AGENCY NAME:



|AGENCY NAME: |ANNUAL: ( |

| |RECERTIFICATION: ( |

|MCH NURSE CONSULTANT: |REGION: |VISIT DATE: |

|# Active Charts Randomly Selected for review: |Woman: |Infant: |Child: |Total = |

|OUTCOME INDICATOR: |IDHS Reports; |# Records Reviewed |# Expected |# Completed |% in |Data from IDHS |Performance Standard or State |

| |Reporting Period | | | |Compliance |Reports |Average |

|Assessments (701, 706-at-risk, 710, 711, 712, 713, 708 A-R) | | | | | | |

|630.20E monitoring. At least annually, appropriate professional health personnel of the Division and its consultants shall review each project for appropriateness of services and quality of care furnished to recipients in |

|accordance with the project plan |

|I. Agency Requirements and Provider Qualifications |

|The agency must agree to help program participant apply for benefits |Code: |All Kids log | | | | |

|under the All Kids Health Insurance Program or referral to the closest |630.220b2 |Case Notes | | | | |

|application agent. |Contract | | | | | |

|Ensure enrollment or SV01 code 807 | | | | | | |

|Direct service staff for the program must meet the standards; proof of |Code: |Copies of licenses/ | | | | |

|current licensure must be available. Case managers must meet the |630.220b6 |Certification on file. | | | | |

|qualifications as listed in the MCH Code. |630.220c |Job/position descriptions.| | | | |

| |Contract |Interview with manager. | | | | |

|Agency to maintain access to in-house RN services for consultation | | | | | | |

|related to assessment\evaluation of client risk levels and needs. | | | | | | |

|Case Manager Assistants: para-professionals and lay workers may be used|Code: |Policy and Procedures | | | | |

|to perform some case management functions under the supervision of the |630.220e3 |Chart Review Discussion | | | | |

|case manager. | |with program supervisor or| | | | |

| | |staff | | | | |

|Intake, follow-up with participants or providers to ensure that | |Position | | | | |

|participants are accessing needed services, provision of support and | |Descriptions | | | | |

|assistance that participants may require to access services. | |Observation | | | | |

| | | | | | | |

|Outreach activities. | | | | | | |

|II. Clinical Record : The Participants’ clinical record shall contain, but is not limited to : |

|General Case management Activities |Code: |Policy/Procedure | | | |Note: If client has received Perinatal Depression Screening by PCP, |

|Documentation of: |630.220d |Manual | | | |document on SV01 screen listing provider with date screened or if using|

|Missed appointments and attempts to follow-up on missed appointments of |Cornerstone |Chart Review | | | |the optional AS01 CMSE screen list provider with the date screened. |

|those participants the case manager or physician have identified as |Manual |All Kids Log (optional) | | | |The CMSE responses will populate the SV01, but the comments will not |

|non-compliant. | | | | | |transfer. |

| | |Cornerstone Report and | | | | |

|Each service rendered by the case manager | |Screens: PA07 Enrollment | | | | |

|Home visits: At Risk Prenatal & Infant | |(PA03) | | | | |

|Face-to-face infants | |Program Info (PA15) | | | | |

|At Risk | |Most recent Cornerstone | | | | |

|Not At Risk | |Quarterly Perf. Reports, | | | | |

|Face-to-face prenatal clients | |Release of Information | | | | |

|At Risk | |Consent, SV01 Service, | | | | |

|Not At Risk | |AS01 Entry/comment FP: | | | | |

|Well Child Visit | |PA10 Postpartum | | | | |

|Immunizations current for age or | |SV02 Activity, PA14 | | | | |

|Perinatal depression screening | |Entry for contacts-Work | | | | |

|Family Planning Status | |Plan defined, RF03 | | | | |

|Release of information to providers of necessary services | |Referral History | | | | |

|Coordination of Care | |Contract | | | |Medical care coordination includes adequacy of prenatal care, all |

|Adequacy of Prenatal Care (Kessner Index) | | | | | |referrals needed are made, including follow up, immunizations, EPSDT |

|First trimester initiation of prenatal care | | | | | |visits & PCP. Case notes coordination with medical provider. |

|Primary Physician Notified of FCM enrollment | | | | | | |

|EI referral/all referrals | | | | | | |

| | | | | | | |

| | | | | | | |

| | | | | | | |

|III. 630.220c1 Case Management Process |

|EVALUATION ITEM |Code part |EVALUATION MECHAMISM | |NOT |N/A | |

| |630/Contract/C-Stone | |MET |MET | |CO: Commendation |

| |Quarterly Reports | | | | |COMMENTS KEY: R: Recommendation |

| | | | | | |RQ: Required (typed bold) |

|Assessment of needed health and social services assessment(s) to |Code: |Case Notes | | | | |

|determine need for health, mental health, educational, vocational, |630.220ela & |Review P&P & C-Stone | | | | |

|substance abuse treatment, childcare, transportation, oral health, |630.220e13 |Screens | | | | |

|prenatal and postpartum depression screening, and family planning status| |Assessments- | | | | |

|& other services. |Performance Standard |AS01: 711, 712, 713 | | | | |

| |90% |701-Other Service Barrier | | | | |

|Over rides less than 10% |Contract |706-Home | | | | |

| | |assessment/At | | | | |

| |Contract |Risk, AS01 | | | | |

| | |Prenatal Ed-710 or | | | | |

| | |Prenatal Education per | | | | |

| | |Agency P/P | | | | |

| | |Anticipatory Guidance | | | | |

| | |708 A-L, CM04, CM02/CM03 | | | | |

| | |Perinatal Depression | | | | |

| | |SV01-825 | | | | |

| | |Agency’s recent HSPR0749 | | | | |

| | |report | | | | |

|Development of an Individual Care Plan |Code: |Policy & Procedures | | | | |

| |630.220elb & |Chart review | | | | |

|List of all service providers involved |630.220e2 |Cornerstone | | | | |

| |Performance |Screens: | | | | |

|List of agencies to which participant referred |Standard 90% |Care Plan | | | | |

| | |Goals-CM02 | | | | |

|Problem list and plans for resolution |Contract |Planned | | | | |

| | |Services-CM03 | | | | |

|Evidence of updates and follow-up activity. | |Case Notes – | | | | |

| | |CM04, RF01, RF03 | | | | |

| | |WkPlan Defined | | | | |

|EVALUATION ITEM |Code part |EVALUATION MECHAMISM | |NOT |N/A | |

| |630/Contract/C-Stone | |MET |MET | |CO: Commendation |

| |Quarterly Reports | | | | |COMMENTS KEY: R: Recommendation |

| | | | | | |RQ: Required (typed bold) |

|Perform standardized development screening by age 1 year, i.e., (if not |Contract |SV01 824 | | | | |

|performed on site, referral to CFC is made and followed). If receiving |Performance |Case Notes | | | | |

|EI services, developmental screening not required but screening dates |Standard |RF01/RF03 | | | | |

|must be documented on SV01. Denver II or Ages & Stages Questionnaire or|80% | | | | | |

|any approved screening tool as indicated by the IHFS Handbook for | | | | | | |

|Providers of Healthy Kids. | | | | | | |

|Referrals | |Cornerstone screens: | | | |All referrals are to be recorded on the RF01 cs Screen. Use the |

|Referrals of participants to appropriate providers within the community |Contract Performance |Case Notes – CM04 &/9r | | | |comment line of the RF01 Screen to document follow up. Or documented by|

|for services identified in the individual care plan and |Standard 100% |Service Provider Selection| | | |agency approved policy. |

|documented on the RF01. | |(RF01, RF03) CM02, CM03 | | | | |

|WIC | | | | | | |

|Family Planning | | | | | | |

|Perinatal depressions screening if not provided by FCM agency | | | | | | |

|Linkages/Referral Agencies | | | | | | |

|Other: Intimate Partner Violence, Substance Abuse, Housing, etc. as | | | | | | |

|needed | | | | | | |

|Documentation of follow-up for referrals made on the RF01: | |RF01/RF03 | | | | |

|WIC | |Or by agency approved | | | | |

|FP | |policy | | | | |

|Perinatal depression screening if not provided by FCM agency | | | | | | |

|Linkages/Referral Agencies | | | | | | |

|Other: Intimate Partner Violence, Substance Abuse, Housing, etc. as | | | | | | |

|needed | | | | | | |

| | | | | | | |

| | | | | | | |

| | | | | | | |

| | | | | | | |

|EVALUATION ITEM |Code part |EVALUATION MECHAMISM | |NOT |N/A | |

| |630/Contract/C-Stone | |MET |MET | |CO: Commendation |

| |Quarterly Reports | | | | |COMMENTS KEY: R: Recommendation |

| | | | | | |RQ: Required (typed bold) |

|3. Referrals to EI are completed on all Infants and children 0-3 if |Performance Standard |814 on CM02, CM03, CM04 or| | | | |

|indicated by developmental screening, including follow-up. |100% |by agency approved policy | | | | |

|Client Education |Contract |Anticipatory Guidance | | | | |

|Provide Healthy Start/Grow Smart brochures |Code: |Screens, SV02 | | | | |

|from HCFS or approved equivalent |630.210.D |Activity Entry | | | | |

|information (SV01) |630.210.E |Case Notes, SV01 | | | | |

|2. Post information on accessing free | |CMSE optional | | | | |

|Transportation and, or SV01 code | |PN SV01 803 Code | | | | |

|code 938 or 813. | |Hard copy of | | | | |

|Educational materials given: SV01 | |Reproductive Life Plan in | | | | |

|code 807 (Agency policy; moving toward | |client chart | | | | |

|usage of DHS FCM prenatal standardized | |Agency approved | | | | |

|curriculum) | |Policy/Procedure | | | | |

|Reproductive life plan Preconception/Interconception Education | | | | | | |

| |Contract | | | | | |

|Provider implements their QA Plan annually and completes their annual |Contract |QA Policy & Procedures, | | | | |

|summary report of QA activities. Provider must maintain a quality |Quality |QA Plan, | | | | |

|assurance process with internal policies and practices related to |Assurance |APORS Satisfaction Survey | | | | |

|quality improvement within FCM program. See exhibit B#8 | |Work Plan | | | | |

| | | | | | | |

|Policies & Procedures relate to Outreach, case finding & care management| | | | | | |

|Distributed APORS Client satisfaction survey as instructed by IDPH. | | | | | | |

|Data analysis on key maternal/infant outcomes identified in the agency’s| | | | | | |

|QA plan. | | | | | | |

|Work Plan developed with evidence of | | | | | | |

|monitoring for progress | | | | | | |

| | | | | | | |

| | | | | | | |

|IV. FCM WORKPLAN PROGRESS REPORT |

|Evaluation of Number/percentage of ‘overrides’ for P and I client categories: |

|(Utilize the 747 and 749 reports) Overrides to be ................
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