Administrative Overview

ADMINISTRATIVE OVERVIEW SERVICE SPECIFIC ATTACHMENT Medication Dispensing System

A. Please describe how your Medication Dispensing System works:

B. After receiving a call from the ASAP to initiate service, describe your agency's procedures. Include expected time frames. What is the average time between ASAP referral and the start of service to the client?

C. What is your policy for notifying ASAP agency about problems encountered that affect or could affect completion of the authorized service?

D. Describe your process for testing in-home equipment. How frequently is testing done? What documentation is kept on file? Who is responsible for the testing?

E. What is your proposed service rate for Medication Dispensing System?

$ per Describe any additional charges.

F. In the event of a power failure (e.g. electric, telephone), will the medication dispenser continue to access medications?

G. What is your agency’s policy in the event that equipment is damaged or lost?

H. Describe the process for retrieval of equipment once a client is terminated from ASAP agency:

1 SERVICE SPECIFIC ON-SITE REVIEW Medication Dispensing System

Please note the documents and records which will be required for the client files and/or employee files to be reviewed at the time of on site evaluation.

Employee Records Review

Provider: ______

Date: ______

Monitor: ______

Start Date Termination Date Number of reference checks

Orientation: Date

Job Description(s)

Ongoing training: dates

Annual Performance Appraisal: Date

Licenses

CORI Check

Comments

2 SERVICE SPECIFIC ON-SITE REVIEW Medication Dispensing System

Please note the documents and records which will be required for the client files and/or employee files to be reviewed at the time of on- site evaluation.

Client Records Review

Provider: ______

Date: ______

Monitor: ______

Current Authorization in file

ID Info – name; address; phone; DOB

Emergency Responder(s) name, phone, location of keys.

Physician(s) name and phone

Hospital name and phone

Medical/ social diagnosis

Name of current CM/RN Source of referral Date of referral Service start date

BLDG # written on referral, if applicable Installation date

Termination: date, removal of unit, if applicable

Comments