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Below are a few examples of ePSR Surveys (a set of Quality Standards that are measures of the quality of service your organization provides). The Quality Standards includes in these example ePSR Surveys are for illustrative purposes only. You can design any Standards you want. We also have a library of Standards that you might find helpful to use or modify.

Choose other examples here: 

(Unsure what some of the below terms mean? Click here to see a glossary.)

ePSR Survey Title  
  Supportive Employment Services
Scoring Frequency  
  Monthly
Designed For




  Program-wide:
  
Allow Disagreement  
  No
Survey-specific  
Instructions  
not provided
List of Quality Standards
 
1A General Service Activities
1A.01 Individual Schedule
Operational Definition

a. What - A day planner, personal appointment book or calendar is maintained.

b. When - Daily or weekly.

c. Who - Each individual receiving services.

d. How - Based on a review of the planner, book or calendar, a "TRUE" is scored if:

    1) If it is current rather than rote;

    2) There is evidence of at least one personally chosen recreational/leisure activity in the previous week; and

    3) There is evidence of at least one instructional lesson that week for learning a personally selected skill. Modifications to these criteria can be accepted with a signed and dated approval by the service manager documented in the support plan notebook on the PSR Variations Form.

1A.02 Staff Schedule
Operational Definition

a. What - Staff schedules are maintained in central office and the apartments.

b. When - Changed as needed to remain current.

c. Who - Contract person is responsible for maintaining schedule.

d. How - Based on a review of the current schedules and the contact person`s documentation, a `TRUE` is scored if the schedules indicate the person currently working or variations have been recorded by the contact person or other designated person.

(Special Designations: Special Designation List / Special #2; )

1A.03 Substitute Instructions
Operational Definition

a. What. Substitute instruction are maintained.

b. When. Kept current.

c. Who. Contact person.

d. How. Based on a review of the Substitute Instruction Form, a "TRUE" is scored if it is dated and signed by the responsible contact person, confirmed as current at least monthly, it is completely filled out, and relevant protocols are attached. If medications are indicated, the instructions must be consistent with the medication chart.

1B Service Delivery/Individual Service Plan
1B.01a Support Plans Implemented - Protocol
Operational Definition: There should be one or more support plans/teaching methods for each ISP objective (which should be distinguished from ISP activities). To score PSR, list key word or phrase (e.g., cooking, cleaning, grooming, shopping, budgeting, etc.). Any exceptions must be documented on the PSR Variations Form. a. What. For each identified method in the support plan, there is a written protocol, i.e., a written step by step description of how that particular service is to be provided. b. When. Within 30 days of ISP meeting date or within one week of revision of or addition to the ISP. c. Who. Contact person. d. How. Based on a review of the ISP and the protocols in the support plan notebook, a "TRUE" is scored if: 1) There is at least one protocol associated with the ISP objective; 2) It lists or othewise describes in step by step detail how to implement the procedure or method; 3) It clearly describes the frequency and method for determining and documenting procedural reliability. 4) It clearly
1B.01b Support Plans Implemented - Data Sheet
Operational Definition: a. What. For each ISP objective, there is a corresponding data sheet. b. When. By the end of the day or as specified in the protocol. c. Who. Support staff. d. How. Based on a review of each protocol and the associated data sheet, a "TRUE" is scored if: 1) The data sheet is up to date as specified in the protocol. 2) The last scheduled reliability check was carried out and documented; and 3) The reliability index was calculated at the 85% level or met other criteria that may have been prescribed on the protocol.
1B.01c Support Plans Implemented - Graphs or Other Data
Operational Definition: a. What. For each ISP objective, there is a corresponding data summary. b. When. By the end of the week or as specified in the protocol. c. Who. Support staff. d. How. Based on a review of each protocol and the associated data sheet, a "TRUE" is scored if: 1) The prescribed summary is up to date as specified in the protocol; 2) The summary corresponds to the data sheet for all data points since the last check; and 3) The summary is clearly and fully labeled, including an indication of the year.
1C Health and Safety
1C.01 Medication Given Appropriately
Operational Definition: a. What - Medicatin is given as prescribed.

b. When - As prescribed.

c. Who - Support staff

d. How - Based on a review of medication labels, physician`s orders and the medication chart, a "TRUE" is scored if:
1) Each medication has a written order signed by a physician (verbal or phone orders must be documented appropriately and signed by a physician within 72 hours);
and
2) Physician`s order(s) is (are) consistent with the medication chart(s) and medication label(s).
1C.02 Medication Stored Appropriately
Operational Definition: a. What. Medication is safely stored. b. When. When not being given. c. Who. Support Staff. d. How. Based on observation of medication storage box and a review of the PSR Variations Form, a "TRUE" is scored if: 1) It is being stored in a safe, discrete place; and 2) It is locked, if the need for this is indicated on the PSR Variations Form.
1C.03 Medication Chart
Operational Definition: a. What. Medication chart is accurate and current. b. When. Filled out as medication is given. c. Who. Support Staff. d. How. Based on a review of the medication chart and the person`s medication bottles, a "TRUE" is scored if: 1) It is filled out correctly; and 2) Includes information from last time medication was taken by the individual.
Client Safety
Operational Definition: What?: this is intended to capture the progress made with client safety

How?: Score `+` if the client did not engage in any unsafe activity, such as
        - run away
        - etc.

When?: over the prior month.

(Special Designations: Special Designation List / Special #1; )

1D Finances and Budgeting
1D.01 Financial Responsibility Policy
Operational Definition: a. What. Financial responsibility policy is explained b. When. Upon intake. c. Who. Management staff. d. How. Based on a review of the case file, a "TRUE" is scored if all consumer`s parents or other responsibly parties have signed a copy of the financial responsibility policy indicating that they have read and understood it.
1D.02 Reconciliation of Consumer Moneys
Operational Definition: a. What. Consumer moneys are accounted for. b. When. Weekly. c. Who. Support staff. d. How. Based on a review of the weekly reconciliation sheets for the period since the previous PSR, a "TRUE" is scored if: 1) The appropriate form was used; 2) The form was properly completed; and 3) Moneys were accounted for to the nearest $1.00
1D.03 Bills Paid
Operational Definition: Bills are paid by due date on bill, and no late charges nor service interruption have been incurred within month. If this is a specific issue for a person, a written plan is in place and implemented. a. What. Consumer household bills are paid on time. b. When. Monthly. c. Who. Support staff. d. How. Based on a review of the consumer`s budget, check book and bills for the previous month, a "TRUE" is scored if: 1) All bills were paid by due date; 2) No late charges were incurred; 3) There have been no service interruptions; 4) If paying bills on time has been an issue, a plan has been written and implemented.
1E Positive Futures Plan
1E.01 Personal Profile Session
Operational Definition: a. What. A consumer profile is developed. b. When. Before services are initiated. c. Who. Based on a review of the Personal Profile and Positive Futures Plan, a "TRUE" is scored if the profile has been completed.
1E.02 Futures Plan Session
Operational Definition: a. What. Each consumer has a Positive Futures Plan. b. When. Within 30-days of service initiation. c. Who. Management staff. d. How. Based on a review of the Positive Futures Plan, a "TRUE" is scored if it was completed within the first 30-days of service
1E.03 Circle of Support Logistics
Operational Definition: a. What. Circles of support meet. b. When. Once per quarter unless special circumstances arise. c. Who. Focus person and/or appointed secretary are responsible for meeting invitations and meeting coordination and for preparing and distributing minutes.. d. How. Based on a review of meeting minutes, a "TRUE" is scored if: 1) Minutes for the last meeting are available; 2) Were distributed within one week of the meeting; and 3) Indicate that the meeting was held within the quarter or as otherwise scheduled at the immediately preceding meeting.
1F Staff Development
1F.01 CBTs Complete
Operational Definition: a. What. All staff complete competency based training. b. When. Seven of the 16 topics should be completed during the first week of employment, one additional topci during each subsequent two weeks of employment, 13 within three months of employment and all 16 within the first six months of employment, or as otherwise scheduled in writing by the Manager. c. Who. All staff. d. How. Based on a review of the CBT control sheet, a "TRUE" is scored if all staff are on target with the above schedule.
1F.02 Staff Meetings/Inservices
Operational Definition: a. What. Staff attend mandatory staff meetings and inservice sessions. b. When. Monthly staff meetings and quarterly inservice sessions. c. Who. All designated staff. d. How. Based on a review of the last month`s staff meeting and last quarter`s inservice minutes, a "TRUE" is scored if all staff attended or were excused in writing from attending by the Manager.
1F.03 Contact Meetings
Operational Definition: a. What. Staff attend contact meetings. b. When. Weekly or as otherwise scheduled. c. Who. Support staff. d. How. Based on a review of the minutes and/or the contact meeting agenda form from the last scheduled contact meeting, a "TRUE" is scored if: 1) All appropriate staff attended; and 2) All tasks assigned at previous contact meeting were completed on schedule.