ODA has established the PASSPORT Conditions of Participation and Service Specifications as the standards by which all PASSPORT services must be delivered. The Conditions of Participation apply to all service providers. The Service Specifications define and set the standards for each individual service and apply only to providers of those individual services.
There are key elements of the Conditions of Participation and Service Specifications that are viewed as basic "structural elements." These identify the agency's basic organizational structure, policies, procedures, documentation formats and current service to the community. Development of a quality community provider base is an ODA value. To ensure consumer choice, we have developed technical assistance mechanisms to assist applicants in understanding and complying with the Conditions of Participation and Service Specifications. The PASSPORT Administrative Agency representative will identify areas of non-compliance and provide a timeframe for corrective action.
Typical non-compliance findings are: documentation formats that do not provide for consumer or worker signature, record retention policies that do not meet the six-year requirement, documentation of personnel orientation, qualifications and training and documentation demonstrating compliance with criminal record check requirements. An applicant has only thirty days to clearly demonstrate it is in full compliance with all Conditions of Participation and Service Specifications. If an applicant cannot demonstrate it is in full compliance within the allotted time, the application for certification will be denied and the applicant must wait for a period of one year to reapply.
During the on-site pre-certification visit, the reviewer(s) will be assessing key elements of the Conditions of Participation and Service Specifications. For instance, the reviewer(s) will review consumer files to ensure documentation of service provided is clear and complete and includes required elements such as a record of the tasks completed, date and time of aide's arrival and departure, signatures of both the consumer and aide, evidence that the tasks completed were authorized in the consumer's service plan, evidence the agency nurse conducted an initial assessment of the consumer, etc. The reviewer(s) will also review employee files to ensure documentation clearly indicates the employee was qualified to be hired; the employee underwent a criminal record check, etc. In addition, reviewer(s) will review the provider's table of organization, billing records, and written policies and procedures.
