THURSDAY TARGETED TRAINING: Reporting Regulations and Requirements Stacy L. Nonnemacher, Ph.D. Clinical Director October 11, 2012

Agenda Review DPW Rules & Regulation, Title 55: Chapter 51.15: Provider Records Review DPW Rules & Regulation, Title 55: Chapter 51.16: Progress Notes Highlight sample forms developed by BAS These changes go into effect immediately. If you have any questions, please contact your Regional Office Rep.

THIS FOLLOWING APPLIES TO All AAW providers, with the exception of Assistive Technology and Environmental Modifications *Supports Coordinators will collect Monthly Progress Notes but are not expected to complete either the MONTHLY Progress Note or the Encounter Form.

ENCOUNTER FORM

REGULATION “DPW Rules & Regulation, Title 55: Chapter 51.15: Provider Records,” a provider must “document that the [services] for which it claims payment were provided to the participant and that information submitted in support of the payment is true, accurate and complete.”

PURPOSE To provide a description of what occurred during the delivery of each service. A “Summary of Activities” section reminds direct support staff that activities must relate to goals and objectives on the participant’s ISP. During monitoring, BAS will use Encounter Forms to crosscheck against PROMISe claims to verify financial accountability. And the Encounter Form will serve as a reference for the provider when compiling the Monthly Progress Note

COMPLETING THE ENCOUNTER FORM Location of Service: Should correspond with the physical location of service delivery. If the participant receives services for this date primarily in the home (greater amount of time spent in the home for this specific day than in an employment or community setting) please enter “residence.”   Total Units: Enter the total billable units based on the specified increments in the Provider Information Table. For example, an encounter that starts at 12:30 pm and ends at 4:30 pm would equal 4 hours or 16 15-minute units. Participant Signature: The participant receiving services must sign this form to verify that service details are correct. The participant or his/her representative should not sign unless all information above “Goals Details” is completed. The service provider may then fill out the remaining sections without participant verification.

COMPLETING THE ENCOUNTER FORM Staff Signature: Staff signature is verification of service delivery and goal details/summary of activities. Staff should not sign this form until all service details are recorded.   Goals & Objectives Details: Goals can be pre-populated based on the ISP. Only list goals and objectives listed in the ISP and approved by the Bureau of Autism Services Regional Office. Be sure to use the wording in the ISP. If more than five goals or four objectives are worked on during a session, please attach additional pages. Summary of Activities Details: This section should include observations or data collected during the session. Be sure to: Align data collected with the goal/objective addressed; Ensure that enough detail is provided to justify the amount of time spent delivering the service; Record when the goal has been completed or needs revision in this section, if applicable.

MONTHLY PROGRESS NOTE

*THIS NOTE REPLACES THE PREVIOUS QUARTERLY REPORT REQUIREMENT AND THE MONTHLY PROGRESS UPDATE REQUIRED BY BEHAVIORAL SPECIALIST SERVICE* BSS: Please ensure that Desired Behavioral Objectives are the same as the objectives submitted to the SC for inclusion in the ISP Goals section.

REGULATION “DPW Rules & Regulation, Title 55: Chapter 51.16: Progress Notes,” a provider shall “complete a monthly progress note that substantiates the claim for the provision of a [service] it provides at least monthly. A provider shall maintain [Monthly Progress Notes] in a participant's record.”

PURPOSE To report to the SC on the participant’s progress made toward goals and objectives. If a provider believes there needs to be a change in the service, the goal, the objective, frequency, etc., this is the tool to use to make that recommendation and justify the need for the change.

COMPLETING THE MONTHLY PROGRESS NOTE If the service is occurring on a less than monthly frequency, the provider should complete one Monthly Progress Note for each time the service is provided.        This form must be submitted each month to the participant’s SC no later than the 10th of the following month. Be sure to keep copies of Monthly Progress Notes in the participant’s file to be referenced during monitoring.

WHAT USE ARE THE ENCOUNTER FORM AND MONTHLY PROGRESS NOTE???

BAS will monitor for Monthly Progress Notes to comply with regulations BAS will monitor for Monthly Progress Notes to comply with regulations. The Encounter Form is not mandatory but is highly recommended to ensure thorough documentation of service delivery.

FOR THE ISP TEAM TO… Evaluate whether progress is being made toward goals and objectives in the ISP that are linked to the service (need to be specific to the objective written) Example: Objective- When given the opportunity at work, Matt will respond to a greeting by saying “hello” 100% of the time without job coach prompts for one quarter. Progress- Based upon the data, this month Matt has responded to a greeting 85% of the time independently with no prompts. Document that provider activities are aligned with the goals and objectives agreed upon by the ISP team Ensure that the service is being delivered in the way it is intended per the ISP and the AAW service definition (scope, limitations, staffing, etc.).

IF YOU HAVE AN EXISTING AGENCY FORM PLEASE ENSURE THE FOLLOWING IS CAPTURED… 1. Participant’s name 2. Provider agency’s name 3. Name of service 4. Amount, frequency and duration of the authorized and delivered service 5. Description of activities 6. Name, title, signature of person completing the form and date signed 7. Signature of the participant and date of service delivery (Encounter Form only)

IMPLEMENTATION

PROVIDER SUPPORTS COORDINATOR ENCOUNTER FORM MONTHLY PROGRESS NOTE Complete for time spent supporting the participant. Must be signed by participant or representative. Keep in participant file. Consolidate progress/data from the encounter form and note participant progress for one month period of time. Submit the 10th of each month for the previous month. SUPPORTS COORDINATOR Collect from providers monthly. Consolidate MPNs quarterly and capture progress information in HCSIS “Quarterly Summary Report” for each service.

Timeline for Implementation IMPLEMENTATION TIMELINE: MONTHLY PROGRESS NOTES Quarter Ends in this Month Submit Quarterly Report to SC? Submit 1st Monthly Progress Note for this Month First Monthly Progress Note Due Date September Yes October 11/10/2012 November 12/10/2012 No 10/10/2012 December If a Quarterly Report was due from the provider to the SC prior to September, the provider must still submit the overdue Quarterly Report to allow the SC to submit a complete and accurate Quarterly Summary Report in HCSIS.

Frequently asked questions Available on the virtual training center (provider Need to know)

NEXT THURSDAY TARGETED TRAINING: October 25th: ISPs: Beyond Compliance This training will discuss components of the ISP and the need to focus on person centered, quality plans.