Incomplete or Ineffective Process; 2 = Effective Process  "]
[]
["Obs. 2","Is there evidence of a process to ensure proper steps and indicated parameters are followed when administering PRN medications? "]
["Obs. 2a","Are step-by-step instructions available for UDDP for all methods of PRN MA utilized in the setting? "]
["Obs. 2b","Is there evidence that UDDP understand and are following indicated parameters for PRN medications?"]
["Obs. 2c","Were interviewed UDDP aware of step-by-step instructions (where, why, and when to use), and whom to contact with questions about PRN MA? "]
["Obs. 2d","Briefly describe the process. If the process is missing/ineffective, please note area(s) of concern in box below.  Then, in blue drop down box to the right of the text box, please rate the process: 0 = No Process; 1 = Incomplete or Ineffective Process; 2 = Effective Process  "]
[]
["Obs. 3","Is there evidence of a process to ensure proper steps, as indicated, are followed when completing a HRA, including consideration of parameters as appropriate? "]
["Obs. 3a","Are step-by-step instructions available for UDDP for all HRA utilized in the setting? "]
["Obs. 3b","Is there evidence that UDDP understand and are following indicated parameters for HRA?"]
["Obs. 3c","Were interviewed UDDP aware of step-by-step instructions (where, why, and when to use), and whom to contact with questions about HRAs? "]
["Obs. 3d","Briefly describe the process. If the process is missing/ineffective, please note area(s) of concern in box below.  Then, in blue drop down box to the right of the text box, please rate the process: 0 = No Process; 1 = Incomplete or Ineffective Process; 2 = Effective Process  "]
[]
["Documentation"]
["Doc 1","Is there evidence of a process for confirming accurate transcription of medication and/or HRA orders by UDDP?"]
["Doc 1a","Is there evidence that UDDP follow the process?"]
["Doc 1b","Were interviewed UDDP knowledgeable about the process? "]
["Doc 1c","Briefly describe the process. If the process is missing/ineffective, please note area(s) of concern in box below.  Then, in blue drop down box to the right of the text box, please rate the process: 0 = No Process; 1 = Incomplete or Ineffective Process; 2 = Effective Process   "]
[]
["Doc 2","Is there evidence of a process for ensuring the complete and accurate documentation of MA performed by the UDDP that includes medications given and/or missed, held, refused, or discontinued?"]
["Doc 2a","Is there evidence that UDDP know and follow the process? "]
["Doc 2b","Were interviewed UDDP knowledgeable about the process? "]
["Doc 2c","Briefly describe the process. If the process is missing/ineffective, please note area(s) of concern in box below.  Then, in blue drop down box to the right of the text box, please rate the process: 0 = No Process; 1 = Incomplete or Ineffective Process; 2 = Effective Process  "]
[]
["Doc 3","Is there evidence of a process for ensuring complete and accurate documentation of HRAs performed by the UDDP that includes activities completed and/or missed, held, refused, or discontinued?"]
["Doc 3a","Is there evidence that UDDP know and follow the process? "]
["Doc 3b","Were interviewed UDDP knowledgeable about the process? "]
["Doc 3c","Briefly describe the process. If the process is missing/ineffective, please note area(s) of concern in box below.  Then, in blue drop down box to the right of the text box, please rate the process: 0 = No Process; 1 = Incomplete or Ineffective Process; 2 = Effective Process  "]
[]
["Doc 4","Is there evidence of a process by which initials/signatures of UDDP documenting on the MAR can be identified? "]
["Doc 4a","Is there evidence that UDDP know and follow the process?"]
["Doc 4b","Were interviewed UDDP knowledgeable about the process? "]
["Doc 4c","Briefly describe the process. If the process is missing/ineffective, please note area(s) of concern in box below.  Then, in blue drop down box to the right of the text box, please rate the process: 0 = No Process; 1 = Incomplete or Ineffective Process; 2 = Effective Process   "]
[]
["Coordination of Care/Communication "]
["CC 1","Is there evidence of a process for the reporting of situations/symptoms as defined in the Training Manual for Certification 1 Prescribed Medications and Health Related Activities? "]
["CC 1a","Is there evidence that UDDP follow the process? "]
["CC 1b","Were interviewed UDDP knowledgeable about the process?"]
["CC 1c","Briefly describe the process. If the process is missing/ineffective, please note area(s) of concern in box below.  Then, in blue drop down box to the right of the text box, please rate the process: 0 = No Process; 1 = Incomplete or Ineffective Process; 2 = Effective Process  "]
[]
["CC 2","Is there evidence of a process for reporting medication errors, unsafe MA, and unsafe HRA practices as Unusual Incidents (UI)/Major Unusual Incidents (MUI)? "]
["CC 2a","Is there evidence that UDDP follow the process? "]
["CC 2b","Were interviewed UDDP knowledgeable about the process? "]
["CC 2c","Are there documented MA/HRA errors during the past 12 months?  Please describe in the box below."]
[]
["CC 2d","Is there evidence of a pattern in any documented MA/HRA errors?  If yes, please describe in the box below."]
[]
["CC 2e","Is there evidence of follow-up and documentation related to the MA/HRA errors?  Please describe in the box below.  "]
[]
["CC 2f","Are there unresolved issues related to the documented/undocumented MA/HRA errors? Please describe in the box below."]
[]
["CC 2g","Briefly describe the process. If the process is missing/ineffective, please note area(s) of concern in box below.  Then, in blue drop down box to the right of the text box, please rate the process: 0 = No Process; 1 = Incomplete or Ineffective Process; 2 = Effective Process  "]
[]
["CC 3","Is there evidence of a process for addressing the administration of medications and/or HRAs when individuals are not at home; such as community outings or a family visit?"]
["CC 3a","Is there evidence that UDDP follow the process? "]
["CC 3b","Were interviewed UDDP knowledgeable about the process? "]
["CC 3c","Briefly describe the process. If the process is missing/ineffective, please note area(s) of concern in box below.  Then, in blue drop down box to the right of the text box, please rate the process: 0 = No Process; 1 = Incomplete or Ineffective Process; 2 = Effective Process  "]
[]
["CC 4","Is there evidence of a process for provision of MA and/or HRA if the scheduled personnel is unavailable?  (What is the back-up plan?) "]
["CC 4a","Is there evidence that all UDDPs know and have access to the back-up plan? "]
["CC 4b","Were interviewed UDDP knowledgeable about the process?"]
["CC 4c","Briefly describe the process. If the process is missing/ineffective, please note area(s) of concern in box below.  Then, in blue drop down box to the right of the text box, please rate the process: 0 = No Process; 1 = Incomplete or Ineffective Process; 2 = Effective Process  "]
[]
["CC 5","Is there evidence of a process for addressing urgent/emergency situations with emergency numbers easily accessible? "]
["CC 5a","Is there evidence that UDDP follow the process? "]
["CC 5b","Were interviewed UDDP knowledgeable about the process? "]
["CC 5c","Briefly describe the process. If the process is missing/ineffective, please note area(s) of concern in box below.  Then, in blue drop down box to the right of the text box, please rate the process: 0 = No Process; 1 = Incomplete or Ineffective Process; 2 = Effective Process  "]
[]
["CC 6","Is there evidence of a process for locating the emergency contact(s) for the individual(s) receiving MA/HRA? "]
["CC 6a","Is there evidence that UDDP know and use the process? "]
["CC 6b","Were interviewed UDDP knowledgeable about the process?"]
["CC 6c","Briefly describe the process. If the process is missing/ineffective, please note area(s) of concern in box below.  Then, in blue drop down box to the right of the text box, please rate the process: 0 = No Process; 1 = Incomplete or Ineffective Process; 2 = Effective Process  "]
[]
["CC 7","Is there evidence of a process for scheduling routine and as needed appointments in a timely manner?"]
["CC 7a","Is there evidence of a process for UDDP (or persons assisting with appointments) to know and communicate current health information to Healthcare Providers, as needed, and at appointments?"]
["CC 7b","Is there evidence of a process for UDDP (and/or person(s) assisting with appointments) to record and relay information following health appointments and/or contact with Healthcare Providers to all necessary support persons? This may include but is not necessarily limited to: guardians/family, managers, ADS, other UDDP, SSA and other Team members?"]
["CC 7c","Is there evidence that the communication of health and healthcare information, to and from Healthcare Personnel and team members, is effective?"]
["CC 7d","Is there evidence that the communication of health and healthcare information, to and from Healthcare Personnel and team members, is known and used by UDDP?"]
["CC 7e","Were interviewed UDDP knowledgeable about the process?"]
["CC 7f","Briefly describe the process. If the process is missing/ineffective, please note area(s) of concern in box below.  Then, in blue drop down box to the right of the text box, please rate the process: 0 = No Process; 1 = Incomplete or Ineffective Process; 2 = Effective Process  "]
[]
["CC 8","Is there evidence of a process that ensures new or changed orders for MA and HRA (and the reasons for them) or changes in health conditions (diagnosis/status) are recorded and communicated to all applicable team members and personnel? (such as family/guardian, other UDDP, ADS, other Healthcare Providers, SSA, etc.)  "]
["CC 8a","Is there evidence that all team members know and follow this process?"]
["CC 8b","Were the interviewed UDDP knowledgeable about the process?"]
["CC 8c","Briefly describe the process. If the process is missing/ineffective, please note area(s) of concern in box below.  Then, in blue drop down box to the right of the text box, please rate the process: 0 = No Process; 1 = Incomplete or Ineffective Process; 2 = Effective Process  "]
[]
["CC 9","Is there evidence of a process for obtaining needed supplies, new medications and/or refills in a timely manner?"]
["CC 9a","Is there evidence that UDDP know and use this process?"]
["CC 9b","Were interviewed UDDP knowledgeable about this process?"]
["CC 9c","Briefly describe the process. If the process is missing/ineffective, please note area(s) of concern in box below.  Then, in blue drop down box to the right of the text box, please rate the process: 0 = No Process; 1 = Incomplete or Ineffective Process; 2 = Effective Process  "]
[]
["Delegation of Nursing Tasks "]
["D 1","Are any nursing TASKS being delegated per OAC 4723-13? (Other than G/J Tube medications/nutrition/fluids, and insulin or injectable treatments for metabolic glycemic disorders).  If no delegated nursing tasks, select \"N/A\" in drop down box D 1 and D 10 and continue to the next section.  "]
["D 2","Is there evidence of a current RN assessment?  (Assessment to be completed prior to the start of delegation and reassessed, at a minimum, annually)"]
["D 3","Is there evidence of a process to ensure current orders for the delegated treatment?"]
["D 4","Is there evidence of UDDP having received proper training as specified in OAC 4723-13? "]
["D 5","Is there evidence of a statement of nursing delegation for delegated tasks?"]
["D 6","Is there evidence of the UDDP receiving delegation from a nurse, including Individual Specific Training, for the individual(s) receiving this support?"]
["D 7","Is there evidence of  step-by-step instructions for delegated actions to be taken, including applicable parameters?"]
["D 8","Were interviewed UDDP knowledgeable about the task and delegation process? "]
["D 9","Were interviewed UDDP able to identify the delegating nurse and how/when/why to contact the nurse directly?  Indicate method of contact in box below.   "]
[]
["D 10","Briefly describe the process. If the process is missing/ineffective, please note area(s) of concern in box below.  Then, in blue drop down box to the right of the text box, please rate the process: 0 = No Process; 1 = Incomplete or Ineffective Process; 2 = Effective Process  "]
[]
["Delegation of G-Tube, J-Tube Medications/Nutrition/Fluids"]
["GJ 1","Do any of the individuals receive medications/nutrition/fluids via G-Tube or J-Tube?   If no G/J Tube delegation, select \"N/A\" in drop down box GJ 1 and GJ 11 and continue to the next section.  "]
["GJ 2","Is there evidence of a current RN assessment?  (Assessment to be completed prior to the start of delegation and reassessed, at a minimum, annually)"]
["GJ 3","Does the RN assessment indicate that the tube is stable and labeled? "]
["GJ 4","Is there evidence of a process to ensure current orders  are in place, and only transcribed by a nurse, for any medication, nutrition, or fluids directed by a person with Ohio prescriptive authority?"]
["GJ 5","Is there evidence of UDDP having proper Cat 1 and Cat 2 Certification for MA via G-Tube or J-Tube? "]
["GJ 6","Is there evidence of a statement of nursing delegation for medication, nutrition, or fluids via G-Tube or J-Tube? "]
["GJ 7","Is there evidence of the UDDP each receiving delegation from a nurse, including Individual Specific Training, for the individual(s) receiving this support?"]
["GJ 8","Is there evidence of  step-by-step instructions for all actions to be taken with G/J tube, including applicable parameters?"]
["GJ 9","Were interviewed UDDP knowledgeable about the task, availability of step-by-step instructions, and delegation process? "]
["GJ 10","Were interviewed UDDP able to identify the delegating nurse and how/when/why to contact the nurse directly?  Indicate method of contact in box below.  "]
[]
["GJ 11","Briefly describe the process. If the process is missing/ineffective, please note area(s) of concern in box below.  Then, in blue drop down box to the right of the text box, please rate the process: 0 = No Process; 1 = Incomplete or Ineffective Process; 2 = Effective Process  "]
[]
["Delegation of Insulin and/or Injectable Treatments for Metabolic Glycemic Disorders"]
["INJ 1","Do any of the individuals receive insulin or injectable treatments for metabolic glycemic disorders that are not self-administered?    If no insulin or injectable treatments for metabolic glycemic disorders are delegated, select \"N/A\" in drop down box INJ 1 and INJ 11 and continue to the next section.  "]
["INJ 2","Is there evidence of a current RN assessment?  (Assessment to be completed prior to the start of delegation and reassessed, at a minimum, annually)"]
["INJ 3","Is there evidence of a process to ensure current orders are in place, and only transcribed by a nurse, for any insulin or injectable treatments for metabolic glycemic disorders  directed by a person with Ohio prescriptive authority?"]
["INJ 4","Is there evidence of UDDP having proper Cat 1 and Cat 3 Certification for administration of insulin or injectable treatments for metabolic glycemic treatments? "]
["INJ 5","Is there evidence of a statement of nursing delegation for insulin or injectable treatments for metabolic glycemic disorders? "]
["INJ 6","Is there evidence of the UDDP each receiving delegation from a nurse, including Individual Specific Training, for the individual(s) receiving this support?"]
["INJ 7","Is there evidence of  step-by-step instructions for all actions to be taken for the administration of insulin or injectable treatments for metabolic glycemic disorders, including applicable parameters?"]
["INJ 8","Were interviewed UDDP knowledgeable about the task, availability of step-by-step instructions, and delegation process? "]
["INJ 9","Were interviewed UDDP able to identify the delegating nurse and how/when/why to contact the nurse directly?  Indicate method of contact in box below."]
[]
["INJ 10","Was a labeled container available for the disposal of sharps?"]
["INJ 11","Briefly describe the process. If the process is missing/ineffective, please note area(s) of concern in box below.  Then, in blue drop down box to the right of the text box, please rate the process: 0 = No Process; 1 = Incomplete or Ineffective Process; 2 = Effective Process  "]
[]
["Outcomes:  0 = No Process; 1 = Incomplete or Ineffective Process; 2 = Effective Process  "]
["Certification and Provider Supervision"]
["MA Certification on DODD Website",null,{"$f":"C39","v":0}]
["Agency/Supervisor Tracking MA Certification Dates",null,{"$f":"C43","v":0}]
["Individual Specific Training",null,{"$f":"C47","v":0}]
["Maintain Annual Skills Checks ",null,{"$f":"C51","v":0}]
["Provider Monitoring for Correct Technique and Documentation",null,{"$f":"C55","v":0}]
["Use of VNS, Epinephrine auto-injector, and/or OTC Topical Products Without Prescription",null,{"$f":"C61","v":0}]
["Preparation"]
["Self-Administration Assessment",null,{"$f":"C67","v":0}]
["Storage and Care of Medications",null,{"$f":"C72","v":0}]
["Controlled Substances",null,{"$f":"C78","v":0}]
["Standard and Universal Precautions",null,{"$f":"C83","v":0}]
["Orders for Medications and Health Related Activities from Ohio Authorized Prescriber",null,{"$f":"C88","v":0}]
["Observation"]
["Implementation of Proper Steps in Administration of Routine Medications",null,{"$f":"C97","v":0}]
["Implementation of Proper Steps in Administration of PRN Medications",null,{"$f":"C103","v":0}]
["Implementation of Proper Steps in the Completion of HRAs",null,{"$f":"C109","v":0}]
["Documentation"]
["Transcription of Orders onto Medication/Treatment Administration Record ",null,{"$f":"C115","v":0}]
["Documentation of MA",null,{"$f":"C120","v":0}]
["Documentation of HRAs",null,{"$f":"C125","v":0}]
["Corresponding Signatures and Initials on Medication/Treatment Administration Record",null,{"$f":"C130","v":0}]
["Coordination of Care/Communication"]
["Reportable Situations or Symptoms",null,{"$f":"C136","v":0}]
["Medication Errors, Unsafe MA, Unsafe HRA, UI/MUIs",null,{"$f":"C149","v":0}]
["Preparation for Outings",null,{"$f":"C154","v":0}]
["If Scheduled Personnel is Unavailable",null,{"$f":"C159","v":0}]
["Emergency or Urgent Situations",null,{"$f":"C164","v":0}]
["Emergency Contacts",null,{"$f":"C169","v":0}]
["Communication Regarding Healthcare Appointments",null,{"$f":"C177","v":0}]
["Changed Orders for MA and/or HRA",null,{"$f":"C182","v":0}]
["New or Refilled Medications",null,{"$f":"C187","v":0}]
["Delegation of Nursing Task(s)"]
["Nursing Delegation",null,{"$f":"C200","v":0}]
["Delegation of G-tube, J-tube Medications/Nutrition/Fluids"]
["G-Tube/J-Tube Medications/Nutrition/Fluids, Certification 2",null,{"$f":"C214","v":0}]
["Delegation of Insulin and/or Injectable Treatments for Metabolic Glycemic Disorders"]
["Insulin and/or Injectable Treatments for Metabolic Glycemic Disorders, Certification 3",null,{"$f":"C228","v":0}]
["RN Findings & Recommendations"]
["Processes and Performance areas of strength: Processes that are well developed as evidenced by functional outcomes of safe accurate medication administration and well prepared certified UDDP"]
[]
["Immediate Action Required (Note to Provider: Your QA RN is available, upon request, to offer guidance or for assisting to locate resources for the correction of any identified issues) "]
[]
["Concerns and Root Causes Identified by RN Assessment and RN Recommendations (Note to Provider: Your QA RN is available upon request to offer information, direction to resources for needed education, or guidance in the correction of any identified issues) "]
["Certification and Provider Supervision"]
[]
["Preparation"]
[]
["Observation"]
[]
["Documentation"]
[]
["Coordination of Care"]
[]
["Delegation of Nursing Task(s)"]
[]
["G/J Tube"]
[]
["Insulin and/or Injectable Treatments for Metabolic Glycemic Disorders"]
[]
["POI or any subsequent reports and documentation related to this review should use the Review Date, Address and Provider Name in the title to identify documents as specifically related to this review."]

{"sheet":"Sheet2","index":1,"n_rows":7,"n_cols":4,"rows_kept":7,"cut":false,"hidden":false,"merged":[]}
["YesNo","Rating","MAService","Title"]
["Yes ",0,"Routine","Director"]
["No",1,"PRN","DSP"]
["Partial",2,"Both","Guardian / Family"]
["N/A","N/A","None ","Site Manager"]
[null,null,null,"SSA"]
[null,null,null,"Other"]