Questionnaire for Situational Information

Questionnaire for Situational Information
Information about the QSI for Waiver Support Coordinators This presentation provides information about the Questionnaire for Situational Information (the QSI) for Waiver Support Coordinators. It has been prepared by the Agency for Persons with Disabilities. Session One includes background information and answers to questions about the role of the Waiver Support Coordinator with the QSI. Session Two provides in-depth information about the content of the QSI. To view this session, follow these instructions. The narration contains additional information. Click on the Notes tab on the right side of the window to view the text of the narration. Click the arrow on the left side of the control bar at the bottom of the window to begin Session One. Questionnaire for Situational Information

Information for Waiver Support Coordinators Session One provides information about the QSI that is important for Waiver Support Coordinators. You can download a copy of the QSI to view during the presentation. Click on the paper clip icon on the bottom right of the window. Select the QSI Version 4.0 file to download and print. Questionnaire for Situational Information

What is the purpose of the QSI? The QSI is a standardized needs assessment tool. It is designed to gather information about a person’s life situation. This information will be used to assist in planning for support and service needs and is only one part of a person-centered planning process. What is the purpose of the QSI? The QSI is a valid and reliable needs assessment tool developed by the Agency for Persons with Disabilities. It is designed to gather key information about a person to assist in planning for support and services. It is only one part of a person-centered planning process. Data resulting from the administration of this assessment will be used to better understand people served by APD both as individuals and as a group. Collective data from the QSI will be used to examine demographic characteristics and common support needs. What is learned from the QSI will assist in the development of more self-directed support and services options offered by the agency and will be used as important information in developing support plans. At the individual level, the agency’s policy is to promote person-centered planning in the delivery and management of services. Each person’s preferences and vision is paramount in developing goals, services, and success. As the person’s preferences and priorities change over time, APD will administer the QSI periodically and use it in combination with a variety of other types of information about the individual to build a person-centered approach to service delivery. The QSI information reflects a person's need for support in key life roles and areas of daily living. It focuses on the person’s need for assistance during the normal course of a routine day, as well as needs that relate to the person’s behavioral and physical status. Together these life areas are explored to identify information about the types of services and support the person may require now and in the future. Questionnaire for Situational Information

Why was the QSI developed? Florida Statute and federal regulations for Medicaid waivers require a standardized needs assessment process. A systematic and reliable instrument will be used to determine levels of services Client characteristics and other appropriate assessment methods are used along with the QSI to develop the support plan for the individual receiving services. Why was the QSI developed? Florida Statute and federal regulations for Medicaid waivers require the agency to use a standardized needs assessment process. The QSI is the systematic and reliable instrument that will be used. The QSI is the approved assessment tool for the Agency. The client characteristics and information including other assessment methods are used along with the QSI to develop the support plan for the individual receiving services. A QSI has been completed for all individuals currently on waiver programs. The Agency began completing the QSI for individuals who are on the waiting list for waiver services in April 2009. Questionnaire for Situational Information

How was the QSI created? Information was gathered from national experts to identify major barriers and supports for good health, safety, and quality of life Instruments used in Florida were evaluated. Florida Status Tracking Survey Individual Cost Guidelines Assessments used in other states were also reviewed Validity and reliability tests for the QSI have been completed How was the QSI created? Information was gathered from national experts to identify major barriers and supports for good health, safety, and quality of life. Instruments used in Florida were evaluated, including the Florida Status Tracking Survey and Individual Cost Guidelines. Assessments used in other states were also reviewed. Validity and reliability tests have been completed on the QSI and will continue to be conducted. Necessary refinements will be made to assure that the information gathered from the QSI accurately reflects a person’s support needs. Questionnaire for Situational Information

How is the QSI different from previous assessment tools? The QSI gathers information for planning. Impact of major life changes Support needed for community inclusion and fulfillment of adult roles The QSI includes vision, hearing, and communication in the assessment of Functional Status The assessment of Behavioral Status focuses on the types of support and intervention needed. The assessment of Physical Status remains focused on health and medical needs. How is the QSI different from previous assessment tools? Through conversations with the person and those who know him or her best, the QSI gathers information for planning, including the impact of major life changes and support needed for community inclusion and fulfillment of adult roles. The QSI includes vision, hearing, and communication in the assessment of Functional Status. The assessment of Behavioral Status focuses on the types of support and intervention needed by the person. The assessment of Physical Status remains focused on the types of support and intervention needed for medical and health care issues. Questionnaire for Situational Information

What is assessed by the QSI? General Information Life Change and Adjustment; Community Inclusion and Fulfillment of Valued Adult Roles Functional Status Behavioral Intervention and Support Status Physical Status What is assessed by the QSI? The content of the QSI targets a wide range of information. General Information includes the demographic and personal identification information from the ABC database. Life Changes and Community Inclusion focus on a person’s life changes and plans for the next year as well as the need for assistance while living, working, fulfilling valued adult roles, and participating in the community. Functional Status focuses on a person’s need for support during the normal course of a routine day for activities, such as hygiene, eating, and dressing. Information is also gathered about the person’s vision, hearing, communication, and ambulation. Behavioral Status focuses on the need for assistance and intervention as a result of one or more major behavioral issues. Physical Status focuses on the individual’s medical conditions and need for medications and other types of treatment. The APD certified assessor completes all of these sections. Questionnaire for Situational Information

How will the QSI be used? The QSI will be administered at the time of eligibility determination The results of the QSI will be used as a part of the person-centered planning process used to develop the person’s support plan The results of the QSI will be reviewed annually and re-administered at least every three years to identify possible changes How will the QSI be used? The QSI has been given to all persons on waiver services. It is currently being administered to those on the wait list. Eventually, the QSI will be administered at the time of APD eligibility determination. The results will be used by the support coordinator in combination with a person’s desired outcomes and preferences for the development of the person’s support plan. It will be reviewed at least annually by the support coordinator and family and people that are important in the person’s life. This dialogue and review will facilitate maintaining the accuracy of the QSI and will be helpful in identifying any possible changes needed in the QSI or in the development of the support plan. The QSI will be readministered at least every three years for persons served on the waiver program. The QSI can also be readministered to identify possible changes in the event that an individual experiences major life changes, such as moving from one residential setting to another, or when the person has experienced major changes in his or her behavioral or medical condition. Questionnaire for Situational Information

What is person centered planning? The person has the authority to define and pursue the goals important to them Personal relationships and community membership are valued All networks and systems of support must collaborate in support of the person’s goals and needs People and families must participate as valued partners in all decision making What is person centered planning? The person centered planning process builds on the personal strengths of each individual and focuses the planning for supports and services on the goals that are meaningful to the person. A person centered plan is creative and customized. It includes natural supports as a key part of the support system. Natural supports and community resources are identified to assist the person in meeting priority needs and achieving goals that are important so they can live, work, and play in their community. Individuals and their families participate as valued partners in all decision making. Questionnaire for Situational Information

How is the support plan developed using the QSI? Uses information gathered from the individual, family, and friends, the QSI, and other relevant information Reflects individually determined goals and needs and resources, including personal resources, natural supports, community resources, school systems, government programs, etc. The scores are not as critical as the information obtained from the QSI on the types of supports and services the individual needs. How is the support plan developed using the QSI? The support coordinator develops a support plan using a person centered planning process at least annually with the person, family, and friends. Information used during the person centered planning process comes from a variety of sources, including the QSI, to develop the most effective support plan to meet the individual’s needs. The support plan is based on the individual’s personal goals and needs for supports and services. The information gathered from the QSI contains additional descriptions and details about the person’s needs that are not solely based on the numerical scores in the assessment tool. Questionnaire for Situational Information

Who can administer the QSI? Qualified assessors are hired by APD area offices. They must be certified to administer the Questionnaire. QSI assessors are required to have a bachelor’s degree and four years of related experience working with persons with developmental disabilities. They must demonstrate competencies in conducting interviews and reliability in rating the items. Who can administer the QSI? Qualified assessors are hired by APD area offices. They must be certified to administer the Questionnaire. QSI assessors are required to have a bachelor’s degree and four years of related experience working with persons with developmental disabilities. They must demonstrate competencies in conducting interviews and reliability in rating the items. Questionnaire for Situational Information

How is the QSI completed? The QSI assessor reviews the current Support Plan and other relevant records to identify general information, accomplishments, goals, health history, and service details. Face-to-face interviews are conducted with the person with a disability and the legal representative, and others as appropriate. The QSI assessor analyzes the information and rates the items. The ratings are recorded in QSI online application. How is the QSI completed? The QSI assessor reviews the current Support Plan and other related records to identify general information, accomplishments, goals, health history, and service details. Face-to-face interviews are conducted with the person and the legal representative, and others as appropriate. If the person is legally competent, the assessor only needs to interview him or her. The assessor must obtain consent from the person or legal representative to interview others, including family members and personnel who provide services for the individual. The support coordinator does not have to be present during the interview or assessment process. However, the QSI assessor will also include information from the support coordinator when learning about the person. The assessor analyzes the information and rates the items on the QSI. The ratings are recorded in the QSI online application. Questionnaire for Situational Information

Who gets the results? A synopsis report is provided to the person or legal representative. A complete copy can be provided, on request. The person or legal representative may give others a copy of the report, if they wish. The support coordinator will review the results of the completed QSI and review the support plan to be sure it addresses all necessary supports and services. Who gets the results? A synopsis report of the QSI assessment is provided to the person by the assessor. This report includes all items on the questionnaire and the rating assigned to each one. A complete copy with all possible ratings can be provided at the request of the person or guardian. The person or legal representative may choose to give others a copy of the report. If the QSI is changed or updated, the support coordinator will print a copy of the synopsis report for the individual’s central record. Questionnaire for Situational Information

What is the QSI online tool? All assessments are recorded and stored using the QSI online tool, available on the APD intranet The support coordinator will be able to access the records of the persons served The local Area Office will provide training on the online tool. The Central Office will give the support coordinator a password and username. What is the QSI online tool? All assessments are recorded and stored using the QSI online tool, available on the APD intranet. The QSI online tool provides a database to record and store all QSI assessments. The support coordinator will be able to access the records of the persons served. The support coordinator will be able to view the results and make a copy of the report. The local Area Office will provide training on the online system and the Central Office will provide the user name and password once the Area Office training is completed. Questionnaire for Situational Information

What is required of the support coordinator? The support coordinator will provide access to the records for the QSI assessor. Temporarily transfer records Follow protocol in Central Records Policy to secure records, including copies Provide records to the QSI assessor within three business days. What is required of the support coordinator? The QSI assessor will ask the support coordinator to provide access to the individual’s records. The support coordinator may temporarily transfer the records to the QSI assessor. The Central Records Operating Procedure and the protocol outlined in the procedure must be followed. Support coordinators are asked to provide records to the QSI assessor within three business days (or 72 hours) of the request. Questionnaire for Situational Information

What else is required of the support coordinator? Participate in interviews when requested. Use the results of the QSI and other relevant information to develop the person’s support plan. Responsible for noting changes in Life Changes and Community Inclusion. What else is required of the support coordinator? The support coordinator has valuable information about the individuals they support. The support coordinator may be asked to participate in the interviews when requested, and may be interviewed by the QSI assessor or may be asked to be present for the interviews of the individual they support or others. The results of the QSI, along with other assessments or reports about the individual will be important pieces to be used in the development of the person’s annual Support Plan. The QSI provides a comprehensive assessment of the person’s functional, behavioral, and physical status. Questionnaire for Situational Information

You have completed the first session. Go the second session to learn more about the content of the QSI. You have now completed the first session. Go to the second session to learn more about the content of the QSI. Click on Session Two at the top right of the screen or the arrow on the control bar at the bottom. Questionnaire for Situational Information

Content of the QSI Session Two: Content of the QSI The second session of the presentation provides in-depth information about the content of the QSI. If you haven’t already done so, you can download the copy of the QSI to use during the presentation. Click on the paper clip icon on the bottom right of the window. Select QSI Version 4.0 file to download and print. To view this session, follow these instructions. The narration contains additional information. On the right side of the window, click on the Notes tab to see the complete text of the narration. Click the arrow on the left side of the control bar at the bottom of the window to begin Session Two. Questionnaire for Situational Information

General Information/ Demographic Information This is a screen from QSI online tool, where all records are maintained for the QSI assessments. You will be able to search for the records you want to view. You can navigate to the different sections by clicking on the titles on the left. You will see a link to Demographic Information. This section is also called General Information in the paper copy. Questionnaire for Situational Information

General/Demographic Information The information is pre-filled from the ABC database. The support coordinator is responsible for ensuring that the ABC database is accurate and up-to-date. The support coordinator should immediately update ABC when changes or errors are identified. General/Demographic Information You can find this section on pages 5 and 6 in the QSI document. The General or Demographic Information is pre-filled in the online tool from the ABC database. If you find any information that is not accurate, follow standard procedures to submit the changes to update the ABC database immediately. You may also be asked by the QSI assessor for help with submitting changes to the ABC database. The General Information lists demographic information, life status, guardian information, current residence, and primary and secondary diagnoses. See pages 5-6 Questionnaire for Situational Information

Life Change and Adjustment Information Life Change and Adjustment Information This section provides an indication of the amount of stress that the individual may be experiencing due to major life changes. The ratings in this section are not included in the final levels of support calculations. However, it provides very important information for planning purposes. Questionnaire for Situational Information

Life Change and Adjustment Information Keep track of any changes that occur Include a description in your case notes for that day. Notify the QSI assessor if there is a significant change in condition Keep the ABC demographic information up to date As the individual’s support coordinator, you will be expected to keep track of any changes that occur in the person’s life and make a case note entry for that day. If you keep a paper copy of the synopsis report in the person’s central record, make notations on the paper copy. The support coordinator should notify the QSI assessor at any time there is a significant change in condition. You will also be expected to update ABC at any time you become aware of a change that will impact the demographic section of the QSI. Examples include a new address or change in guardianship status. It is your responsibility to keep the ABC demographic information up to date. Questionnaire for Situational Information

8a. Life Changes (examples) No life changes experienced Death or loss of a long-term caregiver Survivor of a major physical assault Gaining a new family member Major change in living conditions Major change in daytime activities Major change in eating habits We will now look at the items in this section. This is the first item, 8a. Life Changes. It is on page 7 in the QSI. The first option is “No life change experienced over the past 12 months.” Types of changes include death or loss of a long-term caregiver, survivor of a major physical assault, gaining a new family member, major change in living conditions, major change in daytime activities, and major change in eating habits. These are examples of the statements on the list. More than one statement can be checked. See page 7 Questionnaire for Situational Information

Levels of Life Change Stress Low Moderate Significant To follow-up, you may want to let caregivers know about the particular life changes and observe the person for any health or behavioral changes. Referrals for medical or behavioral support may be required if problems arise. The level of life stress is automatically calculated based on the statements that are checked. The level of stress is rated as low, moderate, or significant. You can find a description of these levels on page 7 of the QSI. To follow-up, you may want to let caregivers know about the particular life changes and observe the person for any health or behavioral changes. Referrals for medical or behavioral support may be required if problems arise. This is particularly important for individuals whose life stress rating is moderate or significant. See page 7 Questionnaire for Situational Information

8b. Signs and Symptoms of Emotional or Behavioral Distress (examples) Avoidance of favorite activities and friends Suicidal thoughts, plans or suicide attempts Property destruction (major, repeated) Self-injurious behaviors (pica, head banging, etc.) 8c. Was this person screened by a qualified professional for any of the conditions? 8b. and 8c. Signs and Symptoms of Emotional or Behavioral Distress Turn to page 8 in the QSI. These items are designed to identify signs and symptoms of emotional and behavioral distress that have had on-set or significant intensification in the past year. Examples include avoidance of favorite activities and friends; suicidal thoughts, plans, or suicide attempts; property destruction that is major or repeated; or self-injurious behaviors such as pica or head banging. Check to see if the person was screened by a qualified professional for any of the listed conditions. You should also make sure that the person has services and support to address the identified needs. See page 8 Questionnaire for Situational Information

8d. Life Changes that this Person is Likely to Experience (examples) Loss/change of significant long-term primary caregiver Major surgery requiring hospitalization Change in place of residence Major change in work or daytime activities 8d. Life Changes that this Person is Likely to Experience over the Next 12 Months. This is on page 8 in the QSI. This item asks if the person is likely to experience life changes in the next year. The list is similar to 8a. Examples include loss or change of a significant long-term primary caregiver, major surgery requiring hospitalization, or change in place of residence. Use this information to plan for skills and supports needed to deal with these changes. You may want to let caregivers know so they can plan appropriately for these changes. See page 8 Questionnaire for Situational Information

9a. Does the Person Plan to Move in the Next 12 Months? (examples) Chooses to remain in current home Chooses to remain in current home, but cannot do so without additional help Must move for reasons of health and safety Is unsure about moving 9a. Does the Person Plan to Move in the Next 12 Months? Turn to page 9 in the QSI. This item asks about plans for moving. For example, the person may choose to remain in the current home; or choose to move for reasons of health and safety; or is unsure about moving. See page 9 Questionnaire for Situational Information

10. Legal Status (examples) Person is an adult with no pre-need directives or any form of guardianships. Person has a partial or full guardian advocate. Person is an adult and has a guardian ad litem. Person is a minor child 10. Legal Status This item is also on page 9 in the QSI. This item records the person's legal status. Only one box should be checked. The assessor should use the documentation in the central record to determine who has legal authority to make medical decisions for this individual. For example, the individual may be an adult with no pre-need directives or any form of guardianship. The person may be his own legal representative. The person may have a partial or full-guardian advocate. The person may have delegated his rights to medical decisions to someone else via power of attorney or health care surrogate. He or she may also have a court-appointed guardian or guardian advocate If the person is a minor child, then the parents are his legal representative (unless parental rights have been severed by a court). Careful attention should be given for children in foster care or in care of the Department of Children and Families. See page 9 Questionnaire for Situational Information

11. Language Spoken or Understood The primary language that is spoken or understood by the person: English, Spanish, Sign Language, Does Not Apply or Other 11. Language Spoken or Understood This is also on page 9 in the QSI. This item records the primary language that is spoken or understood by the person: English, Spanish, Sign Language, Does Not Apply, or Other. See page 9 Questionnaire for Situational Information

Community Inclusion & Valued Adult Roles These items are only required for individuals 18 years or older. Community Inclusion Valued Adult Roles Employment The rating is based on the level of personal support required by the person to complete tasks now and for the next year. Community Inclusion & Fulfillment Of Valued Adult Roles This section is only required for adults, age 18 and older. The items in this section were previously used by the Agency in other assessment tools. The items include Community Inclusion, Valued Adult Roles and Employment. This section is used to plan supports to facilitate greater participation in the community. The rating is based on the level of personal support required by the person to complete tasks now and for the next 12 months. Questionnaire for Situational Information

Community Inclusion & Valued Adult Roles Level 1: The individual does not need any personal support. Level 2: The individual needs personal support and it is limited to occasional reminders or verbal prompts and/or physical assistance. Level 3: The individual needs personal support and requires daily reminders, verbal and/or physical prompts. Levels 4/5: The individual needs personal support from someone and requires supervision to complete Community Inclusion and Valued Adult Roles Turn to page 10 in the QSI. These are the ratings used for this section. Level 1—The individual does not need any personal support. Level 2—The individual needs occasional reminders and prompts. Level 3—The individual needs daily reminders and prompts. Levels 4 and 5 are identical. They both state that the individual needs support from someone and supervision, not just reminders or prompts. Level 4 should be the highest rating. In the next version of the tool, Level 5 will be removed. Do Not Know is used when the person has not had an opportunity to do this task and it is not known if he or she needs support. Items rated Do Not Know may be re-assessed and changed to the level of support required to do the activity. The important follow-up question for a Do Not Know rating is “How can we find out?” Not Applicable is used when the person will not do that activity during the next 12 months. Any ratings of Not Applicable should be re- assessed as soon as it is anticipated the person will participate in that activity or to determine the desires of the individual to participate in that activity or valued role. The significant follow-up question for Not Applicable is “How can we support the person in this community activity?” See page 10 Questionnaire for Situational Information

Community Inclusion Activities (examples) 12a. The person can find a place to live and manage leases or rent arrangements 12d. The person can shop for food, clothes, and other personal items. 12e. The person can arrange and attend social outings… 12h. The person can keep him/herself safe in the neighborhood 12j. The person can do his/her own housekeeping Community Inclusion Activities The items are on page 10 of the QSI. Let’s look at a few examples. 12a. The person can find a place to live and manage lease or rental agreements. If the individual‘s supported living coach located the apartment and negotiated the lease, then the rating is a Level 4, even though the person may have legally signed the lease. 12d. The person can shop for food or clothes… If the person can pick out items when shopping, but needs help with paying for items, the rating is a Level 3. 12e. The person can arrange and attend social outings… This implies that the individual can plan social outings and then attend them on a regular basis. If the individual requires a family member or personal care assistant to accompany him or her, the rating is a Level 4. 12j. The person can do his/her own housekeeping. If the individual can only do one housekeeping task independently, such as pulling up the covers on the bed, but requires someone to do all the rest of the tasks, the rating is a Level 4. See page 10 Questionnaire for Situational Information

Fulfillment of Valued Adult Roles in the Community 12l. The person can parent his/her minor children… 12m. The person can function as a spouse or domestic partner… 12n. The person can fulfill the role of a valued and trusted employee… 12o. The person can vote, follow community rules… Fulfillment of Valued Adult Roles in the Community Turn to page 11 in the QSI. These items use the same rating scale as Community Inclusion. Here are some examples. 12l. The person can parent his/her minor children… If the person does not have any children, “Does Not Apply” should be checked. If the person has children, the rating should reflect the amount of support required for the care and parenting of the children. 12m. The person can function as a spouse or domestic partner… The rating relates to amount of support required for the maintenance of a stable, intimate, ongoing relationship. For example, if the person requires occasional reminders or counseling, this is a Level 2. 12n. The person can fulfill the role of a valued and trusted employee… This item should reflect ratings for previous items, particularly 12b (locate a job and manage a career) and 12i (regularly participate in work activities). 12o. The person can vote, follow community rules… If the person must be reminded to comply with rules and laws on a daily basis, this is a Level 3. See page 11 Questionnaire for Situational Information

Employment Information 13a. Does the person currently have a job? 13b. Does the person need help with a job currently held? 13c. … is the person interested in getting a job? Employment Information Turn to page 12 in the QSI. 13a. Does the person currently have a job? Employment includes work for pay that is at least minimum wage. Employment does not include activities that only involve people with disabilities or require participants to have a disability. If the person is working, he or she should be asked item 13b. Does the person need help with a job currently held? If the person is not working, he or she should be asked 13c,… is the person interested in getting a job? See page 12 Questionnaire for Situational Information

QSI Scoring Plan Functional, Behavioral, and Physical Status Individual items are rated: 0 to 4 A status rating is calculated for each section: 1 (minimum) to 6 (maximum) QSI Overall Support Level 1 (Basic) to 5 (Intensive) Scoring Plan Functional, Behavioral, and Physical Status The remaining sections of the QSI include a variety of items to generate information about types and levels of support the person may require now and in the near-term future. Each item is rated separately, using a rating scale of 0 to 4. A zero rating (0) indicates that no problems are observed or no support is needed. A rating of 4 generally indicates that a maximum level of personal support and assistance is required. The ratings of the items are compiled and analyzed and a status rating is calculated for each section. The status ratings range from 1 to 6, with 1 considered as minimal and 6 considered as intensive. Finally, an Overall Support Level is calculated based on the status ratings. The Overall Support Level ranges from 1 to 5. Questionnaire for Situational Information

Functional Status The Functional Status section focuses on a person’s need for assistance during the course of a routine day. Questionnaire for Situational Information

Functional Status: Sensory Functioning 14. Vision 15. Hearing The first two items assess sensory functioning. Turn to pages 13 and 14 in the QSI. Sensory Functioning involves vision and hearing. How adequate is the person’s vision or hearing for daily functioning? The ratings reflect the extent to which the person’s sensory status affects capacities in performing daily activities and the type of adaptive or assistive technology used by the person. Ratings of 0 or 1 indicate that the functioning is minimally impacted, although the person may use glasses or hearing aids. Higher ratings are assigned when the person requires high technology assistive devices or the direct assistance of another person. See pages 13-14 Questionnaire for Situational Information

Functional Status: Essential Living Skills 16. Eating 17. Ambulation 18. Transfers These items focus on Essential Living Skills. Turn to pages in the QSI. 16. Eating. How independently does the person eat? If a person needs assistance to complete a meal, a rating of 1 to 3 applies depending on the frequency and type of assistance that is needed. 17. Ambulation. Does the person require support or assistance to move about? Is personal assistance required for changing positions or does the disability prevent sitting upright? If a person can get around independently, even with a walker, the rating is 0. 18. Transfers. Can the person transfer (move) him or herself or is supervision or physical assistance required? The need for lifting equipment is rated the highest. See pages 15-16 Questionnaire for Situational Information

Functional Status: Essential Living Skills 19. Toileting 20. Hygiene 21. Dressing These items also focus on Essential Living Skills. Turn to pages in the QSI. 19. Toileting. How independently can the individual use the toilet? How often is assistance or prompting needed? If the individual uses incontinent briefs, a rating of 3 applies. 20. Hygiene. Is prompting or physical assistance required to meet personal hygiene needs? Persons who are dependent on others or are consistently uncooperative receive higher ratings. 21. Dressing. Is supervision or physical assistance required? A person who needs substantial assistance or is uncooperative is rated the highest. See pages 17-18 Questionnaire for Situational Information

Functional Status: Essential Living Skills 22. Communications 23. Self-protection 24. Ability to Evacuate (place of residence) These items complete the Functional Status section. Turn to pages in the QSI. 22. Communications. Individuals who depend upon the support of others for the use of sign language interpreters or communication devices are rated 3. A person with no currently identified method of communication is rated the highest. 23. Self-protection. Are special precautions or supervision required to protect the person? If special precautions are needed, such as alarms and special care in selecting caregivers, the highest rating is assigned. 24. Ability to Evacuate (place of residence). The rating is based on the amount of personal direction or physical assistance required. The highest rating is for maximum assistance or for persons who are not cooperative. A Functional Status Rating is automatically calculated based on the ratings of the individual items. Items are weighted in the calculation of the status rating. The Functional Status Rating ranges from 1—minimum to 6—maximum. See pages 18-19 Questionnaire for Situational Information

Behavioral Intervention and Support Status Behavioral Intervention and Support Status The items in this section relate to six categories of serious behavior problems. The ratings reflect the current interventions and amount of support the individual has received over the past year for each type of problem behavior. Questionnaire for Situational Information

0. NONE required 1. OCCASIONAL verbal prompts, instructions, or redirection from caregiver 2. FREQUENT prompts, instructions, or redirection, environmental modification, restriction from caregiver 3. Frequent, PLANNED INTERVENTION Or – Assistance from others or restrictions are frequently necessary – Uses one psychotropic medication – Was admitted to crisis stabilization unit 4. Use of physical, mechanical, or chemical restraint Or – Uses one psychotropic medication with changes or two or more medications, or intensive behavioral services – Resides in secure facility, intensive residential treatment center, or psychiatric hospital The Behavioral Status section uses ratings of 0 to 4. Turn to page 21 for information about the ratings. 0. No intervention or support was required. 1. Occasional verbal prompts, instructions, or redirection from caregiver. 2. Frequent prompts, instructions, or redirection, environmental modification, or restriction from caregiver. 3. Frequent planned intervention includes options: a frequent, planned intervention, even if informal; or assistance from others or restrictions. A rating of 3 is also applied for use of one psychotropic medication for that behavior or admission to a crisis stabilization unit. 4. Use of physical, mechanical, or chemical restraint includes options: the use of a restraint or a protective device. 4 is applied for use of one psychotropic medication with changes or two or more medications; or intensive behavioral services. 4 is also applied if the person has resided in a secure facility, received intensive residential treatment, or been in a psychiatric hospital over the past 12 months. See page 21 Questionnaire for Situational Information

Behavioral Status 25. Hurtful to Self/Self-injurious Behaviors 26. Aggressive/Hurtful to Others 27. Destructive to Property Behavioral Intervention and Support Status Turn to pages in the QSI. 25. Hurtful to Self/Self-injurious Behaviors. This item includes interventions required as a result of hurtful behaviors directed at oneself, such as pica, drug or alcohol abuse, or threats or attempts at suicide. 26. Aggressive/Hurtful to Others. This item includes interventions that result from the use of behaviors that harm others, including threats to kill. 27. Destructive to Property. This includes interventions aimed to prevent behaviors that result in destruction of property, stealing, or setting fires. See pages 22-24 Questionnaire for Situational Information

Behavioral Status 28. Inappropriate Sexual Behavior 29. Running Away 30. Other Behaviors That May Result in Separation from Others These are the rest of the items for Behavioral Status See pages in the QSI. 28. Inappropriate Sexual Behavior. These behaviors include sexual behaviors that are offensive to others or are perpetrated toward others. Promiscuous behavior is not included because it is considered consensual. 29. Running Away. This item relates to the intent to intentionally leave or run away, and not individuals who wander away due to cognitive issues or inability to find their way back to a particular setting. 30. Other Behaviors That May Result in Separation from Others. This includes screaming, crying, yelling, sleep disturbance, rocking, and other types of socially disruptive behaviors. A Behavioral Status Rating is automatically calculated based on the ratings of the individual items. Items are weighted in the calculation of the Behavior Status Rating, which ranges from 1—minimum support to 6—maximum support. Turn to pages in the QSI. 30. Other Behaviors That May Result in Separation from Others. This includes screaming, crying, yelling, sleep disturbances, rocking, and other types of socially disruptive behaviors. A Behavioral Support Level is automatically calculated based on the ratings of the items. Items are weighted in the calculation of the Support Level,. The Behavioral Support Level ranges from 1—minimum support to 6—maximum support. See pages 25-27 Questionnaire for Situational Information

Guidelines for Behavior Follow-up Consultation Need for assistance from the Area Behavior Analyst to complete the scoring of the QSI tool Behavioral Status Rating of 3 or higher Emergency health and safety need Urgent need that requires a provider to complete a behavior assessment Need for a change in behavioral services Guidelines for Follow-up Consultation The QSI assessor uses these guidelines to determine if follow-up consultation is needed. Need for assistance from the Behavior Analyst to complete the scoring of the QSI tool Behavioral Status Rating of 3 or higher Emergency health and safety need Urgent need that requires a provider to complete a behavior assessment Need for a change in behavioral services The Behavior Analyst may discuss the scoring with the assessor and if warranted, a change in scoring will be made based on professional judgment or additional information. The follow-up consultation will be documented in the Notes Section of the person’s QSI. As the support coordinator, the QSI assessor may request a review of existing supports and services to determine if any follow up or changes are needed. The support coordinator should follow up with the person to ensure that supports and services are being effectively delivered. See page 28 Questionnaire for Situational Information

Physical Status The Physical Status section is concerned with life situations and physical conditions that may pose a need for medical interventions or health care for the person. The rating criteria uses a 0 to 4 scale with different descriptions for each item. A Physical Status Rating is automatically calculated based on the ratings of the individual items. Items are weighted in the calculation of the Physical Status Rating, resulting in a rating from 1—minimum support to 6—maximum support. Questionnaire for Situational Information

Physical Status 32. Injury Caused by Self-injurious Behavior 33. Injury Caused by Aggression toward Others or Property These items include injuries that require medical treatment related to behavioral concerns. Turn to pages in the QSI. 32. Injury to the Person Caused by Self-injurious Behavior. Injuries that are not serious or can be treated by simple first aid receive lower ratings. Higher ratings reflect the need for medical attention, threatened or attempted suicide, or life threatening behaviors. 33. Injury to the Person Caused by Aggression toward Others or Property. The highest rating is used when tissue breakdown, multiple contusions, life threatening injuries, or sexual predatory behavior occurs. See pages 30-31 Questionnaire for Situational Information

Physical Status 34. Use of Mechanical Restraints or Protective Equipment for Maladaptive Behavior 35. Use of Emergency Chemical Restraints 36. Use of Psychotropic Medications These items include use of medications and restraints related to behavioral concerns. Turn to pages in the QSI. 34. Use of Mechanical Restraints or Protective Equipment for Maladaptive Behavior. Mechanical restraints are devices used for the purpose of restricting a person’s movement. Positioning devices, such as trays or shoulder straps or protective equipment for medical conditions, such as a helmet for an individual with uncontrolled seizures, are not considered to be mechanical restraints. 35. Use of Emergency Chemical Restraints. This item is concerned with the frequency of use of drugs in an emergency to control behavior. If the individual requires medication before any medical or dental procedure, that is also considered in this item. 36. Use of Psychotropic Medications. Psychotropic medications control psychiatric symptoms, such as anxiety, mood disturbances, or schizophrenia or certain types of problem behaviors. The ratings reflect the number of medications, any changes in the past year, or significant side effects. Anyone on Reglan, regardless of the reason, receives the highest rating because of its side effects. See pages 32-33 Questionnaire for Situational Information

Physical Status 37. Gastrointestinal Conditions (include vomiting, reflux, heartburn, or ulcer) 38. Seizures 39. Antiepileptic Medication Use Physical Status Turn to pages in the QSI. 37. Gastrointestinal Condition. Conditions include vomiting, reflux, heartburn, or ulcer. The frequency of episodes of gastrointestinal symptoms is considered in this item. The highest rating reflects a need for hospital admission. 38. Seizures. Ratings are highest for a person whose seizures interfere with functional activity or require hospital admission or emergency room visits. 39. Antiepileptic Medication Use. Ratings reflect the use of antiepileptic drugs, any changes in dosage or drugs, or the need for emergency room treatment or hospitalization. See pages 34-35 Questionnaire for Situational Information

Physical Status 40. Skin Breakdown 41. Bowel Elimination 42. Nutrition Physical Status. Turn to pages in the QSI. 40. Skin Breakdown. Skin breakdown in this item is limited to problems from pressure sores or poor circulation often observed as a red or dusky color of the skin, particularly on buttocks, elbows, heels, or hips. Higher ratings are given if the person developed a pressure ulcer that required medical attention. 41. Bowel Function. This item considers the need for diet modification, fiber supplements, or routine medication for bowel elimination. 42. Nutrition. The key indicators for nutrition are body weight and the need for a special diet recommended by a physician or nutritionist. The highest rating is assigned to individuals who are below desired weight, exhibit morbid obesity, or suffer recurrent related medical conditions. Other considerations include a chewing or swallowing disorder, metabolic disorder, low serum protein, or use of a feeding tube with complications. See pages 36-37 Questionnaire for Situational Information

Physical Status 43. Treatments (Physician Prescribed) 44. Assistance in Meeting Chronic Health Care Needs 45. Individual’s Injuries 46. Falls Physical Status Turn to pages in the QSI. 43. Treatments (Physician Prescribed). This item is limited to the use of physician-prescribed procedures. An automatic rating of “4” is given if the prescribed procedures must be carried out by a licensed nurse and cannot be taught and delegated to a non-licensed person. Physical therapy and occupational therapy are not included in this item. 44. Assistance in Meeting Chronic Health Care Needs. The amount of supervision and varying levels of assistance required for medications and monitoring of chronic health conditions are rated in this item. 45. Individual’s Injuries. This item assesses the number and frequency of injuries and the type of medical attention required. If the individual requires a hospital admission, the highest rating is used. 46. Falls. Falls may be due to dizziness from medication side effects, or due to any reason. This item assesses the number and frequency of falls and the type of medical attention required. If the individual requires a hospital admission, the highest rating is used. See pages 38-41 Questionnaire for Situational Information

Physical Status 47. Physician Visits/Nursing Services 48. Emergency Room Visits 49. Hospital Admissions 50. Days Missed at Job, School, Recreation, or Other Day Activities Due to Illness (past 12 months) These items complete the Physical Status section. Turn to pages in the QSI. 47. Physician Visits/Nursing Services. This item assesses the total number of physician visits or nursing services, including annual and quarterly medical assessments, and other visits including emergency appointments. 48. Emergency Room Visits. The need for any emergency room visit is assessed by this item. The highest rating is for visits that result in hospital admission. 49. Hospital Admission. The number of hospital admissions is assessed by this item. The highest rating is for admission to the intensive care unit. 50. Days Missed at Job, School, Recreation, or Other Day Activities Due to Illness during the past 12 months. This item assesses the frequency of days missed at regularly scheduled day activities due to illness. If the person does not attend due to guardian objections, the rating is 0. See pages 41-42 Questionnaire for Situational Information

Guidelines for Medical Follow-up Consultation Need for assistance from Medical Case Manager to complete the scoring of the QSI tool Physical Status Rating of 3 or higher Emergency health and safety need Urgent need that requires a provider to complete a nursing assessment Need for a change in medical services These guidelines are used by the QSI assessor to determine the need for follow-up consultation with the Medical Case Manager. Need for assistance from the Medical Case Manager to complete the scoring of the QSI tool Physical Status Rating of 3 or higher Emergency health and safety need Urgent need that requires a provider to complete a nursing assessment Need for a change in medical services The Medical Case Manager may discuss the scoring with the assessor, and, if warranted, may change the scoring based on professional judgment or additional information. The follow-up consultation will be documented in the Notes Section of the person’s QSI. As the support coordinator, the QSI assessor may ask that you review existing supports and services and determine if follow up changes are required. The support coordinator should follow up with the person to ensure that supports and services are being effectively delivered. See page 43 Questionnaire for Situational Information

The Status Ratings for the Functional, Behavioral and Physical sections are calculated separately and then combined in an Overall Support Level by the online tool. The Overall Support Level ranges from 1 (Basic) to 5 (Intensive). Questionnaire for Situational Information

What if I have more questions? Contact your own area office Check the APD website What if I have more questions? If you have any questions, please feel free to contact your own area office. You may also check the APD website for updates. Questionnaire for Situational Information

Thank you You have completed the presentation on the Questionnaire for Situational Information for Waiver Support Coordinators. You will be sent an verifying that you have completed this presentation. You will also be required to attend an area office training specific to QSI procedures. Please print the certificate verifying that you have completed this presentation and take it with you to the area office training. Click on this icon: Thank you. You have completed the presentation on the Questionnaire for Situational Information for Waiver Support Coordinators. You will be required to attend an area office training specific to QSI procedures. You will need to download and print a copy of the certificate verifying your completion of this presentation and take it to your area office training. Please contact your area office for further details. Now click the document icon to request the certificate. Questionnaire for Situational Information

Questionnaire for Situational Information

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