Form 470-5551 "Community-Based Neurobehavioral Rehabilitation Services (Cnrs) Provider Quality Management Self-assessment" - Iowa

What Is Form 470-5551?

This is a legal form that was released by the Iowa Department of Human Services - a government authority operating within Iowa. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on November 1, 2020;
  • The latest edition provided by the Iowa Department of Human Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form 470-5551 by clicking the link below or browse more documents and templates provided by the Iowa Department of Human Services.

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Download Form 470-5551 "Community-Based Neurobehavioral Rehabilitation Services (Cnrs) Provider Quality Management Self-assessment" - Iowa

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Community-Based Neurobehavioral Rehabilitation Services
(CNRS) 2020 Provider Quality Management Self-Assessment
This form is required for entities enrolled to provide CNRS in the state of Iowa.
Each provider is required to submit one, four section self-assessment by January 1, 2021. This form is
to be completed and submitted via fillable PDF as directed on the Provider Quality Management Self-
Assessment webpage. A password-protected electronic signature is required in Section D in order for
this document to be accepted. Incomplete self-assessments will not be accepted.
Section A. Identify the organization submitting this form.
Section B. Identify each organization service location.
Section C. Select the response option from the dropdown menu that indicates the most accurate
response for each item. Response options include Yes or No. If required areas are incomplete, the self-
assessment will be returned to the organization and must be resubmitted.
Section D. Please complete and sign as directed.
Questions can be directed to the CNRS mailbox: (CNRS@dhs.state.ia.us).
Section A. Organization Identification
Identify the organization completing the form by providing the following information using the text entry
fields below.
Employer ID Number (EIN) (9 digits):
Associate NPI:
Organization Name:
Mailing Address:
City:
State:
Zip Code:
Administrative Director:
Email:
Telephone:
Self-Assessment (SA) Contact Person:
Title:
SA Contact Person Email:
Telephone:
Organization Website Address:
470-5551 (Rev. 11/20)
Page 1 of 9
Community-Based Neurobehavioral Rehabilitation Services
(CNRS) 2020 Provider Quality Management Self-Assessment
This form is required for entities enrolled to provide CNRS in the state of Iowa.
Each provider is required to submit one, four section self-assessment by January 1, 2021. This form is
to be completed and submitted via fillable PDF as directed on the Provider Quality Management Self-
Assessment webpage. A password-protected electronic signature is required in Section D in order for
this document to be accepted. Incomplete self-assessments will not be accepted.
Section A. Identify the organization submitting this form.
Section B. Identify each organization service location.
Section C. Select the response option from the dropdown menu that indicates the most accurate
response for each item. Response options include Yes or No. If required areas are incomplete, the self-
assessment will be returned to the organization and must be resubmitted.
Section D. Please complete and sign as directed.
Questions can be directed to the CNRS mailbox: (CNRS@dhs.state.ia.us).
Section A. Organization Identification
Identify the organization completing the form by providing the following information using the text entry
fields below.
Employer ID Number (EIN) (9 digits):
Associate NPI:
Organization Name:
Mailing Address:
City:
State:
Zip Code:
Administrative Director:
Email:
Telephone:
Self-Assessment (SA) Contact Person:
Title:
SA Contact Person Email:
Telephone:
Organization Website Address:
470-5551 (Rev. 11/20)
Page 1 of 9
Section B. Service Locations
Complete for each service location. Include location from Section A if CNRS is provided at that location.
Do not include location from Section A if CNRS is not provided at that location.
If the organization requires technical assistance, contact the CNRS Mailbox (CNRS.dhs.state.ia.us) or
click for help.
Check box if organization has more than 12 service locations. If checked, leave Section B blank. A
QIO Quality Reviewer will contact you with an additional document to complete.
Location 1
Location 2
Location 3
Location Name
Address
City
State
NPI
Legacy Number
Executive Director (ED)
ED Credentials
Administrator (Admin)
Admin Credentials
Location 4
Location 5
Location 6
Location Name
Address
City
State
NPI
Legacy Number
Executive Director (ED)
ED Credentials
Administrator (Admin)
Admin Credentials
Location 7
Location 8
Location 9
Location Name
Address
City
State
NPI
Legacy Number
Executive Director (ED)
ED Credentials
Administrator (Admin)
Admin Credentials
Location 10
Location 11
Location 12
Location Name
Address
City
State
NPI
Legacy Number
Executive Director (ED)
ED Credentials
Administrator (Admin)
Admin Credentials
470-5551 (Rev. 11/20)
Page 2 of 9
Section C. State and Federal Standards
For each of the following standards, the organization must select a response from each dropdown
menu.
Indicating “Yes” means the organization currently has in place policies and/or practices
meeting the proposed standards and can provide documented evidence verifying such.
Indicating “No” means the organization does not currently have policies, practices, and
documented evidence in place. When a “No” is indicated, the organization must document in
the space provided at the end of each area plans to meet the standards. The plan must identify
the organization’s timeline for meeting the standards. Implementation of corrective action to
address current Code of Federal Regulations (CFR), Iowa Code (IC), or Iowa
Administrative Code (IAC) standards must be completed within 30 days of the date in
Section D of this form.
This annual Provider Quality Management Self-Assessment will be returned to the organization if all
sections are not completed, responses chosen are not compliant with CFR, IC, or IAC or otherwise
deemed unacceptable.
If the organization requires technical assistance, contact the CNRS Mailbox (CNRS.dhs.state.ia.us) or
click for help.
I. Provider Eligibility
IAC Chapter 77.52
At a minimum, all providers will maintain evidence that:
Select One
1. The mission statement encompasses members’ needs, desires, and abilities.
Yes
Select One
2. The organization is fiscally sound and established fiscal accountability.
Yes
Select One
3. The program administrator shall be Certified Brain Injury Specialist Trainer (CBIST)
Yes
through the Academy of Certified Brain Injury Specialists or a certified brain injury
specialist under the direct supervision of a CBIST or a qualified brain injury professional
as defined in rule 441 IAC 83.81(249A) with additional certification as approved by the
Department.
Select One
4. A minimum of 75 percent of the organization’s administrative and direct care personnel
Yes
shall (1) have a bachelor’s degree in human services-related field, (2) have an
associate’s degree in human services with two years of experience working with
individuals with brain injury, (3) be an individual who is in the process of seeking a
degree in the human services field with two years of experience working with individuals
with brain injury, or (4) be a certified brain injury specialist or have other brain injury
certification as approved by the Department.
If indicating “No,” describe the plan to meet the standard(s):
II. Training Requirements
IC 253B.16, 232.69, and IAC Chapter 77
Prior to direct service provision and subsequent ongoing training should include at a
minimum:
Select One
Yes
1. Completion of the Department-approved brain injury training modules.
Select One
Yes
2. Member rights.
Select One
Yes
3. Confidentiality and privacy.
Select One
4. Individualized rehabilitation treatment plans.
Yes
470-5551 (Rev. 11/20)
Page 3 of 9
Within 30 days of commencement of direct service provision and annually thereafter, employees
shall complete:
Select One
1.
Cardiopulmonary resuscitation (CPR)
Yes
Select One
Yes
2.
First-aid.
Select One
Yes
3.
Fire prevention and reaction.
Select One
4.
Universal precautions.
Yes
Select One
The organization’s written policy and procedure for the identification and report of child
5.
Yes
and dependent adult abuse to the Department pursuant to 441-Chapters 175 and 176.
Within the first six months of commencement of direct service provision employees shall
complete:
Select One
Yes
1. The promotion of a program structure and support for persons served so they can re-
learn or re-gain skills for community inclusion and access.
Select One
Yes
2. Compensatory strategies to assist in managing ADLs (activities of daily living).
Select One
Yes
3. Quality of life issues.
Select One
Yes
4. Behavioral supports and identification of antecedent triggers.
Select One
Yes
5. Health and medication management.
Select One
Yes
6. Dietary and nutritional programming.
Select One
Yes
7. Assistance with identifying and utilizing assistive technology.
Select One
Yes
8. Substance abuse and addiction issues.
Select One
Yes
9. Self-management and self-interaction skills.
Select One
10. Flexibility in programming to meet members’ individual needs.
Yes
Select One
11. Teaching adaptive and compensatory strategies to address cognitive, behavioral,
Yes
physical, psychosocial, and medical needs.
Select One
Yes
12. Community accessibility and safety.
Select One
Yes
13. Household maintenance.
Select One
14. Support to the member’s family or support system related to the member’s
Yes
neurobehavioral care.
Select One
Yes
15. Initial abuse and mandatory reporter training (Using the approved DHS online training).
Within the first 12 months of the commencement of direct service provision employees shall
complete:
Select One
1. A Department-approved, nationally recognized certified brain injury specialist training.
Yes
Annually or as otherwise required, employees shall complete:
Select One
Yes
1. Fire prevention and reaction.
Select One
Yes
2. Universal precautions.
Select One
Yes
3. Cardiopulmonary resuscitation (CPR).
Select One
4. First Aid.
Yes
Select One
Yes
5. Subsequent abuse and mandatory reporter training (every three years).
If indicating “No,” describe the plan to meet the standard(s):
470-5551 (Rev. 11/20)
Page 4 of 9
III. Governing Body
IAC Chapter 78
At a minimum the organization’s governing body shall:
Select One
Yes
1. Have an active role in the administration of the organization.
Select One
2. Receive and use input from local community stakeholders, members participating in
Yes
services, and employees and shall provide oversight that ensures the provision of high-
quality supports and services to the members.
If indicating “No,” describe the plan to meet the standard(s):
IV. Outcome-Based Standards
IAC Chapter 78
At minimum, the organization is able to demonstrate that:
Select One
Yes
1. Members are valued.
Select One
2. Members or their responsible party provides consent regarding which personal
Yes
information is shared and with whom.
Select One
Yes
3. Members receive assistance with accessing financial management services as needed.
Select One
4. Members receive assistance with obtaining preventative, appropriate, and timely
Yes
medical and dental care.
Select One
Yes
5. Members’ living environment is reasonably safe and located in the community.
Select One
Yes
6. Members’ desire for intimacy is respected and supported.
If indicating “No,” describe the plan to meet the standard(s):
Treatment Plan
The treatment plan shall include:
Select One
1. The member’s individual strengths, barriers, and interests.
Yes
Select One
2. Goals which are based on the member’s need for services.
Yes
Select One
Yes
3. Neurobehavioral challenges and environmental needs as identified in the member’s
individual standardized comprehensive functional neurobehavioral assessment.
Select One
4. The member and the member’s treatment team evaluate the member’s progress
Yes
towards treatment goals regularly and no less than quarterly and are revised as the
member’s status or needs change to reflect the member’s progress and response to
treatment.
Select One
Yes
5. The member’s initial treatment plan is submitted to Iowa Medicaid Enterprise (IME)
within 30 days of admission for approval.
Select One
6. The member’s treatment plan does not exceed 180 days.
Yes
If indicating “No,” describe the plan to meet the standard(s):
470-5551 (Rev. 11/20)
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