ICF PROGRAM CHART AUDIT
Individual Chart Being Reviewed
First Name
Last Name
Date of audit/review
-
Month
-
Day
Year
Date
Location
Park West
Johnstown
Review Completed by:
First Name
Last Name
Email of person completing audit:
example@example.com
QIDP assigned to individual
First Name
Last Name
Type a question
Yes
No
N/A
Annual IPP held within 365 days
Quarterly IPPs present and current
Consents current
PCP document current in chart
PCP document matches in apt.
AT scheduled present and current
IPP summary and discharge plan
Meeting minutes and signature page present and current for all meetings
Programs prioritized
Programs in place and match plan and data sheets
Data recorded properly
Programs within projected completion dates?
Programs being revised, added, deleted per program strategies
Program Strategies current
30 day packets organized and current
ALL assessments/CFAs present and all recommendations addressed in plan
Path to employment clear and current-match plan
Work plan present
Financial supports page present and compliant
Medical apt summary present
MUI/UI reports for prior year present
QIDP notes done at least quarterly
Addendums present for all significant changes
Workshop visits present quarterly
Inventory updated
Were any adaptive equipment needs/devices listed in plan with supports in place to ensure they are being worn/used properly and that staff are prompting to wear/use these items as per plan
Detailed Explanation of any areas not meeting compliance:
Submit
Should be Empty: