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Home My WebLink AboutExhibit 1 Log Cabin Training Center 1~~- 0 0 r ,.. Z II> .. <: '" z c .~ .... ,1006- /b;( 1ft) Exhibit 1 ~. e 1 , t STREET ____'~5.00' ~ ~ @) $~ f;;\ V o o () I~ n ,.. .. .1:: is en ..18 .c ~..... M"'" . '" ~ o o o o o CJ "0-;,;;.0" ~_.. 8~" -!~T.R [E T --+--'."'~:. ;,.." 20 1 r I :J>- ,.... ,.. .... -< Exhibit 3.2.1 Office of Community Services Log Cabin Training Center Inventory Report Item Quantity Location Singer Sawing Machine 1 Classroom 1 Sharp 27" TV set with remote control 4 Classrooms 1, 2, 3 & Client Service Office Sony Radio/CD/Cassette player/recorder no electric cord 1 Classroom 2 Siemens telephone 5 Offices and Classrooms 1 & 2 Gateway Computer with monitor" keyboard & mouse 1 Classroom 2 RCA Widescreen 52" TV with control 1 Classroom 3 RCA VCR with control 1 Classroom 3 DVD Player/recorder with control 3 Classrooms 1 , 2 & 3 Dell computer (white) with keyboard, monitor & mouse 1 Classroom 3 Magnavox 17" TV set with remote control 1 Kitchen Frigidaire Stove Oven 1 Kitchen General Electric Dishwasher 1 Kitchen Cuisinart Mini Processor 2 Kitchen Black & Decker Can opener 2 Kitchen Sun Bean Mixer 1 Kitchen Krups Food Processor (Optipro) 2 Kitchen T-Fal Steamer 2 Kitchen True Refrigerator 1 Kitchen True Freezer 1 Kitchen Grilling Machine (George Foreman) 2 Kitchen Gray Desk 2 Classroom 1 Black Storage Cabinets 2 Classroom 1 Small File Cabinet 1 Classroom 1 Blue Chairs 14 Classroom 1 TV Desk 1 Classroom 1 Blue Chairs 2 Kitchen Tables 12 Classroom 2 Blue Chairs 20 Classroom 2 Gray File Cabinet 1 Classroom 2 Black Storage Cabinets 2 Classroom 2 Tables 11 Classroom 3 Desk 1 Classroom 3 Blue Chairs 21 Classroom 3 Black Storage Cabinets 2 Classroom 3 Gray Chair 1 Classroom 3 Blue Chairs 8 Client Service Office Gray Chair 1 Client Service Office Conference Table 1 Client Service Office Desk 1 Client Service Office Book Shelf 1 Client Service Office File Cabinets (brown) . 2 Client Service Office Art Easel 2 Client Service Office Small Garywood Draw 1 Client Service Office Desks 2 Support Employment Gray Chair 1 Support Employment Blue Chairs 1 Support Employment Book Shelf 1 Support Employment Gray Desk 1 Administrator's Office Gray Cabinet 1 Administrator's Office Table 1 Administrator's Office Grav File Cabinet 1 Administrator's Office Gray Chair 1 Administrator's Office Blue Chair 1 Administrator's Office Cork Boards 2 Classroom 1 Wall Clock 3 Classrooms 1, 2 & 3 Electronic Mist Air-freshener 3 Classrooms 1, 2 & 3 Fire Extinguishers 3 Classrooms 1, 2 & 3 Drv Erase Boards 3 Classroom 1, 2 & Client Service Office Cork Boards 2 Hallway Display Cases 2 Hallway Classroom supplies various Classrooms 1, 2 & 3 21 Developmental Services Adult Day Training (ADT) Services Monitoring Protocol Day training programs for adults are training services intended to support the participation of individuals in daily, meaningful, valued routines of the community. For adults this may include work-like settings that do not meet the definition of supported employment. ADT Off-site models include the following services that teach specific job skills and other services directed at meeting specific employment objectives: · Enclave - A group approach to training where individuals with disabilities work either as a group or dispersed individually throughout an integrated work setting with supervision by the provider. · Mobile Crew - A group approach to training where a crew (lawn maintenance, janitorial) of individuals with disabilities are in a variety of community businesses or other community settings with supeIVision by the provider. · Entrepreneurial- A group approach to training where individuals with disabilities work in a small business created specifically by or for the individuals. Cite Probes Explanation of Monitoring Tool Symbols/Codes n Alert: Denotes a critical standard or cite relating to health. safety and rights. A deficiency requires a more intense corrective aGtion and follow-up cycle. "W" Weighted Element: A "W" followed by 2.0 or 4.0 in the Cite colunm denote.s elements that have a greater impact on the monitoring score. "R" Recoupment: An "R" in the Cite column denotes an element that is subject to recoupment of funds by the State if the element is "Not Met." Standard: The provider successfully supports individuals to achieve desired goals and needed services through individualized training programs and meaningful daily routines and activities. For the following cites associated with this standard: Review results of the person-centered reviews, information available from individuals receiving the service and available documentation. The purpose of this section is to determine provider performance and the quality of supports in this area. Do not score a cite as met solely based on the presence of the documentation. 1 The provider develops an Ask the provider to describe the implementation individualized implementation plan planning process, including: W2.0 (IP) for all consumers. Review results and recommendations from Person-Centered Reviews for cites 1 - 8. · Who is typically involved? · When does it usually take place? · What happens with the IP once it is developed? Exhibit 7.1 Cite 2 W2.0 3 An individualized implementation plan (lP) is developed under the direction of the consumer. The IF identifies goal(s) and needs from the individual's support plan and other pertinent sources appropriate to the individual. Probes . . Ask individuals receiving services about their participation in the IF development Do services reflect interest and goals that they have? · Ask the provider how a consumer is involved in the development of their implementation plan. Is this participation documented in any way? )or Determine if there is consumer sign-off on the plan or any changes to the plan to indicate acceptance. )or Review monthly summaries to detennine if updates are being made to the IF. )or Determine if the provider evaluates the strategies or methods for effectiveness and how frequently. · Ask the provider to describe how they monitor the progress of the individuals that that they seIVe · Look for evidence that the provider is actively monitoring the progress of individuals. · Look for evidence of IF updates being made based on an individual achieving goals or not. · Look for evidence that individuals reviewed are making progress toward achieving identified goals. · Talk to consumers, family or guardians about the progress that is being made in achieving ~oals. · Ask the provider about their process for ensuring their implementation plan is effective and contains information related to these standards. (The IF may include information from other sources, but at a minimum must contain goals from the support plan.) · The IF identifies training programs and activities to accomplish desired goals and identified needs. · Ask individual about training/activities in which they are involved. Do they feel these are beneficial? Are they interested in the trainingtactivities? · Interactively, with the provider, review a sample of implementation plans. During review, )or Explore with the provider what other sources of infonnation about an individual influence the implementation plan. Adult Day Training (ADT) Services Monitoring Protocol Page 2 Cite Probes 4 The IP identifies strategies and . Look for evidence of provider~eveloped methods to assist the individual in implementation plan forms or other structures meeting goal(s) as well as the data put in place to ensure that data is captured consistently and in such a way that it can be collection system to be used to analyzed over time. assess success and achievement. ~ Ask the provider how they determine strategies and methods that will assist individuals in meeting goals. 5 The implementation plan includes a Review the IP to ensure it contains this NEW description of methods that the infonnation. provider will use to ensure the individual makes an informed choice concerning the types of work and meaningful day activities (type of activities). 6 The IP is reviewed periodically to Review IP and provider's policies, as applicable, determine whether progress is being to detennine if IPs are reviewed at stated time W2.0 made and is updated to reflect new frames, and changes documented per stated interests, goals, needs, or strategies procedures. to promote meaningful progress. ..,~ Adult Day Training (ADT) Services Monitoring Protocol Page 3 Cite Probes 7 The provider is tracking and acting Review monthly summaries and the annual report on an individual's progress or lack to determine whether progress is noted. Determine whether: of progress. . Activities. supports, tasks accomplished and training provided are detailed; . Follow-up is performed if indicated; . Progress statements contain objective (data/fact based) as well as subjective information; Look for evidence that recommendations for changes in approach are made when progress is not being made. . Look for evidence that individuals are making progress and that the provider is actively monitoring the progress of individuals. Examine monthly summaries and annual report information. . Talk to consumers, family or guardians about the progress that is being made in achieving goals. Are they learning new skills? Do they have suggested improvements or changes to the service system? . Review recommendations and results from the Person-Centered Reviews applicable to the provider to assist in determining whether progress is being made and the individual is included in the service delivery system. Adult Day Training (ADT) Services Monitoring Protocol Page 4 ....... Cite Probes 8 The provider has taken action on the Sample size is at least two person~entcred results reported through the person reviews in those instances when more than ODe has been conducted. 100% of the sample centered review process. equals a designation of 'Met.' . Determine if any person-centered reviews have been conducted with consumers receiving services and supports from this provider. . Ask the provider if they have received person-centered review results and what action they have taken based on the results. . Interactively, with the provider, review records and documentation for individuals that have taken part in the person-centered review process. Detennine if there is any documented evidence that the provider has acted on the recommendations in the report. . Talk with individuals who participated in the person centered review to determine whether changes were discussed with them and have been made. Are they satisfied with the seIVice changes? Note: If there have been no person-centered reviews conducted with individuals fOr which this provider renders services and supports, score this element 'Not Applicable. ' Note: The provider may address the Person- Centered Reviews recommendations in a manner other than that identified in the report. As appropriate to the individual goals, needs, and interests: 9 Services stress training in activities . Review results and recommendations from of daily living. Person-Centered Reviews to assist in 10 Services stress training in self- determining compliance with cites 8 - 13. advocacy. . Ask the provider/staff about the services and supports they offer. 11 Services stress training in adaptive . Ask the provider/staff to describe the and social skills. characteristics of the individuals receiving 12 Services are age and culturally seIVices and supports. appropriate. . Ask the provider/staff how they approach training with an individual. . Ask the provider/staff how they handle age and cultural differences of individuals, . Interactively with the provider, review a sample of implementation plans. . Talk with individuals to determine if the services/goals are important and appropriate for them. Are they individualized? Varied? 13 Training activities and routine are . Ask the provider how they determine that meaningful to the individual and the services and supports they deliver are W2.0 consistent with the support plan and meaningful to an individual. approved cost plan. . Determine if the provider offers a variety of activities that are of interest to the ..'. Adult Day Training (ADT) Services Monitoring Protocol Page 5 Cite Probes individual. . Do programs and activities appear to be individualized, or "one size fits all",? . Ask individuals whether the activities are based on the individual's interest, choice or related goal or need, not the convenience of the provider. . Discuss with the individual whether skills training and activities match with the individual's expectations. Note: This can be community service activity. 14 Off site ADT services teach specific . Review results and recommendations from job skills and other services directed Person~Centered Reviews. at meeting specific employment . Ask individuals to describe their work routines and any training they receive. Are objectives. they satisfied with the level of services? ADT -Off Site models include >>> Enclave - A group approach to training " where individuals with disabilities work either as a group or dispersed individually throughout an integrated work setting with supervision by the .'- provider. >>> Mobile Crew - A group approach to training where a crew (lawn maintenance, janitorial) of individuals with disabilities are in a variety of community businesses or other community settings with supervision by the provider. >>> Entrepreneurial- A group approach to training where individuals with disabilities work in a small business created specifically by or for the individuals. . Ask the provider about the focus of off-site training activities. . Ask the provider to describe some of the off site training activities that are being offered. -- Note: This can be community service activity. Score this element 'Not Applicable' if provider is not sponsoring any of the off site programs noted 15 Facility-based and off-site programs . Ask the individuals/provider/staff if any of pay individuals receiving ADT for the programs they provide offer pay to W2.0 performance of productive work; individuals pay is commensurate with members . Look for wage schedules and evidence that of general work force doing similar individuals are being paid for their work. work. Note: Individuals receiving ADT services who are performing productive work that benefits the organization or would have to be done by someone else if not done by the individual must be paid Pay follows per wage and hour regulations of the Deoartment of Labor. Adult Day Training (ADT) Services Monitoring Protocol Page 6 Cite Probes 16 At least annually, providers conduct . Talk to individuals to determine whether they an orientation informing individuals are aware of employment options and how W2.0 of supported employment and other they obtained this information. competitive employment . Determine from provider/staff how orientation information is presented. Review opportunities in the community. documentation. Standard: The provider and all of the provider's staff are qualified to provide Adult Day Training sen'ices. 17~~ Level two background screenings Review available personnel files or records to are complete for all direct service ascertain compliance. Check for: W4.0 employees. . Notarized affidavit of good moral character; . Proof of local background check . Documentation of finger prints submitted to FDLE for screening and screening reports on file . Criminal records that include possible disqualifiers have been resolved through court dispositions. " 18n All employees undergo background Review available personnel files or records to re-screening every 5 years. verify that employees undergo background re- W4.0 screening at least every 5 years .'. Look for evidence of completion and submission of an FDLE Form. identified as either attachment 30r4. Note: Fingerprint cards are not required on resubm;ss;on. 19 Managers or directors have no full . Review a job description for a manager or time responsibility for providing director. servIces. . Interview several managers and directors and ask them to describe their day-to-day responsibilities. 20 Program director has bachelor's Review the program director's personnel record degree and two years related and qualifications. experience. Note: Related experience substitutes on a year- for-year basis fOr the required college education. 21 Instructors (supervisors) have Review instructor/supervisory staff personnel associate's degree and two years records for qualification requirements. experience in related field. Note: Related experience substitutes on a year- for-year basis fOr the required collef!e education. 22 Direct service staff work under Interview direct service staff to detemtine appropriate supervision. >> Who supervises their work Adult Day Training (ADT) SeIVices Monitoring Protocol Page 7 Cite 23 Staffing ratio does not exceed ten (10) individuals per direct service staff for facility-based programs. W2.0 24 Direct service staff must be at least 18 years of age and has a high school diploma or equivalent. Probes >> How many individuals they are responsible for in their day-to-day activities. Administrative staff and those not providing direct services to individuals are not considered direct seIVice staff, unless temporarily assigned to cover for intennittent absences of direct ser vice staff to maintain authorized ratios. Area office approval is required if the ratio exceeds 1: 10. Review the service authorizations and/or waiver from the Area office. Review a sample of direct service staff personnel records, job descriptions and qualifications. Note: Two years of related experience may substitute for a diploma. Experience requirements are applicable to new hires as of the initiation of the Quality Assurance program being conducted by Delmarva. Employees hired before the initiation of this contract cannot be the sole reason that a provider receives a designation of "Not Met" at this element. Standard: The provider and the provider's staff meet training requirements for delivery of Adult Day Training services. For all the following cites associated with this standard: Review Area office requirements for mandatory meetings and training documentation. Review provider's training records to determine if documentation is maintained, and at a minimum includes: The topic of the training; Length of the training session; Training dates; Participants' signature; Instructor's name; Objectives and/or a syllabus. NOTE: The Area office is not the sole source for a provider to find training programs and activities referred to in the Core Assurances. Providers may develop their own curriculum for their staff, or providers and their staff may attend a pro~am offered through another provider. 25 The provider attends mandatory meetings and training scheduled by the Area office and/or Agency. Adult Day Training (ADT) Services Monitoring Protocol · Ask the provider if they are aware of Area office and Agency mandatoI)' meeting and training schedules. Ask the provider if they can produce any notices, announcements or agendas received about meetings or training. · Ask the provider what Area office and Agency meetings or training they have attended during the review period. · Ask the provider for any evidence they have to verify attending the meeting or training. · Look for evidence in documents supplied by the provider of attendance at Area office and Agency meetings, such as notes in personnel files or other records. Note: If the Area office has not sponsored any mandatory meetings, score this element as 'Not Applicable. . Page 8 Cite Probes 26 Independent vendors and agency . Ask the provider and/or their staff about what staff receive training on types of training programs they have and W2.0 responsibilities and procedures for continue to attend. maintaining health, safety and well Tnuning on heal~ safety and well-being of being of individuals served. individuals could include such topics as: . Fire safety for the environment; . Evacuation procedures in the event of natural or other disasters; . Training on what to do in the event of personal health emergencies involving consumers; . Transportation safety; . Basic infection control training, e.g., hand washing before and after all contact with consumers. . Appropriate mealtime inteIVentions . Positioning requirements, as applicable Refer also to the provider's policy in this area to detennine compliance: 27 Independent vendors and agency Determine if: staff receive training on medication . The provider ~ a policy related to their own administration and on supervising and/or staff training on medication administration or supeIVision of self- individuals in the self-administration administration of medication. of medication. . The provider and/or staff receive training on medication administration or supervision of self-administration of medications, when applicable to their job responsibilities and the needs of individuals in the program. . Detennine if medication administration training includes evidence of a return demonstration of the training by an RN for the provider and staff . Detennine if the training includes recognizing adverse drug reactions, drug-to- drug interactions or food and drug interactions. . Detennine if training is provided by a qualified trainer (physician or Registered Nurse); the curriculum used is developed or approved by an RN or other appropriate entity (e.g. Area office). Note: A provider's policy on medication administration mqy be that their program does not administer or supervise seJ.f-administration of medications and all staflare made aware of this position and trained on this policy. Adult Day Training (ADT) Services Monitoring Protocol Page 9 Cite Probes 28 Independent vendors and agency Look for evidence that the provider and/or staff staff receive training on required have received training on the type and format of documentation for service(s) documentation that is required for the seIVices rendered. and supports that they render. Examples of this training could include: . The proper format and content of a progress note, . Recording data related to an individual's progress towards achieving goals, . Documenting the activities that individuals participate in during their time with the provider. . Instruction on documentation that is required for reimbursement and monitoring purposes. . Development of an individual Implementation Plan and supporting documentation requirements. 29 Direct service staff has received Look for documented evidence that direct seIVice NEW training in the Agency's Direct Care staff have received this training or an equivalent Core Competencies Training. which has been approved by the Agency. ""of Training was received within the required timefrnmes as developed by the Agency. 1bis training may be completed using the Agency's web-based instruction, self-paced instruction or classroom-led instruction. Self- paced instmction must be approved by the Area Office prior to use. 30 Independent vendors and agency Look for evidence that the provider and/or staff staff receive training on have been familiarized with and have had some responsibilities under the Core training related to the Core Assurances section of their Waiver Services Agreement and the DS Assurances. Waiver SeIVices Florida Medicaid Coverage and Limitations handbook. Examples of this training could include instruction on: . The rights of individuals in the program and how the provider respects these rights; . Maintaining confidentiality of consumer information; . Offering individual's choice of seIVices and supports; . Recognizing and reporting of suspected abuse, neglect or exploitation; . Assisting individuals in achieving personal goals and desired outcomes; . Rendering services in an ethical manner. Adult Day Training (ADD Services Monitoring Protocol Page 10 Cite Probes 31 Independent vendors and agency Look for evidence that the provider and/or staff staff receive training on have been familiarized with and have had training responsibilities under the related to the seIVice specific sections of their Waiver Services Agreement and the DS Waiver requirements of specific services SeIVices Florida Medicaid Coverage and offered. Limitations handbook. Examples of this training could include instruction on: . Implementation plan development and monitoring; . Specifics of rendering seIVices and supports; . Service limitations; . SeIVice documentation requirements . Billing for seIVices; and . Outcomes established for seIVice delivery. 32 Independent vendors and agency Look for evidence that the provider and/or staff staff receive training on use of have received training on using desired outcomes personal outcomes to establish a for individuals as the guide for rendering setVices person-centered approach to service and supports. delivery. Examples of this training could include ~.. instruction on: . Designing training programs that address the consumers goals from the Support Plan; . Involving the consumer and/or family in the development of the implementation plan; . Designing services and supports from the standpoint of the outcome that is desired by the individual and/or family. . Training in Personal Outcome Measures, or another person-centered planning approach. . Individualizing service delivery methods. Refer also to the provider's policy in this area to determine specified training. Note: This does not mean that the provider must have received the official Personal Outcome Measures training (with the exception a/Support Coordinators). Other person-centered approaches are acceptable. Adult Day Training (ADT) Services Monitoring Protocol Page II Cite Probes 33 Independent vendors and agency Look for evidence that the provider and/or staff staff receive training specific to the assigned to render services and supports to W2.0 needs or characteristics of the individuals have received some orientation to an individual and their unique characteristics and individual as required to needs. successfully provide services and supports. The family or guardian, a physician or nurse, other providers or people who are in regular contact with and understand the unique characteristics and needs of the individual can provide this orientation. Examples of this training could include instruction on: . Communicating with the individual; . Repositioning requirements for the individual; . Instruction on a behavior program, if applicable to the individual; . Appropriate positioning/mealtime inteIVention. . Specific training to implement a training program tailored to an individual's goals. This training may be one-on-one in nature, and therefore documentation may not take the form of an agenda, or curriculum with handouts and outline. Look also for evidence in the consumer records, such as in progress notes or other provider documentation. 34 Proof of current training and . Independent vendors and agency staff certification is available for all staff complete this training within 30 days of in Cardiopulmonary Resuscitation initially providing services. (CPR). . Determine if the provider and staff receive reuaining according to the requirements established by the sponsoring organization or according to regulations. . Review personnel files and other provider training records for evidence of required CPR training. . Review CPR certificates or CPR training - documentation to detennine expiration date and need for updated training. Note: A certified trainer must provide CPR traininrz. Adult Day Training (ADT) Services Monitoring Protocol Page 12 Cite Probes 35 Proof of current training is available . Independent vendors and agency staff for all staff in AIDS and infection complete this training within 30 days of control. initially providing services. . Detennine if the provider and staff receive retraining according to the requirements established by the sponsoring organization or according to regulations. . Review personnel files and other provider training records for evidence of required training. . Infection control may be a separate training or included and documented. as part of the AIDS training as "universal precautions." Note: American Red Cross First Aid Training does not meet the requirements for HIVIAIDS training. 36 Staff attends eight (8) hours of . Review personnel files and other provider annual in-service training related to training records for evidence of required W2.0 implementation of individually training. tailored services. . If applicable, ask staff about the in-service ..... training that they have received. 37 Proof of required training in . Review personnel files and other provider recognition of abuse and neglect to training records for evidence of required include domestic violence and training. sexual assault, and the required . If applicable, ask staff about the in-service reporting procedures is available for training that they have received. all independent vendors and agency . Training should include prevention, detection and reporting requirements. staff Standard: Services are provided at an intensity and duration necessary for successful support of tbe individuals served. 38 Services are rendered at a time . Look for evidence in provider records that mutually agreed to by the individual service times have been discussed with the - and provider. individual. . Ask the provider to describe how service times are negotiated with individuals. . Ask consumers if the time of the service is consistent with their needs and expectations. Note: This selVice generally begins at the age of 22 when an individual is out of the public school system, or if the person has graduatedfrom the public school system. However, an individual can begin adult day training at the age of 16 if the public school system is willing to provide fUnding for this selVice throughout the person's legal age of eli[(ibilityfor school system selVice. 39 In facility-based ADT individuals . Review recommendations and results of the spend a minimum of four hours in Person-Centered Reviews applicable to the Adult Day Training (ADT) Services Monitoring Protocol Page 13 Cite Probes W2.0 specific training or program provider. activities designed to meet . Ask the provider for any schedules or individual needs and personal goals documentation of individuals in the sample being reviewed to determine the amount of defined in the support plan(s). time spent in training and program activities related to needs/goals. . ObseIVe and talk with individuals receiving services and.supports--ask them about the variety of activities they are offered. Are the activities consistent with what they want for supports and services? . Ask the provider to describe how they collect data to detennine an individual's success and achievement of goals from their implementation plan . Ask the provider how they assess the successes and achievements of individuals in their programs . Look for evidence that the provider's data collection system is being eonsistentIy implemented . For full-time participants. This will vary if the person attends on a part -time basis. -'" Note: ADT services are usually limited to a specific number of days per year, operating a minimum of6 hours per day on a regularly scheduled basis. Adult day training services may be provided as an adjunct to other services included on an individual's support and cost plan. For example: An individual may receive Supported Employment or other services for part of a day or week and adult day training services at a different time of the day or week. Adult day training services will only be billable for the prorated share of the day or week that the individual actually attended that service. Note: An individual cannot receive a more than a total of 3 5 hours a week of a paid support, or a combination of paid supports designed to be used as a meaningful day activity. An individual may not receive a combination of ADT, NRSS or Supported Employment services that exceeds 35 hours per week. 40 Services are provided in a . Review recommendations and results of the designated adult day training center Person-Centered Reviews applicable to the or other training sites in the provider. community as agreed to by the . Ask the provider to identify where training is provided. individual and provider. . Look for evidence that individuals have agreed to the locations. . Talk with individuals encountered during the site visit about the locations where they are Adult Day Training (ADT) SeIVices Monitoring Protocol Page 14 Cite Probes receiving training. Was a choice prcsented? Arc they satisfied? 41 Providers of incidental Detennine if the provider transports individuals. transportation comply with program ~ If transportation is provided in personal requirements cars and/or agency vehicles, check personnel files to verify that valid licenses, vehicle registration and proof of insurance coverage are CWTent. ~ The Area office should be notified of any traffic violations immediately with "- the exception of parking tickets. ~ Ask the provider about their system to assure vehicle safety. ~ Ask to see any written procedures if they .. .' are available. Note: Incidental transportation is considered that which is outside of the transportation for disadvantaged program. - Adult Day Training (ADT) SeIVices Monitoring Protocol Page 15 Cite I I Probes Standard: The provider maintains sufficient reimbursement and monitoring documentation to verify service delivery and to evaluate each individual's services and supports. Note: Score based on the presence or absence of the re uired documentation. 42R Provider has at a minimum an Interactively, with the provider, review a sample individual implementation plan. of implementation plans to determine they contain. at a minimum: . Name, address and contact information of the individual served; . Goal(s) from the support plan that the seMce will address. . Strategies employed to assist the individual in meeting the support plan goal(s). . System to be used for data collection and assessing the individual's progress in achieving the support plan goa1(s). . For ADT, include a description of methods that the provider will use to ensure the individual makes an informed choice concerning types of work and meaningful day activities. .,,,, Additionally, the implementation plan may include training objectives appropriate to the individual's programs and seIVices. This Cite is subject to recoupment if not available. 43 R The IF is developed, at a minimum, . Review records to compare seIVice within 30 days of new service authorization date with IF development initiation, or within 30 calendar days timeframes. of service authorization effective . How does the provider monitor that IF's are being completed within state defined date when services are being timeframes? continued. The implementation plan is submitted to the waiver support coordinator at the time of the first claim submission, and at least annually thereafter at the time of the support plan update and, any time major or significant updates and changes are made before they are implemented. 'This Cite is subject to recoupment if not available within 30 days of the effective date of the authorization. Adult Day Training (ADT) Services Monitoring Protocol Page 16 ~. Cite Probes 44 Provider has at a minimum Interactively, with the provider, review a sample supporting data (notes) to the of records to determine if they contain supporting implementation plan. data that: . Identifies the individual's progress toward achieving the goal(s) identified in the implementation plan; Supporting data may include: . Progress notes relevant to training and activity sessions. (May include information from the monthly summary and Annual Report. ) . Any assessments used to identify additional needs/desires of the individual. . Data or data displays from training sessions. . Other information gathered and used to determine strategies, meaningful activities or approaches. Supporting data may be used to create the monthly swnmmy of progress for the individual. Review the provider's policies/procedures and strategies on the IP to detennine what supporting data is to be collected and how. 45R Provider has at minimum, copies of Interactively, with the provider, review the daily NEW service log(s). service logs and claims submissions for the period being reviewed. SeIVice logs are to be submitted to the waiver support coordinator on a monthly basis. Note: A service log contains the individual's name, social security number, Medicaid ID number. the description o/the service, activities, supplies or equipment provided and corresponding procedure code, times and dates service was rendered This Cite is subject to recoupment if not available. ~ Adult Day Training (ADT) Services Monitoring Protocol Page 17 ...,,.' Cite Probes 46R Provider has at a minimum a Interactively, with the provider, review a sample monthly summary of an individual's of records to detennine if they contain a monthly summary note indicating an individual's progress, progress toward achieving support or lack thereof, toward achieving the goal(s) plan outcomes for the period being identified on the implementation plan for the reviewed. month billed. ~ Progress statements in the monthly summary should contain objective (data/fact based) as well as subjective information. ~ Progress statements should be consistent with available supporting data and information. >> This should not be just the submission of progress notes to the support coordinator. The provider should draw some conclusions in a sentence or statement. Review monthly summaries and the annual report to determine whether progress is noted. " Determine whether: . Activities, supports, tasks accomplished and training provided are detailed; ~,. . Follow-up is performed if indicated; . Progress statements contain objective (data/fact based) as well as subjective information; Look for evidence that recommendations for changes in approach are made when progress is not being made. This Cite is subject to recoupment as monitoring documentation if not available. 47R Provider has at a minimum an Interactively, with the provider, review a sample annual report. of records to detennine if they contain an annual, written report that indicates the individual's progress toward their support plan goal(s) for the year. Progress statements in the annual report should contain objective (data/fact based) as well as subjective information. Progress statements should be consistent with monthly summaries and other supporting data. The report is to be submitted to the waiver support coordinator prior to the annual support plan update. This Cite is subject to recoupment as monitoring documentation if not available. Adult Day Training (ADT) SeIVices Monitoring Protocol Page 18 Cite Probes 48 Provider has at a minimum results of Interactively, with the provider, review a sample the annual satisfaction survey. of records or other files and reports to determine if they contain satisfaction survey results and resulting quality improvement measures that have been put in place as a result of the survey. 49 Provider has at a minimum Interactively, with the provider, review any performance data on the Projected performance improvement data that is available Service Outcomes. related to projected seIVice outcomes defined in Chapter One of the OS Waiver Services Florida Medicaid Coverage and Limitations handbook. Standard: Provider bills for sen'ices as authorized. SOR ADT services are limited to the . Interactively, with the provider, review a amount, duration and scope of the sample of approved cost plans and/or seIVice service described on the individual's authorizations in comparison with claims support plan, current approved cost data, attendance logs, supporting data and monthly summaries. plan and service authorization. . Verify that the provider has on file a service authorization for the seIVices provided. . Review staffing ratios as compared to seIVice authorizations or the cost plan to determine if the provider is in compliance. Tbis Cite is subject to recoupment if the provider is rendering the service witbout an authorization, or is biDing for more than the authorized service levels. Adult Day Training (ADT) SeIVices Monitoring Protocol Page 19 Cite Probes 51 R The provider bills tor adult day . Interactively, with the provider, review training as defined and specified in documentation and billing procedures. the DS Waiver Services Medicaid . Determine if the provider has a process to ensure that documentation is on file before a Coverage and Limitations handbook. claim is generated. . Determine if tbe provider has a process for verifying that billing is performed in accordance with program requirements. . Review claims and billing data to determine that ADT services are not being provided concurrently (at the same time) with PCA, NRSS, or Companion services. . Transportation between day training sites is included as a component part of the ADT services and included in the rate paid to the provider of this service. . When the supervisor of a mobile crew or enclave does not meet the qualifications for a supported employment coach, even when the .. individual meets the criteria for supported employment, the support is billed as adult day training-off site. . If the support is provided to groups larger ~.. than eight individuals, regardless of the wage, the service is billed as adult day training off site. . If the support is provided in groups of eight or less and the individuals are paid less than minimum wage, the service is billed as adult day training off site. . Provider is not billing for any day an individual is absent from the service. Note: ADT services are training services expected to enhance skills and achieve individual goals and outcomes. Note: Check billing against attendance log and claims. This Cite is subject to recoupment for any individual when there is evidence that the iudividual is not receiving tbis senice as defined (e.g., no evidence of training services or meaningful activities for the individual and services were billed). Standard: The provider meets projected service outcomes established for service deliverv. 52 The provider has established a . Ask the provider to discuss the goals and systematic method to collect Projected SeIVice Outcomes that they are projected service outcome data. monitoring. . Ask the provider what data they are collecting and how they collect the data (e.g., record review, specially developed forms Adult Day Training (ADT) Services Monitoring Protocol Page 20 Cite Probes completed by employees, consumer satisfaction surveys, etc.) · Ask for samples of the tools or other evidence that confirms data is being collected and monitored. · Ask the provider to describe how it is determined they are meeting Projected . Service Outcomes. · If the provider has any data or reports that they produce and maintain related to the Projected Service Outcomes, ask to see these reports and identify how long the provider has been tracking this data 53 The provider reviews data periodically and corrective measures are put in place if the data indicates that the goal is not being achieved. . Ask the provider how it is determined they are achieving Projected SeIVice Outcomes. Ask the provider how frequently they perform this monitoring. Ask the provider if they have identified any areas in need of improvement and what corrective actions they have taken. Look for evidence that the provider is collecting and monitoring data according to the time fi3ines they have defined. . . . For elements 54-59, document findings in comments as #met/total sample. 100% of the sample must meet criterion in' order for the elements to be designation 'Met' except where otherwise indicated. Outcomes should be measured considering individual skills and circumstances. Reviewers will determine achievement of Projected Service Outcomes at the time of the review. Reviewers will also use the results and status of recommendations from the Person- centered Reviews applicable to the provider, information (rom the sample records and documentation reviewed, and discussions with the individuals receiving the services. Adult Day Training (ADT) Services Monitoring Protocol Page 21 -,. Cite Probes 54 Individuals receiving services . Look for evidence in supporting data that the demonstrate an increase in abilities individuals are making progress towards W2.0 consistent with their support plan. achieving their personal goals. Note: Based on the age, level of functioning, interest and health condition, the individual is assisted with the acquisition, retention or maintenance of skiDs reflective of their interests. The activities must be meaningful to the individual. For example, an individual with Alzheimer's., the provider tailors interventions based on the needs of the individual which may include skill maintenance. Through interview with the individual/staff it can be verified that the individual has made progress at least on one step of the goal and this is verified through documentation. Interview guardian, if necessary. 55 Individuals served who have a stated Reviewers should look for documentation to support plan goal to be employed in support that the provider has communicated the W2.0 the community, have been provided referral and followed up on person's desire for with specific information, employment. opportunities for exploration, and Review supporting documentation and/or the the necessary support to make implementation plan for evidence that the progress towards this goal on provider is educating and/or providing supported employment or other information related to the individual's goal. competitive employment Note: If there is no stated support plan goal for opportunities. the individual to be employed in the community, score this 'not applicable' . Provider may utilize outside resources to address this element with their consumers (VR representative, S5 Administrators, Employers). 56 Individuals served who have a stated Provider may utilize outside resources to address NEW support plan goal to be involved in this element with their consumers. the community in another type of Review supporting documentation and/or the arrangement such as volunteer work implementation plan for evidence that the provider have been provided with specific is educating and/or providing information and information, opportunities for supports for exploration and experience related to exploration, and necessary support the individual's goal. to make progress towards the goal. Note: If there is no stated support plan goal for the individual to be involved in another type of arrangement, score this 'not applicable'. Adult Day Training (ADT) Services Monitoring Protocol Page 22 Cite Probes 57 All Individuals served who have Review annual satisfaction survey for results. responded to the annual satisfaction Discuss satisfaction with individuals receiving W2.0 survey are satisfied with the services seIVices. based on the results or the provider has addressed any concerns raised Review steps/actions that the provider took to during the survey respond to individual's concerns. Provider should track the results of the satisfaction surveys and address aggregate concerns. Provider should ensure the effectiveness of any corrective measures put in place by monitoring the status of quality improvement initiatives as needed and makes adjustments as necessary to ensure improvement in their service delivery system. " Look for documentation that the provider has distributed satisfaction surveys to each individual receivinl! the service. 58 Individuals achieve goals on their Review provider docwnentation to detennine support plan throughout the year" whether the individual has achieved a current or W2.0 previous support plan goal. Provider must demonstrate evidence that 80% of the individuals sampled achieved at least one goal on their current or previous support plan within the last twelve months. Inteniew individual and guardian if necessary. 59 Individuals demonstrate freedom of Look for evidence that the provider offers the choice, including being informed individual choices. W2.0 about rights and service options (i.e., Interview individual to detennine if they are more inclusive programs, supported provided with opportunity to express choice. employment, etc.). Providers are educating and/or infonning individuals about their rights and services, including supporting employment and specific ADT services. Adult Day Training (ADT) Services Monitoring Protocol Page 23 Cite I I Probes If the provider is not rendering senices to individuals that have problems with behavior such as diose that follow, score tbeelements in this section Not Applicable. Tyoes of Problems with Bebavior: Actions of the individual which, without behavioml, physical, or chemical intetvention 1. Have resulted in self-inflicted, detectable, external or internal damage requiring medical attention or are expected to increase in frequency, duration, or intensity resulting in self-inflicted, external or internal damage requiring medical attention. 2. Have occurred or are expected to occur with sufficient frequency, duration or magnitude that a life-threatening situation might result. including excessive eating or drinking, vomiting, ruminating, eating non-nutritive substances, refusing to eat, holding one's breath, or swallowing excessive amounts of air. 3. Have resulted in external or internal damage to other people that require medical attention or are expected to increase in frequency, duration or intensity resulting in external or internal damage to other persons that requires medical attention. 4. Have resulted or are expected to result in major property damage or destruction. S. Have resulted or are expected to result in arrest and confinement by law enforcement personnel Standard: Behavioral Services result in objective and measurable improvements in behavior that are consistent with the individual's outcomes. 60 When rendering services and supports to individuals identified as having problems with behavior, the provider is assisted by a qualified professional or professionals who meet the requirements in the Medicaid Handbook for the type of service the professional is providing. 61 Behavior Service goal(s) are consistent with and relate directly to the individual's personal outcomes/goals. Adult Day Training (ADT) SeIVices Monitoring Protocol H individuals in the program experience problems with behaviors determine from the provider what qualified behavioral professional assists them with senices for this individual. .,. Determine if the behavioral professional is · An employee of the provider, review personnel files. · On contract or an adjunct to the service under review, request that qualifications be available during the time of the review. Ask to speak with the certified or licensed professional(s) responsible for developing inte1Ventions or supports for the individual(s). If psychotropic medications are used, then a licensed physician must be involved. For other services (e.g., counseling) refer to the Medicaid Waiver Handbook for provider qualifications. Look for evidence that the prescribing professional is monitoring the individual 1 : I staffing ratios must be approved by the Area office LRC. Look for evidence that this approval was received. Review the person's support plan. if available, service authorization information, the implementation plan and the individual's behavioral plan (intervention/treatment/therapy plan) to determine if a clear connection exists between behavioral supports and seIVices and the persons stated personal outcomes/goals. Page 24 Cite Probes 62 The individual has a written, Review record(s) of individuals that the provider individual plan developed by a or staff has identified as having problems with certified or licensed professional that behaviors. Is a behavior plan present, and who clearly identifies what will change developed the plan? as a result of intervention, the Review the individual's records and the behavior intervention( s) to be used and how services plan to dctemtine: progress will be measured. . The problem with behavior is described in writing and in objective measurable terms. . There is evidence that inteIVentions, treatments and therapies were based on the results of an assessment of the problem with behavior by the behavior seIVice professional. . There is documentation that inteIVcntions account for medical problems, significant life changes, or other factors that might worsen the problem with the behavior. . If the individual was evaluated by a physician .. or other medical professional to rule out potential medical problems that might account for the problem with behavior. .,0 Note: The plan may be written by someone other than the behavior service professional. but must be approved by the professional. 63 Written consent to use the plan was . Review records and other documentation to obtained from the individual or determine that signed consent is on file. If W2.0 guardian. consent was not obtained, look for documentation of the reason. . Talk with individuals receiving the seIVice. Are they aware of the plan and interventions? Are they in agreement with the need for inteIVention and approaches used? 64 Implementers (provider staff) of the . Ask staff to describe the procedures and the plan are able to carry out the plan as circumstances under which they are used written. . ObseIVe the actual use of the procedure or inteIVention if possible. . Interview the individual for their understanding of implementation of the plan. . Review personnel and training records to verify staff training on the program. 65 A system is in place to assure that . Review behavior seIVice plan to determine if procedures are carried out as a plan to monitor implementation is W2.0 designed. available. . Review provider or behaviordl professional documentation to detennine if monitoring occurs as planned. . If there are problems with implementation, are these addressed and corrected? Adult Day Training (ADT) Services Monitoring Protocol Page 25 Cite Probes 66 There is evidence of progress or lack Review available and required documentation to thereof in reducing the problem with determine whether progress in being made, or if W2.0 behavior. lack of progress, that there is a plan for the continuation, modification or termination of services. Documentation available for review to detenninc whether progress is being made should include: . Data collected on plan implementation. Are the data collected as required in the plan? . Data displays (graphed). Review to determine progress and currency of graphing. . Progress should be verified in writing as a progress note or summary. Note: Some measurable progress must be demonstrated or predicted or the current array of services must be seriously questioned 67 Emergency procedures (e.g., . Determine if a written procedure is available. reactive strategies, crisis Is the procedure individualized? management procedures) used by . Review any procedures that the provider has the provider for problems with for emergency or crisis management. (Note: The provider may have general procedures, behavior are developed and as well as individualized Reviewers should implemented under the guidance of look at both.) certified or licensed behavioral . Determine who developed the emergency or services professionals. crisis management procedure, and if it is approved by the LRC or the Area office. . Determine if the procedure identifies: ~ How staff will be trained; ~ What documentation must be kept and submitted upon use of the emergency procedure. 68 Staff are able to use the procedure . Review personnel and training records to when and as designed determine whether staff has been trained in the use of these procedures. (Certain procedures such as ACT or TEAM require periodic retraining or certification.) . Determine whether only trained staff is - allowed to use these procedures. . Talk with individuals and staff to determine their awareness of, and familiarity with these procedures. Adult Day Training (ADT) Services Monitoring Protocol Page 26 - Cite Probes 69 Records are kept on the use of the Request to see reports on use of emergency emergency procedure and procedures. Verify the following: occurrences of the problem . Daily reports on the employment of physical, chemical, or mechanical restraints by those behavior. specialist authorized in the use of such restraints are made to the chief administrator of the program. . A monthly summary including the type of restrcrint, the duration of usage and the reasons therefore will be submitted to the Area office administrator and the district local advocacy committee. (Note: Reports may be sent to the Area office Developmental Disabilities Program Office for routing to Area office Administrator.) . Review the agency procedure for reporting the use of emergence inteIVentions. . Determine if the use of emergency intetventions was properly reported. Review '. documented number of restraints reported to the Local Review Committee. Note: ifemergency or crisis procedures have not ~.. been used, score this element Not Applicable. Aduh Day Training 11-22-OS.doc 03.06.02; 03.12.02; 03.13.02; 09,05.02; 09.12.02;12.27.02;02.04.03;02.10.03; 02.25.03; 10-24-05; 11-22-05 Adult Day Training (ADT) Services Monitoring Protocol Page 27 Developmental Services Adult Day Training (ADT) Services Monitoring Checklist Provider Number: Provider Name: Review Date: Provider Address: Reviewer Name: District: Location: o Agency Provider o Solo Provider o Onsite Review o Desk Cite .. I Met I Not Met T N/A Explanation of Monitoring Tool Symbols/Codes n Alert: Denotes a critical standard or cite relating to health, safety and rights. A deficiency requires '- ~ a more intense corrective action and follow-up cycM. "W" Weighted Element: A "W' followed by 2.0 or 4.0 in the Cite column denote.s elements that have a greater impact on the monitoring score. "R" Recoupment: An "R" in the Cite column denotes an element that is subject to recoupment of funds by the State if the element is "Not Met." Standard: The provider successfully supports individuals to achieve desired goals and needed services through individualized training programs and meaningful daily routines and activities. 1 The provider develops an individualized W2.0 implementation plan (IP) for all consumers. 2 An individualized implementation plan (IP) is W2.0 developed under the direction of the consumer. 3 The IP identifies goal(s) and needs from the - individual's support plan and other pertinent sources . appropriate to the individual. 4 The IP identifies strategies and methods to assist the individual in meeting goal(s) as well as the data collection system to be used to assess success and achievement. 5 The implementation plan includes a description of NEW methods that the provider will use to ensure the individual makes an informed choice concerning the types of work and meaningful day activities (type of activities). w,. Cite Met Not Met N/A 6 The IP is reviewed periodically to determine whether progress is being made and is updated to reflect new W2.0 interests, goals, needs, or strategies to promote meaningful progress. 7 The provider is tracking and acting on an individual's progress or lack of progress. 8 The provider has taken action on the results reported through the person centered review process. [Note: If there have been no person-centered reviews conducted with individuals/or which this provider renders se",ices and supports. score this element as "Not Applicable. 'J As appropriate to the individual goals, needs, and interests: 9 Services stress training in activities of daily living. 10 Services stress training in self-advocacy. 11 Services stress training in adaptive and social skills. 12 Services are age and culturally appropriate. 13 Training activities and routine are meaningful to the W2.0 individual and consistent with the support plan and approved cost plan. 14 Off site ADT services teach specific job skills and other services directed at meeting specific employment objectives. 15 Facility-based and off-site programs pay individuals W2.0 receiving ADT for performance of productive work; pay is commensurate with members of general work force doing similar work. 16 At least annually, providers conduct an orientation W2.0 informing individuals of supported employment and other competitive employment opportunities in the community. Standard: The provider and all of the provider's stafT are qualified to provide Adult Day Trainin2 services. 17~ Level two background screenings are complete for all direct service employees. W4.0 18~ All employees undergo background re-screening every 5 years. W4.0 19 Managers or directors have no full time responsibility for providing services. 20 Program director has bachelor's degree and two years related experience, 21 Instructors (supervisors) have associate's degree and two years experience in related field. 22 Direct service staff work under appropriate supervision. Adult Day Training (ADT) Services Monitoring Checklist Page 2 ...,. Cite Met Not l\'let N/A 23 Staffing ratio does not exceed ten (10) individuals per direct service staff for facility-based programs. W2.0 24 Direct service staff must be at least 18 years of age and has a high school diploma or equivalent. Standard: The provider and the provider's staff meet training requirements for delivery of Adult Day Training services. 25 The provider attends mandatory meetings and training scheduled by the Area office and/or Agency. 26 Independent vendors and agency staff receive training on responsibilities and procedures for maintaining W2.0 health, safety and well being of individuals served. 27 Independent vendors and agency staff receive training on medication administration and on supervising individuals in the self-administration of medication. 28 Independent vendors and agency staff receive training on required documentation for service(s) rendered. 29 Direct service staff has received training in the NEW Agency's Direct Care Core Competencies Training. 30 Independent vendors and agency staff receive training on responsibilities under the Core Assurances. 31 Independent vendors and agency staff receive training on responsibilities under the requirements of specific services offered. 32 Independent vendors and agency staff receive training on use of personal outcomes to establish a person- centered approach to service delivery. 33 Independent vendors and agency staff receive training specific to the needs or characteristics of the individual W2.0 as required to successfully provide services and supports. 34 Proof of current training and certification is available - for all staff in Cardiopulmonary Resuscitation (CPR). 35 Proof of current training is available for all staff in AIDS and infection control. 36 Staff attends eight (8) hours of annual in-service training related to implementation of individually W2.0 tailored services. 37 Proof of required training in recognition of abuse and neglect to include domestic violence and sexual assault, and the required reporting procedures is available for all independent vendors and agency staff Standard: Services are provided at an intensity and duration necessary for successful support of the individuals served. Adult Day Training (ADT) SeIVices Monitoring Checklist Page 3 Cite Met Not Met N/A 38 Services are rendered at a time mutually agreed to by the individual and provider. 39 In facility-based ADT individuals spend a minimum of four hours in specific training or program activities W2.0 designed to meet individual needs and personal goals defined in the support plan(s). 40 Services are provided in a designated adult day training center or other training sites in the community as agreed to by the individual and provider. 41 Providers of incidental transportation comply with program requirements Standard: The provider maintains sufficient reimbursement and monitoring documentation to verify service delivery and to evaluate each individual's services and supports. Note: Score based on the presence or absence of the required documentation. 42R Provider has at a minimum an individual '. implementation plan. 43 R The IF is developed, at a minimum, within 30 days of new service initiation, or within 30 calendar days of -'. service authorization effective date when services are being continued. 44 Provider has at a minimum supporting data (notes) to the implementation plan. 45R Provider has at minimum, copies of service log(s). NEW 46R Provider has at a minimum a monthly summary of an individual's progress toward achieving support plan outcomes for the period bein~ reviewed. 47R Provider has at a minimum an annual report. 48 Provider has at a minimum results of the annual satisfaction survey. 49 Provider has at a minimum performance data on the Projected Service Outcomes. Standard: Provider bills for services as authorized. 50R ADT services are limited to the amount, duration and scope of the service described on the individual's support plan, current approved cost plan and service authorization. 51 R The provider bills for adult day training as defined and specified in the DS Waiver Services Medicaid Coverage and Limitations handbook. Adult Day Training (ADT) Services Monitoring Checklist Page 4 Cite I Met Not Met I N/A Standard: The provider meets projected service outcomes established for service deliverv. 52 The provider has established a systematic method to collect projected service outcome data. 53 The provider reviews data periodically and corrective measures are put in place if the data indicates that the goal is not being achieved. 54 Individuals receiving services demonstrate an increase in abilities consistent with their support plan. W2.0 55 Individuals served who have a stated support plan goal to be employed in the community, have been provided W2.0 with specific information, opportunities for exploration, and the necessary support to make progress towards this goal on supported employment or other competitive employment opportunities. 56 Individuals served who have a stated support plan goal NEW to be involved in the community in another type of arrangement such as volunteer work have been provided with specific information, opportunities for exploration, and necessary support to make progress towards the goal. 57 All Individuals served who have responded to the annual satisfaction survey are satisfied with the W2.0 services based on the results or the provider has addressed any concerns raised during the survey 58 Individuals achieve goals on their support plan throughout the year W2.0 59 Individuals demonstrate freedom of choice, including being informed about rights and service options (i.e., W2.0 more inclusive prowams, supported employment, etc.). Adult Day Training (ADT) SeIVices Monitoring Checklist Page 5 Cite I I Met I Not Met I N/A If the provider is not rendering services to individuals that have problems with behavior such as those that foOow, score the elements in this section Not Applicable. Types of Problems with Behavior: Actions of the individual which, without behavioral, physical, or chemical intervention 1. Have resulted in self-inflicted, detectable, external or internal damage requiring medical attention or are expected to increase in frequency, duration, or intensity resulting in self-inflicted, external or internal damage requiring medical attention. 2. Have occurred or are expected to occur with sufficient frequency, duration or magnitude that a life-threatening situation might result, including excessive eating or drinking, vomiting, ruminating, eating non-nutritive substances, refusing to eat, holding one's breath, or swallowing excessive amounts of air. 3. Have resulted in external or internal damage to other people that require medical attention or are expected to increase in frequency, duration or intensity resulting in external or internal damage to other persons that requires medical attention. 4. Have resulted or are expected to result in major property damage or destruction. 5. Have resulted or are expected to result in arrest and confinement by law enforcement personnel Standard: Behavioral Services result in objective and measurable improvements in behavior that are consistent with the individual's outcomes. 60 When rendering services and supports to individuals identified as having problems with behavior, the provider is assisted by a qualified professional or professionals who meet the requirements in the .'. Medicaid Handbook for the type of service the professional is oroviding. 61 Behavior Service goal(s) are consistent with and relate directly to the individmll's personal outcomesl~oals. 62 The individual has a written, individual plan developed by a certified or licensed professional that clearly identifies what will change as a result of intervention, the intervention(s) to be used and how progress will be measured. 63 Written consent to use the plan was obtained from the individual or guardian. W2.0 64 Implementers (provider staff) of the plan are able to carry out the plan as written. 65 A system is in place to assure that procedures are carried out as designed. W2.0 66 There is evidence of progress or lack thereof in reducing the problem with behavior. W2.0 67 Emergency procedures (e.g., reactive strategies, crisis management procedures) used by the provider for problems with behavior are developed and implemented under the guidance of certified or licensed behavioral services orofessionals. 68 Staff are able to use the procedure when and as designed Adult Day Training (ADT) Services Monitoring Checklist Page 6 Cite Met Not Met N/A 69 Records are kept on the use of the emergency procedure and occurrences of the problem behavior. Aduh Day Training Checklist 11-23-05.doc 03.06.02; 03.12.02; OJ. 13.02; 09,05.02; 09.12.02;12.27.02;02.10.03; 11-23-05 ~. ." Adult Day Training (ADT) Services Monitoring Checklist Page 7 Developmental Services Support Coordination Monitoring Protocol Support Coordination is the service of advocating, identifying, developing, coordinating and accessing supports and services on behalf of an individual, or assisting the individual or family to access supports and services on their own. These services may be provided through waiver and other Medicaid State Plan services, as well as needed medical, social, educational, other appropriate services, and community resources regardless of the funding source through which access is gained. The waiver support coordinator is responsible for assessing the individual's needs, preferences and future goals (outcomes). From that information, the waiver support coordinator assists the individual in developing a support plan and cost plan. Cite Probes Explanation of Monitoring Tool Symbols/Codes n Alert: Denotes a critical standard or eite relating to health, safety and rights. A deficiency requires a more intense corrective action and follow-up cycle. "W" Weighted Element: A "W" followed by 2.0 or 4.0 in the Cite column denote.s elements that have a greater impact on the monitoring score. "R" Recoupment: An "R" in the Cite column denotes an element that is subject to recoupment of funds b the State if the element is "Not Met." Standard: The Support Coordinator assists the individual in determining his or her ersonal oals and future needs throu h com rehensive Su ort Plannin activities. For the following elements of performance associated with this standard: Review results of the person- centered reviews, information available from individuals receiving the service and available documentation. The purpose of this section is to determine provider performance and the quality of supports in the areas of advocacy, identification of outcomes and goals for the individual and assisting the individual to access appropriate supports to meet these outcomes and goals. Do not score an element as met solei based on the resence 0 the documentation. The Su ort Coordinator: 1 Assists individuals with determining · desired outcomes and supports needed using the Personal Outcome Measures (POM) and other techniques (e.g. person centered planning) during each support plan year. W2.0 Support Coordination Monitoring Protocol . Ask the support coordinator how and when they gather infonnation about the POM and how often it is updated. Ideally, the POM should be completed over the course of the year and not in one session and used throughout the year. Detennine other techniques used to determine desired outcomes. VerifY the support coordinator's verbal report through review of a sample of individual records. Make a determination as to whether the outcome instnunent appears to reflect the individual's goals and needs. Analyze the extent to which the infonnation obtained through the POMs is used as the basis for su rt 1annin . . . Page 1 Cite Probes 2 Assists individuals to identify needs . Ask the support coordinator when they using the assessment instrument complete the assessment and how often approved by the APD prior to the it is updated . Verify the support coordinator's verbal development of the support plan. report through review' of an individual's record . Make a determination of whether information and scoring appears to legitimately reflect the needs of the individual under review. . Analyze the extent to which the information obtained through the approved assessment is used as the basis for sunnnrt n1annin~. 3 Assists individuals to make . Ask the provider to provide an example decisions and informed choices as of an individual that they have recently W2.0 indicated by the person's situation assisted in making decisions and .. informed choices. Detennine if throughout the support plan year. sufficient information was given to the individual for an informed decision or choice to be made. A discussion of the risks, benefits and consequences of decisions should be apparent in discussion with the provider and in the supporting documentation in progress notes. . Review this individual's record with the provider to determine that documentation supports what the provider is supplying vernally. . Review progress notes for the sample selected to determine whether this assistance is provided routinely and appropriately for the situations reviewed. 4 Develops the support and cost plan . Review the sample: Look for support to reflect the individual's desired and cost plans to deternrine that they are W2.0 personal outcomes and individual completed annually (at a minimum for needs. the current review period). ~ Determine whether the support and cost plan appropriately reflects information gathered during the support planning process. Does the plan reflect the goals and outcomes identified by the individual? ~ Does the plan reflect the needs and current situation of the individual as described in progress notes reviewed? ~ Determine whether the support and cost plan reflect a decrease in reliance on paid supports and an increase in natural or generic SUPPOrts of the individual's choice. Support Coordination Monitoring Protocol Page 2 Cite Probes 5 Reviews with individuals, at least Note: The purpose of the support annually at the time of support plan coordinator's review is to assist the individual in planningfor thefuture, to assist development, available options for in defining personal goals and tofaci/itate services and supports, (includes both informed choice. The review should include paid and unpaid service options). what the individual can expect from providers of specific services in meeting the individual's goals and need... Ask the support coordinator how they help people with knowing options for services. Review records in the sample to determine examples of individuals that they have been assisted in making decisions and informed choices. . Review individual records with the support coordinator to determine that documentation supports what the " provider is supplying verbally. . Analyze the results of person-centered reviews involving the support coordinator to identify positive or .c'. nee:ative performance trends 6 Annually completes a report of . Annual report is part of the Support Plan. progress for individuals as specified Look for a report on the individual's in APD policy. progress to determine that requirement is met . Determine whether unmet goals and needs have been positively addressed in the current Dlan. 7 Assists individuals to meet goals and . Ask the support coordinator about their outcomes through linkages with knowledge of, or how they become W2.0 natural and generic supports. knowledgeable about neighborhood and community supports and services. . Review progress notes and other information to determine whether natural and generic supports are pursued. . Determine to what extent the individual is involved in this process. Are choices - and interests explored and develoned? 8 When natural and generic supports . Ask the coordinator how they assist are not available, assist the individuals with using Medicaid State individual in locating services Plan and DS Medicaid waiver services, available through local, state or shared funding with the Department of Education, V.R. and other funding federal sources, including Medicaid sources. and the DS Medicaid waiver. . Determine through progress notes how support linkages occur. . Determine to what extent individuals are involved in this process. Are choices and options explored and developed? Is information about options presented as well as opportunities to visit service sites and potential vendors? . Check how and whether the provider Support Coordination Monitoring Protocol Page 3 Cite Probes determined the most cost beneficial approach for seIViccs, and still met the individual's needs. 9 Reviews with service vendors the . Review attendance at support plan goals to be achieved for the . meeting to determine if providers were individual and notes these present, if invited to attend. Is there documentation in the progress notes that discussions in progress notes. indicates the support coordinator worked with the individual on who they wished to attend the support plan meeting? . Review progress notes and/or service authorizations to determine if therc was communication with the service vendor to adequately relay the type, intensity, and individualization of the supports the person needs and desired goals. . Review Implementation Plans and other progress information received from service providers. If goals are not consistent with the support plan and individual'desired outcomes, review progress notes for evidence that the coordinator took action to correct the discrepancy. 10 Takes actions necessary to' . Ask the support coordinator to provide coordinate the continuity of supports examples of how communication and and services among providers, coordination is promoted for an individual between paid and wpaid family and others to achieve the supports. Are actions needed to help the goals and outcomes of the person. person achieve outcomes being addressed? . Review progress notes and other infonnation to verify that coordination between supports occurs. Look for trends of lack of coordination rather than incidental omissions. Consider the seriousness of the incident(s) and the resulting consequence(s) of the lack of coordination. 11 Documents all support coordination . Progress notes should contain the "who, services, activities and contacts in what, when, where, why and what's clear and adequate progress notes. next" so that it is clear what action took place and any anticipated actions that should follow. . Notes should detail support coordination activities made on behalf of the individual. . Notes should detail efforts made to assist individuals to achieve outcomes and goals and to become more integrated into communities. . Notes should be complete, legible and contain no unnecessary abbreviations. . Notes should adequately describe Support Coordination Monitoring Protocol Page 4 Cite Probes contacts with the individual, their family and others, identify any issues or concerns and contain adequate follow-up infonTIation to determine resolution. . Use infonnation gathered throughout the review and through examination of progress notes to detennine this element. Standard: The Support Coordinator assists the individual to achieve personal goals and outcomes. For the following element of performance associated with this standard: Review results of the person- centered reviews, information available from individuals receiving the service and available documentation. The purpose of this section is to detennine provider performance and the quality of supports in the areas of advocacy, and assisting the individual to meet outcomes and goals. Do not score an element as met solely based on the presence of the documentation. 12 Has taken action on the results and · Determine if any person-centered " recommendations reported through reviews have tx:e~ condu~ed with W2.0 the person-centered review process. ::=~:e~";~r;:s and ..- . Review records and infonnation for persons participating to determine if there is any documented evidence that the provider has acted on the report. · Review documentation to detennine .that other seIVice providers were made aware of report results and any recommendations for seIVice improvement or change. Did the coordinator discuss with the provider possible actions for addressing the report? · Determine how this infonnation was communicated. Was confidentiality for the individual maintained? · Review progress notes and other documentation to detennine whether the coordinator followed-up with the provider(sTto assure that the report was addressed and appropriate changes made · Review progress notes and other documentation to dctennine whether the coordinator follow-up with the individual to determine satisfaction with the seIVice change or outcome status. Note: If there have been no person-centered reviews, score this element Not Applicable. Standard: Support and Cost Planning information is submitted to the Area Office and shared with the individual and other stakeholders within appropriate timeframes. Support Coordination Monitoring Protocol Page 5 Cite Probes 13 Support and cost plans are provided . Ask the support coordinator about their to the individual or their guardian process and the timing for supplying within 10 calendar days of the support and cost plans to individuals or their guardians effective date, and at any time they . Check for support coordinator are requested. documentation in individual records that support and cost plan information was supplied to the individual or guardian, at a minimum, within timeframes stated. . For the Cost Plan Only: Determine the receipt date from the Area Office; calculate 10 days out to identify when the individual should have received the aODroved olano 14 Cost plans are signed by the . Review cost plans to determine that cost individual or guardian. plans contain the appropriate .. shmature(s). 15 Copies of the support and cost plans . Interactively, with the support are submitted to the Area Office no coordinator, review procedures for later than 20 calendar days prior J.P submitting support and cost plans to the Area Office. the effective date. . Look for evidence in a sample of records to detennine that there is documentation Cost plans, amendments or of the date that these plans are submitted addendums meeting exceptional cost to the Area Office (plans should be date review guidelines must be submitted stamped) to the Area Office within 90 . Cost plans, or amendments to cost plans, calendar days prior to the effective that exceed the average ICF/DD cost for seIVices require special review and date. require more time for review and approval. Refer to Policy Directive 99- 05 REY02. 16 Service authorizations that . Ask the support coordinator about their accurately reflect the Area Office's process and the timing for supplying W2.0 approved service level on the cost approved seIVice authorization to other plan, as well as copies of pertinent supports and services vendors ~ Review record sample: Look for support plan information is given to documentation of when the support other providers of services to coordinator supplied service authorize and initiate service authorization to the service vendor. delivery within ten calendar days of ~ Look for evidence of when the the effective date of the support seIVice vendor began supports and seIVices for the individual plan. ~ InteIView by phone or in person, a sample of seIVice vendors who are supplying supports and seIVices to the individual >> Determine if the service vendor received authorinttion within ten days of the effective date of the support plan. >> Determine what information was sent relatin2 to ~oa1s for the Support Coordination Monitoring Protocol Page 6 Cite Probes individual Note: The support coordinator is not responsible.for meeting time.frames in this element if there is documented evidence that the delay was caused by circumstances outside of the coordinator's control, such as the Area Office not meeting review timelines. Standard: The Support Coordinator advocates for the individual and assists the individual to increase or maintain the capacity to direct formal and informal resources. For the following elements of performance associated with this standard: Review results of the person- centered reviews, information available from individuals receiving the service and available documentation. The purpose of this section is to determine provider performance and the quality and intensify of supports in the areas of advocacv. assistance with informed choice and problem resolution. The Support Coordinator: 17 Assists the individual in evaluating . Seek indications that the support whether the purchased services meet coordinator is evaluating seIVices and W2.0 the individual's expectations. providing feedback to providers and the individual. 18 Assists the individual in determining . Review progress notes and other whether services are age and documentation to determine if thc culturally appropriate. coordinator is gathering information about whether service delivery is 19 Assists the individual in determining meeting expectations from the individual. provider information and whether services address the desired records; family and other interested W2.0 goal(s) and/or need for which they parties. are intended. 20 Assists the individual in determining . Review a sample of records to detennine if the support coordinator is whether services provide appropriate documenting discussions with the W2.0 challenges, motivation and individual or their family about experiences to meet the individual's satisfaction with services goals and expectations. - 21 Reviews with individuals available . During record review dctermine if any options for places to live. changes in service vendors are documented as a result of the W2.0 individual's or family's dissatisfaction 22 Reviews and assists individuals in ADTs with information and/or . When available. analyze the results of W2.0 referral to rehabilitation, vocational person-centered reviews to identify the individual's satisfaction with support habilitation, and other employment coordinator and service vendors. services and employment opportunities available in their . Review records to detennine assistance communitv. and support in this area. A formal Support Coordination Monitoring Protocol Page 7 Cite Probes 23 Provides service counseling for presentation of infonnation and options individuals currently in sheltered should occur annually. W2.0 workshops or segregated work Review progress notes and other . environments to apprise them of the documentation to determine if individual options available to them for choices and desired changes in seIVice meaningful work activities and direction were addressed. training. 24 Discusses with the individual their concerns related to dissatisfaction, quality of service delivery, health and safety, or other issues in order to resolve differences. 25 Provides inform~tion to recipients . This should occur at a minimum of once NEW on residential options available to a year during support planning, but them including owning or renting should also occur when anticipating a their own home, with supports. change in the residential situation 26 Discusses witli providers concerns . Ask the support coordinator about their relating to individual dissatisfaction, process for communicating and W2.0 the quality of service delivery, discussing issues with seIVice vendors individual health and safety, or other . Look for evidence that the support coordinator documents discussions and issues in order to resolve resolutions to issues of dissatisfaction or differences, including health and safety concerns of an recommendations and results from individual. person-centered reviews. . Look for evidence that the support coordinator discusses results and recommendations from applicable Person Centered Reviews with other providers, and follows-up to assure changes are addressed. . Look for evidence that the support coordinator monitors the service vendor's response. 27 Follows-up to provide closure on . If findings indicate there are issues or issues and resolution of problems or concerns, look for evidencc that further W2.0 situations. demonstrates the support coordinator facilitated a resolution or other follow-up with the individual and the service vendor. . Review progress notes to detcnnine actions taken and indications that timely follow-up activities were initiated and, where possible, closure achieved. Support Coordination Monitoring Protocol Page 8 Cite 28 Initiates contact with the Area Office to request assistance in resolving concerns that cannot be resolved through discussion or the normal grievance process. Probes . Ask the support coordinator jf they know that the Area Office is available to assist in the resolution process when necessary. . Ask the support coordinator if they ever had occasion to contact the Area Office for assistance in resolving issues. . Contact is initiated when the coordinator is unable to resolve a concern. Standard: Changes in the individual's service and support needs are dealt with a riatel and timel b the Su ort Coordinator. 29 Progress notes include sufficient Revi~w a sample ~f records for individuals, information concerning any changes specifically focusIDg on the content of I" "nd""d}' "and progress notes. n an I IVl ua s service support needs that require an update to the cost plan. 30 Cost plan updates are initiated when support coordinators become aware of the need for change. Support Coordination Monitoring Protocol Review results of person~ntered reviews for infonnation about whether changes were requested and the responsiveness of the coordinator. Talk with individuals to .determine whether requested service or needs changes were acted upon Note: Efftctive 7/0//01 changes in an individual's service needs that result in an update to the cost plan do not have to have a corresponding update to the support plan. Reason for the changes must he supported in the ro ress notes. . Interactively, with the support coordinator, review a sample of records for individuals, specifically focusing on the cost plan and when updates have occurred. . Discuss with the support coordinator when and what prompted them to update the cost plan. . Determine whether progress notes support that cost plan changes were made within acceptable timeframes. . Cost Plans are submitted to the Area Office within five days of the support coordinator becoming aware of the need for change. (Area Offices have 10 days of their recei t of the u te to re nd.) Page 9 Cite Probes 31 Service authorizations and adequate . Review records to compare timeframes information concerning the for submission of the authorization and W2.0 individuals' goals and needs are sent Area Office approval. . Review infoffilation provided to alter to providers, as appropriate to the seIVices. cost plan change, within 5 working . Talk with a sample of providers to days of receipt of Area Office detennine timefmmes for notice of approval. change. Standard: The Support Coordinator assists the individual to build linkages to natural and e:eneric supports and, when necessary, appropriate paid services. The Support Coordinator: 32 Recruits and locates potential Ask the support coordinator for examples of how service vendors who are acceptable they wolk with the Area Office to identify service vendors for individuals, to the individual,'"are qualified to ~ What influences these individuals? meet the individual's needs in the ~ What consideration is given to cost in most cost-efficient manner possible, these decisions? . Describe the interaction that occurs with the and assists them with waiver Area Office in these cases? enrollment procedures. . Determine if the support coordinator: ~ contacted appropriate service vendors; ~ sought out potential service vendors to render the service; ~ sought assistance from the Area Office to identifY, train and process eligibility documents for new service vendors; ~ assisted with the submission of documents for new vendors if appropriate; ~ notified the Area Office of service vendors needed for the area. . If a needed service was not available in the community, ask the support coordinator how they handle this information (response should be related to data entry in the ABC system.) . Review Area Office policy related to rate negotiations, and cost approval and - documentation from the support coordinator to determine: ~ How families and conswners are included in the decision process. > If rates were compared for vendors of the needed service. )0- If there is a shortage of a service vendor that results in a rise in rates, is there evidence of a collaborative effort to develop or attract additional service vendors in the area? . Review results and recommendations of person-centered reviews. . Talk with individuals about access and availability of services they may need. Are thev satisfied with current vendors? Support Coordination Monitoring Protocol Page 10 Cite Probes 33 Notifies other paid service providers Ask the support coordinator about their when it is determined that an process for communicating and discussing issues with seIVice vendors. W2.0 individual receiving services is no longer Medicaid eligible. Verify description through available documentation that notification is given when information is known. 34 Works with providers and Area . Ask support coordinator about how they Office to plan for possible plan for continuation of seIVices for continuation of services and funding individuals when they are no longer Medicaid eligible. options when an individual's ~ Review documentation of their eligibility is in jeopardy. efforts in the individual's record. 35 Assures that purchased supports and Review policy and current practices with services are not billed in excess of support coordinator to ensure that the annual limits of current approved overspending does not occur . If possible, compare billing information cost plan(s) for individuals. from the Allocation, B.udgeting, and Contract Control (ABC) system against the approved cost plan. Review ABC screen AINBCL and compare to cost plan to ensure expenditures have not exceeded overall annual authorized amount in the cost plan. . If supports and services are exceeding the limits of the approved cost plan, detennine if an amendment was submitted and approved? . Review documentation of last full year of services in the sample of records. . Score as met unless there is actual overspending on an annual basis. The approved annual amount does not have to be divided equally between the 12 months For individuals residing in supported living arraDgements or liceDsed resideDtial facilities who are takiDg aDY psychiatric or aDti-epileptic medications review cites 36-40. Refer to MedicatioD Review Criteria. Standard: The Support Coordinator assures that individuals will be free of risks associated with Drescribed medication. 36 Provider assures a comprehensive . Ask support coordinator about psychiatric (for psychiatric procedures for obtaining information on W2.0 medication) review is completed individuals residing in supported living arrangements or licensed residential annually by a licensed facilities. psychiatrist/neurologist or an . Ask support coordinator about the types A.R.N.P., who acts pursuant to a of information that they request from protocol with the providers and their follow-up process psychiatrist/neurologist. when information is not received. Support Coordination Monitoring Protocol Page 11 Cite Probes 37 Provider assures a medication . Interactively, with the support review by a Licensed Consultant coordinator, review the record of an W2.0 Pharmacist is conducted at least individual that is residing in supported annually when individual is on two living or in a residential facility who is taking psychiatric or anti-epileptic or more medications or meets the medications. criteria for medication review as )0> Look for evidence in progress notes defined in the handbook. of attempts and efforts to arrange for the services noted in elements 36- 40. The Support Coordinator should ensure that individuals living in their own or family 38 Provider assures the individual home are aware of the need to obtain a receives follow-up reviews by the medication review and should pursue this psychiatrist, neurologist or A.R.N.P. service if requested by the individual or family. Request to see evidence of this at a frequency established by these discussion. " practitioners. Review results and'recommendations of person-centered reviews. ...... Talk with individuals about the health care 39 Provider works with Area Office they are receiving. Health Care coordinators to obtain documentation from psychiatric or neurological practitioners if frequency of the follow up review is less frequent than every 90 days. 40 Provider maintains documentation of medical practitioner rationale regarding frequency of follow-up visits in the individual's central record. Support Coordination Monitoring Protocol Page 12 Cite Probes . Standard: The Support Coordinator assures that information relating to the individual is current, correct and transferred a Ilpropriately to other providers. 41 R Providers enter, update and assure . Ask support coordinator about their the accuracy of information procedures for interacting with the ABC W2.0 pertinent to the individual in the system. ABC system, including demographic . How often do they access the ABC system? How frequently do they update information. information in the ABC system? . During record review, compare record information with that appearing in ABC to detennine accuracy and currency. . Review claims and person-centered review information related to the review to compare against available ABC information. Note:'The provider is responsible for the cost of the electronic access to the Agency's intranet site. Failure of the waiver support c~!dinator to enter, update and assure the accuracy of this information could result in the ~oupment of funds paid to the waiver support coordinator. 42 Provider assures that all appropriate . Ask support coordinators to describe central record information is their process for handling of central transferred to new vendors or to the records in instances of individual's transferring to new support coordinators Area Office, within two weeks of or terminating support coordination the effective date of actions such as services. new vendor selection by the . Check with Area Office to determine individual or termination of support that they are receiving central records of coordination services. individuals who tenninate support coordination from the provider. Standard: The Support Coordinator is fully qualified and trained to provide support coordination services. For a// training related elements of peiformance associated with this standard: Review Area Office requirements for mandatory meetings and training documentation. Review provider's training records to determine if documentation is maintained, and at a minimum includes: The topic of the training; Length of the training session; Training dates; Participants' signature; Instructor's name; Objectives and/or a sy//abus. 43~ Level two background screenings Review available personnel files or records to are complete for all direct service ascertain compliance. Check for: W4.0 employees. . Affidavit of good moral character~ . Proof of local background check; . Documentation of finger prints submitted to FDLE for screening and screening reports on file. . Criminal records that include possible disqualifiers have been resolved through court disposition. Support Coordination Monitoring Protocol Page 13 ....,..' Cite Probes 44~ All employees undergo background Review available personnel files or records to screening every 5 years. verify that employees undergo backgroWld W4.0 re-screening at least every 5 years. Look for evidence of completion and submission of an FDLE Form, identified as either attaclunent 3 or 4. Note: Fingerprint cards are not required on resubmission. 45 All solo and agency waiver support . Ask solo support coordinators for the file coordinators (WSCs), directors, that they maintain relative to their managers and supervisors have a credentials and tJaining as required by the Area Office. . Bachelor's degree from an . Review pertinent personnel and training accredited college or university. records at an agency to determine if the agency support coordinators, supeIVisors, directors and managers meet minimum qualifications and training reauirements. 46 All solo WSCs and agency . Ask solo support coordinators for the file supervisors, directors and managers that they maintain relative to their have three years of professional credentials and tJaining as required by the Area Office. . experience in developmental . Review personnel and training records at disabilities, special education, an agency to determine if the agency mental health, counseling, guidance, support coordinators, supervisors, social work or health and directors and managers meet minimmn rehabilitative services (a master's qualifications and training requirements. degree can substitute for one year of experience). 47 All agency WSCs have two years of . Review personnel and training records at professional experience in an agency to determine if the agency developmental disabilities, special support coordinators meet minimum education, mental health, qualifications and training requirements. counseling, guidance, social work or Score this element Not Applicable when health and rehabilitative services (a reviewing a solo provider. master's degree can substitute for one year of experience). Support Coordination Monitoring Protocol Page 14 "... Cite Probes 48 All solo and agency WSCs, . Ask solo support coordinators for the file directors, managers and supervisors that they maintain relative to their have a minimum of 34 hours of credentials and training as required by the Area Office. statewide pre-service training. . Review personnel and training records at an agency to detennine if the agency support coordinators, supervisors, directors and managers meet minimum qualifications and training requirements. . Verify source of training is appropriate per requirements listed below. . Pre-service training for solo providers and agency directors, managers and supervisors must be conducted by the department, or a trainer prior approved by the department. . Support coordinators employed by -, agencies are required to receive the same number of hours of training and are to be trained on the same topics covered in the ..... statewide training; however, this training may be conducted by the support coordination agency. Support Coordination Monitoring Protocol Page 15 Cite Probes 49 All solo and agency WSCs, . Ask solo support coordinators for the file directors, managers and supervisors that they maintain relative to their have a minimum of 26 hours of credentials and training as required by the Area Office. district-specific pre-service training . Review personnel and training records at within 90 days of completion of an agency to determine if the agency statewide pre-service training. support coordinators, supervisors, directors and managers meet minimum qualifications and training requirements. Verify source of training is appropriate per requirements listed below. District specific training for solo providers and agency directors, managers and supervisors must be conducted by the Area Office, or a trainer prior approved by.,the department. Support coordinators employed by agencies are required to receive the same number of hours of training and are to be trained on the same topics covered in the statewide training; however, this training may be conducted by the support coordination agency. Area Office training includes: . Orientation to Area Office staff, responsibilities and resources, . ABC training, and . General Area Office operational procedures. 50 All support coordinators have Note: agency trainers may conduct this NEW district training and certification in training once approved by the Department. the proper administration of the WSCs currently enrolled must become department approved assessment certified within 90 days of the effective date tool for ascertaining the recipient's of the implementation of this rule (June 23, level of need within 90 days of 2oo5?). completion of statewide pre-service Failure to become certified will result in training. The provider must re- termination. certify every two years. Support Coordination Monitoring Protocol Page 16 Cite Probes 51 All solo and agency WSCs have . Ask solo support coordinators for the file Personal Outcome Measures training that they maintain relative to their W2.0 conducted by the department or a credentials and training as required by the Area Office. department certified trainer within . Review pertinent personnel and training 90 days of receiving Area Office records at an agency to determine if the certification. agency support coordinators, supervisors, directors and managers meet minimum qualifications and training requirements. Note: This training satisfies the annually required 24 hours o/job-related trainingfor that year. 52 All solo and agency WSCs who Ask the provider if they have received the have .!lot completed Personal POM training. If the solo provider or all W2.0 Outcome Measures training have a agency WSCs have received the training, trained waiver support coordinator score this element as Not Applicable. in attendance when using the If the solo WSC has not had the training, ask Personal Outcome Measures as part about the arrangements they have in place to of the initial and annual support have a POM trained WSC accompany them planning process. when perfomUng initial and annual support planning with individuals. Ask the agency provider about the process they have in place for WSCs that have not yet attended POM training to be accompanied by a POM trained WSC during initial and annual support planning. This could be a mentoring program or precept prognun, or could be part of routine orientation for new hires. For both solo and agency providers, ask to see some evidence that a POM trained support coordinator is accompanying the untrained individual. This could be documented in the support plan, or on the . POM tool or in another note in the central record. Support Coordination Monitoring Protocol Page 17 Cite Probes 53 All solo and agency WSCs, agency . Ask solo support coordinators for the file supervisors, directors and managers that they maintain relative to their attend 24 hours of job-related in- credentials and training. . Review personnel and training records at service training annually. an agency to determine if the agency support coordinators, supeIVisors, directors and managers meet minimum qualifications and training requirements. . Verify through docwnentation that appropriate trainers are utilized as identified below. Note: Agency internal management meetings do not apply toward the 24 hours requirement unless approved by the Area Office. Note: For agency support coordinators and supervisors. trainers outside the agency must provide 12 hours of the 24-hour in-service requirement.. 54 The provider attends mandatory . Ask the provider if they are aware of meetings and training scheduled by Area Office and Department mandatory the Area Office and/or Department. meeting and training schedules. Ask the provider if they can produce any notices, announcements, or agendas received about meetings or training. . Ask the provider what Area Office and Department meetings or training they have attended during the review period. . Ask the provider for any evidence they have to verify attending the meeting or training. . Look for evidence in documents supplied by the provider of attendance at Area Office and Department meetings, such as notes in personnel files or other --"" records. 55 The provider and/or agency staffhas Look for documented evidence that the NEW received training in the Agency's provider and/or agency staff have received Direct Care Core Competencies this training or an equivalent which has been Training. approved by the Agency. Training was received within the required timeframes as developed by the Agency. This training may be completed using the Agency's web-based instruction. self-paced instruction or classroom-led instruction. Support Coordination Monitoring Protocol Page 18 ~~ Cite Probes 56 The provider and each of its . Ask the provider and/or their staff about employees receive training on what types of training programs they responsibilities and procedures for have and continue to attend. . Look for evidence of training in maintaining health, safety and well- personnel files, human resource records being of individuals served. or other locations as identified by the provider. Training on health, safety and well-being of individuals could include such topics as: . Fire safety for the environment; . Evacuation procedures in the event of natural or other disasters; . Training on what to do in the event of personal health emergencies involving consumers; . Transportation safety; . Basic infection control training, e.g., hand washing before and after all contact with consumers. . Signs and symptoms of illness . Medication administration practices . Recognizing adverse drug reactions, drng-to-drug interactions or food and drug interactions. NOTE: The Area Office is not the sole source for a provider to find training programs and activities referred to in the Core Assurances. Providers may develop their own curriculum for their staff; provider and their staff may attend a program offired through another provider. Support Coordination Monitoring Protocol Page 19 Cite Probes 57 The provider and each of its Look for evidence that the provider and/or employees receive training on staff have received training on the type and required documentation for format of documentation that is required for the services and supports that they render. service(s) rendered. Examples of this training could include: . The proper format and content of a progress note, . Recording data related to an individual's progress towards achieving goals, . Docmnenting the activities that individuals participate in dming their time with the provider. . Instruction on documentation that is required for reimbursement and monitoring purposes. .. NOTE: The Area Office is not the sole source for a provider to find training programs and activities referred to in the ..",,. Core Assurances. Providers may develop their own curriculum for their staff; provider and their staff may attend a program offered through another provider. 58 The provider and each of its Look for evidence that the provider and/or employees receive training on staff have been familiarized with and have responsibilities under the Core had some training related to the Core Assurances section of their Waiver Services Assurances. Agreement Examples of this training could include instruction on: . The rights of individuals in the program and how the provider respects these rights; . Maintaining confidentiality of consumer infolUlation; . OOering individual's choice of services and supports; . Recogniiing and reporting of suspected abuse, neglect or exploitation; . Assisting individuals in achieving personal goals and desired outcomes; . Rendering seIVices in an ethical manner. NOTE: The Area Office is not the sole source for a provider to find training programs and activities referred to in the Core Assurances. Providers may develop their own curriculum for their staff; provider and their staff may attend a program offired through another provider. Support Coordination Monitoring Protocol Page 20 Cite Probes 59 The provider and each of its Look for evidence that the provider and/or employees receive training on staff have been familiarized with and have had training related to the seIVice specific responsibilities under the sections of their Waiver SeIVices Agreement requirements of specific services and the DS Waiver Services Florida offered. Medicaid Coverage and Limitations handbook. Examples of lhis training could include instruction on: . Implementation plan development and monitoring; . Specifics of rendering services and supports; . Service limitations; . Service documentation requirements . Billing for services; and . Outcomes established for service deliveIy. NOTE: The Area Office is not the sole ... source for a provider to find training programs and activities referred to in the Core Assurances. Providers may develop their own curriculum for their staff; provider and their staffmay attend a program offered through another provider. 60 The provider and each of its Look for evidence that the provider and/or employees receive other training staff assigned to render services and supports specific to the needs or to individuals have received some orientation to an individual and their unique characteristics of the individual as characteristics and needs. required to successfully provide services and supports. The family or guardian, a physician or nurse, CBA or other providers or people who are in regular contact with and understand the unique characteristics and needs of the individual can provide this orientation. Examples of this training could include instruction on: . Conununicating with the individual; . Instruction on a behavior program, if applicable to the individual; This training may be one-on-one in nature, and therefore documentation may take the form of an agenda, or curriculum with handouts and outline. Look for evidence in the consumer's record, such as in progress notes or other provider documentation for this evidence. Support Coordination Monitoring Protocol Page 21 Cite Probes 61 Proof of required training in Review persolUlel records and other provider recognition of abuse and neglect training documentation for evidence of and the required reporting required training. . If applicable, ask staff about training procedures, to include domestic they have received. violence and sexual assault, is . Training should include prevention, available for all independent detection and reporting requirements. vendors and agency staff 62 Agency trainers attend a train-the- . Review the agency's training plan for trainer session conducted by the support coordinators for evidence of Department and mandatory refresher Area Office approval courses as required by the . If an agency trainer provides statewide and/or district specific pre-service, Department. review agency training or personnel 63 Agency trainers and the agency records to detennine for each agency training plan are approved by the trainer that they have been prior Area Office prior to training of staff approved by the department. Note to Reviewers: Score these elements as Not Applicable for solo waiver support ~.,. coordinators. Standard: Support Coordinators maintain caseloads within established limits. 64 Waiver support coordinators . Review the support coordinator's maintain a caseload of no more than caseload 36 individuals. . Review claims to detennine whether caseload ever exceeds 36 and detemtine why. 65R When a vacancy occurs the provider . Detennine caseload sizes for may exceed the 36 maximum coordinators. Compare the date of the caseload size for 60 days for each caseload increase to the review date to determine the length of the increase. vacancy. . Determine any vacancies which may impact on the caseload increase. Note: Caseloads may exceed 36 for a period of 60 consecutive days for vacancies; or a period of60 working daysfor leave under the Family and Medical Leave Act. . Review available documentation to determine involvement of Area Office in caseload redistribution for any that exceed the 60 day limit This Cite is subject to recoupment for any caseload over 36 which exceeds 60 consecutive or 60 working days without the required conditions being met. Support Coordination Monitoring Protocol Page 22 Cite Probes 66R Provider must notify the Area Office Review documentation to determine Area of any vacancies or leaves of Office notification and the time line for absence within 5 days of the notification. Notification must be for each vacancy. vacancy. This Cite is subject to recoupment for failure of the provider to notify the Area Office within stated time frames. 67 Provider accepts all individuals who Check with the Area Office: select them for support coordination . to determine if there is any history of services or are referred to them refusing to provide services; within the geographic boundaries . for reasons why consumers changed support coordinators. previously approved by the Area . When available, analyze the results of Office. person-<:entered reviews to identify if the individuaVfamilyl guardian has the support coordinator.they prefer. Exceptions to this requirement may be granted in writing by the Area Office in accordance with Department policy. Exceptions must be maintained on file. 68 Provider expansion or downsizing If downsizing has occurred check; has been accomplished in a manner . For compliance with handbook that prevents, as much as possible, a requirements; negative impact on the individuals . The transition process between support coordinators; served. . For any negative impact to individual. . Any voluntary (short-term) moratorium is reflected in the records of the provider. If expansion has occurred: . The expansion was approved by the Area Office . The provider received at least an 85% on monitoring during the past year; . The provider hired a new support coordinator and provided the required -- training within the 60 day period allowed for exceeding case load sizes; . Required support coordination services . were continued for all individuals in the caseload. Support Coordination Monitoring Protocol Page 23 Cite I I Probes Standard: The support coordinator is accessible to the individual and is available to perform required and needed supports. 69 Provider has an on-call system in . Review provider procedures for on-call place that allows individuals to and back -up systems W2.0 access support coordination services . Ask provider to discuss examples of 24 hours per day, 7 days per week. when these procedures are implemented . Ask if the procedures are tested and how Access to the provider or back-up frequently are available without toll charges to . Analyze results of person-centered the individual. reviews to assure that provider is responsive to calls from individuals . Contact consumers of this provider and ask about responsiveness. . Review support coordination's satisfaction infonnation to determine if ", there have been any concerns raised about visit scheduling or responsiveness to calls/contact. 70 Back-up waiver support . Review support coordination's coordinators are certified and satisfaction infonnation to determine if enrolled waiver support there have been any concerns raised coordinators. about visit scheduling or responsiveness of calls/contact. 71 Name(s) and contact information for . If available, review Area Office back-up waiver support coordinators complaint data to determine if there has are clearly communicated to the been any registered for this support individual and to the Area Office. coordinator around the issue of visit scheduling or contact. . Ask for evidence that demonstrntes certification of back-up provider, e.g., personnel files . Talk to a sample of consumers to determine if they know who to call if th~ir WSC is not available. How are they made aware of back-up arrangements? . Review results of person-centered reviews for concerns in this area. Note: The provider should have a name in writing in their documentation to indicate who their back-up is. This can be an agency or an individual. . Determine how the provider makes information available to individuals and the Area Office on support coordinator back-ups and procedures for accessing services. Support Coordination Monitoring Protocol Page 24 Cite Probes 1 72 Contacts with individuals in . Ask the support coordinator about the I community settings are planned in locations i.Ii which they see individuals advance of the visit and not and how they schedule these visits . Interactively, with the support incidental. coordinator, review records of several individuals to detennine if visits are pre- 73 Contacts with individuals are scheduled with the individual scheduled based on the individual's . Talk to consumers about their contacts W2.0 choice and are at a time and in a with the WSC. Detennine if the contacts location convenient to the individual are scheduled. . . . . When available, obtain information from recelvmg services. person-centered review process to determine if visit pre-scheduling consistently occurs for this provider Standard: The support coordinator provides the amount and type of contact and supports needed to meet the individual's goals an.d needs as evidenced by progress notes and other information. Note: This standard examines the presence or absence of required documentation of support coordination activities. -.,. The individual's central record contains: 74 The individual's current support Review a sample of at least three (3) records planning information including per support coordinator for the information Personal Outcome Measures noted in the standards. information and notes. . Waiver Eligibility Worksheet should be current, correct, dated. and signed by the 75 The individual's current support individual. planning information including the assessment instrument approved by . Support Plan should be dated and signed the Department, and any other by the individual. assessment information used in . Cost plan should be signed by the planning. individual. 76 The individual's current support planning information including the Cite 76 and 77 are subject to recoupment current Waiver Eligibility of funds as reimbursement documentation Worksheet. for each day from the effective date of the 77R The individual's current support support and cost plan that these plans are not available, if the WSC was responsible planning information including the for the delay. current support plan. 78R The individual's current support planning information including the current approved cost olan. 79 The individual's current support planning information including progress notes. Support Coordination Monitoring Protocol Page 25 ~.. Cite Probes 80 R One face-to-face contact with the . Detennine whether progress notes individual, at a frequency based on contain infonnation relating to tasks living situation of the individual, identified for the face-to-face and whether the amount and type of contact related to or accomplishing one or appears sufficient to address the more of the following: individual's needs. [J Assisting individual to reach . When a face-to-face contact is conducted goals of support plan, including with an individual who does not gathering information to identify communicate verbally, there should be an indication that the support coordinator outcomes interacts with and observes the Q Monitoring health and well- individual, and communicates with being of the individual others who know the individual well to a Obtaining, developing and/or detennine infonnation listed. maintaining resources needed or . When possible, face-to-face contacts requested by the individual, should occur in a variety of locations, days of the week and times of the day including natural supports, according to the individual's generic community supports and convenience. other types of resources . Face-to-face contacts should focus on a Increasing the individual's the individual and should not be involvement in the community opportunities for progress reports, etc. from other providers. Q Promoting advocacy or informed . Progress notes should show some choice for the individual evidence of use of the POMs to follow- Q Following up on the individual's up on any issues, conflicts and desired or family's concerns changes to services and supports. Note: Monthly face-to-face contacts are required for individual living in a licensed residential facility or in supported living. For individuals living in their family home, a face-to-face contact is required every three months. This Cite is subject to recoupment of funds as reimbursement documentation for each individual and month when a face-to-face contact was required and did not occur. 81 R Progress notes reflect results of face- Review progress notes in the sample of the to-face visits in the place of support coordinator's records for evidence residence every three months for . that face-to-face visit requirements in the individuals residing in supported individual's place of residence are consistently met when applicable to the living, licensed facilities or in his or individual. Detennine if progress notes her own home. reflect individual and family preference for frequency of visits when the Support Coordination Monitoring Protocol Page 26 "",'" Cite Probes 82R Progress notes reflect results of face- individual lives with his or her family. to-face visits in the place of Cite 80 and 81 are ~'Ubject to recoupment residence at six-month intervals or more frequently if requested by the of funds as reimbursement documentation for eacb individual and occurrence that family, for individuals living with tbe face-to-face contact did not occur at his or her family. tbe required frequency. 83 R Progress notes reflect at least one . Review for the type of additional other contact/activity (non-incidental contact(s) made during the month. Contact should relate to the individual, and non-administrative) per month their seIVices and supports and follow-up related to the individual if a face-to- or planning needed. Administrative face contact was made. activities such as typing, filing, mailing, data entry for billing, or leaving If no face-to-face contact occurred messages are not considered an additional contact. Letter writing would for the month, at leaSt one other qualify as another contact if related to contact/activity (non-incidental and services and benefits specific to a non-administrative) per month consumer's needs. 'This would exclude related to the individual should be form letters to confirm meetings, etc. reflected in the progress notes. These contacts may be either with the individual or with other persons, such as family members, service vendors, community members and so on, and may be conducted face-to-face or by phone. Cite 82 is subject to recoupment as reimbursement documentation if no documentation is available to support this requirement 84 Central records contain copies of . In the record sample, review for the annual or professional reports and presence of annual or professional individual implementation plans reports and implementation plans from other providers. submitted by other providers as . Ask the provider about their process for required and appropriate to each obtaining and maintaining this service. information 85 Central records contain current and . In the record sample, review for the correct demographic information, presence of demographic infonnation, W2.0 including current health and medical health and medication information and information and emergency contacts. emergency contacts. . Ask the provider about their process for keeping this information current Support Coordination Monitoring Protocol Page 27 Cite Probes 86 Central records or provider records In the record sample, review for the presence contain results of annual satisfaction of results of annual satisfaction surveys. surveys. Note: Annual sati~faction survey results and data on selected service outcomes may not be kept in the individual's central record Maintenance in alternative locations is acceptable. 87 Central records or provider records In the record sample, review for the presence contain performance data on the of perfonnance data on the projected service Projected Service Outcomes. outcomes. These include individuals: . Having maximmn freedom of choice in all areas of their lives; . Demonstrating an increase in abilities, self-sufficiency and changes in their lives consistent with personal. goals; . Are satisfied with their support coordination services based on results of annual satisfaction SUIVey or are satisfied that their concerns raised on the SUIVey are being addressed. 88 Central records contain In the record sample, review for the presence documentation through progress of progress notes documenting support notes of all other support coordination activities or contacts. coordination services, activities or contacts that assisted individuals to: Cl Meet their support plan outcomes/personal goals Cl Become more integrated into their communities and/or Cl Address individual's or family's concerns. 89 The WSC shall provide a copy of Review the individual's record to determine NEW the notice of privacy practices ifthere is docriffientation which supports required by HIP AA regulations to compliance with this element. the individual or legal guardian upon initial contact and at any time there is a significant change that necessitates the protection of a recipient's healthcare information. Support Coordination Monitoring Protocol Page 28 Cite Probes 90 If the provider transports the . Ask the provider if they transport NEW recipient in his private vehicle, the individuals in their private vehicles. provider has proof of valid driver's . If an agency provider, ask about procedures that are followed when direct license, car registration, and service staff transport individuals in their Insurance. private vehicles, such as when they collect and how they maintain information on employees rendering transportation. . Review provider and staff personnel files or other records for driver's license, vehicle registration and insurance to determine that they are current. For individuals receiving supported living coaching, complete elements 90 - 93. Score these elements as Not Applicable if no individual in the sample receives this service. 91 Progress notes reflect results of . The coordinator is responsible for quarterly meetings with individuals arranging, scheduling and W2.0 and supported living coaches for documenting a quarterly meeting in .individuals receiving supported which the person, Coordinator and Supported Living Coach review tbe living coaching services current supported living services. . For quarterly meetings occurring with 92 Progress notes reflect review of the individual in the individual's own supported living services to home, the meeting with the supported determine that they are meeting the living coach meets requirements for the quarterly face-to-face visit in the individual's needs. individual's own home. . Review documentation in progress notes 93 Progress notes indicate a review of to determine that the quarterly meeting is the individual's health, safety and scheduled at a time mutually agreeable W2.0 well-being and an updated housing to participants. . The meeting covers the review of survey. supported living needs, satisfaction with coach's services, to assure that there is 94 Progress notes support a review of an updated housing sUIVey, a review of the individual's fiscal status to health, safety and a determination that W2.0 include a review of the individual's financial support is adequate. The financial subsidy should be reviewed and bank statement and other financial updated as needed. information if the supported living coach is acting as fiscal agent. Note: It is the support coordinator's responsibility to schedule the meeting. The purpose is to have a face-to-face with the coach and individual, unless there is documentation that the individual requests that the coach not be present. Support Coordination Monitoring Protocol Page 29 Cite Probes Standard: The support coordinator meets projected outcomes for service delivery. 95 The provider has established a · Ask the provider to discuss the goals and systematic method of data collection Projected Service Outcomes that they are monitoring. to measure success on projected . Ask the provider what data they are service outcomes. collecting and how they collect the data (e.g., record review, specially developed forms completed by employees, consumer satisfaction surveys, etc.) · Ask for samples of the tools or other evidence that confinns data is being collected and monitored. · Ask the provider to describe how it is determined they are meeting \ Projected Service Outcomes. · If theprovider has any data or reports that they produce and maintain related to the goals and projected outcomes, ask to see these reports and identify how long the' provider has been tracking this data. 96 There is evidence that projected service outcome data are reviewed periodically and that corrective measures are put in place if the data indicates the service outcomes are not being achieved. · Ask the provider how it is determined they are achieving Projected Service Outcomes. · Ask the provider how frequently they perfonn this monitoring. · Ask the provider if they have identified any areas in need of improvement and what corrective actions they have taken. · Look for evidence that the provider is collecting and monitoring data according to the time frames they have defined. For elements 96-99. document findings in comments as # met/total sample. 100% of the sample must meet criterion in order for the elements to be designated 'Met' except where otherwise indicated. Outcomes should be measured considering individual skills and circumstances. Reviewers will determine achievement of projected service outcomes at the time of the reVIew Reviewers will also use the results and status of recommendations from the Person- centered Reviews applicable to the provider, information from the sample records and documentation reviewed, and discussions with the individuals receivin~ the services. Support Coordination Monitoring Protocol Page 30 ...... Cite Probes 97 Individuals receiving support Look for evidence that the provider offers the coordination services have freedom individual choiccs at every given W2.0 of choice in all areas of their lives, opportunity. including setting personal goals, InteIView individual to determine if they are being fully informed about service provided with opportunity to exprcss choice. options and making all possible Providers are educating, informing and decisions with regard to the conduct of their lives. providing individuals with opportunities for exposure and experiences regarding their rights, choices and services. If the individual has a legal guardian, look for evidence that they participate in decision- making and receive information regarding services and rights and are afforded choices. 98 Individuals receiving services Look for evidence in supporting data that the W2.0 demonstrate an increase in abilities, individuals are achieving or making progress self-sufficiency and changes in their towards their personal goal. lives consistent with their support Look for evidence that the provider is plan. consistently monitoring and reviewing the individual's progress in all supports and services to assure goal attainment. Look for evidence that the provider has documentation regarding discussions with the individual and support provider when issues or problems are impeding progress and that solutions are facilitated. Through inteIView with the individual/guardian it can be verified that the individual has made progress at least on one of their personal goals, the provider is working with the individual on identifying goals, and this is verified through documentation. .,0 Support Coordination Monitoring Protocol Page 31 Cite Probes 99 All Individuals served who have Review annual satisfaction survey for results. responded to an annual satisfaction Discuss satisfaction with individuals W2.0 survey are satisfied with their receiving seIVices. support coordination services based on the results. or the provider has Review steps/actions that the provider took to addressed any concerns raised respond to individual's concerns. during the survey. Provider should track the results of the satisfaction surveys and address aggregate concerns. Provider should ensure the effectiveness of any corrective measures put in place by monitoring the status of quality improvement initiatives as needed and makes adjustments as necessaty to ensure improvement in their .. service delivery system. Look for documentation that the provider has ." distributed~tisf~tion~eysroe~h individual receivin2 the service. 100 There is evidence that the provider Through interview and documentation look NEW advocates for the individual on an on for evidence that this is occurring and the going basis to achieve a personally provider is assisting the individual in identified goal. advocating for themselves. Examples of advocacy could include: Assisting with obtaining supports and services. Assisting with exploring areas of interest (e.g., places of worship, volunteer opportunities, community organizations, possible employment, etc.) Providing the individual with information in assisting them in making their own decisions. Provide the individual with infonnation on self-advocacy groups. Following up on a request for a change in goals or seIVices and exploration of the individual's personal interest on a continued and on-going basis. For denied services the provider has educated . the individual on due process procedures and helps the indi"iduallook for supports and seIVices to assist the them in achieving their goals. This is part of the interview process with the individual. Support Coordination Monitoring Protocol Page 32 Cite I I Probes NOTE: Score the following elements only when determined appropriate. This service is only for those individuals moving from institutional settings and is billed as transitional support coordination at a higher monthly rate. Score these elements as Not Applicable when this service has not been provided during the review period. Standard: The Support Coordinator assists the individual to successfully transition from an institutional setting to community services, safeguarding the individual's health, safety and support needs. The Support Coordinator: 101 Works with the individual to arrange . for the provision of community- based services and supports upon discharge (waiver and other). 102 Works with the institutional provider and staff and coordinating their activities with facility's discharge planning process. 103 Develops an initial support plan to assist the individual in adjusting to their new living environment, based on the person's goals and needs and current assessments (including the facility's summary of the individual's developmental, behavioral, social, health and nutritional status and post-discharge plan). 104 Assures community supports and services are in place at the time of discharge, and reflect the individual's desired goals and identified needs. 105R Maintains at a minimum weekly face-to-face contact with the individual for the first 30 days following discharge to ensure community supports and services meet the individual's needs. Support Coordination Monitoring Protocol . Ask support coordinator how they conduct transitional support coordination. Talk with consumers about the transitioning experience. When available, obtain infonnation from person-centered review process to .. detennine if transitions are occurring according to plan and that the individual's health, safety and support needs are being addressed. ... Review authori7.ations for services and supports Look for evidence that the individual is receiving services and supports as authorized. Interactively, with the support coordinator, review an individual's record who is receiving, or has received, transitional support coordination services for );> Evidence in support plans of arrangements being made with guidance from the individual );> Services and supports to be effective upon the individual's discharge );> There is evidence the provider worked with the institutional provider and staff to plan for discharge including facility record information and assessments. );> Evidence that the facility's discharge planning process has been involved with the follow-up planning );> Evidence of weekly face-to-face contact with the individual for the first 30 days following discharge );> Support plan update at the end of the 30 day post discharge period . . . . Page 33 Cite Probes 106 Updates the support plan at the end Failure to provide weekly face-to-face of the 30-day period from discharge, contact during the first 30 days following identifying progress made with discbarge may result in recoupment of funding if senices were billed at the transition to community-based living transition rate for tbat period. and changes to supports and services as appropriate. Support Coordination 2-1 6-05. doc Rev. 08.31.01; 09.03.01; 09.07.01; 09,11.01; 09.21.01 final draft; 10-30-01 final changes from DS Program; 11-13-01; 09.16.02; 10.02.02;12.03.02; 01.03; 02.03.03; 02.04.03; 10-25-05; 11-22-05; 2-14-06 .,-,.. Support Coordination Monitoring Protocol Page 34 Developmental Services Support Coordination Monitoring Checklist Provider Number: Provider Name: Review Date: Provider Address: Reviewer Name: District: Location: o Agency Provider o Solo Provider o Onsite Review o Desk Cite N/A Explanation of Monitoring Tool Symbols/Codes ."'- n Alert: Denotes a critical standard or cite relating to health, safety and rights. A deficiency requires a more intense corrective action and follow-up cycle. "W" Weighted Element: A "W" followed by 2.0 or 4.0 in the Cite column denote.s elements that have a greater impact on the monitoring score. "R" Recoupment: An "R" in the Cite colunm denotes an element that is subject to recoupment of funds b the State if the element is "Not Met." Standard: The Support Coordinator assists the individual in determining his or her ort Plannin activities. W2.0 ort Coordinator: Assists individuals with determining desired outcomes and supports needed using the Personal Outcome Measures (POM) and other techniques (e.g. person centered planning) during each su ort Ian ear. Assists individuals to identify needs using the assessment instrument approved by the APD rior to the develo ment of the su ort Ian. Assists individuals to make decisions and informed choices as indicated by the person's situation throu hout the su ort Ian ear. Develops the support and cost plan to reflect the individual's desired personal outcomes and individual needs. Reviews with individuals, at least annually at the time of support plan development, available options for services and supports, (includes both aid and un aid service 0 tions . 2 3 W2.0 4 W2.0 5 Support Coordination Monitoring Checklist Page I Cite Met Not Met N/A 6 Annually completes a report of progress for individuals as specified in APD policy. 7 Assists individuals to meet goals and outcomes through linkages with natural and generic W2.0 supports. 8 When natural and generic supports are not available, assist the individual in locating services available through local, state or federal sources, including Medicaid and the DS Medicaid waiver. 9 Reviews with service vendors the goals to be achieved for the individual and notes these discussions in prowess notes. 10 Takes actions necessary to coordinate the continuity of supports and services among '< providers, family and others to achieve the goals and outcomes of the person. 11 Documents all support coordination services, ..-..... activities and contacts in clear and adequate prowess notes. Standard: The Support Coordinator assists the individual to achieve personal goals and outcomes. (New 2003) 12 Has taken action on the results and recommendations reported through the person- W2.0 centered review process. Note: If there have been no person-centered reviews, score this element Not Applicable. Standard: Support and Cost Planning information is submitted to the district and shared with the individual and other stakeholders within ap propriate timeframes. 13 Support and cost plans are provided to the individual or their guardian within 10 calendar days of the effective date, and at any time they - are reauested. 14 Cost plans are signed by the individual or guardian. 15 Copies of the support and cost plans are submitted to the Area Office no later than 20 calendar days prior to the effective date Cost plans, amendments or addendums meeting exceptional cost review guidelines must be submitted to the Area Office within 90 calendar days prior to the effective date. Support Coordination Monitoring Checklist Page 2 Cite Met Not Met N/A 16 Service authorizations that accurately reflect the Area Office's approved service level on the cost W2.0 plan, as well as copies of pertinent support plan information is given to other providers of services to authorize and initiate service delivery within ten calendar days of the effective date of the support plan. Standard: The Support Coordinator advocates for the individual and assists the individual to increase or maintain the capacity to direct fonnal and informal resources. The Support Coordinator: 17 Assists the individual in evaluating whether the purchased services meet the individ~al' s W2.0 expectations. 18 Assists the individual in determining whether services are age and culturally appropriate. 19 Assists the individual in determining whether services address the desired goal(s) and/or need W2.0 for which they are intended. 20 Assists the individual in determining whether services provide appropriate challenges, W2.0 motivation and experiences to meet the individual's goals and expectations. 21 Reviews with individuals available options for places to live. W2.0 22 Reviews and assists individuals in ADTs with information and/or referral to rehabilitation, W2.0 vocational habilitation, and other employment services and employment opportunities available in their community. 23 Provides service counseling for individuals currently in sheltered workshops or segregated W2.0 work environments to apprise them of the options available to them for meaningful work activities and training. 24 Discusses with the individual their concerns related to dissatisfaction, quality of service delivery, health and safety, or other issues in order to resolve differences. 25 Provides information to recipients on residential NEW options available to them including owning or renting their own home, with supports. Support Coordination Monitoring Checklist Page 3 Cite Met Not Met N/A 26 Discusses with providers concerns relating to individual dissatisfaction, the quality of service W2.0 delivery, individual health and safety, or other issues in order to resolve differences, including recommendations and results from person- centered reviews. 27 Follows-up to provide closure on issues and resolution of problems or situations. W2.0 28 Initiates contact with the Area Office to request assistance in resolving concerns that cannot be resolved through discussion or the normal grievance orocess. Standard: Changes in the individual's service and support needs are dealt with appropriately and timely by the Support Coordinator. 29 Progress notes include sufficient information concerning any changes in an individual's service and support needs that require an update to the cost plan. 30 Cost plan updates are initiated when support coordinators become aware of the need for change. 31 Service authorizations and adequate information concerning the individuals' goals and needs are W2.0 sent to providers, as appropriate to the cost plan change, within 5 working days of receipt of Area Office approval. Standard: The Support Coordinator assists the individual to build linkages to natural and 2eneric supports and, when necessary, appropriate paid services. The SUDDort Coordinator: 32 Recruits and locates potential service vendors who are acceptable to the individual, are qualified to meet the individual's needs in the most cost- efficient manner possible, and assists them with waiver enrollment procedures. 33 Notifies other paid service providers when it is determined that an individual receiving services W2.0 is no longer Medicaid eligible. 34 Works with providers and Area Office to plan for possible continuation of services and funding options when an individual's eligibility is in jeopardy. Support Coordination Monitoring Checklist Page 4 Cite Met Not Met N/A 35 Assures that purchased supports and services are not billed in excess of the annual limits of current approved cost plan(s) for individuals. For individuals residing in supported living arrangements or licensed residential facilities who are taking any psychiatric or anti-epileptic medications review cites 35-39. Refer to Medication Review Criteria. Standard: The Support Coordinator assures that individuals will be free of risks associated with prescribed medication. 36 Provider assures a comprehensive psychiatric (for psychiatric medication) review is completed W2.0 annually by a licensed psychiatrist/neurologist or an A.R.N.P., who acts pursuant to a protocol with the psvchiatrist/neurolo~ist. 37 Provider assures a medication review by a Licensed Consulfant Pharmacist is conducted at W2.0 least annually when individual is on two or more medications or meets the criteria for medication review as defined in the handbook. 38 Provider assures the individual receives follow-up reviews by the psychiatrist, neurologist or A.R.N.P. at a frequency established by these practitioners. 39 Provider works with Area Office Health Care coordinators to obtain documentation from psychiatric or neurological practitioners if frequency of the follow up review is less frequent than every 90 days. 40 Provider maintains documentation of medical practitioner rationale regarding frequency of follow-up visits in the individual's central record. Standard: The Support Coordinator assures that information relating to the individual is current, correct and transferred appropriately to other providers. 41 R Providers enter, update and assure the accuracy of information pertinent to the individual in the W2.0 ABC system, including demographic information. 42 Provider assures that all appropriate central record information is transferred to new vendors or to the Area Office, within two weeks of the effective date of actions such as new vendor selection by the individual or termination of suooort coordination services. Standard: The Support Coordinator is fully qualified and trained to provide support coordination services. Support Coordination Monitoring Checklist Page 5 Cite Met Not Met N/A 43~ Level two background screenings are complete for all direct service employees. W4.0 44~ All employees undergo background screening every 5 years. W4.0 45 All solo and agency waiver support coordinators (WSCs), directors, managers and supervisors have a Bachelor's degree from an accredited college or university. 46 All solo WSCs and agency supervisors, directors and managers have three years of professional experience in developmental disabilities, special education, mental health, counseling, guidance, social work or health and rehabilitative services .. (a master's degree can substitute for one year of experience). 47 All agency WSCs have two years of professional ...... experience in developmental disabilities, special education, mental health, counseling, guidance, social work or health and rehabilitative services (a master's degree can substitute for one year of experience). 48 All solo and agency WSCs, directors, managers and supervisors have a minimum of34 hours of statewide pre-service training. 49 All solo and agency WSCs, directors, managers and supervisors have a minimum of 26 hours of district-specific pre-service training within 90 days of completion of statewide pre-service training. 50 All support coordinators have district training and NEW certification in the proper administration of the department approved assessment tool for ascertaining the recipient's level of need within 90 days of completion of statewide pre-service training. The provider must re-certify every two years. 51 All solo and agency WSCs have Personal Outcome Measures training conducted by the W2.0 department or a department certified trainer within 90 days of receiving Area Office certification. Support Coordination Monitoring Checklist Page 6 Cite Met Not Met N/A 52 All solo and agency WSCs who have not completed Personal Outcome Measures training W2.0 have a trained waiver support coordinator in attendance when using the Personal Outcome Measures as part of the initial and annual support planning process. 53 All solo and agency WSCs, agency supervisors, directors and managers attend 24 hours of job- related in-service training annually. 54 The provider attends mandatory meetings and training scheduled by the Area Office and/or Department. 55 The provider and/or agency staff has received NEW training in the Agency's Direct Care Core '. Competencies Trainin,g. 56 The provider and each of its employees receive training on responsibilities and procedures for ~.. maintaining health, safety and well-being of individuals served. 57 The provider and each of its employees receive training on required documentation for service( s) rendered. 58 The provider and each of its employees receive training on responsibilities under the Core Assurances. 59 The provider and each of its employees receive training on responsibilities under the requirements of specific services offered. 60 The provider and each of its employees receive other training specific to the needs or characteristics of the individual as required to successfully provide services and supports. 61 Proof of required training in recognition of abuse and neglect and the required reporting procedures, to include domestic violence and sexual assault, is available for all independent vendors and a,gency staff 62 Agency trainers attend a train-the-trainer session conducted by the Department and mandatory refresher courses as required bv the Department. 63 Agency trainers and the agency training plan are approved by the Area Office prior to training of staff Support Coordination Monitoring Checklist Page 7 Cite Met Not Met N/A Standard: Support Coordinators maintain caseloads within established limits. 64 Waiver support coordinators maintain a caseload of no more than 36 individuals. 65 R When a vacancy occurs the provider may exceed the 36 maximum caseload size for 60 days for each vacancy. 66R Provider must notify the Area Office of any vacancies or leaves of absence within 5 days of the vacancy. 67 Provider accepts all individuals who select them for support coordination services or are referred to them within the geographic boundaries previously approved by the Area Office. 68 Provider expansion or downsizing has been .. accomplished in a manner that prevents, as much as possible, a negative impact on the individuals served. -" Standard: The support coordinator is accessible to the individual and is available to perform required and needed supports. 69 Provider has an on-call system in place that allows individuals to access support coordination W2.0 services 24 hours per day, 7 days per week. Access to the provider or back-up are available without toll charges to the individual. 70 Back-up waiver support coordinators are certified and enrolled waiver support coordinators. 71 Name(s) and contact information for back-up waiver support coordinators are clearly communicated to the individual and to the Area Office. 72 Contacts with individuals In community settings are planned in advance of the visit and not incidental. 73 Contacts with individuals are scheduled based on the individual's choice and are at a time and in a W2.0 location convenient to the individual receiving services. Support Coordination Monitoring Checklist Page 8 -~ Cite I Met I Not Met I N/A Standard: The support coordinator provides the amount and type of contact and supports needed to meet the individual's goals and needs as evidenced by progress notes and other information. The individual's central record contains: 74 The individual's current support planning information including Personal Outcome Measures information and notes. 75 The individual's current support planning information including the assessment instrument approved by the Department, and any other assessment information used in planning. 76 The individual's current support planning information including the current Waiver Eligibility Worksheet. 77R The individual's current support planning information including the current support plan. 78R The individual's current support planning information including the current approved cost plan. 79 The individual's current support planning information including progress notes. 80R One face-to-face contact with the individual, at a frequency based on living situation of the individual, related to or accomplishing one or more of the following: 0 Assisting individual to reach goals of support plan, including gathering information to identify outcomes 0 Monitoring health and well-being of the individual - Q Obtaining, developing and/or maintaining resources needed or requested by the individual, including natural supports, generic community supports and other types of resources 0 Increasing the individual's involvement in the community 0 Promoting advocacy or informed choice for the individual 0 Following up on the individual's or family's concerns Support Coordination Monitoring Checklist Page 9 -'. Cite Met Not Met N/A 81 R Progress notes reflect results of face-ta-face visits in the place of residence every three months for individuals residing in supported living, licensed facilities or in his or her own home. 82 R Progress notes reflect results of face-to-face visits in the place of residence at six-month intervals or more frequently if requested by the family, for individuals living with his or her family. 83 R Progress notes reflect at least one other contact/activity (non-incidental and non- administrative) per month related to the individual if a face-to-face contact was made. If no face-to-face contact occurred for the month, at least one other contact1activity (non-incidental and non-administrative) per month related to the individual should be reflected in the progress notes. -' 84 Central records contain copies of annual or professional reports and individual implementation plans submitted by other providers as required and appropriate to each servIce. 85 Central records contain current and correct demographic information, including current W2.0 health and medical information and emergency contacts. 86 Central records or provider records contain results of annual satisfaction surveys. 87 Central records or provider records contain performance data on the Projected Service Outcomes. 88 Central records contain documentation through progress notes of all other support coordination services, activities or contacts that assisted individuals to: [J Meet their support plan outcomes/personal goals [J Become more integrated into their communities and/or [J Address individual's or family's concerns. Support Coordination Monitoring Checklist Page 10 Cite Met Not Met N/A 89 The WSC shall provide a copy of the notice of NEW privacy practices required by HIP AA regulations to the individual or legal guardian upon initial contact and at any time there is a significant change that necessitates the protection of a recipient's healthcare information. 90. If the provider transports the recipient in his NEW private vehicle, the provider has proof of valid driver's license, car registration, and insurance. For individuals receiving supported living coaching, complete elements 90 - 93. Score these elements as Not Aoolicable if no individual in the sample receives this service. 91 Progress notes reflect results of quarterly meetings with individuals and supported living " W2.0 coaches for individuals receiving supported living coachimz services 92 Progress notes reflect review of supported living - services to determine that they are meeting the individual's needs. 93 Progress notes indicate a review of the individual's health, safety and well-being and an W2.0 updated housing survey. 94 Progress notes support a review of the individual's fiscal status to include a review of W2.0 the individual's bank statement and other financial information if the supported living coach is acting as fiscal agent. Standard: The SUDDort coordinator meets proiected outcomes for service delivery. 95 The provider has established a systematic method of data collection to measure success on projected service outcomes. 96 There is evidence that projected service outcome data are reviewed periodically and that corrective measures are put in place if the data indicates the service outcomes are not being achieved. 97 Individuals receiving support coordination services have freedom of choice in all areas of W2.0 their lives, including setting personal goals, being fully informed about service options and making all possible decisions with regard to the conduct of their lives. Support Coordination Monitoring Checklist Page 11 Cite 98 W2.0 99 W2.0 100 NEW Met Not Met N/ A Individuals receiving services demonstrate an increase in abilities, self-sufficiency and changes in their lives consistent with their su ort Ian. All Individuals served who have responded to an annual satisfaction survey are satisfied with their support coordination services based on the results. or the provider has addressed any concerns raised durin the surve . There is evidence that the provider advocates for the individual on an on going basis to achieve a personally identified goal. NOTE: Score the following elements only when determined appropriate. This service is only for those individuals moving from institutional settings and is billed as transitional support coordination at a higher monthly rate. Score these elements as Not Ikabte when this service has not been rovided durin the review mod Standard: The Support Coordinator assists the individual to successfully transition from an institutional setting to community services, safeguarding the individual's health, safe and su ort needs. The Su 101 102 103 104 105R 106 ort Coordinator: Works with the individual to arrange for the provision of community-based services and su orts u on dischar e (waiver and other). Works with the institutional provider and staff and coordinating their activities with facility's dischar e lannin rocess. Develops an initial support plan to assist the individual in adjusting to their new living environment, based on the person's goals and needs and current assessments (including the facility's summary of th~individual' s developmentaL behavioral, social, health and nutritional status and ost-dischar elan. Assures community supports and services are in place at the time of discharge, and reflect the individual's desired oals and identified needs. Maintains at a minimum weekly face-to-face contact with the individual for the first 30 days following discharge to ensure community su orts and services meet the individual's needs. Updates the support plan at the end of the 30-day period from discharge, identifying progress made with transition to community-based living and chan es to su orts and services as a ro nate. Support Coordination Monitoring Checklist Page 12 Support Coordination Checklist 2-16.Q6.doc Rev. 08.31.01; 09.03.01; 09.07.01; 09.11.01; 09.21.01 final draft; 10-30.Ql final changes from OS Program; 11-13.Ql; 09.16.02; 10.02.02;12.03.02; 01.03; 02.03.03; 02.04.03;02-10.Q3; 02.25.03; 11-27.Q5; 2-16.Q6 ...,.. Support Coordination Monitoring Checklist Page 13 Developmental Services Supported Living Coaching Services Monitoring Protocol Supported living coaching services provide training and assistance, in a variety of activities, to support individuals who live in their own homes or apartments. These services may include assistance with locating appropriate housing, the acquisition, retention or improvement of skills related to activities of daily living such as personal hygiene and grooming, household chores, meal preparation, shopping, personal finances and the social and adaptive skills necessary to enable individuals to reside on their own. Supported living services mean the provision of supports necessary for an adult who has a developmental disability to establish, live in and maintain a household of their choosing in the community. This includes supported living coaching and other supports. Cite T Probes Explanation of Monitoring Tool Symbols/Codes n Alert: Denotes a critical standard or cite relating to health, safety and rights. A deficiency requires a more intense corrective action and follow-up cycle. "W" Weighted Element: A .oW' followed by 2.0 or 4.0 in the Cite column denote.s elements that . have a greater impact on the monitoring score. "R" Recoupment An "R" in the Cite column denotes an element that is subject to recoupment of funds by the State if the element is "Not Met." Standard: The provider successfully supports the individual to live in his or her own home. For the following elements of performance associated with this standard: Review results of the Person- Centered Reviews, informatWn available from individuals receiving the service and available documentation. The purpose of this section is to determine provider performance and the quality of supports in this area. Do not score an element as met solely based on the presence of the documentation. 1 The provider develops an individualized Ask the provider to describe the implementation plan (IP) for all implementation planning process, including: W2.0 };r Who is typically involved? consumers. };r When does it usually take place? };r What happens with the IP once it is developed? };r How does the provider monitor that IP's are being completed within state defmed timeframes? Review results and recommendations from Person-Centered Reviews for cites 1-9. Note: The Supported Living Supports Strategy Guide can be used, but it MUST BE supplemented with all the required elements for the Implementation Plan. Cite Probes 2 An individualized implementation plan . Review results and recommendations (IP) is developed under the direction of from Person-Centered Reviews W2.0 the consumer. applicable to the provider for cites 2-7 . Ask the provider how each consumer has been involved in the development of their implementation plan. . Talk with individual to determine their level of participation in the IP process. Do services reflect interests and goals that they have? . Interactively with the provider, review a sample of implementation plans. During review, >> Explore with the provider what other sources of information about an individual influence the implementation plan. >> Determine if there is consumer sign- off on the plan or any changes to the .. plan to indicate acceptance. >> Review monthly summaries to determine if updates are being made _,ol to the IP. . Talk to consumers, family or guardians about the progress that is being made in achieving goals. . Ask individual about their participation in the IP process. . Are they satisfied with their goals and supports received? . Have they talked about changes? 3 The IP identifies goal(s) and needs from . Ask the provider about their process for the individual's support plan and other ensuring their implementation plan is pertinent sources appropriate to the effective and contains information individual. related to these standards. (The IP may contain information from other sources, but at a minimmn must contain goals from the support plan.) . The IP identifies training programs and activities to accomplish desired goals and identified needs. . Ask individuals about training and activities in which they are involved. Do they feel these are beneficial? Are they interested in the training and activities? Cite Probes 4 The IP identifies strategies and methods . Look for evidence of provider-developed to assist the individual in meeting implementation plan forms or other goal( s) as well as the data collection structures put in place to ensure that data is captured consistently and in such a system to be used to assess success and way that it can be analyzed over time, achievement. . Determine if the provider evaluates the strategies or methods for effectiveness and how frequently. . Ask the provider how they determinc strategies and methods that will assist individuals in meeting goals. 5 The IP is reviewed periodically to . Ask the providcr to describe how they determine whether progress is being monitor the progress of the individuals W2.0 made and is updated to reflect new that they seIVe interest, goals, needs, or strategies to . Look for evidence that the pro\ider is actively monitoring the progress of promote meaningful progress. individuals. . . Look for evidence of IP updates being made based on an individual achieving goals or not. ..".. . Review IP and provider's policies, as applicable to determine if plans are reviewed at stated time frames, and changes documented per stated procedures. 6 The provider is tracking and acting on Review service log entries and the annual an individual's progress or lack of report to determine whether progress is progress. noted. Determine whether: . Activities, supports and contacts are detailed; . Follow-up is performed if indicated; . Progress statements contain objective (data/fact based) as well as subjective - information; . Recommendations for changes in approach are made when progress is not being made. Cite Probes 7 The provider has taken action on the Sample size is at least two person-centered results reported through the Person- reviews in those instances when more than one has been conducted. 100% of the Centered Review process. sample equals a designation of 'Met.' . Determine if any Person-Centered Reviews have been conducted with consumers receiving services and supports from this provider. . Ask the provider if they have received Person-Centered Review results and what action they have taken based on the results. . Interactively, with the provider, review records and documentation for individuals that have taken part in the person-centered review process. Determine if there is any documented evidence that the provider has acted on '. the recommendations in the report. . Talk with individuals who participated in the person centered review to detennine whether changes were discussed with -'. them and have been made. Are they satisfied with the seIVice changes? Note: If there have been no person-centered reviews conducted with individuals for which this provider renders services and supports, score this cite as 'Not Applicable. ' Note: The provider may address the recommendations in a manner other than that identified in the report. 8 The provider assists individuals in Functional Community Assessment is the completing a functional community basisfor identifying the types of training, assessment prior to his or her move to a assistance and the intensity afsupport rendered by the provider. It is a tool supported living arrangement. designed to assist the provider in becoming familiar with the individual and his/her 9 The provider assists individuals in capabilities and needs, This assessment updating the functional community addresses all areas of daily life including _ assessment annually. relationships, medical and health concerns, personal care, household and money management, community mobility, recreation and leisure. . Ask the provider to describe their process for completing and updating the functional community assessment, including when this activity typically occurs. . Interactively, with the provider, review a sample of these assessments to determine when they are completed and when they are updated. . Talk with individuals to determine their level of participation in this process. Cite Probes 10 The provider forwards a copy of the The Housing Survey is the basis for surveying completed initial Housing Survey to the a prospective home to ensure that it is safe. individual's support coordinator within Note: The quarterly update to the Housing 10 working days of the selection. survey should be presented in aface-to-face 11 The provider updates the Housing meeting between the supported living coach, Survey quarterly and has it available for the individual and the support coordinator. W2.0 review by the waiver support The individual may invite others to attend coordinator at the time of the The meeting should cover the individual's financial statu:,~ supported living services coordinator's quarterly home visit. and the individual's health, safety and well- 12 The provider's quarterly updates to the being. support coordinator include a review of Ask the provider to describe the process W2.0 the individual's overall status of health, . safety and well-being. for completing and updating the Housing SUIVey for individuals. . Determine when this activity occurs, what is included in the completion and updating process in terms of review. . Determine if and when the provider submits the initial, and reviews and submits the revised Housing Survey to an individual's support coordinator. . Intemctively, with"the provider, review a sample of records of individuals that have a completed Housing Survey, and look for dates of completion and submission to support coordinators. . Determine whether SUIVeys appear to appropriately reflect the individual's living situation. . Look for evidence of updates to the Housing SUIVey . Look for docwnentation (date, reviewer signature, etc.) that the quarterly reviews took place, the survey was reviewed, and who was in attendance. . Discuss with individuals their level of participation in this process. Cite Probes 13 The provider assists individuals in The Financial Profile is an analysis of the completing the Financial Profile and household costs and revenue sources associated with maintaining a balanced submitting it to the waiver support monthly budget for the individual. The coordinator no more than 10 days analysis will substantiate the needfor a following the selection of housing by the month(v subsidy or initial start-up costs, and individual. should be a source of information for determining strategies for assisting the person in money management. Note: The quarterly update to the financial profile should be presented in aface-to-face meeting between the supported living coach, the individual and the support coordinator. The individual may invite others to attend The meeting should cover the individual's financial status, supported living services and the individual '.'I health, safety and well- being. . Ask the provider to describe the process for completing a financial profile for an individual, including when this activity usually takes place. ." . Interactively, with the provider, review a sample of records to determine that the financial profile is included as part of the individual '.'I Implementation Plan. . Determine whether surveys appear to have been updated and whether they appropriately reflect the individual's financial situation. . Look/or evidence of updates to the Financial Profile. . LookfOr documentation (date, reviewer signature, etc.) that the quarterly reviews took place, the financial profile was reviewed, and who attended . Discuss with individuals their level of participation in this process. Note: lfthe financial profile indicates a need for a one time or recurring subsidy, the profile must be submitted to the waiver support coordinator and approved by the Area Office before the individual signs a lease. Cite Probes 14 Providers acting as fiscal agents for the Look for documentation that a review of the individual must provide bank statements bank statements takes place at the time of the and other financial to the support quarterly review with the support coordinator. coordinator for review at the time of the . Discuss with the provider what other quarterly meeting. financial docwnents are reviewed. (e.g. mortgage or rent payments, utilities. etc.) . Determine whether the provider has signed written consent to act as the fiscal agent. . Talk with individuals to determine their satisfaction with this support. . Review results and recommendations from person-centered reviews. Note: If the provider is not acting asfiscal agent, score this cite as 'Not Applicable. ' " 15 Provider assists individuals to be fiscally . Ask the provider to describe, using responsible in their decision making and specific examples, how they assist W2.0 to assure that affordable choices are ..'.1 individuals in being fiscally responsible. made. . Individuals with resource limitations are counseled by the coach on the benefits of sharing cost with a roommate and other cost saving means . Check provider documentation to detennine that this assistance is being noted. . Talk with individuals to detennine the level of support in this area . Review results and recommendations from Person-Centered Reviews. 16 As appropriate to the individual's goals, Review results and recommendations from needs, and interests, services are Person-Centered Reviews to assist in scoring provided in the individual's place of cites 16-17. . Ask the provider where they typically residence or in the community. provide supported living coaching services. . Determine whether the services and activities are based on the individual's interest, choice or related goal or need, and not the convenience of the provider. . Talk with individuals to determine where services are provided and whether they have input into seIVice location. ~. Cite Probes 17 As appropriate to the individuals' goals, . Ask the provider to describe, using needs, and interests, the supported living specific examples, how they coordinate W2.0 coach works with other providers and an coaching services and supports with other providers. individual's waiver support coordinator . Review claims and other documentation to avoid activity duplication. to determine if services unnecessarily duplicate or overlap. (e.g. supported living coach and in-home support staff should not perform same functions.) . Determine if the provider has routine contact individuals' support coordinators and other providers. . Check provider documentation to determine that this contact is being noted. . Talk with individuals receiving the service to detennine how supports are delivered. Standard: The provider and aU employees of the provider are qualified to provide SUDDorted LiviD2 services. 18~ Level two background screenings are Review available personnel files or records to complete for all direct service ascertain compliance. Check for: W4.0 employees. . Notarized affidavit of good moral character; . Proof of local background check . Documentation of finger prints submitted to FDLE for screening and screening reports on file; . Criminal records that include possible disqualifiers have been resolved through court disposition 19;tj All employees undergo background re- . Review available personnel files or screening every 5 years. records to very that employees undergo W4.0 background fe-screening at least every 5 years. . Look for evidence of completion and submission of an FDLE Form, identified as either attaclunent 3 or 4. Note: Fingerprint cards are not required on resubmission. Cite 20 Independent providers and employees of agencies who render services have a bachelor's degree from an accredited college or university with a major in nursing, education, or social, behavioral or rehabilitative science. Probes In lieu of a bachelor's degree, a person rendering these services has an associate's degree from and accredited college or university with a major in nursing, education or social, behavioral or rehabilitative science and two years of experience. Experience in one of the previous(v mentionedfields can substitute on ayear-for-year basisfor the required college education. ...,,,.. . Ask the independent vendor about their qualifications and experience. . Ask to see a copy of the provider's resume and personnel file. Review file for documentation of qualifications. · If possible, query the Area Office before the visit, to check the enrollment file references. · Detennine if the provider participates in at least one monitoring review per year and has been certified by the Area Office. (Certification usually occurs at the time of enrollment.) Review a sample of agency staff persoMel files. · Check job descriptions, to detennine that the provider is requiring these qualifications. · Check job applications completed by the employee and/or resumes of employees for required experience. · Determine if the provider participates in at least one monitoring review per year and has been certified by the Area Office. (Certification usually occurs at the time of enrollment.) Standard: The provider and the provider's staff meet training requirements for delivery of Supported Living services. For all the following elements of performance associated with this standard: Review Area Office requirementsfor mandatory meetings and training documentation.. Review provider's training record v to determine if documentation is maintained and at a minimum includes: The topic of the training; length of the training session; Training dates; Participants' signature; Instructor's name; Objectives and/or a syllabus. NOTE: The Area Office is not the sole source for a provider to find training programs and activities referred to in the Core Assurances. Providers may develop their own curriculwn for their staff, or providers and their staff may attend a oro.lmlJIl offered through another provider. Cite Probes 21 Agency employees and independent . Ask the provider to describe the type of providers are required to attend at least training that is required for Supported 18 hours of pre-service training prior to Living Coaching and how they arrange for this training for themselves or assuming job responsibilities employees. . Review personnel files and other provider training records for evidence that required training bas taken place or is scheduled. . Determine that services are not being rendered to individuals before the provider or providers' staffs have had the required training. . Ask agency employees to describe the training they have received and when the training occurred, or when it will occur in the case of retraining. Ensure the provider receives this training according to the time lines established by the Agency. Note: If the provider was enrolled prior to October 2003, only 12 hours of pre-service training is required. If the provider has received the correct number of pre-seIVice trainin~ hours, score this element as "met" 22 Agency employees and independent . Ask the provider to describe the type of providers have eight (8) hours of annual training that is required for Supported W2.0 in-service training. Living Coaching and how they arrange for this training for themselves or employees. . Review personnel files and other provider training records for evidence that required training has taken place or is scheduled. . Detennine that services are not being rendered to individuals before the provider or providers' staffs have had the -- required training. . Ask agency employees to describe the training they have received and when the training occurred, or when it will occur in the case of retraining. Cite Probes 23 Agency employee and independent . Ask the provider to describe the type of provider training consists of, at a training that is required for Supported minimum, a detailed review of the most Living Coaching and how they ammge current (now using the 1997 for this training for themselves or employees. publication), A Guide to Supported . Review personnel files and other Living in F7orida, an overview of pr~dertrmmngrecorosfur~iden~ affordable housing options and home that required training has taken place or modifications, and Rule 65B-11, Florida is scheduled. Administrative Code. . Determine that services are not being rendered to individuals before the provider or pr~ders' staffs have had the required training. . Ask agency employees to describe the training they have received and when the training occurred, or when it will occur in the case of retraining. " 24 Proof of current training and . Independent vendors and agency staff certification in Cardiopulmonary complete this training within 30 days of Resuscitation (CPR) is available for all initially providing services. independent providers or agency staff . Review provider, or a sample of agency staff personnel files and/or training records for evidence of required training. Training documentation must be maintained on file. . Determine if the pr~der or agency staff receive retraining according to the CPR requirements established by the sponsoring organization or requirement. . Review CPR certificates or CPR training documentation to detennine expiration date and need for updated training. Note: A certified trainer must provide CPR training. Cite Probes 25 Proof of current training in AIDS and . . Independent vendors and agency staff infection control is available for all complete this training within 30 days of independent providers and agency staff initially providing services. . Determine if the independent vendor and agency staff receives retraining according to the requirements established by the sponsoring organization or regulation. . Review personnel files and other provider training records for evidence of required training. . Infection control may be a separate training or included and documented as part of the AIDS training as "universal precautions" . Note: American Red Cross First Aid Training does not meet the requirements for HIV/ AIDS-training. ~. rO' Cite Probes 26 The provider attends mandatory . Ask the provider if they are aware of meetings and training scheduled by the Area Office and Agency mandatory Area Office and/or Agency. meeting and training schedules. Ask the provider if they can produce any notices, aunouncements or agendas received about meetings or training. . Ask the provider what Area Office and Agency meetings or training they have attended during the review period. . Ask the provider for any evidence they have to verify attending the meeting or training. . Look for evidence in documents supplied by the provider of attendance at Area Office and Agency meetings, such as notes in personnel files or other records. Note: If the Area Office has not sponsored any mandatory meetings, score this cite as 'Not Applicable. . 27 Independent providers and agency staff Ask the provider and/or their staff about what receive training on responsibilities and types of training programs they have and W2.0 procedures for maintaining health, continue to attend. safety and well-being of individuals Training on health, safety and well-being of served. individuals could include such topics as: . Fire safety for the environment; . Evacuation procedures in the event of natural or other disasters; . Training on what to do in the event of - personal health emergencies involving consunlers; . Traffic/transportation safety; . Basic infection control training, e.g., hand washing before and after all contact with consumers. ... Cite Probes 28 Independent providers and agency staff' Determine if: receive training on medication . The provider has a policy related to their W2.0 administration and on supervising own and/or staff training on medication administration or supervision of self- individuals in the self-administration of administration of medication. medication. . The provider andlor staff receive training on medication administration or supervision of self-administration of medications, when applicable to their job responsibilities and the needs of individuals in the program. . Determine if medication administration training includes evidence of a return demonstration by an RN of the trnining by the provider and staff. . Determine if the training includes recognizing adverse drug reactions, drug-to-drug interactions or food and ., drug interactions. . Determine if training is provided by a qualified trainer (physician, registered nurse); the curriculwn used is developed ...,011' or approved by an RN or other appropriate entity (e.g. Area Office). Note: A provider's policy on medication administration may be that their program does not administer or supervise self- administration of medications and all staff are made aware of this position and trained on this policy. 29 Independent providers and agency staff Look for evidence that the provider and/or receive training on required staff have received tmining on the type and documentation for service(s) rendered. fonnat of documentation that is required for the seIVices and supports that they render. Examples of this training could include: . The proper fonnat and content of a progress note, . Recording data related to an individual's progress towards achieving goals, . Documenting the activities that individuals participate in during their time with the provider. . Instruction on documentation that is required for reimbursement and monitoring purposes. . Development of an Individual Implementation Plan and supporting documentation requirements. Cite Probes 30 Independent providers and agency staff Look for evidence that the provider and/or receive training on responsibilities under staff have been familiarized with and have the Core Assurances. had some training related to the Core Assurances section of their Waiver SeIVices Agreement and the DS Waiver Services Florida Medicaid Coverage and Limitations handbook. Examples of this training could include instruction on: . The rights of individuals in the program and how the provider respects these rights; . Maintaining confidentiality of consumer infonnatio~ . . Offering individual's choice of services and supports; . Recognizing and reporting of suspected abuse, neglect or exploitation; " . Assisting individuals in achieving personal goals and desired outcomes; . Rendering seIVices in an ethical manner. ...... 31 Independent providers and agency staff Look for evidence that the provider and/or receive training on responsibilities under staff have been familiarized with and have the requirements of specific services had training related to the seIVice specific offered. sections of their Waiver Services Agreement and the OS Waiver Services Florida Medicaid Coverage and Limitations handbook. Examples of this training could include instruction on: . Implementation plan development and monitoring; . Specifics of rendering seIVices and supports; . Service limitations; . SeIVice documentation requirements . Billing for services; and . Outcomes established for service delivery. Cite Probes 32 Independent providers and agency staff Look for evidence that the provider and/or receive training on use of personal staff have received training on using desired outcomes to establish a person-centered outcomes for individuals as the guide for approach to service delivery. rendering seIVices and supports. Examples of this training could include instruction on: . Designing training programs that address the consumers goals from the Support Plan; . Involving the consmner and/or family in the development of the implementation plan; . Designing services and supports from the standpoint of the outcome that is desired by the individual and/or family. . Training in Personal Outcome Measures or another person centered planning .. approach. . Individualizing service delivery methods. ~.. Refer also to the providers policy in this area to determine training specified. Note: This does not mean that the provider must have received the official Personal Outcome Measures training (with the exception of Support Coordinators). Other person-centered approaches are acceptable. Cite Probes 33 Independent providers and agency staff Look for evidence that the provider and/or receive other training specific to the staff assigned to render services and supports W2.0 needs or characteristics of the individual to individuals have received some orientation to an individual and their unique as required to successfully provide characteristics and needs. services and supports. The family or guardian, a physician or nurse, other providers or people who are in regular contact with and understand the unique characteristics and needs of the individual can provide this orientation. Examples of this training could include instruction on: . Communicating with the individual; . Repositioning requirements for the individual; . Instruction on a behavior program, if applicable to the individual; . Specific training to implement a training program tailored to an individual's goals. This training maybe one-on-one in nature, and therefore documentation may not take the fonn of an agenda, or curriculum with handouts and outline. Look for evidence in the consumers record, such as in progress notes or other provider documentation for this evidence. 34 Proof of required training in recognition . Review personnel files and other of abuse and neglect to include domestic provider training records for evidence of violence and sexual assault, and the required training. required reporting procedures is . If applicable, ask staff about the in- available for all independent vendors service training that they have received. and agency staff . Training should include prevention, detection and reporting requirements. Cite I Probes Standard: Services are pr(}vided at an intensity and duration necessary for successful support of the individuals served. 35 Each supported living coach shall Review with the provider their NEW maintain a caseload of no more than ten current list of individuals receiving individuals who are receiving supported services. Review the provider's living coaching services. claims data to ensure compliance. 36 Services are rendered at a time and place . Ask the provider to supply evidence that mutually agreed to by the individual and they work with the individual to identify the provider. service times. . Review the provider's satisfaction survey to detennine if this is an area that is covered and if the provider has any results. . If the provider collects complaint data, ask to see the data and determine if any " complaints have been reported relative to service times. . Ask the individual if the time and location of the service is consistent with .'. their needs and expectations. . Determine from discussions with the provider and with individuals that alternative times for supported living coaching are being offered . Review results and recommendations of person centered reviews applicable to the provider to detennine whether choices are optimized. 37 Services are provided on a one on one . If services are provided with two or NEW basis. more individuals present, the amount of time must be prorated based upon the number of individuals receiving the service. 38 Providers have an on-call system that . Ask the provider to describe their on-call allows individuals' access to services for and back-up systems. W2.0 emergency assistance 24 hours-per-day, . Determine that telephone access to the 7 days a week. provider or the backup proVider is Cite Probes 39 Independent providers must specify a available without ton charges to the backup person to provide supports in the individual. event he or she is unavailable. . Determine if independent provider's backup providers are certified and enrolled Medicaid providers and certified as a supported living provider pursuant to rule 65B-ll, Florida Administrative Code. . Determine through discussion with individuals that provider accessibility meets their expectations. Do they have difficulty reaching the provider? Are they satisfied with the amount of access? . Review results and recommendations of person centered reviews. NOTE: Score this cite as 'Not Applicable' when evaluating an Agency. '. ~.. 40 Supported living coaching services are · Check demographic data in the provider's provided only to adults (age 18 or over) files for age. and a copy of the individual's who rent or own their own homes or lease. apartments in the community. . Review individual's lease if available in the provider's files. The individual receiving supported living services must appear on the lease either singularly, with a roommate or a guarantor. · Look for evidence or ask individuals whom they pay monthly for rent. · Providers, or their immediate family are not the individual's landlord, nor do they have any interest in the ownership of the housing unit. 41 Individuals receiving supported living . Interactively, with the provider. review coaching services live where and with progress note documentation to W2.0 whom they choose. determine how the individual made Cite Probes 42 Individuals receiving supported living living arrangement decisions. services have control over the household . Speak. with any individual(s) about their W2.0 and its daily routines. living arrangements and if they were involved in the decision and if the arrangements are desirable. . Review results and recommendations from person centered reviews to examine choice, living options/decisions and satisfaction with community integration. . Review results of the annual satisfaction survey. 43 Services are made available to . Ask the provider to describe, using individuals within 90 days prior to specific examples, when supported moving or to individuals who are in the living coaching services are typically process of looking for a place of their made available to individuals. . Interactively, with the provider, review own. records and documentation to detennine 44 Supported living coaching services are when services are made available to not provided to individuals who live in individuals that are moving or looking family homes, foster homes, or group for alternative living arrangements. homes, except for the 90 days prior to . Detennine that these services are only rendered 90 days prior to an individual's the individual moving into their own move from residential habilitation. homes or apartments. . Talk with individuals about services and review person centered reviews applicable to the provider. ~,. Cite Probes 45 Waiver program providers and Note: Incidental tran~portation is considered employees of waiver providers who that which is outside of the transportation for provide incidental transportation comply disadvantaged program. with all program requirements. . Determine if the provider transports individuals. ~ If transportation is provided in personal cars and/or agency vehicles check for current vehicle registration and proof of insurance coverage. ~ Check for provider and employee valid and current driver's license as applicable. ~ Ask the provider about their system to assure vehicle safety. >> The Area Office should be notified of any traffic violations " immediately, with the exception of parking tickets. Cite I I Probes Standard: Tbe provider maintains sufficient reimbursement and monitoring documentation to verify service delivery and to evaluate each individual's services and supports. Note: Score based on the presence or absence of required documentation. 46 R Provider has at a minimum, a copy of Review a sample of provider records to the service log or time intervention log determin~ that. . for the period being reviewed. · COPl~S of sefVlc~ logs are availa~le and contam the reqwred documentation. ~ Progress notes including documentation of activities, supports and contacts with the individual, other providers and agencies with dates and times, ~ A summary of support provided during the contact, ~ Any follow-up needed, and ~ Progress toward achieving Support Plan goals. Service logs are to be submitted to the waiver support coordinator on a monthly basis. Note: A service log contains the individual's name, social security number, Medicaid ID number, the description of the service, activities, supplies or equipment provided and corresponding procedure code, times and dates service was rendered. This Cite is subject to recoupment as reimbursement documentation if not available. Cite Probes 47R Provider has at a minimum, an Interactively, with the provider, review a individual implementation plan, and/or sample of implementation plans to determine J transition plan (if applicable). they contain, at a minimum: . Name, address and contactinfonnation of the individual served; . Goal(s) from the support plan that the service will address. . Strategies employed to assist the individual in meeting the support plan goal(s). . System to be used for data collection and assessing the individual's progress in achieving the support plan goal(s). . For SLC, include the frequency of the supported living service. . How home, health and community safety needs will be addressed and the supports required to meet these needs. " . The method for accessing the provider 24-hours per-day, 7-days per-week for emergency assistance. . A description of how natural and generic _,.a' supports will be used to assist in supporting the individual. . A financial profile that includes strategies for assisting the person in money management, when requested by the individual or guardian, and the amount approved for the supported living subsidy (the financial profile is critical in detennining whether or not the housing selected by the individual is within their financial means and will identify the need for monthly subsidy which must be approved by the Area Office). Additionally, the implementation plan may include training objectives appropriate to the individual's programs and services. This Cite is subject to recoupment as monitoring documentation if not available. Cite . Probes 48R The IP is developed, at a minimum, . Review records to compare service within 30 days of new service initiation authorization data with IP development (implementation plan complete and copy time frames. . How does the provider monitor that lP sent to support coordinator at time of are being completed within stated time first billing), or within 30 calendar days frames? of service authorization effective date . Review records to determine that support when services are being continued. coordinator supplied with a copy of the plan at the time of initiation and when significant updates are made to the plan. The implementation plan is submitted to the waiver support coordinator at the time of the first claim submission, and at least annually thereafter at the time of the support plan update and, any time major or significant updates and changes are made before they are implemented. This Cite is subject to recoupment as reimbursement documentation if not available within 30 days of the effective date of the authorization. 49 Provider has at a minimum, an annual . .Ihteractively, with the provider, review a written report summarizing the sample of records to determine if they W2.0 individual's progress toward achieving contain an annual, written report that the goal(s) from the support plan. indicates the individual's progress toward their support plan goal(s) for the year. . The annual report should reflect progress statements made in the service log and other supporting documentation. Reports should include ~ Objective (fact-based) information reflecting the results of training and supports provided to the individual over the course of the year, ~ Subjective information (opinions), and ~ Recommendations. . Look for evidence that the Annual Report was sent to the support coordinator prior to the annual support plan update. ~. Cite Probes 50 Provider has at a minimum a copy of the Interactively, with the provider, review a annual satisfaction survey maintained in sample of records or other files and reports to the individual's record. determine if they contain a copy of the completed satisfaction survey and resulting quality improvement measures that have been put in place as a result of the survey. Note: StafJproviding direct supported living services to the individual may not assist in the survey activity fOr that individual. A family member, guardian, support coordinator or another person should be enlisted to assist the individual. 51 The provider forwards a copy of the Look for evidence that the provider has annual satisfaction survey to the waiver forwarded satisfaction survey results to the support coordinator. waiver support coordinator. TIris could be a note and date on the copy of the survey that is maintained in the individual's file or a sentence in the progress notes. 52 Provider has at a minimum, Interactively, with the provider, review documentation of a quarterly meeting in records of individuals for evidence of W2.0 which the individual, the waiver support quarterly meetings with the support coordinator and the supported living coordinator. coach review supported living services. Quarterly meetings with the individual and support coordinator should cover at least the following topics: . Financial statement and bank record review, when applicable . Housing survey and any updates . Updates to demographic, health, medical, and emergency information. . Are supported living coaching services being carried out as identified in the support plan - Note: It is the responsibility of the support coordinator to set up the quarterly meeting at a time convenientfor all participants. Ifno meeting was set, look for evidence that the supported living provider attempted to satisfY this requirement. They are an active, not passive partner in this. ~ ,01' Cite Probes 53 When the provider is acting as fiscal Interactively, with the provider, review agent for the individual, provider has at records of individuals for evidence of a minimum, progress notes in the quarterly meetings with the support service log indicating that the supported coordinator. living coach and waiver support Quarterly meetings with the individual and coordinator review bank statements and support coordinator should cover at least the financial records quarterly. following topics: . Financial statement and bank record review, when applicable . Housing survey and any updates . Updates to demographic, health, medical, and emergency information. Note: It is the responsibility of the support coprdinator to set up the quarterly meeting at a time convenient for all participants. If no meeting was set, lookfor evidence that the .. supported living provider attempted to satisjj; this requirement. They are an active, not passive partner in this. 54R Provider has at a minimum;an initial Interactively, with the provider, review Housing Survey containing quarterly records of individuals for evidence of an updates of the individual's health and initial Housing Survey and quarterly updates. safety status. Tbis Cite is subject to recoupment as monitoring documentation if not available. 55 Provider makes available an initial Note: The Housing Survey and updates can Housing Survey with quarterly updates be provided at the quarterly meetings to the waiver support coordinator. between the SLC and WSC or it can be provided to the JVSC prior to the quarterly meeting. Interactively, with the provider, review a sample of individual records to determine there is evidence of a meeting or transmission of the Housing survey and updates to the WSC contained in the service log/progress notes. Cite Probes 56 Provider has at a minimum, up-to-date Interactively, with the provider, review a information regarding the demographic, sample of individual records to determine health, medical and emergency they contain ~ Current demographic, hea1tb, medical information, and a complete copy of the and emergency infonnation, and current support plan, if approved by the ~ A complcte copy of the current support individual/guardian, for each individual plan (if permitted by the served. individuaVguardian). Determine from providcr how often infonnation is updated. Is there evidence that the provider shares the individual's updated information with their waiver support coordinator? '. Standard: Provider bills for services as authorized. 57R Supported living coaching services are . Interactively, with the provider;ieview limited to the amount, duration and daily service logs and monthly progress scope of the services described in the notes. . Compare services provided against the individual's support plan and current service authorization for the sample approved cost plan. under review. . Verify that service authorizations are on file for each individual. . Review claims infonnation and compare against authorization and billing. This Cite is subject to recoupment if the provider is rendering the service without an authorization, or is billing for more than the authorized service levels. Cite Probes 58R Provider does not bill separately for . Interactively, with the provider, review a transportation that is required during a sample of claims submitted for payment. supported living activity. . Compare the sampled claims with service records for individuals and claims information. . Ask the provider to describe and discuss billing policies and procedures. . Ask the provider if they have had any difficulty with denied claims. This Cite is subject to recoupment for any amount billed separately for transportation that was included in the supported living rate. 59R The provider bills for supported living Supported Living Coaching services are coaching as defined and specified in the training services expected to enhance skills DS Waiver Services Medicaid Coverage and achieve individual outcomes. handbook. Services do not to exceed 40 quarter hour units per day. ..- This Cite is subject to recoupment for any individual when there is evidence that the individual is not receiving this senice as defined. (e.g. No evidence of training services or meaningful support for the individual, and senices were biDed.) Standard: The provider meets Projected Service Outcomes established for service delivery. 60 The provider has established a . Ask the provider to discuss the goals and systematic method of data collection for Projected Service Outcomes that they are outcome data. monitoring. . Ask the provider what data they are collecting and how they collect the data (e.g, record review, specially developed fonns completed by employees, consumer satisfaction surveys, etc.) . Ask for samples of the tools or other evidence that confirms data is being collected and monitored. . Ask the provider to describe how it is detennined they are meeting \ Projected Service Outcomes. . If the provider has any data or reports that they produce and maintain related to the goals and projected outcomes, ask to see these reports and identify how long the provider has been tracking this data Cite 61 There is evidence that the data is reviewed periodically and that corrective measures are put in place if the data indicators that the goal is not being achieved. Probes . Ask the provider how it is detelmined they are achieving Projected Service Outcomes. . Ask the provider how frequently they perform this monitoring. . Ask the provider if they have identified any areas in need of improvement and what corrective actions they have taken. . Look for evidence that the provider is coIlecting and monitoring data according to the time frames they have defined. For elements 62-68, document findings in comments as #met/total sample. 100% of the sample must meet criteria in order for the elements to be designated 'Met'. Outcomes should be measured considering individual skills and circumstances. Reviewers will determine achievement of projected service outcomes at the time of the review Reviewers will also use the results and status of recommendations from the Person-centered Reviews applicable to the provider, information from the sample records and documentation reviewed, and discussions with the individuals receiving the services. .. 62 Individuals in supported living are the > Check leases for individual or guardian's lessee or owner of the home in which signatures or the provider's data on lease W2 0 th . d and mortgage information. . ey rest e. 63 All Individuals served who have responded to the annual satisfaction W2.0 survey are satisfied with the services based on the results, or the provider has addressed any concerns raised during the survey. Note: Lessee may be co-signed as long as the individual's signature also appears on the lease. Review annual satisfaction survey for results. Discuss satisfaction with individuals receiving services. Review steps/actions that the provider took to respond to individual's concerns. Provider should track the results of the satisfaction surveys and address aggregate concerns. Provider should ensure the effectiveness of any corrective measures put in place. Look for documentation that the pro\iider has distributed satisfaction surveys to each individual receiving the service. Cite Probes I 64 Individuals in supported living live in Is the provider aware of the rule and the homes occupied by no more than two waiver process? W2.0 other beneficiaries with developmental Ask the provider how they determine if they disabilities and in areas in which persons are in compliance with the rule. with disabilities account for no more than 10% of the houses or 10% of the Determine with the provider if they have units in an apartment complex, unless inquired or that they aware of oUter otherwise waived by the Agency. residential placements in the complex or neighborhood. Look for documented evidence that the provider has contacted and coordinated with the Area Office. The provider has requested a waiver if deemed necessary. 65 Individual are supported to live in their Review documentation, and interview staff own Home. and individual to ascertain weather the -. provider is effectively coordinating and W2.0 trouble shooting to ensure the individual's success in the community. ..- The individuals are assisted with locating housing and managing their household. The individual's living situation has not been jeopardized due to lack of supports and services. The individuals are assisted with the acquisition, retention or improvement of skills related to activities of daily living 66 Individuals who use the supports Review documentation and interview increase their level of participation or stafl7individuals. W2.0 independence in the community. Indicators may be: ~ Evidence of building and/or maintaining natural support systems, and/or ~ Exercising rights and privileges as fully participating members of the community. ~ Evidence that the provider supports or advocates for the individuals in increasing their community inclusion activities. Note: Community inclusion should demonstrate how the individual actively participates in the activities that he/she chooses. Cite 67 W2.0 68 NEW Individuals demonstrate freedom of choice in all areas of their lives as evidenced by setting personal goals, being fully informed about service options and making all possible decisions with regard to the conduct of their lives. Individuals achieve goals on their support plan. ...,,0' Probes Look for evidence that the provider offers the individual choices at every given opportunity. Interview individual(s) to detennine if they are provided with the opportunity to experience choice. Providers are educating and/or infomling individuals about their rights and services/support options. Look for evidence that the individual and legal guardian, if appropriate, have participate in decision- making and receive infonnation regarding services and rights and are afforded choices Review provider documentation to determine whether the individual has achieved a current or previous support plan goal. Provider must demonstrate evidence that 80% of the individuals sampled achieved at least one goal on their current or previous support plan during the last twelve months. Inteniew individual and guardian if necessary. Standard: Personal funds are appropriately maintained and are accounted for accuratelv. 69 Separate checking or savings accounts are maintained for individual's personal W2.0 funds. 70 W2.0_ 71 W2.0 72 If a single trust account is maintained for personal funds of all individuals, there is separate accounting for each individual. Account(s) is reconciled monthly to the account total as noted on the bank statement Account statements and reconciliation records are retained for review. Determine if the provider acts as a fiscal agent, manages, stores and/or retains funds belonging to an individual. If yes, determine if the conditions outlined in cites 69-73 are being met. Talk with individuals concerning their fund management and satisfaction with this support. Review results and recommendations from person centered reviews applicable to the provider. . Re"iew provider policies and procedures Cite Probes 73 Individual and provider funds are not on managing, storing or retaining funds commingled. belonging to an individual. W2.0 . Interactively, \vith the provider, review records of individuals for which the provider is managing, storing or retaining personal funds. Look for written permission from the individual or guardian. . Determine if any complaints or grievances have been filed against the provider relative to the handling of an individual's personal funds. . When available, analyze results of person-centered reviews to identify if providers are consistently following the process outlined in the standard and sub. standards when managing, storing or retaining an individual's personal funds. . Ensure that the provider maintains on file receipts for individual purchases of $25.00 or more. ~.... 74 The provider has written consent to Determine from records that the provider manage funds or act as fiscal agent. maintains on file a written consent to manage W2.0 funds signed by the individual, if competent, or their guardian. - C~ I IProb" If the provider is not rendering senrices to individuals tbat bave problems with behavior such as thOle that follow, I/Core the elements in this section Not Applicable. TVDes of Problems with Behavior: Actions of the individual which, without behavioral, physical, or chemical intervention I. Have resulted in self-inflicted. detectable, external or internal damage requiring medical attention or are expected to increase in frequency, duration, or intensity resulting in self-inflicted, external or internal damage requiring medical attention. 2. Have occurred or are expected to occur with sufficient frequency, dwation or magnitude that a life-threatening situation might result, including excessive eating or drinking. vomiting. ruminating, eating non-nutritive substances, refusing to eat, holding one's breath, or swallowing excessive amounts of air. 3. Have resulted in external or internal damage to other people that require medical attention or are expected to increase in frequency, dwation or intensity resulting in external or internal damage to other persons that requires medical attention. 4. Have resulted or are expected to result in major property damage or destruction. 5. Have resulted or are expected to result in arrest and confinement by law enforcement personnel Standard: Behavioral Services result in objective and measurable improvements in behavior that are consistent with the individual's outcomes. 75 When rendering services and supports to individuals identified as having problems with Qehavior, the provider is assisted by a qualified professional or professionals who meet the requirements in the Medicaid Handbook for the type of service the professional is providing. 76 Behavior Service goal(s) are consistent with and relate directly to the individual's personal outcomes/goals. If individuals in the program experience problems with behaviors, determine from the provider what qualified behavioral professional assists them with services for this individual. Determine if the beha"ioral professional is . An employee of the provider, review personnel files. · On contract or an adjunct to the service underreview,requestiliatqualifications be available during the time of the review. Ask to speak with the certified or licensed professional(s) responsible for developing interventions or supports for the individua1(s). If psychotropic medications are used, then a licensed physician must be involved. For other services (e.g., counseling) refer to the Medicaid Waiver Handbook for provider qualifications. Look for e\idence that the prcscribing professional is monitoring the individual Review the person's support plan, if available, service authorization information, the implementation plan and the individual's behavioral plan (interventionltreatmentlthcrapy plan) to detennine if a clear connection exists between behavioral supports and services and the persons stated personal outcomes/goals. Cite Probes 77 The individual has a written, individual Review record(s) of individuals that the plan developed by a certified or licensed provider or staff has identified as having professional that clearly identifies what problems with behaviors. Is a behavior plan will change as a result of intervention, present, and who developed the plar. the intervention( s) to be used and how Review the individual's records and the progress will be measured. behavior services plan to determine: . The problem with behavior is described in writing and in objective measurable tenns. . There is evidence that interventions, treatments and thempies were based on the results of an assessment of the problem with behavior by the behavior service professional. . There is documentation that interventions account for medical problems, significant life changes, or other factors that might worsen the problem with the behavior. . If the individual was evaluated by a physician or other medical professional to rule out potential medical problems that might account for the problem with behavior. Note: The plan may be written by someone other than the behavior service professional. but must be approved hy the professional. 78 Written consent to use the plan was . Review records and other documentation obtained from the individual or to determine that signed consent is on W2.0 guardian. file. If consent was not obtained, look for documentation of the reason. . Talk with individuals receiving the service. Are they aware of the plan and interventions? Are they in agreement with the need for intervention and approaches used? 79 Implementers (provider staff) of the . Ask staff to describe the procedures and plan are able to carry out the plan as the circumstances under which they are written. used . Observe the actual use of the procedure or intervention if possible. . Interview the individual for their understanding of implementation of the plan. . Review personnel and training records to verify staff training on the program. Cite Probes 80 A system is in place to assure that . Review behavior service plan to procedures are carried out as designed. determine if a plan to monitor W2.0 implementation is available. . Review provider or behavioral professional documentation to determine if monitoring occurs as planned. . If there are problems with implementation, are these addressed and corrected? 81 There is evidence of progress or lack Review available and required thereof in reducing the problem with documentation to determine whether progress W2.0 behavior. in being made, or if lack of progress, that there is a plan for the continuation, modification or termination of services. Documentation available for review to determine whether progress is being made should include: . Data collected on plan implementation. Are the data collected as required in the .'. plan? . Data displays (graphed). Review to determine progress and currency of graphing. . Progress should be verified in writing as a progress note or summary. Note: Some measurable progress must be demonstrated or predicted or the current array of services mu:"t be seriously questioned. 82 Emergency procedures (e.g., reactive . Determine if a written procedure is strategies, crisis management available. Is the procedure procedures) used by the provider for individualized? problems with behavior are developed . Review any procedures that the provider has for emergency or crisis management. - and implemented under the guidance of (Note: The provider may have general certified or licensed behavioral services procedures. as well as individualized. professionals. Reviewers should look at both.) . Determine who developed the emergency or crisis management procedure, and if it is approved by the LRC or the Area Office. . Determine if the procedure identifies: ~ How staff will be trained; ~ What documentation must be kept and submitted upon use of the emergency procedure. Cite Probes 83 Staff are able to use the procedure when . Review personnel and training records to and as designed determine whether staff has been trained in the use of these procedures. (Certain procedures such as ACT or TEAM require periodic retraining or certification. ) . Determine whether only trained staff is allowed to use these procedures. . Talk with individuals and staff to determine their awareness of, and familiarity with these procedures. 84 Records are kept on the use of the Request to see reports on use of emergency emergency procedure and occurrences procedures. Verify the following: of the problem behavior. . Daily reports on the employment of physical, chemical, or mechanical restraints by those specialist authorized in the use of such restraints are made to ". the chief administrator of the program. . A monthly summmy including the type of restraint, the duration of usage and the reasons therefore will be submitted to the -'. Area Office administrator and the local advocacy committee. (Note: Reports may be sent to the Area Office Developmental Disabilities Program Office for routing to Area Office Administrator.) . Review the agency procedure for reporting the use of emergence interventions. . Determine if the use of emergency interventions was properly reported. Review documented number of restraints reported to the Local Review Committee. Note to reviewer: If emergency or crisis procedures have not been used. score this element Not Applicable. - Supported Living Coaching 11-22-05.doc REV 10-29-01; 11-01-01; 11-13-01; 09.27.02; 01.03; 02.04.03; 10-25-05; 11-22-05 Developmental Services Supported Living Coaching Services Monitoring Checklist Provider Number: Provider Name: Review Date: Provider Address: Reviewer Name: District: Location: o Agency Provider o Solo Provider o Onsite Review o Desk ~.. Cite Met Not Met I N/A Explanation of Monitoring Tool Symbols/Codes n Alert: Denotes a critical standard or cite relating to health, safety and rights. A deficiency requires ~ ~ a more intense corrective action and follow-up cycle. "W" Weighted Element: A "W' followed by 2.0 or 4.0 in the Cite column denote$ elements that have a greater impact on the monitoring score. "R" Recoupment: An "R" in the Cite column denotes an element that is subject to recoupment of funds by the State if the element is "Not Met." Standard: The provider successfully supports the individual to live in his or her own home. t The provider develops an individualized implementation plan (IP) for all consumers. W2.0 2 An individualized implementation plan (IP) is developed under the direction of the consumer. W2.0 3 The IP identifies goal(s) and needs from the individual's support plan and other pertinent sources appropriate to the individual. 4 The IP identifies strategies and methods to assist the individual in meeting goal(s) as well as the data collection system to be used to assess success and achievement. S The IP is reviewed periodically to determine whether progress is being made and is updated to reflect new W2.0 interest, goals, needs, or strategies to promote meaningful prOJUess. 6 The provider is tracking and acting on an individual's progress or lack of progress. 7 The provider has taken action on the results reported through the Person- Centered Review process. .,. Cite Met Not Met N/A S The provider assists individuals in completing a functional community assessment prior to his or her move to a supported living arrangement. 9 The provider assists individuals in updating the functional community assessment annually. 10 The provider forwards a copy of the completed initial Housing Survey to the individual's support coordinator within 10 working days of the selection. 11 The provider updates the Housing Survey quarterly and has it available for review by the waiver support W2.0 coordinator at the time of the coordinator's quarterly home visit. 12 The provider's quarterly updates to the support coordinator include a review of the individual's overall W2.0 status of health, safetv and well-being. 13 The provider assists individuals in completing the Financial Profile and submitting it to the waiver support coordinator no more than 10 days following the selection of housing by the individual. 14 Providers acting as fiscal agents for the individual must provide bank statements and other financial to the support coordinator for review at the time of the quarterly meeting. 15 Provider assists individuals to be fiscally responsible in their decision making and to assure that affordable W2.0 choices are made. 16 As appropriate to the individual's goals, needs, and interests, services are provided in the individual's place of residence or in the community. 17 As appropriate to the individuals' goals, needs, and interests, the supported living coach works with other W2.0 providers and an individual's waiver support coordinator to avoid activity duplication. . Standard: The provider and all employees of the provider are qualified to provide Supported Livin2 services. ISn Level two background screenings are complete for all direct service employees. W4.0 19n All employees undergo background re-screening every 5 years. W4.0 20 Independent providers and employees of agencies who render services have a bachelor's degree from an accredited college or university with a major in nursing, education, or social, behavioral or rehabilitative science. Supported Living Coaching Services Monitoring Checklist Page 2 Cite I I Met Not Met I N/A Standard: The provider and the provider's staff meet training requirements for delivery of Supported Livin~ services. 21 Agency employees and independent providers are required to attend at least 18 hours of pre-service training prior to assuming job responsibilities 22 Agency employees and independent providers have eight (8) hours of annual in-service training. W2.0 23 Agency employee and independent provider training consists of, at a minimum, a detailed review of the most current (now using the 1997 publication), A Guide to Supported Living in Florida, an overview of affordable housing options and home modifications, and Rule 65B-Il, Florida Administrative Code. 24 Proof of current training and certification in Cardiopulmonary Resuscitation (CPR) is available for .. all independent providers or agency staff 25 Proof of current training in AIDS and infection control is available for all independent providers and agency ,.,.,of' staff 26 The provider attends mandatory meetings and training scheduled by the Area Office and/or Agency. 27 Independent providers and agency staff receive training on responsibilities and procedures for maintaining W2.0 health, safety and well-being of individuals served. 28 Independent providers and agency staff receive training on medication administration and on supervising W2.0 individuals in the self-administration of medication. 29 Independent providers and agency staff receive training on required documentation for service(s) rendered. 30 Independent providers and agency staff receive training on responsibilities under the Core Assurances. 31 Independent providers and agency staff receive training on responsibilities under the requirements of specific services offered. 32 Independent providers and agency staff receive training on use of personal outcomes to establish a person- centered approach to service delivery. 33 Independent providers and agency staff receive other training specific to the needs or characteristics of the W2.0 individual as required to successfully provide services and supports. 34 Proof of required training in recognition of abuse and neglect to include domestic violence and sexual assault, and the required reporting procedures is available for all independent vendors and agency staff Supported Living Coaching Services Monitoring Checklist Page 3 Cite I Met Not Met N/A Standard: Services are provided at an intensity and duration necessary for successful support of the individuals served. 35 Each supported living coach shall maintain a caseload NEW of no more than ten individuals who are receiving supported living coaching services. 36 Services are rendered at a time and place mutually agreed to by the individual and the provider. 37 Services are provided on a one on one basis. NEW 38 Providers have an on-call system that allows individuals' access to services for emergency assistance W2.0 24 hours-per-day, 7 days a week. 39 Independent providers must specify a backup person to provide supports in the event he or she is unavailable. 40 Supported living coaching services are provided only to adults "(age 18 or over) who rent or own their own homes or apartments in the community. 41 Individuals receiving supported living coaching services live where and with whom they choose. W2.0 42 Individuals receiving supported living services have control over the household and its daily routines. W2.0 43 Services are made available to individuals within 90 days prior to moving or to individuals who are in the process of looking for a place of their own. 44 Supported living coaching services are not provided to individuals who live in family homes, foster homes, or group homes, except for the 90 days prior to the individual moving into their own homes or apartments. 45 Waiver program providers and employees of waiver providers who provide incidental transportation comply with all pro~ram reQuirements. Standard: The provider maintains sufficient reimbursement and monitoring documentation to verify service delivery and to evaluate each individual's services and supports. Note: Score based on the presence or absence of required documentation. 46R Provider has at a minimum, a copy of the service log or time intervention log for the period bein~ reviewed. 47R Provider has at a minimum, an individual implementation plan, and/or transition plan (if applicable). Supported Living Coaching Services Monitoring Checklist Page 4 Cite Met Not Met N/A 48R The IP is developed, at a minimum, within 30 days of new service initiation (implementation plan complete and copy sent to support coordinator at time of first billing), or within 30 calendar days of service authorization effective date when services are being continued. 49 Provider has at a minimum, an annual written report summarizing the individual's progress toward W2.0 achieving the goa1(s) from the support plan. 50 Provider has at a minimum a copy of the annual satisfaction survey maintained in the individual's record. 51 The provider forwards a copy of the annual satisfaction survey to the waiver support coordinator. 52 Provider has at a minimum, documentation of a quarterly meeting in which the individual, the waiver W2.0 support coordinator and the supported living coach '. review supported living services. 53 When the provider is acting as fiscal agent for the individual, provider has at a minimum, progress notes in the service log indicating that the supported living coach and waiver support coordinator review bank statements and financial records Quarterlv. 54R Provider has at a minimum, an initial Housing Survey containing quarterly updates of the individual's health and safety status. 55 Provider makes available an initial Housing Survey with quarterly updates to the waiver support coordinator. 56 Provider has at a minimum, up-to-date information regarding the demographic, health, medical and emergency information, and a complete copy of the current support plan, if approved by the individual/guardian, for each individual served. Standard: Provider bills for services as authorized. 57R Supported living coaching services are limited to the amount, duration and scope of the services described in the individual's support plan and current approved cost plan. 58R Provider does not bill separately tor transportation that is required during a supported livin.g activity. 59R The provider bills for supported living coaching as defined and specified in the DS Waiver Services Medicaid Coverage handbook. Supported Living Coaching Services Monitoring Checklist Page 5 ..,.' Cite I Met Not Met N/A Standard: The provider meets Projected Service Outcomes established for service delivery. 60 The provider has established a systematic method of data collection for outcome data. 61 There is evidence that the data is reviewed periodically and that corrective measures are put in place if the data indicators that the goal is not bein,g achieved. 62 Individuals in supported living are the lessee or owner of the home in which they reside. W2.0 63 All Individuals served who have responded to the annual satisfaction survey are satisfied with the W2.0 services based on the results, or the provider has addressed any concerns raised durin,g the survey. 64 Individuals in supported living live in homes occupied by no more than two other beneficiaries with W2.0 developmental disabilities and in areas in which persons with disabilities account for no more than 10% of the houses or 10% of the units in an apartment complex, unless otherwise waived by the A~ency. 65 Individual are supported to live in their own Home. W2.0 66 Individuals who use the supports increase their level of participation or independence in the community. W2.0 67 Individuals demonstrate freedom of choice in all areas of their lives as evidenced by setting personal goals, W2.0 being fully informed about service options and making all possible decisions with regard to the conduct of their lives. Standard: Personal funds are appropriately maintained and are accounted for accurately. Note: Determine if/he provider acts as afiscal agent, manages, stores an/or retainsJUnds belonging to an individual. lfno, score cites 66-7/ 'Not Applicable '. lfyes, determine if the conditions outlined in cites 66-7/ are beinf!, met. 69 Separate checking or savings accounts are maintained for individual's personal funds. W2.0 70 If a single trust account is maintained for personal funds of all individuals, there is separate accounting for W2.0 each individual. 71 Account(s) is reconciled monthly to the account total as noted on the bank. statement W2.0 ~" Supported Living Coaching Services Monitoring Checklist Page 6 Cite Met Not Met N/A 72 Account statements and reconciliation records are retained for review, 73 Individual and provider funds are not commingled. W2.0 74 The provider has written consent to manage funds or act as fiscal agent. W2.0 If the provider is not rendering lervices to individuals that bave problems "ith behavior such as thole that fono", score tbe elements in this section Not Applicable. Types of Problems with Behavior: Actions of the individual which, without behavioral, physical, or chemical intervention 1. Have resulted in self-inflicted, detectable, external or internal damage requiring medical attention or are expected to increase in frequency, duration, or intensitr resulting in self-inflicted, external or internal damage requiring medical attention 2. Have occurred or are expected to occur with sufficient frequency, duration or magnitnde that a life-threatening situation might result, including excessive eating or drinking, vomiting, ruminating, eating non-nutritive substances, refusing to eat, holding one's breath, or swallowing excessive amounts of air. '. 3. Have resulted in external or internal damage to other people that require medical attention or are expected to increase in frequency, duration or intensitr resulting in external or internal damage to other persons that requires medical attention. 4. Have resulted or are expected to result"lil major property damage or destruction 5. Have resulted or are expected to result in arrest. and confinement by law enforcement personnel Standard: Behavioral Services result in objective and measurable improvements in behavior that are consistent with the individual's outcomes. 75 When rendering services and supports to individuals identified as having problems with behavior, the provider is assisted by a qualified professional or professionals who meet the requirements in the Medicaid Handbook for the type of service the professional is providinJ!;. 76 Behavior Service goal(s) are consistent with and relate directly to the individual's personal outcomes! goals. 77 The individual has a written, individual plan developed by a certified or licensed professional that clearly identifies what will change as a result of intervention, the intervention(s) to be used and how progress will be measured. 78 Written consent to use the plan was obtained from the individual or guardian. W2.0 79 Implementers (provider staff) ofthe plan are able to carry out the plan as written. 80 A system is in place to assure that procedures are carried out as designed. W2.0 Supported Living Coaching Services Monitoring Checklist Page 7 _. Cite Met. Not Met N/A 81 There is evidence of progress or lack thereof in reducing the problem with behavior. W2.0 82 Emergency procedures (e.g., reactive strategies, crisis management procedures) used by the provider for problems with behavior are developed and implemented under the guidance of certified or licensed behavioral services professionals. 83 Staff are able to use the procedure when and as designed 84 Records are kept on the use of the emergency procedure and occurrences of the problem behavior. Supported Living Coaching Checklist 11-27-05.doc REV 10-29-01; 11-01-01; 11-13-OI; 09.27.02; 01.03; 02.04.03; 02-10-03; 11-27-05 ." Supported Living Coaching Services Monitoring Checklist Page 8