Description of tools: This is a series of checklists used by Goodhue County staff when reassessing people for the waiver programs.

Transcription

1 HCBS Waiver Review Initiative Description of tools: This is a series of checklists used by Goodhue County staff when reassessing people for the waiver programs. This tool was obtained from Goodhue County Health & Human Services through the Minnesota Department of Human Services HCBS Lead Agency Review. To inquire if the tools are available in an accessible format, or if you have questions about the use of the tool, please contact the Minnesota Department of Human Services at (651) Assistance Provided by:

2 DD ANNUAL DOCUMENTS WHEN ON WAIVER Client Name Service Agreement Dates Care plan to Case aide Have releases of information signed & SCHA Release of Info- HIPAA tab in PHDoc S:\Work Tools\Forms\DD Unit\forms\CONSENT FOR THE RELEASE OF PROTECTED HEALTH INFORMATION 2.docx _ HIPPA S:\Work Tools\Forms\DD Unit\forms\HIPPA Notice 9-13.docx _ Emergency and back up plans S:\Work Tools\Forms\DD Unit\forms\Emergency Back up Plan fillable 9-13.pdf Related Conditions checklist if necessary Complete screening Complete Waiver application yearly (Title 19) Complete ICF/MR Eligibility Form Complete ISP-Save in Hazel or PHDoc Adult S:\Work Tools\Forms\DD Unit\forms\ISP 2002.doc Child S:\Work Tools\Forms\DD Unit\forms\ISP kids.doc Provider worksheets Update social history Have ISP signature page signed and request they complete the survey S:\Work Tools\Forms\DD Unit\forms\ISP Signature page.pdf S:\Work Tools\Forms\DD Unit\forms\Survey.pdf Mail/ ISP to all team members Complete Service Agreement 1/22/2016

3 RULE 79 Diagnostic Assess. q 3 years Functional assess. q 6 months Abby signs off on S:\Work Tools\Forms\Social Services\Mental Health\Adult Mental Health\Functional Assessment.pdf ISP- q 6 months S:\Work Tools\Forms\DD Unit\forms\ISP 2002.doc S:\Work Tools\Forms\DD Unit\forms\ISP Signature page.pdf SCHA SCC/MSC+/Ability Care Comp. Health Assessment 3/26/14 (in CCM) ICT Communication Form (in CCM) Recommendation for State Plan Home Care Services (RN, HHA, PCA) Fax SCHA Care Plan (in CCM) Send to client/guardian Denise S. signature page of care plan (if no other case aide) Documents needed in File Psychological Eval Adaptive/Functional Assessment Guardianship Papers IEP (if applicable) 1/22/2016

4 MNChoices Reassessment Checklist CADI / BI Screening Care plan to case aide date:_ Service Agreement Dates: Client Name Date to Case Aide Complete Release of Information form under HIPAA consent tab ROI, put in date signed HIPAA form signed 1x per year *Complete GRH Client Housing Information- as appropriate *Complete Application for Title XIX form 1x per year, (DHS 2727) copy of rights to client Complete MNChoices on computer Caregiver assessment as needed Complete PCA Checklist if client receiving PCA services Print PCA summary found under print tab on the top (if getting PCA services) Print LTC doc from MNChoices If does NOT meet LOC send DTR or Notice of Action Complete Community Support Plan Worksheet (DHS 6791A) white copy to client, yellow copy to chart Complete/update Community Support Plan (CSP/CSSP DHS 6791B)- client sign yearly Save Community Support Plan to PhDoc Complete care plan worksheet (optional) MD NPI # if receiving home care services Copy of support plan/ recommendation letter to client unless specify otherwise: Discuss Advanced Directive as appropriate Complete Provider worksheets as needed, dependent on services client receives (found on HAZEL) Document visit in PHDoc as a careplan visit Make sure Frame matches primary ICD-10 Lock MNChoices under disposition

5 Client Name: Date SA to start:_ II: CASE AIDE initial when completed Import/Export LTCC to screen document, print Enter Screening document to MMIS Enter info to Rates Mgmt System in SSIS Enter Service Agreement to MMIS Mail Community Support Plan- copy to client or other, attach copy of signature page. Type/mail recommendation letter (if CSP was not done) & copy of Title XIX form (DHS 2727) Print envelope *=fillable forms

6 MNChoices Reassessment Checklist CADI /BI /ABILITY CARE / SCHA Care plan to case aide date: Service Agreement Dates: Client Name Date to Case aide Complete Release of Information form under HIPAA consent tab ROI, put in date signed HIPAA form signed 1x per year *Complete GRH Client Housing Information- as appropriate *Complete Application for Title XIX form (DHS 2727) 1x per year, copy of rights to member Complete MNChoices on computer Caregiver assessment as needed- Mail to _ Save assessment report & eligibility summary in CCM, scan & save in CCM, SCHA signature page for MNChoices Send to SCHA that MNChoices is completed (countyinfo@mnscha.org) see forms in CCM Complete PCA checklist if client is receiving PCA services Print PCA summary- found under print tab on the top (if getting PCA services) Print LTC doc from MNChoices Complete Community Support Plan Worksheet (DHS 6791A) white copy to client, yellow copy to chart If does NOT meet LOC send DTR or Notice of Action Complete/update Community Support Plan- under assessments in CCM- if on Ability Care, member sign yearly Complete care plan worksheet (optional) Close old Community Support Plan Copy of support plan to member unless specify otherwise: Discuss Advanced Directive as appropriate Complete Recommendation for Authorization of MA Home Care Services, as appropriate Complete Interdisciplinary Care Team (ICT) Comm. Form in CCM Complete Provider worksheets as needed, dependent on services client receives (found on HAZEL) Document visit in CCM under contacts Make sure Frame matches primary ICD-10 Lock MNChoices under Disposition

7 Client Name: Date SA to start:_ II: CASE AIDE initial when completed Fax Recommendation for Auth. of MA Home Care Services, as needed Import/Export LTCC to screen document, print if not MNChoices Update case mix under program as needed Print CSP from CCM Enter Screening document to MMIS Enter info to Rates Mgmt System in SSIS Enter Service Agreement to MMIS Mail Community Support Plan- copy to member or other, attach copy of signature page. Mail Member Rights (Ability Care) & copy of Title XIX form (DHS 2727) Fax Dr. letter (ICT) via Right Fax Print envelope Contact note in CCM *=fillable forms

8 MNChoices Reassessment Checklist EW/AC Care plan to case aide date: Service Agreement Dates: Client Name *If not on MA, complete 135 day eligibility worksheet, (single or married) have client sign (if needed) (DHS 2630) Date to Case Aide If client new on MA, and has been on AC or has been on MA and now off, see Case aide for help. If new to MA, will need to exit AC, and open on different waiver. *Complete AC Client Disclosure Form, client sign (if needed) (DHS 3548) *Complete ECS eligibility worksheets if going on ECS Complete Release of Information form under HIPAA consent tab ROI, put in date signed *Complete GRH Client Housing Information form- as appropriate *HIPAA form signed 1x per year (DHS 2727) *Complete Application for Title XIX form 1x per year, copy of rights to client Complete MNChoices on computer Caregiver assessment as needed Complete PCA checklist if client receiving PCA services Print PCA summary-found under print tab on the top (if getting PCA services) Print LTC doc from MNChoices If client does NOT Meet LOC send DTR or Notice of Action Complete Community Support Plan Worksheet (DHS 6791A) white copy to client, yellow copy to chart Complete/update Community Support Plan(CSP/CSSP DHS 6791B)- client sign yearly Save Community Support Plan in PhDoc Complete care plan worksheet (optional) MD NPI # if receiving home care services Copy of support plan to member and recommendation letter- your comments from community support plan (Sec. III) will be typed on form letter, unless specify otherwise: Complete Advanced Directive as appropriate Complete Res. Care tool- as appropriate Save Res. Care Tool to PhDoc, as appropriate Res. Care Tool to facility- ZIXSECURE as appropriate Document visit in PHDoc as a careplan visit Make sure Frame matches primary ICD-10 code Lock MNChoices under Disposition

9 Client Name: Date SA to start:_ II: CASE AIDE initial when completed Import/Export LTCC to screen document, print Enter Screening document to MMIS Enter Service Agreement to MMIS Mail Community Support Plan- copy to member or other Print envelope Send Res. Care workbook to State, as appropriate Res. Care Verification code, fax to facility, enter to workbook, file in client chart *= fillable forms

10 MNChoices Reassessment Checklist EW/SCHA (use if client on MNChoices initial and went onto SCHA) Care plan to case aide date: Service Agreement Dates:_ Client Name Date to case aide Complete Release of Information form under HIPAA consent tab ROI, put in date signed HIPAA form signed 1x per year (DHS 2727) Complete ECS eligibility worksheets if going on ECS *Complete Application for Title XIX form 1x per year, copy of rights to member *Complete GRH Client Housing Information form- as appropriate Complete MNChoices on computer Caregiver assessment complete as needed Complete PCA checklist if client receiving PCA services Print PCA summary-found under print tab on the top (if getting PCA services) Print LTC doc from MNChoices Save assessment report and eligibility summary in CCM Complete SCHA MNChoices signature page, scan and save in CCM Send to SCHA MNChoices completed see forms in CCM If does NOT meet LOC send DTR or Notice of Action Complete Community Support Plan Worksheet (DHS 6791A) white copy to client, yellow to chart Complete/update Community Support Plan- under assessments in CCM, member sign yearly If provider not listed in dropdown when creating SA- handwrite in correct provider Close old Community Support Plan Copy of support plan to member unless specify otherwise: Name & address Complete care plan worksheet (optional) Discuss Advanced Directive as appropriate Complete SCHA Elderly Waiver Notification Fax Form(not needed if in CL) case aide will mail/fax Complete Interdisciplinary Care Team (ICT) Communication Form in CCM Complete Res. Care tool- as appropriate Save Res. Care tool to PhDoc, as appropriate Res. Care Tool to facility- ZIXSECURE as appropriate Document visit in CCM under contacts Make sure Frame matches primary ICD-10 Lock MNChoices under Disposition

11 Client Name: Date SA to start:_ II: CASE AIDE initial when completed _ Fax SCHA Waiver Notification form Import/Export LTCC to screen document, print- if not MNChoices Update case mix under program as needed Print copy of CSP from CCM Enter Screening document to MMIS Enter Service Agreement to MMIS Mail Community Support Plan- copy to member or other, attach copy of signature page. Mail Member Rights (MSC+ or SCC) & copy of Title XIX form (DHS 2727) Print envelope Fax Dr. letter (ICT) form via Right Fax Contact note in CCM Res. Care workbook- ZIXSECURE- as appropriate Res. Care Verification code, fax to facility, enter to workbook, file in client chart *fillable forms

12 Reassessment Checklist CADI / BI Screening Care plan to case aide date: Service agreement dates:_ Client Name Date to Case Aide Complete Release of Information form under HIPAA consent tab ROI, put in date signed HIPAA form signed 1x per year *Complete GRH Client Housing Information- as appropriate *Complete Application for Title XIX form 1x per year, (DHS 2727) copy of rights to client Complete Level 1 screen form on computer Save Level 1 form in PHDoc * Complete LTCC form on computer make sure Dr. NPI # is correct (DHS 3428A) Caregiver assessment as needed- Mail to _ Save LTCC form in PHDoc If does NOT meet LOC send DTR or Notice of Action Complete/update Community Support Plan (CSP/CSSP DHS 6791B)- client sign yearly Save Community Support Plan to PhDoc Complete care plan worksheet (optional) MD NPI # if receiving home care services Copy of support plan/ recommendation letter to client unless specify otherwise: *Complete BI assessment- as appropriate (DHS 3471) Complete BI eligibility determination, yearly- as appropriate Discuss Advanced Directive as appropriate Complete Provider worksheets as needed, dependent on services client receives (found on HAZEL) Document visit in PHDoc as a careplan visit or if on SCHA in CCM under contacts Make sure Frame matches primary ICD-10

13 Client Name: Date SA to start:_ II: CASE AIDE initial when completed Import/Export LTCC to screen document, print Enter Screening document to MMIS Enter info to Rates Mgmt System in SSIS Enter Service Agreement to MMIS Mail Community Support Plan- copy to client or other, attach copy of signature page. Type/mail recommendation letter (if CSP not done) & copy of Title XIX form (DHS 2727) Print envelope *=fillable forms

14 Reassessment Checklist EW/AC Care Plan to case aide dates: Service Agreement Dates: Client Name Date to Case Aide *If not on MA, complete 135 day eligibility worksheet, (single or married) have client sign (if needed) (DHS 2630) If client new on MA, and has been on AC or has been on MA and now off, see Case aide for help. If new to MA, will need to exit AC, and open on different waiver. *Complete AC Client Disclosure Form, client sign (if needed) (DHS 3548) *Complete ECS eligibility worksheets if going on ECS Complete Release of Information form under HIPAA consent tab ROI, put in date signed *Complete GRH Client Housing Information form- as appropriate *HIPAA form signed 1x per year (DHS 2727) *Complete Application for Title XIX form 1x per year, copy of rights to client Complete Level 1 screen form on computer Save Level 1 in PHDoc *Complete LTCC form on computer make sure Dr. NPI# is correct (DHS 3428A) Caregiver assessment as needed- Mail to _ Save LTCC form in PHDoc If client does NOT Meet LOC send DTR or Notice of Action Complete/update Community Support Plan(CSP/CSSP DHS 6791B)- client sign yearly Save Community Support Plan in PhDoc Complete care plan worksheet (optional) MD NPI # if receiving home care services Copy of support plan to member and recommendation letter- your comments from community support plan (Sec. III) will be typed on form letter, unless specify otherwise: Complete Advanced Directive as appropriate Complete Residential Care tool- as appropriate Save Res. Care Tool to PhDoc, as appropriate Res. Care Tool to facility- ZIXSECURE as appropriate Document visit in PHDoc as a care plan visit or if on SCHA in CCM under contacts Make sure Frame matches primary ICD-10 code

15 Client Name: Date SA to start:_ II: CASE AIDE initial when completed Import/Export LTCC to screen document, print if not MNChoices Enter Screening document to MMIS Enter Service Agreement to MMIS Mail Community Support Plan- copy to member or other Print envelope Send Res. Care workbook to State, as appropriate Res. Care Verification code, fax to facility, enter to CL workbook, file in client chart *= fillable forms