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Training and Coaching DSPs for Excellence in Documentation April 2019
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What we will cover What is important for you to know
Rule/Manual References Scope of Service Well written plans = Good documentation Documentation Requirements Training Resources Documentation Template Skills Guide
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Rules/Manuals As a person charged with teaching documentation it is imperative that you know the rules. Administrative Rules & Provider Manuals Copies should be shared with providers, you will want to request these if you do not have them.
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Scope of Service It is critical that you understand the components of each service you are providing. They can be found both in IAC and the provider manual. ICF members no longer need a SIS unless they are going to access HCBS
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Scope of Service IAC Code Chapter 441-78
H & D Waiver BI Waiver Elderly Waiver PD Waiver Aids/HIV CMH Waiver ID Waiver Habilitation ICF members no longer need a SIS unless they are going to access HCBS
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Scope of Service - Provider Manuals
HCBS Provider Manual - Pages 27-90d Habilitation Manual - Pages a
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Well Written Plans = Good Documentation
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If you missed our Webinar:
Writing A Strong Service Plan, it is available on IACP Website This will give your staff information on how to write objectives that will assist your staff in writing good documentation. documentation series can be found on link.
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Clear Objective = Yes to these Questions
Are the conditions clear so everyone knows how or when this is to be worked on? Is the behavior something I can SEE? (overt skill) Is the skill really the behavior I want to see changed? Is it written for the client not the staff? Is it specific to 1 skill-not compounded? Do I have enough performance criteria so that it’s not a 1 and done type objective? Is it positive and strength based? Is the methodology clear and concise so that staff implementing the plan know when to document their observations of the targeted behavior, their interaction with the member and the member’s response to those interactions?
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Documentation Requirements IAC 79.3 & Provider Manuals
The documentation rules are the same for all medicaid services and are found in IAC 79.3 (2)3. The provider manuals are slightly different in that they more clearly state what is being looked at for the services described in that manual. So we will review those.
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HCBS Manual The record for each service provided shall include information necessary to substantiate that the service was provided and shall include the following: The specific procedures or treatments performed. The complete date of the service, including the beginning and ending date if the service is rendered over more than one day. Waiver services
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HCBS Manual The complete time of the service, including the beginning and ending time (including AM and PM designation) if the service is billed on a time-related basis. The location where the service was provided The name, dosage, and route of administration of any medication dispensed or administered as part of the service.
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HCBS Manual Any supplies dispensed as part of the service.
The first and last name and professional credentials, if any, of the person providing the service. The signature of the person providing the service, or the initials of the person providing the service if a signature log indicates the person’s identity.
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HCBS Manual For 24-hour care, documentation for every shift of the services provided, including the member’s response to the services provided and the person who provided the services.
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Habilitation Manual The provider’s file for each Medicaid member must include progress notes for each date of service that detail specific services rendered related to the covered habilitation service for which a claim is submitted to the Iowa Medicaid program.
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Habilitation Manual The following items must be included in each progress note entry, for each Medicaid member, and for each date of service: The date and amount of time services were delivered, including the beginning and ending time of service delivery.
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Habilitation Manual The first and last name and title of provider staff actually rendering service, as well as that person’s signature. The place of service (i.e., location where service was actually rendered). (Note: UHC is holding providers to the Hab provider manual which states (pg 50):The first and last name and title of provider staff actually rendering service, as well as that person’s signature. )
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Habilitation Manual A description of the specific components of the Medicaid-payable habilitation service being provided (using service description terminology from the covered services section of this manual). The name, dosage, and route of administration of any medication administered, when it is a part of the service. Note: the name, dosage and route can be on the MAR
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Habilitation Manual The nature, extent, and number of units of the habilitation service that was rendered. The progress note must describe what specifically was done, and include the progress and barriers to achieving the goals and objectives as stated in the member’s comprehensive service plan.
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Training Resources
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Develop Training Resources for your staff
List the scope of service for each service they will be providing. Develop a Q & A document Assure they understand each member’s service plan. Develop an FAQ for documentation
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Develop Training Resources for your staff
Use common intervention terminology. Develop a template that gives them the pattern to write good documentation. Have a uniform way to train all DSP and direct line supervisors.
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Scope of Service Example
Home Based Hab SCL-ID Daily Day Habilitation Adaptive skill development Assistance with activities of daily living Community inclusion Transportation (except to and from a day program) Adult educational supports Social and leisure skill development Personal care Protective oversight and supervision Community Skills Training Personal Mgmt Skills ($, meal prep, community integration, select food at grocery store, etc. Socialization Communication Skills Personal Environment support svcs-help person do things that keep them in least restrictive environment Transportation Activities of Daily Living (ADL) Individual Advocacy Physiological Txmt (med mgmt.) Psychotherapeutic txmt (assist w/ behaviors, beliefs, emotions, etc) Intellectual functioning. Physical and emotional health and development. Language and communication development. Cognitive functioning. Socialization and community integration. Functional skill development. Behavior management. Responsibility and self-direction. Daily living activities. Self-advocacy skills. Mobility.
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FAQ Example Q. When do I need to complete documentation?
A. Within 24 hours after providing the service. (you must never document prior to providing a service, doing so would be considered fraud) Optum provider manual requires on page 60: Treatment record entries should be made on the date services are rendered and include the date of service; if an entry is made more than 24 hours after the service was rendered, the entry should include the date of service, date of the entry, and a notation that this is a late entry
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FAQ Example Q. How much should I document?
A. Documentation Must Support the service… ASK: Is what’s documented something that should take that amount of time? ASK: Does my note clearly show that I provided support/skill building throughout a shift? Your notes need to have in it what’s necessary but they don’t need to be full length documentaries.
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FAQ Example Q. If I am working with 4 members, is it ok to copy documentation from one to another as they all were involved in the same activity? A. NO! Documentation must be specific to the person and the encounter – cutting and pasting...NEVER allowed. Don’t do it. This includes cutting and pasting documentation for one member for one day to the next. Cloning is the same as cutting and pasting
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FAQ Example Q. What is a good note?
A. Ask yourself: If I read this tomorrow or next week would I: Be able to see what skill the staff supported the member in? Be able to see how I, as staff, supported the member’s need. Be able to see how the member responded to that support? Be able to see if the member made progress with that intervention? Be able to see that the services authorized in the member’s service was implemented If the answer is YES to these questions, you wrote a good note.
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Template Example - (HCBS SCL)
1 Staff (verb)-what did you do/action you took. · Supported · Reviewed · Identified · Explained · Assisted · Listed · Developed · Provided… · Modeled (skill Choices - based on Scope of Service) · Community Skills Trng · Personal Mgmt Skills ($, meal prep, community integration, select food at grocery store, etc. · Socialization · Communication Skills · Personal Environment support svcs-help person do things that keep them in least restrictive environment · Transportation · Activities of Daily Living (ADL) · Individual Advocacy · Physiological Txmt (med mgmt.) · Psychotherapeutic txmt (assist w/ behaviors, beliefs, emotions, etc) by (action steps) 2 Client responded to this skill teaching (reason or explanation) 3 (Did or did not make) progress on the above objective (___ obj.) b/c or by
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Give your staff a template
1 Staff modeled a social skill by engaging Sally in a conversation around her weekend outing with her family. 2 Sally responded to this teaching skill Openly sharing about a funny experience she had in a restaurant when her dad misunderstand what the waitress asked him. 3 Made Progress on the above objective Sharing her feelings when asked and being open to communicate to others and not withdrawing from social interactions.
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Give your staff a template
1 Staff reviewed the personal care skill of how to wash Joan’s hair by talking through the steps of washing, rinsing, then conditioning. 2 Joan Responded To this teaching skill By Listening to staff’s feedback and then proceeding with her shower. 3 Made Progress on her personal care objective Using all needed products and taking her shower on Tuesday as scheduled.
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