Patti Meire, Esq. Program Coordinator Betty Vines Program Specialist VA Public Guardianship Program Annual Monitoring Assessments and Care Plans Patti Meire, Esq. Program Coordinator Betty Vines Program Specialist

Assessments and Care Plans Case records

Program Regulations Require “The client's record shall contain a Virginia Uniform Assessment Instrument (UAI) or a similar comprehensive assessment instrument, a care plan, a values history, the annual report by guardians submitted to the Department of Social Services as required by § 64.2-2020 of the Code of Virginia, the annual accounting to the Commissioner of Accounts as required by § 64.2- 1305 of the Code of Virginia, and all applicable court orders and petitions. A client's record shall be completed and on file within 60 days of the program's appointment as guardian.” There is some confusion about what this means.

General Information UAIs are not the assessment tool used for all clients Assessment instruments are generally associated with eligibility for a particular state or federally funded benefit. Assessment instruments usually are created annually, or when there is a material change in an individual’s needs Many of the UAIs found in case records were quite old Many different care plans, particularly for clients receiving Waiver services through Home and Community Based Services (HCBS) Care plans are generally created annually and reviewed by the provider quarterly. If quarterly reviews uncover a significant change in the client’s needs, a new care plan may be required.

Current Documents Care plans in client records should not be old and/or outdated DSS/COA reports in client records should not be old and/or outdated All documents in the client record will be the most up-to-date version of the document available

Record Keeping Good & Bad News Good news – Client records will be inspected only for actual up-to-date care plans that are not more than 12 months old. DARS will not require that files include the formal written record of all quarterly reviews Good news – For client’s with an ID/DD waiver, DARS will be looking only for comprehensive care plans developed jointly by all providers and the CSB/BHA Bad news – Client records will be inspected for up-to-date assessment instruments that are no more than 12 months old Local programs have the freedom to keep whatever other documents the program believes to be helpful in doing its job and should keep any documentation that the Program Director determines is necessary to perform your fiduciary duty as guardian Files should be organized so they are easily understood by DARS, substitute case managers and/or Program Directors if they are hit by a bus For ID/DD Waiver – DARS will be looking for the Individual Support Plan (ISP) from the CSB/BHA We are using the term Case Manager in our presentations but we realize programs have various names for the employees that work with clients in that 20:1 ratio. It is the program, not DARS who is the guardian but DARS asks that files be organized so that they are easily understood by DARS and by a substitute case manager coming in to provide services in case the normal case manager, or the Program Director is hit by a bus.

Program Contracts Require Client records will include other records necessary or proper to perform guardianship services (e.g., court orders, DNRs, end-of-life decisional reports) DARS does request that certain documents be kept in client records under this provision, but for now, we want to talk about Assessments and Care Plans

Assisted Living Facility Residents 22 VAC 40-73-440; 22VAC 40-73-450

Assessments for ALF Residents Virginia UAI not more than 12 months old in working file State regulations require completion of a UAI for all ALF residents (private and public pay) prior to admission, at least annually, and whenever there is a significant change in a resident’s condition May use UAI from a prior placement when moving from another ALF but cannot be more than 12 months old PGP may move older UAIs to a storage file If the person has been moved from another ALF, the document used by the current ALF may be the UAI prepared for the prior placement (i.e., the UAI may be transferred with the client) but the UAI that the current ALF is relying on cannot be more than 12 months old.

Care Plans for ALF Residents Comprehensive Individual Service Plan (ISP) must be prepared by ALF within 30 days of admission ISPs must be reviewed and updated at least once every 12 months and as needed if the resident’s needs change Most recent ISP should be included in the “Care Plan” section of the PGP’s working file and should not be more than 12 months old Older care plans may be moved to a storage file ISPs should be signed by the PGP as the legal representative of the resident

Care Plans Exception ALFs are not required to prepare ISPs for residents who are assessed as capable of maintaining themselves in an independent living status If this exception applies to a PGP client, the Care Plan section of that client’s PGP working file should include a written statement signed by the PGP’s case manager and a senior staff member of the ALF

Nursing Home Residents 12 VAC 40-73-450.C; 42 CFR § 483.20 (b)(2) & (k)(2)

Assessments for Nursing Home Residents A Virginia UAI is created at admission to the NH A Virginia UAI that is not more than 12 months old in PGP’s working file Comprehensive Minimum Data Set (MDS ) that is not more than 12 months old in PGP’s working file If the NH states the UAI was not required for admission, get a letter to that effect from the NH & include it in the “Assessment” section of the file UAIs from prior NH admissions and MDS that are more than 12 months old may be moved to a storage file DARS will not inspect for quarterly MDS reviews, but if a new, mid-year comprehensive MDS is created, include in PGP’s working file

Care Plans Comprehensive MDS assessment will result in the development of a new care plan Most recent care plan should be included in the “Care Plan” section of the PGP’s working file Care plan should not be more than 12 months old Older care plans may be moved to a storage file Care plans should be signed by the PGP as the legal representative of the resident

Care Plans Care plans are reviewed quarterly after each quarterly MDS assessment review If a quarterly identifies a significant change in the resident’s condition or needs, a new comprehensive MDS assessment should be prepared New comprehensive MDS assessment will generate a new care plan New care plan and new comprehensive MDS assessment should be maintained in the PGP’s working file It is not necessary to keep the quarterly care plan reviews in the PGP’s working file DARS does not believe it is necessary to keep the quarterly care plan reviews in the PGP’s working file because if a quarterly identifies a significant change in the resident’s condition or needs, a new comprehensive MDS assessment should be prepared, which will generate the creation of a new are plan (which new care plan, along with the new comprehensive MDS assessment, should be maintained in the PGP’s working file).

Intellectual Disability/ Developmental Disability Waivers www.dbhds.virginia.gov

Assessments – ID/DD Waiver Clients Supports Intensity Scale (SIS) is used to determine individual support levels Conducted every 3 years for adults Provides information to assist in the development of the Individual Support Plan (ISP) Section 1 – Support Needs Index (home living, community living, lifelong learning, employment activities, health and safety and social activities) Section 2 – Supplemental Protection and Advocacy Scale Section 3 – Exceptional Medical and Behavioral Needs

Assessments – ID/DD Waiver Clients Virginia Individual Developmental Disability Eligibility Survey (VIDES) used to determine functional eligibility for Developmental Disability (DD) Waivers Eight categories: Health status, Communication, Task Learning Skills, Personal/Self Care, Motor Skills, Behavior, Community Living Skills and Self-Direction Waivers include: Building Independence, Community Living and Family & Individual Support Completed upon initial application to waiver, at enrollment (no more than 6 months) and annually to determine continued eligibility

Assessments – ID/DD Waiver Clients Most recent SIS and VIDES should be maintained in the PGP’s working file in the “Assessment” section. The SIS in the file should not be more than three years old. The VIDES should not be more than 12 months old. Older versions can be moved to storage. Copies of SIS assessments are required to be sent out to family/guardians and providers within 15 business days of the SIS interview by the SC/CM Request copies of the VIDES if not provided Copies may be obtained from your SC/CM

Care Plans – ID/DD Waiver Clients Community Services Board (CSB)/Behavioral Health Authority (BHA) uses an Individual Support Plan (ISP) Captures the supports and actions to be taken during the year by each service provider Created by the individual, SC/CM, family members/guardians, service and support providers and others interested in the welfare of the individual Five essential components of plan: Essential Information, Personal Profile, Shared Plan, Agreement (all partners and service providers sign in agreement) and Plan for Supports (PFS) PFS details the support activities and action steps for every Medicaid service provider PFS is developed utilizing information in the ISP and SIS

Care Plans – ID/DD Waiver Clients Cover 1 year period Updated annually and/or when significant changes occur Revised plans will still reflect the same program year SCs/CMs complete quarterly reviews which summarize quarterlies from service providers. DARS will not inspect for these Most recent ISP prepared by the CSB should be in PGP’s working file in the “Care Plan” section Plan names may vary by CSBs but will capture same information in 5 essential components Old versions may be moved to a storage file Keep copies of all signed documents signed by PGPs

Intermediate Care Facilities for Individuals with Intellectual Disabilities ICF/IID www.dbhds.virginia.gov

Assessments – ICF Residents LOFs are the required tool for admissions May be changing to the VIDES Comprehensive Functional Assessment (CFA) - completed annually Type of assessment may vary by provider CFA must have required areas from the regulations CFA may be combined reports Used during person centered planning meetings to create ISP SIS does not substitute for the CFA The LOF and the most recent CFA should be included in the “Assessment” section of the PGP’s working file CFA should not be more than 12 months old

Care Plans – ICF Residents Individual Service Plan (ISP) Updated annually and when changes occur Quarterly reports contain detailed summaries of services being provided along with updates Most recent care plan should be included in the “Care Plan” section of the PGP’s working file and should not be more than 12 months old DARs will not inspect for quarterly reviews

Other Community Living Options Contact dars

Case-by-Case Basis Assessments and care plans to be included in the PGP’s working file will be determined on a case-by-case basis Assessments: May have a Medicaid Waiver monitored by DMAS. If that is the case, may have an annual UAI which should be included in the file. Otherwise contact DARS to discuss alternative assessment tool options (if any) to be included in the PGP’s working file Care Plans: Contact DARS to discuss what kind of care plans (if any) will be included in the PGP’s working file

Questions

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