OAAS LOC/POC QUALITY REVIEW TOOL INSTRUCTIONS

Transcription

1 COMPONENT 1: LOC QUALITY REVIEW Purpse: Fr use as a review with the OAAS Quality Review Tl t ensure crrect prcess was fllwed fr Level f Care (LOC) determinatin, Minimum Data Set-Hme Care (MDS-HC) administratin, and Plan f Care (POC) cmpletin. Used when and by whm: Supprt Crdinatin Supervisrs must perfrm entire POC packet audit prir t apprving and submitting each POC. OAAS Reginal Office Mnitrs must perfrm the audit during the entire Supprt Crdinatin Mnitring POC recrd review and additinally, when warranted. Hw: Gather the POC, MDS-HC, and MDS-HC Ntebk. Review the dcuments t determine whether the assessr fllwed the audit evaluatin prcess crrectly as described belw in sectins I. thrugh V. Use the Quality Review Tl t dcument all instances in which the assessr did nt fllw crrect prcess. (The tl aligns with the instructins belw). Remediate all incrrect findings. Transitining ut f a Nursing Facility t HCBS: Individuals leaving a nursing facility are deemed, by their presence in the nursing facility, t meet the nursing facility level f care and imminent risk eligibility criteria. LOCET screening is nt required fr transitin ut f a nursing facility t an HCBS prgram. MDS-HC assessment is perfrmed nt fr LOC determinatin, but t assure the individual can safely transitin and plan fr develpment f an individualized plan f care. Refer t Level f Care Eligibility Manual, Sectin 9.2 Transitining Out f a Nursing Facility t HCBS. Transitining frm HCBS Prgram T HCBS Prgram: Refer t Level f Care Eligibility Manual, Sectin 9.1 Transitining Frm One HCBS Prgram t Anther HCBS Prgram. 1

2 I. Level f Care Determinatin A. Indicate which Pathway(s) f Eligibility were met: Activities f Daily Living (ADL) PW and/r Cgnitive Perfrmance PW and/r Behavir PW 1. If Yes, prceed t II.1.Level f Care pathway f eligibility had been met. If nne f the abve pathways were met prceed t Step B: Degree f Difficulty Questins (DDQ) Prtcl. B. Applicatin f Degree f Difficulty Questins (DDQ) 1. The DDQ prcess allws fr individuals wh may nt have had the benefit f anther persn s assistance during the specified lk-back perid, t be evaluated based n his/her level f difficulty in cmpletin f the ADLs. The DDQ prcess takes int cnsideratin the degree f difficulty that an individual may be experiencing in cmpletin f the ADLs PW. DO NOT USE the DDQs fr determining ADL pathway eligibility unless: There is a scre f 0 (Independent) n any f the fur (4) late-lss ADLs (Bed Mbility, Transferring, Tilet Use r Eating) and yu have determined that the persn is experiencing sme degree f difficulty in cmpletin f that ADL(s). An individual must scre at least a 3, Limited Assistance, r greater n the late-lss ADLs f Bed Mbility, Transferring, and Tilet Use, r at least a 4, Extensive Assistance, r greater n the late-lss ADL f Eating in rder t trigger the ADL pathway n the MDS-HC. If this des nt ccur, the individual will nt trigger ADL PW. Initial MDS-HC Assessment Applicatin f DDQ: If the initial MDS-HC did nt trigger ADL PW, Cgnitive Perfrmance PW, and/r Behavir PW then the DDQ prcess must be applied. The individual must have a scre f 0 (Independent) n any f the fur (4) late-lss ADLs (Bed Mbility, Transferring, Tilet Use r Eating) and yu have determined that there are circumstances that caused the persn t have difficulty in self-perfrmance f thse late-lss ADLs. At the cnclusin f the MDS-HC assessment, yu will return t Sectin H.2. f the MDS-HC nly if yu have determined thrugh bservatin and/r participant/ caregiver statements as applicable, there are circumstances that cause the persn t have difficulty in the self-perfrmance f thse late-lss ADLs, where he scred 0 (Independent). Examples: He/she becmes shrt f breath upn excretin, fatigues easily, has fallen during his/her attempts t perfrm the ADL, experiences pain that interferes with the safe perfrmance, r cmpletin f the ADL. 2

3 Annual Reassessments, Status Change, Fllw up Applicatin f DDQ: The DDQ criteria fr meeting LOC n the ADL pathway must nt t be rutinely applied n MDS-HC reassessments unless the individual meets the fllwing criteria: The individual des nt scre at least a 3 (Limited Assistance, r greater) n any late-lss ADLs f Bed Mbility, Transferring, r Tilet Use, OR scred less than a 4 (Extensive Assistance) n the late-lss ADL f Eating. The individual did nt receive frmal (paid) Hme and Cmmunity-Based Supprts (HCBS) during the 3 day ADL lk-back perid due t extenuating circumstances ut f his/her cntrl (e.g., Direct Service Wrker did nt shw up as care planned); AND Yu determine that the individual is experiencing difficulty in self- perfrmance f ne r mre f the fur late-lss ADLs cded as 0, Independent, in Sectin H.2. f the MDS-HC Reassessment. If the individual des nt meet the ADL LOC pathway via applicatin f the DDQs, r the assessr determines that the individual des nt meet the criteria fr applicatin f the DDQ he/she must prceed t determine if the individual is eligible fr Service Dependency PW. Dcumentatin f the Degree f Difficulty Questins (DDQ) 2. If the individual meets the DDQ criteria the supprt crdinatr/assessr must dcument in the MDS- HC electrnic Ntebk that the individual has met the ADL LOC pathway per applicatin f the DDQs (Refer t the DDQ Questins). 3. The extenuating circumstances that lead t use f DDQs and the dcumentatin supprting the degree f difficulty respnse must be clearly dcumented in the MDS-HC electrnic Ntebk in rder fr the persn t meet the ADL pathway criteria via applicatin f the DDQS. Yu must dcument in the MDS-HC electrnic Ntebk bservatins/cmments n which yu based yur decisin t use the DDQs. Yu must als dcument the persn s respnse t the DDQs. DO NOT CHANGE the riginal ADL scre f 0, Independent, fr the late-lss ADLs where DDQs are applied (Leave as it was riginally scred). The dcumentatin in the MDS-HC electrnic Ntebk will prvide the verificatin that LOC was met n the ADL pathway by applicatin f the DDQ prcess. Individuals wh meet the LOC eligibility criteria via applicatin f the DDQ prcess will be determined t meet LT-PCS Prgrammatic criteria. LT-PCS prgram criteria met via applicatin f DDQs must als be dcumented in the MDS-HC electrnic Ntebk. Refer t Level f Care Eligibility Manual, Sectins

4 Degree f Difficulty Questins If 0 is scred in either bed mbility, eating, transferring, and/r tilet use, and the DDQ criteria as described abve are met, ask the fllwing DDQs as applicable: D yu have truble with: a) psitining yurself in bed (including mving t and frm lying psitin, turning frm side t side, and psitining bdy while in bed); b) eating (including taking in fd by any methd, including tube feeding - hw persn actually cnsumes fd - excludes meal preparatin); c) transferring frm ne surface t anther (including mving t and between surfaces t/frm bed, chair wheelchair, standing psitin excludes t/frm bath/tilet); d) using the tilet (including using the tilet r cmmde, bedpan, urinal, transferring n/ff the tilet, cleaning self after tilet use r incntinent episde, changing pad, managing special devices required (stmy r catheter), and adjusting clthes. Ask these questins individually fr each f the late-lss ADLs where the persn has scred a 0, Independent, and where yu determined the persn is experiencing sme degree f difficulty in cmpleting that ADL. If the respnse is Yes ask Hw hard is it fr yu t d? A little difficulty A lt f difficulty A respnse f A little difficulty will indicate the persn is getting the ADL dne, but may have sme pain, weakness r must cmpensate by using an assistive device t steady self. A respnse f A lt f difficulty will indicate the persn meets the LOC ADL pathway via applicatin f the DDQs. The persn is getting ADLs dne but with marked pain r fails t cmplete all subtasks f the ADL mst f the time, r cmpletes the ADL in an extended perid f time because f medical limitatins (shrtness f breath, falls due t unsteady gait). 4. If the individual des nt meet the ADL LOC pathway via applicatin f the DDQs, r the assessr determines that the individual des nt meet the criteria fr applicatin f the DDQ he/she must dcument in the MDS-HC electrnic Ntebk bservatins/cmments n which yu based yur decisin. If the individual being assessed is underging an MDS-HC Initial Assessment and des nt meet LOC eligibility criteria, the assessr must use Table 1 t rule ut r rule in the pssibility f the individual meeting LOC criteria fr the fllwing pathways: Physician Invlvement Treatments and cnditins Skilled Rehabilitatin Therapies 4

5 If the individual being assessed is underging an MDS-HC Reassessment (Annual, Fllw Up r Status Change) and failed t meet DDQ criteria, the reviewer must determine if the individual is eligible fr the Service Dependency PW. C. Explre criteria fr Service Dependency Pathway: Refer t Level f Care Eligibility Manual, Sectin 5.4 Service Dependency Pathway and Sectin 7.4 Review f the Service Dependency Pathway. Used nly fr Annual/Reassessments, nt initial assessments. T identify individuals wh are currently enrlled and receiving services prir t 12/01/2006 with n break in service t the present day. Service Dependency Pathway is used t qualify individuals wh meet criteria if n ther pathway f eligibility is met. 1. SC will have t cntact OAAS RO t verify apprval fr services prir t 12/01/2006, with n break in services. If the participant cntinues t meet LOC based n Service Dependency Pathway, dcument in the MDS-HC electrnic Ntebk, LOC is met under Service Dependency Pathway. 2. Dcument in the MDS-HC electrnic Ntebk whether r nt Pathway was met and list supprting dcumentatin. If Service Dependency Pathway is met prceed t II.1. D. Explre criteria fr Physician Invlvement Pathway: Refer t Level f Care Eligibility Manual, Sectin 5.5 Physician Invlvement Pathway. 1. Evaluate/investigate whether there is acceptable, medical supprting dcumentatin such as the apprpriate frm designated by OAAS t dcument the individual s medical status and cnditin, the hspital discharge summary, OT/PT ntes, r Hme Health Frm which verifies that the individual meets ne f the belw: a) One day f MD visits AND at least fur new rder changes, bth ccurring in the last 14 days; b) At least tw days f MD visits AND at least tw new rder changes, bth ccurring in the last 14 days. 2. Dcument in the Ntebk whether r nt Pathway was met and list supprting dcumentatin. E. Explre criteria fr Treatments and Cnditins Pathway: Refer t Level f Care Eligibility Manual, Sectin 5.6 Treatments and Cnditins Pathway. The intent f this Pathway is t identify individuals with unstable medical cnditins that may be affecting his/her ability t care fr himself/herself. The Treatments and cnditins PW is nt 5

6 met if the cnditins have been reslved, r they n lnger affect functining r the need fr care. 1. Evaluate/investigate whether there is acceptable, medical supprting dcumentatin such as the apprpriate frm designated by OAAS t dcument the individual s medical status and cnditin, the hspital discharge summary, OT/PT ntes, r Hme Health Frm which verifies that the individual meets ne f the belw: i. Stage 3-4 pressure sres in the last 14 days ii. Intravenus feedings in the last 7 days iii. Intravenus medicatins (IV) in the last 14 days iv. Daily trachestmy care, daily respiratr/ventilatr usage, r daily suctining in the last 14 days v. Pneumnia within the last 14 days and has assciated IADL /ADL needs r restrative nursing care needs vi. Daily respiratry therapy in the last 14 days (includes use f inhalers, heated nebulizers, pstural drainage, deep breathing, aersl treatments, and mechanical ventilatin which must be prvided by a qualified prfessinal. Des nt include hand held medicatin dispensers). vii. Daily insulin injectins with tw r mre rder changes in the last 14 days: supprting dcumentatin shall be required fr the daily insulin usage and the required rder changes viii. Peritneal r hemdialysis in last 14 days. 2. Dcument in the MDS-HC electrnic Ntebk whether r nt Treatments and Cnditins PW was met and list supprting dcumentatin. F. Explre criteria fr Skilled Rehabilitatin Therapies Pathway Refer t Level f Care Eligibility Manual, Sectin 5.7 Skilled Rehabilitatin Therapies Pathway. 1. Evaluate/investigate whether there is acceptable, medical supprting dcumentatin such as the apprpriate frm designated by OAAS t dcument the individual s medical status and cnditin, the hspital discharge summary, OT/PT ntes, r Hme Health Frm which verifies that the individual meets ne f the belw: a)at least 45 minutes f active Physical Therapy, Occupatinal Therapy and/r Speech therapy given in the last 7 days; b) At least 45 minutes f active Physical Therapy, Occupatinal Therapy and/r Speech therapy scheduled fr the next 7 days. 2. Dcument in the MDS-HC electrnic Ntebk whether r nt Pathway was met and list supprting dcumentatin. 6

7 II. Cmplete: MDS-HC is cmpleted 1. Fill in every field with item, letter, and/r number in all required fields. Example: the middle initial is nt a required field. Example: the middle initial is nt a required field. Finding Examples: MDS-HC Sectin CC. Referral Items (Cmplete at intake nly), field 7. Prir NH Placement field was left blank. MDS-HC Sectin R. Assessr Infrmatin fields 1.a. Signature f Assessment crdinatr; 1.b. Title f Assessment Crdinatr, and 1.c. Date Assessment Crdinatr signed as cmplete left blank. III. Crrect: MDS-HC is perfrmed accrding t guidelines 1. Use accurate infrmatin and bservatins: Fr lk back perids (i.e. lk at last 3 days fr ADLs, except bathing which is in the last 7 days, r unless therwise specified such as 30 days, 90 days, etc.) During visit / telephne calls Hme Health, therapy, r service prvider paper wrk in hme a. ADL measures what persn actually did r was nt able t d within each ADL categry; measures perfrmance. Des nt measure what was dne fr the individual. b. IADL measures the ability t d task; what culd they d regardless f current invlvement with infrmal supprt. Lk at the entire prcess; including all tasks / subtasks. 2. Check dcumentatin in the MDS-HC Ntebk and the POC t verify crrectness. Finding Examples: MDS-HC Sectin P.3. Identified the use f xygen that was partially managed by thers. There were n infrmal supprts identified in the MDS-HC and the MDS-HC electrnic Ntebk. The POC identified infrmal supprts. MDS-HC Ntebk dcumented participant walked 2 hurs t his appintment and made 3 trips t the stre, but MDS-HC cding identified participant received assistance with lcmtin. IV. Cding: MDS-HC is crrectly cded 1. Accurately cded the MDS-HC scales and assessment data accrding t guidelines. 7

8 Finding Examples: Sectin P. Service Utilizatin (in last 7 days): Tw (2) Treatments, Therapies, Prgrams nly included care prvided in the hme r n an utpatient basis, nt hspital r nursing hme. This infrmatin is cllected elsewhere. Sectin P. 2. c All Other Respiratry Treatments: were administered by a qualified prfessinal in the hme, nt self/family. There shuld be dcumentatin in the MDS-HC electrnic Ntebk identifying the prescribed treatment. This des nt include use f inhalers. 2. Must be cded crrectly befre crrelated r will nt make sense. Finding Examples: Cded Crrectly Ttal dependence (Cde 6) fr ADL/IADL is used when participant is practically cmatse. There shuld be very few scres f Ttal Dependence. The full perfrmance f an activity shuld be cded. There may be ne episde f an activity that they can/cannt perfrm, but nt all tasks / subtasks. Crrelated: ADL dressing lwer bdy, tilet use, persnal hygiene and bathing was cded as 6. Cgnitive assessment indicated the participant understd hw t perfrm these tasks and used a walker r crutches fr lcmtin in huse which appeared participant used at least sme f his/her hands and arms. V. Crrelatin: MDS-HC crrelates t MDS-HC Ntebk entries, POC, and ther sectins f the MDS-HC 1. a. D all sectins f the MDS-HC match? b. Des review f the entire MDS-HC paint a mental picture f the individual? c. Des the MDS-HC match the MDS-HC Ntebk? d. Des the MDS-HC match the POC? e. Des the mental picture make sense? If crrelatin des nt make sense, questin the accuracy in cding. 8

9 Examples f Crrect Crrelatin: N cgnitive impairments, received xygen 24 hurs, able t manage xygen n wn, health cnditins included shrtness f breath, and diagnses included emphysema/copd/asthma. Limited assistance with transfer and tileting, infrmal supprt available, cntinent f bladder and bwel, ne fall (MDS-HC Ntebk dcumented tripped n rug which was remved), ambulated with walker in and ut f huse, diagnses included strke with paralysis and participant received hme health skilled nurse and physical therapy visits. Examples f pr crrelatin that requires further investigatin: Used walker t ambulate, but required extensive assistance with eating. Restraints identified, but n infrmal supprt and lives alne. Severely impaired cgnitive status, but n infrmal supprt. Supervisin with upper dressing and required maximum assistance with feeding. MDS-HC Sectin G. Infrmal Supprt Services identified that care giver resided with participant. MDS- HC Ntebk dcumented caregiver lived ver an hur away. POC identified participant lived alne. The MDS-HC assessment, MDS-HC Ntebk, and the POC supprts shuld ALL match. MDS-HC Sectin G. Infrmal Supprt identified 2 care givers that did nt prvide ADL/IADL. MDS-HC Ntebk dcumented that the daughters were n lnger available t prvide ADL/IADL. POC identified 6 days a week f services and that the daughters were available t assist n sme ccasins. COMPONENT 2: POC Quality Review Tl Purpse: The OAAS POC Quality Review Tl is utilized t ensure that the POC is cmplete and it dcuments apprpriate strategies t address identified needs and risks. The reviewer cmpares the Minimum Data Set-Hme Care (MDS-HC) and ther assessment infrmatin alng with the cmpleted POC. This tl prvides the RO staff and SC supervisrs with a structured, cmprehensive methd t effectively assess the plan f care fr cmpleteness and quality. CAPs (Fur Categries: Clinical; Cgnitive/Mental Health; Physical/Functinal; and Scial Life), SC Mnitring Review Elements,and OAAS Perfrmance Measures frm the fundatin fr the Quality f Cntent Review Used when and by whm: Supprt Crdinatin Supervisrs must review and apprve the POC prir t submissin. 9

10 OAAS Reginal Office staff perfrm the POC Quality Review during Annual Supprt Crdinatin Mnitring and when warranted. 1. All required demgraphic sectins f the POC have been cmpleted: Review Sectins A. -D. f the POC t verify that all sectins have been cmpleted crrectly. 2. The Participant Prfile clearly summarizes the participant s status in each f the fur categries: Review Sectin E. f the POC t determine whether the participant s status has been clearly summarized in tw t three sentences per categry and crrelates with the infrmatin fund in the assessment. 3. All cmpnents f the Clinical Issues Categry are cmprehensive and crrect: Review the Clinical Issues Categry t determine the fllwing: Triggered CAPs are identified. Related CAPs are identified. Shrt term gals are identified. Lng term gals are identified. All needed assistance/interventins are identified. Dcumented assistance/interventins take int cnsideratin the participant s likes and preferences. Family/Infrmal supprts are identified in amunt, frequency, and duratin they are available and include any recmmendatins. Frmal services are identified are identified in the amunt, frequency, duratin and type, and include any recmmendatins. The cmbinatin f frmal and infrmal supprts described in the POC address all identified needs. Persnal gals and preferences are addressed. Cmmunity resurces and services that meet the participant s needs as identified. 4. All cmpnents f the Cgnitive/Mental Health Issues Categry are cmprehensive and crrect: See number three. 10

11 5. All cmpnents f the Physical/Functinal Issues Categry are cmprehensive and crrect: See number three. 6. All cmpnents f the Scial Life Issues Categry are cmprehensive and crrect: See number three. 7. Flexible Schedule is cmpleted crrectly: Review Sectin G. f the POC t determine whether the flexible schedule is crrect. 8. Budget Wrksheet is cmpleted crrectly: Review Sectin H. f the POC t determine whether the budget is cmpleted crrectly. 9. All required persns have signed verifying participatin in the planning prcess: Review Sectin I. t determine whether the required persns have signed. Review Cgnitive Perfrmance Scale t determine whether a Respnsible Representative signature is required. 10. Applicant/Participant Acknwledgement is signed by the apprpriate persn: Review Cgnitive Perfrmance Scale t determine whether a Respnsible Representative signature is required in Sectin J. 11. Plan f Care Actin sectin is cmpleted crrectly: Review Sectin K. t determine whether it is cmpleted crrectly. 12. Ntice f Apprval and Fair Hearing Rights is cmpleted crrectly. Review Sectin L. t determine whether is cmpletely crrectly. 11

12 13. The POC includes evidence that the participant s needs fr Medicatin Administratin and Health-Related Tasks have been identified with strategies develped t meet thse needs. Refer t the OAAS Medicatin Administratin and Health-Related Tasks Planning Reference Guide t determine whether the POC includes the required infrmatin. 14. The POC includes evidence that the participant s risk factrs have been identified and strategies develped t mitigate thse risks. Refer t the Cmmunity Chices Waiver Risk Assessment & Referral Screening Tl t determine whether the POC includes the required infrmatin. 15. The POC includes evidence that the participant s CIRs fr the past year have been assessed and strategies develped t prevent recurrence. t Refer t the OAAS CIR Analysis and Risk Assessment Planning Reference Guide determine whether the POC includes the required infrmatin. 16. The Emergency Preparedness Planning & Agreement Frm identifies respnsible parties and their rles with apprpriate signatures indicating agreement. Review the Emergency Preparedness Planning & Agreement Frm t determine whether: The participant s emergency preparedness and respnse plan identify respnsible parties and their rles, functins, and respnsibilities fr immediate implementatin in the event f a natural disaster r ther emergency. There is evidence that persns respnsible fr implementing the emergency preparedness and respnse plan have been fully infrmed and agree t carry ut their identified rles, functins, and respnsibilities as evidenced by their signature. 12

13 17. The Individualized Back-up Staffing Plan & Agreement Frm identifies respnsible parties and their rles with apprpriate signatures indicating agreement. Review the Individualized Back-Up Staffing Plan & Agreement Frm t determine whether: The participant s written back-up plan identifies respnsible parties and their rles, functins, and respnsibilities fr immediate implementatin in the event that a service wrker cannt wrk when Scheduled There is evidence that persns respnsible fr implementing the backup plan have been infrmed and agree t carry ut their identified rles, functins, and respnsibilities 18. Date apprved POC mailed t participant and applicable prviders: Enter the date that the POC was mailed t participant and applicable prviders. 13