Provider Documentation · PDF fileProvider Documentation Training NC Innovations Waiver December 17, 2012 A New Multi-County Area Authority Merging The Durham Center and Wake LME

Provider Documentation Training

NC Innovations Waiver

December 17, 2012

A New Multi-County Area Authority Merging The Durham Center and Wake LME

Short Range Goal Format NC Innovations Waiver

According to the North Carolina Innovations Technical

Guide (Version 1.0 – June 2012), Providers of NC

Innovation services are required to:

Develop and implement short-range goals.

Develop and implement task analysis/strategies.

Ensure short-range goals and task analysis are in place prior to

plan implementation.

Ensure short-range goals and task analysis or strategies are

signed by the participant or legally responsible person.


Alliance Behavioral Healthcare has developed a

standardized format for short term goals.

NC Innovations Waiver providers in Cumberland, Durham,

Johnston, and Wake will begin using the new format when

developing short term goals for participants with January

2013 birthdays.




Documenting:

Completing the Individual Support Plan Short Range Goals

Long Range Outcome Section:

The information in this section will be developed by the team at the annual plan meeting.

Will be documented by the care coordinator on the ISP.

Will be restated by the service provider on the short range goal format.



Important things to remember when thinking about Long Range Outcomes: They are the individual’s desired life outcomes.

They are broad in scope, but must still be attainable for the

individual.

It is expected that the same long range outcome will not remain on the plan year after year.

Obtaining a specific service is never an appropriate outcome.



Where am I now in Relationship to the Outcome section:

The information in this section will be developed by the team at the plan meeting.

Will be documented by the care coordinator on the ISP.

Will be restated by the service provider on the short range goal format.



What are the prerequisite skills needed section: The service provider will indicate the necessary skills that

the individual should already possess in order to work on the short term objective identified.

Does the individual supported possess these skills? The service provider will include specific, detailed

information regarding the individual’s current skills as they relate to the short range goal.



Short Range Goals section:

Should directly relate to the achievement of the Long Range Outcome.

All goals should be measurable (for habilitative services), observable, and attainable.

All goals should describe the desired behavior based upon the individual’s wants/needs.



Short Range Goals:

There are 3 parts to each Short Range Goal.

Condition – is/are the circumstance(s) in which the

behavior will occur.

Behavior – is the clearly defined action that the individual will do.

Criteria – is the measurement of performance.



Example:

At least one time per week, Patty will wash her clothes with 3 or less verbal prompts for 2 consecutive months.

Condition – At least one time per week

Behavior – Patty will wash her clothes

Criteria – with 3 or less verbal prompts for 2 consecutive months



Support to Reach Goal – list the service/support necessary to achieve the long range outcome.

Who will provide support/location(s) – Identify the provider who will be responsible for providing the service/support and the location of where the service will occur (using the location codes).




Estimated Frequency for each location – There will be two parts to this section.

1. List the total hours per week of the service (10 hours per week)

2. Break out the time spent at each location to run the goal. (10% at home, 90% in community)

Target Date – should be no longer than 1 year and in most instances will be the last day of the individual’s birth month.

Schedule to run goal- state the typical times that the individual would work on the particular goal during the week. If there is flexibility that may be needed to run the goal, explain that in this section. This will be included in the schedule completed by the Care Coordinator.

Materials needed – list the items that will be needed in order to complete the goal.

Positive Reinforcement – list the forms of praise that the person responds positively to in order to foster goal progression. Note-this should not be a form of bribery. What is written here should not conflict with anything that may be outlined in an individual’s behavior support plan.




Task Analysis: Steps for person supported – list the steps for task completion or

strategies for the person supported. Goals around behavioral needs may be more appropriate to have strategies listed in this section. • A task analysis would be used to assist a participant with a specific

self-help or daily living skill. • A strategy is a long-term plan of action designed to achieve a

particular outcome. Strategies are used to make a problem easier to understand and solve.

Staff’s actions –This section lists the actions the staff will take in order

to assist the individual to complete the task outlined in the short range goal. The actions listed should be specific and staff should have an intervention that correlates to each step the individual will take.

Quarterly Progress Summary NC Innovations Waiver

Documenting:

The Quarterly Progress Summary


Quarterly Review/Progress Summary:

Service providers are required to complete quarterly progress summaries for habilitative services to reflect the participant’s progress toward the short-range goal and long-range outcomes that have been implemented in the Individual Support Plan.


The following Innovations Services require a quarterly progress summary:

Community Networking

Day Supports

In-home skill building

Intensive In Home Supports

Personal Care

Residential Supports

Supported Employment


The progress summary should contain at a minimum:

• Participant’s name

• Medicaid Number

• Date of the quarterly review and dates that the review covers

• The goals reflected in the current ISP

• Progress towards goals

• Recommendations for continuation, revision or termination of an outcome

• Signature of the individual who completed the review.


The progress summary should be completed quarterly based on the participant’s ISP year and should be completed separately for each service.

The quarterly progress note shall be documented within seven (7) working days of the close of the quarterly progress period.


If a progress summary is not documented in this time frame, it shall be considered a “late entry”.

The documentation shall be noted as a “late entry” and should include at a minimum the date the documentation was made and the date when the documentation should have been entered.

Example: Late entry made on 5/18/13 for 5/7/13


If at the time the quarterly progress summary is completed by the QP and NO changes to the goals are needed based on the individual’s progress, this would be noted in the progress summary and no changes to the short range goal plan are required.

If at the time the quarterly progress summary is completed by the QP and changes to the goals ARE needed based on the individual’s progress, this would be noted in the progress summary and within the ISP (goal review section). The QP is responsible for obtaining the guardian and/or participant’s signatures on the plan as required.


No changes to goal(s) needed:

Note in progress summary.

QP must sign the summary.

No changes to plan needed.

No signatures needed on plan.

Changes needed to goal(s):

Note in progress summary.

QP must sign the summary.

Make revisions to the short-range goal plan.

Signatures are required on the plan.


The individual and guardian should be involved in these discussions and should agree with whether or not changes are made.

All changes should be communicated to the Care Coordinator and a copy of the revised goal(s) should be provided to the participant and/or guardian.

You do not need to wait until quarterly review time to make needed

changes to the short-range goals. If you see something is not working during a quarter, you can and should make the needed change(s) at that time.

Person centered planning is a dynamic process and should contain

review and revision of the plan as often as the participant’s life circumstances/needs change. (NC Innovations Technical Guide Version 1.0-June 2012)


Although short range outcomes will not be submitted to

Utilization Management for service authorization review, providers should have appropriate and adequate documentation in place at all times.

*Note: There may be instances where Utilization Management has questions and would like to see additional information in order to complete the review process. They may ask for short-range goals to be submitted during these times. Providers will be expected to make all documentation available

to Care Coordinators, the MCO and others (Evaluators, etc.) as needed.

Back-Up Staffing NC Innovations Waiver

Documenting:

Back-Up Staffing


All participants will have a back-up staffing plan outlined in their ISP. This will be discussed by the team at the annual plan meeting and documented by the Care Coordinator.

The purpose is to ensure that the health and safety needs of the participant are met.

The plan outlines whether back-up staff are paid or unpaid, their contact information, and whether any specialized training is required.


It is the responsibility of the direct care service provider to ensure that back-up staff is available in the event the regularly scheduled staff is unable to provide the medically necessary services as scheduled.

Failure to provide back-up staffing is considered a Level I incident.

The provider will be responsible for completing a Back-Up Staffing Incident Report Form.

Forms should be submitted to Alliance Quality Management within 72 hours of the incident.

Back-up staffing incident reports are NOT included in the Quarterly Incident Report Summary submitted to Alliance’s Quality Management Department.


The Back-Up Staffing Incident Report is completed even if the participant/guardian declines the back-up staff offered. There is a place to note this on the report.

Be prepared to report on the following: description of the incident, how the participant was affected by the lack of staff and service provision, how the time was covered, and any follow-up provided.

General Information NC Innovations Waiver

As a direct care service provider, please take the time to familiarize yourself with all the requirements and guidelines under the NC Innovations Waiver.

You should be familiar with the NC Innovations Technical Guide:

http://www.ncdhhs.gov/dma/lme/Final_NC_Innovations_Manual_06252012.pdf





I/DD Specialist Contact Information NC Innovations Waiver

• Vince Wagner • 910 222-6129 • [email protected]

Cumberland

• Sara Wilson • 919 651-0089 • [email protected]

Durham

• Lori Caviness • 919 989-5557 • [email protected]

Johnston • Tammy Ramirez Tanya Held • 919 857-9115 919 664-7933 • [email protected] [email protected] Wake

mailto:[email protected]





I/DD Specialist Contact Information NC Innovations Waiver

The Provider Network Department of Alliance also hosts a NC Innovations Conference Call for service providers every Friday afternoon from 2:00-3:00pm to address provider questions regarding Innovations services.

For more information:

http://www.alliancebhc.org/weekly-nc-innovations-conference-call











General Information NC Innovations Waiver

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Provider Documentation · PDF fileProvider Documentation Training NC Innovations Waiver December 17, 2012 A New Multi-County Area Authority Merging The Durham Center and Wake LME