Importance of the Plan of Care and Documentation Assisted Living ...

Importance of the Plan of Care
and Documentation
in
Assisted Living Facilities
Idaho Health Care Association
Idaho Center for Assisted Living
August 2012
Sue Harvey, R.N.
Session Objectives
‣ Distinguish between different Medicaid
reimbursement programs for Residential
Assisted Living Facilities (RALFs)
‣ Overview of Uniform Assessment Instrument
(UAI) and rules/guidelines regarding
documentation
‣ Significant Change Form
‣ Notification Form
‣ Quality Assurance/Quality Improvement
(QA/QI) process
Medicaid
‣ Two programs available for residents in
Assisted Living Facilities
‣ Aged and Disabled (A&D) Waiver
‣ Resident meets Nursing Facility Level of Care
(NF LOC)
‣ State Plan Personal Care Service (SP/PCS)
Resident has some needs, but does not
meet NF LOC – hands on care is “medically
necessary”
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Medicaid
‣ State and Federally funded
‣ Rules and Regulations set
requirements for programs
‣ Both Residential Care Rules and
PCS/A&D Rules apply
Determining Medical Eligibility
‣ Medicaid Nurse administers the UAI
‣ Score determines if resident meets NF
LOC or SP/PCS level
‣ If qualified both financially and
medically, the resident is approved for
Medicaid payment
The UAI
Section One ……Demographics
Section Two ……Activities of Daily Living
Section Three……Medical Information
Section Four……Cognitive & Behaviors
Support Plan……Calculations of Rates and
Cost Effectiveness
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Section One
Demographics
• Name - MID Number - DOB
• Emergency contact - formal/informal
supports - legal rep
• Source of info - NSA and date - location
of assessment
• Who was present and gave information
• Overview of history and problems
• Abuse, neglect and exploitation
Section Two - 2 week look back
Activities of Daily Living
1. Preparing meals 10. Finances
2. Eating meals 11. Shopping
3. Toileting 12. Laundry
4. Mobility 13. Housework
5. Transferring 14. Wood/Coal
6. Personal Hygiene 15. Night needs
7. Dressing 16. Emergency Response
8. Bathing 17. Medication
9. Transportation 18. Supervision
Section Three
Health Information
Primary Physician info
Diagnosis
Pertinent physical mental history
Last hospitalization and why
Medications - usage, allergies
Bowel and bladder info
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Section Three
Health information - continued
Skin problems
Treatments and therapies
Vision and hearing
Receptive and expressive problems
Height and weight
Section Four - 1 month look back
Psychological/Social/Cognitive Information
• Not diagnosis, but record specific
abilities and limitations
• Important for the nurse to get
additional clarification and collateral
contact info for participants
• How problem impacts their quality of
life and ability to care for self
Section Four - continued
• The Supervision score in Section 2 is
calculated from answers in this section
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Section Four - continued
• Orientation
• Memory
• Judgment
• Hallucinations (visual auditory tactile…no basis in
reality)
• Delusions ( beliefs not based on fact special powers,
being persecuted or being spied upon)
Section Four - continued
• Anxiety
• Depression
• Wandering
• Disruptive/Socially Inappropriate
Behavior
• Assaultive/Destructive Behavior
Section Four - continued
• Danger to self
• Alcohol/Drug Abuse (substance abuse usage
to extent it interferes with functioning)
• Self-Preservation/Victimization
/Exploitation
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Support Plan
Calculations of Rate and Cost Effectiveness
‣ Snap shot of unmet needs
‣ Point calculation and NF LOC
‣ Cumulative cognitive areas determines
Supervision score
‣ Cost effective - Cost to Medicaid to
demonstrate that being in community is
more cost effective than NF placement
Support Plan - (continued)
‣ Tool used for multiple community based
services, not just RALFs
‣ Share of Cost (SOC) calculation
‣ Authorization log
The UAI (continued)
‣ A&D Waiver if 12 points or more
‣ Generates a daily rate
‣ Resident income can be higher
‣ May have a co-pay
‣ SP/PCS if less than 12 points
‣ Generates payment levels in units
‣ More restricted income limits – Medicaid
eligible
‣ No co-pay from resident
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RALF Staff’s role
‣ Provide input to Medicaid nurse as
appropriate for completion of the UAI
‣ Develop Negotiated Service agreement in
accordance with RALF rules
‣ Review and utilize UAI information that is
received from BLTC (Bureau of Long Term Care)
following assessment to help build the NSA
‣ Document care provided
Residential Care or Assisted Living
Facilities in Idaho IDAPA 16.03.22
• 311. Requirements for the Negotiated
Service Agreement
• The NSA must be completed and signed
within 14 days of admission, regardless of
funding source
• Interim plan must be developed and used
while NSA is being completed
Requirements for the Negotiated Service
Agreement (NSA) - continued
• Clearly identify the resident, describe services
provided, frequency, and how services are to
be delivered
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311. 02. Requirements for the Negotiated
Service Agreement (NSA) - Key Elements
a. based on UAI
b. provides for coordination of services and
instruction to facility staff
c. level of support in ADLs
d. health services
e. level of assist with meds
f. frequency of needed services
g. scope of needed assistance
Requirements for the Negotiated Service
Agreement (NSA)-Key Elements - continued
h. habilitation needs – identify programs being
used
i. training needs, specify program being used
j. identification of specific behavioral symptoms,
situations that trigger the behavior symptoms
and the specific interventions for each
behavioral symptom
k. physician or authorized providers signed and
dated orders
Requirements for the Negotiated Service
Agreement (NSA)-Key Elements - continued
l. admission records
m. community support systems
n. resident’s desires
o. transfer plans
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Requirements for the Negotiated Service
Agreement (NSA)-Key Elements - continued
p. discharge plans
q. identification of individual services
being provided d by other providers
r. other identified needs
Medicaid Enhanced Plan
Benefits IDAPA 16.03.10
• 304. Personal Care Services (PCS):
Procedural Requirements
Medicaid Enhanced Plan
Benefits IDAPA 16.03.10
• 328. Aged or Disabled Waiver Services:
Procedural Requirements
• 328.04. Individual Service Plan
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Medicaid Enhanced Plan
Benefits IDAPA 16.03.10
• 328.05. Service Delivered Following a
Written Plan of Care
• 328. 06. Provider Records
• 328.07. Provider Responsibility for
Notification
Additional Roles of RALF Staff
‣ Notify Medicaid Nurse of significant
change of condition using standard form
‣ Update NSA according to change of
condition
Significant Change Form
• Identifies significant change in
participant's functioning that results in
an increase or decrease in UAI unmet
needs
• A change in participant that affects more
than one (1) area of functioning in
health status and requires review of
Care Plan/NSA
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Significant Change Form
Completion
• Review Section II of the current UAI,
review guideline definitions and
determine if there has been a change in
functioning.
• Describe the change in the correct
section. Fill out only the area in which a
change in function has occurred.
Significant Change Form
• The Supervision score is calculated from
information in Section 4 of the UAI
Significant Change Form
• Submit Significant Change Form ASAP
• The effective date of the significant
change is the date the completed
form is received by Medicaid.
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Notification of Change Form
A formal document sent to the Bureau of Long
Term Care (BLTC) to alert them of changes
• Admission from RALF to NF
• Readmission to RALF from NF
• Moves
• Discharged/readmitted from hospital
• Deceased
• Other - can be used for initial admission info
QA/QI
The Quality Improvement Strategy
under which the State operates is a
formal, comprehensive system that
ensures that the waiver meets the
assurances and requirements
contained in the waiver application.
QA/QI
• Through an ongoing process of discovery,
remediation and system improvement the State
assures the health and welfare of participants
p
by monitoring:
• level of care determinations
• individual service plans and service delivery
• provider qualifications
• participant health and welfare
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QA/QI
• NR Home Visit Form completed annually
on each participant
• Completed with redetermination
• Returned to the RALF with other participant
information to be reviewed by RALF
• Any problems must be addressed in an
appropriate and timely manner
QA/QI
• In addition to the RALF correcting issues
identified immediately
• NR Home visit forms are entered into a
database that allows reports to be run
quarterly to identify trends that will require a
Corrective Action Plan (CAP)
• Letters to the provider will be sent out from
HUB QI Specialists
References Available
‣ Medicaid website has Regulations as
well as forms and checklists
‣ www.healthandwelfare.idaho.gov
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Resources Available
‣ Idaho Care Line 211
‣ Pharmacy (pre-auth) (208)364-1829
‣ Dental (Idaho Smiles) 1-800-936-0978
‣ Transportation (AMR) 1-877-503-1261
‣ Durable Medical (DME) 1-866-205-7403
Conclusion
‣ Questions?
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