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Community Care Service Program Waiver Services July 14, 2011
Leroy Altman, RN, Program Director, Lorraine O’Neal, RN, Human Services Program Auditor, Marcia Stanford, RN, Human Services Program Auditor, Georgia Department of Community Health, Office of Inspector General, Program Integrity Section
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DCH Mission ACCESS RESPONSIBLE HEALTHY Access
to affordable, quality health care in our communities Responsible health planning and use of health care resources Healthy behaviors and improved health outcomes
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DCH Initiatives FY 2011 FY 2011 Continuity of Operations Preparedness
Customer Service Emergency Preparedness Financial & Program Integrity Health Care Consumerism Health Improvement Health Care Transformation Public Health Workforce Development
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Community Care Service Program
The Community Care Service Program assists individuals who are older and/or functionally impaired to continue living in their own homes and communities as an alternative to nursing home placement. Individuals served by the program are required to meet the same level of care for admission to a nursing facility and be Medicaid eligible or potentially Medicaid eligible.
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Supervision of Services for CCSP
Registered Nurse supervision is required for the following services: Adult Day Health (ADH) Alternative Living Services (ALS) Personal Support Services (PSS & PSSX) Out of Home Respite Care (RC) Skilled Nursing Services (SNS) Registered Nurse supervision is not required for: Home Delivered Meals (HDM) Emergency Response Services (ERS)
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Supervision of Services for CCSP
Licensed Practical Nurse (LPN) must be supervised by a Registered Nurse (RN). LPN supervisory documentation must be reviewed and co-signed within 10 days by the supervising RN. Registered Nurse Supervision is required for some services to: Provide Medical Oversight Assessing Monitoring Implementing/arranging interventions to prevent or delay unnecessary and costly institutional placement To ensure that the provider serves the member effectively To ensure that the provider serves the member safely in the community
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Supervision of Services for CCSP
Registered Nurse Task: Assessing & Evaluating member’s needs Reviewing Level of Care & Placement Instrument Conducting supervisory and re-evaluations Developing and revising member care plans Preparing and reviewing progress notes Maintaining communication with other service providers Counseling & education of member, caregiver & staff
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Supervision of Services for CCSP
Registered Nurse Task continued: Assignment Decision Tree Generated by the Georgia Board of Nursing RN may assign task to unlicensed personnel Assist the RN in evaluating tasks
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Supervision of Services for CCSP
Supervision Guidelines All supervisor visits, notes and contacts must be labeled as such and legible Errors shall be corrected according to currently accepted standards of medical practice Names and titles must be legible Signatures must be original (not a stamp) Secure Electronic Signatures are acceptable Refer to Part II for requirements applicable to different categories of service Visits must be face-to-face
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Supervision of Services for CCSP
Supervisory Visit Documentation must include: Evaluation of the member’s health status Evaluation of the quality of care being rendered Results of the care being rendered Planned interventions Follow-up for problems identified A checklist does not replace narrative documentation, but can be used in addition to support narrative.
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Supervision of Services for CCSP
Medications – Monitoring and Administration RN must monitor medicines Over-the-counter Prescription Member records must include A current medication list - name, dose, route and frequency All drug side effects observed Documentation of reports of problems identified with medication/s Physician’s order to change medication/s Administration of Medications Only the attending physician may prescribe therapeutic or preventive medication/s
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Clinical Records Clinical Records Maintain Records
Clinical records must be maintained in accordance with Accepted professional standards and practices Documentation must substantiate the services billed to Medicaid Clinical records provides information on the quality of care Maintain Records As necessary to disclose fully the extent of services provided Medical necessity for the provision of such services For a minimum of five (5) years after the date of service initiated
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Clinical Records Records must reflect at a minimum
Date of Service Member name Medical history Service provided Diagnosis Prescribed drugs or treatment ordered Signature of the treating provider If there is a conflict with requirements you must refer to Part II for more stringent documentation requirements applicable to different categories of service.
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Adult Day Health Supervision
ADULT DAY HEALTH SERVICES (ADH) (Always refer to the GENERAL CCSP MANUAL for other requirements) Adult Day Health Supervision Medical monitoring activities include, but are not limited to: Monitoring vital signs and weights, as needed (rev 4/2011) Oxygen use Supervising medications Glucose testing Skin care Supervising care Progress Notes at least monthly RN must review, date and sign the Member Service Record Form monthly RN must review, date and sign the Activity Participation Record Form monthly
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Adult Day Health Supervision
ADULT DAY HEALTH SERVICES (ADH) (Always refer to the GENERAL CCSP MANUAL for other requirements) Adult Day Health Supervision RN must review, date and initial the Member Care Plan at least monthly RN must supervise all services RN’s supervisory visits must be labeled “RN Supervisory visit” RN must review and sign all LPN progress notes Supervisory visit at least once a month LPN may conduct and document a face-to-face supervisory visit every other month RN must conduct a supervisory visit at least every 62 days
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ADH Service Record Form
ADULT DAY HEALTH SERVICES (ADH) (Always refer to the GENERAL CCSP MANUAL for other requirements) ADH Service Record Form Members attendance Full day Part day Absent code Document any therapy Personal care Meals Other provided services
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ADH Activity Participation Record
ADULT DAY HEALTH SERVICES (ADH) (Always refer to the GENERAL CCSP MANUAL for other requirements) ADH Activity Participation Record Indicate members activity for each day Write a narrative of pertinent information Each entry must be initialed Enter member participation for the month At month end the RN and other staff must sign the record
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ALS Supervision All ALS members’ must be supervised by the RN
ALTERNATIVE LIVING SERVICES (ALS) (Always refer to the GENERAL CCSP MANUAL for other requirements) ALS Supervision All ALS members’ must be supervised by the RN The LPN may be the on-call contact – with the RN accessible to the LPN Conducted at least twice monthly by RN or LPN The visits must be at least 14 days apart between the 1st visit of the month and the 2nd visit At each supervisory visit, the provider nurse reviews, initials and dates the member care plan RN reviews, signs and dates the member services form monthly
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ALTERNATIVE LIVING SERVICES (ALS) (Always refer to the GENERAL CCSP MANUAL for other requirements)
ALS Supervision The RN is to know all prescription and over-the-counter medications for members. The MAR must show Name of medication Dosage Route date and time dosage taken Observed drug side effects & actions to address side effects Signature & date of the person supervising medications RN reviews, signs and dates MAR monthly
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RC Supervision RN must do the supervisory visit
OUT OF HOME RESPITE (RC) (Always refer to the GENERAL CCSP MANUAL for other requirements) RC Supervision RN must do the supervisory visit Review, revise and initial client care plan at least every two months Review, initial and date the Client Service Form at least monthly Conduct face-to-face supervisory visits at least every two months Prepare progress notes RN must review, initial and date progress note entries by other staff RN must instruct staff on progress note protocol. RN must provide follow up on problems identified. Communicate with care coordinators, other CCSP providers, family and/or other caregivers
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PERSONAL SUPPORT SERVICES (PSS) (Always refer to the GENERAL CCSP MANUAL for other requirements)
PSS Supervision The Licensed Practical Nurse (LPN) may perform supervisory visits and the note must be cosigned by the RN within 10 days of the visit The LPN is supervised by the RN Required every two month (within 62 calendar days) or Required every three months (within 92 calendar days) for all members who receive 24 units or less of services weekly RN must supervise and monitor the care of those members whose health status and situation involve complex observations
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PERSONAL SUPPORT SERVICES (PSS) (Always refer to the GENERAL CCSP MANUAL for other requirements)
PSS Supervision At each supervisory visit, the provider nurse reviews, initials and dates the member care plan RN reviews, signs and dates the member services form monthly RN must review, initial and date progress note entries by other staff
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Member Service Record Form
PERSONAL SUPPORT SERVICES (PSS) (Always refer to the GENERAL CCSP MANUAL for other requirements) Member Service Record Form Services must be documented each time service is delivered Date of service (month, date, year) Member name Specific time in and time out Number of hours of services Specific task performed Member signature Personal support Aide signature
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ERS Supervision If unable to reach member for testing
EMERGENCY RESPONSE SERVICES (ERS) (Always refer to the GENERAL CCSP MANUAL for other requirements) ERS Supervision Skilled Supervision not required Supervisor must have ERS equipment training Experience Once a Month Supervision Member test the system via a personal transmitter of the ERS Purpose of the supervision Detect malfunction To determine member’s ability to use system properly If unable to reach member for testing Three attempts must be made within five business days
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HDM Supervision Skilled Supervision not required
HOME DELIVERED MEALS SERVICES (HDM) (Always refer to the GENERAL CCSP MANUAL for other requirements) HDM Supervision Skilled Supervision not required Monthly supervision required HDM log has three months of supervision on one log Each month the supervisor Reviews Signs and dates the monthly log The provider is to check Meal accumulation Refrigerator/freezer and Cooking equipment Meal consumption
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Very Important Read Your Manuals
The Information in the Manuals is essential Manuals are subject to updates quarterly…so check for updates All CCSP services are required to comply with the Policies and Procedures for Medicaid/Peachcare for Kids, Part I, Chapters 100 through 500, Community Care Service General Manual, Part II, Chapters , in conjunction to the specific service manuals PSS must also comply with Rules and Regulations for Private Home Care Providers, Chapter manual ALS must also comply with Rules and Regulations for Personal Care Homes, Chapter , DCH, HFRD and Rules and Regulations for Disaster Preparedness Plans, Chapter , DCH, DPH SNS must also comply with Rules and Regulations for Private Home Care Providers, Chapter manual
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UTILIZATION REVIEW (UR) – AREAS OF REVIEW
Utilization Review includes the following areas, however this is not an all inclusive work tool. Reviews may include observation and determination in addition to elements listed such as cleanliness, safety, staffing, permits, etc. Medical Plan of Treatment/Recertification Sixty (60) Day Summary Member Care Plan Supervisory Visits Clinical Progress Notes Service Record Form Medications Level of Care
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UTILIZATION REVIEW (UR) – AREAS OF REVIEW (con’t)
Client Assessment Instrument/Initial Care Plan Comprehensive Care Plan Services and Frequency of Visits Using proper billing Codes for Services rendered Quality of Care Emergency Procedure Plan Advance Directives Directions to Member's Home Non-compliance with required policies and procedures will subject the provider to adverse action up to and including monetary recoupment and termination.
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