Community Care Service Program Waiver Services July 14, 2011

1. Community Care Service Program Waiver ServicesJuly 14, 2011 Leroy Altman, RN, Program Director, Lorraine O’Neal, RN, Human Services Program Auditor, Marcia Stanford, RN, Human Services Program Auditor, Georgia Department of Community Health, Office of Inspector General, Program Integrity Section

2. DCH Mission RESPONSIBLE HEALTHY ACCESS Access to affordable, quality health care in our communities Responsible health planning and use of health care resources Healthy behaviors and improved health outcomes

3. DCH InitiativesFY 2011 FY 2011 Continuity of Operations Preparedness Customer Service Emergency Preparedness Financial & Program Integrity Health Care Consumerism Health Improvement Health Care Transformation Public Health Workforce Development

4. Community Care Service Program • The Community Care Service Program assists individuals who are older and/or functionally impaired to continue living in their own homes and communities as an alternative to nursing home placement. • Individuals served by the program are required to meet the same level of care for admission to a nursing facility and be Medicaid eligible or potentially Medicaid eligible.

5. Supervision of Services for CCSP • Registered Nurse supervision is required for the following services: • Adult Day Health (ADH) • Alternative Living Services (ALS) • Personal Support Services (PSS & PSSX) • Out of Home Respite Care (RC) • Skilled Nursing Services (SNS) • Registered Nurse supervision is not required for: • Home Delivered Meals (HDM) • Emergency Response Services (ERS)

6. Supervision of Services for CCSP • Licensed Practical Nurse (LPN) must be supervised by a Registered Nurse (RN). • LPN supervisory documentation must be reviewed and co-signed within 10 days by the supervising RN. • Registered Nurse Supervision is required for some services to: • Provide Medical Oversight • Assessing • Monitoring • Implementing/arranging interventions to prevent or delay unnecessary and costly institutional placement • To ensure that the provider serves the member effectively • To ensure that the provider serves the member safely in the community

7. Supervision of Services for CCSP • Registered Nurse Task: • Assessing & Evaluating member’s needs • Reviewing Level of Care & Placement Instrument • Conducting supervisory and re-evaluations • Developing and revising member care plans • Preparing and reviewing progress notes • Maintaining communication with other service providers • Counseling & education of member, caregiver & staff

8. Supervision of Services for CCSP • Registered Nurse Task continued: • Assignment Decision Tree • Generated by the Georgia Board of Nursing • RN may assign task to unlicensed personnel • Assist the RN in evaluating tasks

9. Supervision of Services for CCSP • Supervision Guidelines • All supervisor visits, notes and contacts must be labeled as such and legible • Errors shall be corrected according to currently accepted standards of medical practice • Names and titles must be legible • Signatures must be original (not a stamp) • Secure Electronic Signatures are acceptable • Refer to Part II for requirements applicable to different categories of service • Visits must be face-to-face

10. Supervision of Services for CCSP • Supervisory Visit Documentation must include: • Evaluation of the member’s health status • Evaluation of the quality of care being rendered • Results of the care being rendered • Planned interventions • Follow-up for problems identified • A checklist does not replace narrative documentation, but can be used in addition to support narrative.

11. Supervision of Services for CCSP Medications – Monitoring and Administration • RN must monitor medicines • Over-the-counter • Prescription • Member records must include • A current medication list - name, dose, route and frequency • All drug side effects observed • Documentation of reports of problems identified with medication/s • Physician’s order to change medication/s • Administration of Medications • Only the attending physician may prescribe therapeutic or preventive medication/s

12. Clinical Records • Clinical Records • Clinical records must be maintained in accordance with • Accepted professional standards and practices • Documentation must substantiate the services billed to Medicaid • Clinical records provides information on the quality of care • Maintain Records • As necessary to disclose fully the extent of services provided • Medical necessity for the provision of such services • For a minimum of five (5) years after the date of service initiated

13. Clinical Records • Records must reflect at a minimum • Date of Service • Member name • Medical history • Service provided • Diagnosis • Prescribed drugs or treatment ordered • Signature of the treating provider • If there is a conflict with requirements you must refer to Part II for more stringent documentation requirements applicable to different categories of service.

14. ADULT DAY HEALTH SERVICES (ADH) (Always refer to the GENERAL CCSP MANUAL for other requirements) Adult Day Health Supervision • Medical monitoring activities include, but are not limited to: • Monitoring vital signs and weights, as needed (rev 4/2011) • Oxygen use • Supervising medications • Glucose testing • Skin care • Supervising care • Progress Notes at least monthly • RN must review, date and sign the Member Service Record Form monthly • RN must review, date and sign the Activity Participation Record Form monthly

15. ADULT DAY HEALTH SERVICES (ADH) (Always refer to the GENERAL CCSP MANUAL for other requirements) Adult Day Health Supervision • RN must review, date and initial the Member Care Plan at least monthly • RN must supervise all services • RN’s supervisory visits must be labeled “RN Supervisory visit” • RN must review and sign all LPN progress notes • Supervisory visit at least once a month • LPN may conduct and document a face-to-face supervisory visit every other month • RN must conduct a supervisory visit at least every 62 days

16. ADULT DAY HEALTH SERVICES (ADH) (Always refer to the GENERAL CCSP MANUAL for other requirements) ADH Service Record Form • Members attendance • Full day • Part day • Absent code • Document any therapy • Personal care • Meals • Other provided services

17. ADULT DAY HEALTH SERVICES (ADH) (Always refer to the GENERAL CCSP MANUAL for other requirements) ADH Activity Participation Record • Indicate members activity for each day • Write a narrative of pertinent information • Each entry must be initialed • Enter member participation for the month • At month end the RN and other staff must sign the record

18. ALTERNATIVE LIVING SERVICES (ALS) (Always refer to the GENERAL CCSP MANUAL for other requirements) ALS Supervision • All ALS members’ must be supervised by the RN • The LPN may be the on-call contact – with the RN accessible to the LPN • Conducted at least twice monthly by RN or LPN • The visits must be at least 14 days apart between the 1st visit of the month and the 2nd visit • At each supervisory visit, the provider nurse reviews, initials and dates the member care plan • RN reviews, signs and dates the member services form monthly

19. ALTERNATIVE LIVING SERVICES (ALS) (Always refer to the GENERAL CCSP MANUAL for other requirements) ALS Supervision • The RN is to know all prescription and over-the-counter medications for members. • The MAR must show • Name of medication • Dosage • Route date and time dosage taken • Observed drug side effects & actions to address side effects • Signature & date of the person supervising medications • RN reviews, signs and dates MAR monthly

20. OUT OF HOME RESPITE (RC) (Always refer to the GENERAL CCSP MANUAL for other requirements) RC Supervision • RN must do the supervisory visit • Review, revise and initial client care plan at least every two months • Review, initial and date the Client Service Form at least monthly • Conduct face-to-face supervisory visits at least every two months • Prepare progress notes • RN must review, initial and date progress note entries by other staff • RN must instruct staff on progress note protocol. • RN must provide follow up on problems identified. • Communicate with care coordinators, other CCSP providers, family and/or other caregivers

21. PERSONAL SUPPORT SERVICES (PSS) (Always refer to the GENERAL CCSP MANUAL for other requirements) PSS Supervision • The Licensed Practical Nurse (LPN) may perform supervisory visits and the note must be cosigned by the RN within 10 days of the visit • The LPN is supervised by the RN • Required every two month (within 62 calendar days) or • Required every three months (within 92 calendar days) for all members who receive 24 units or less of services weekly • RN must supervise and monitor the care of those members whose health status and situation involve complex observations

22. PERSONAL SUPPORT SERVICES (PSS) (Always refer to the GENERAL CCSP MANUAL for other requirements) PSS Supervision • At each supervisory visit, the provider nurse reviews, initials and dates the member care plan • RN reviews, signs and dates the member services form monthly • RN must review, initial and date progress note entries by other staff

23. PERSONAL SUPPORT SERVICES (PSS) (Always refer to the GENERAL CCSP MANUAL for other requirements) Member Service Record Form • Services must be documented each time service is delivered • Date of service (month, date, year) • Member name • Specific time in and time out • Number of hours of services • Specific task performed • Member signature • Personal support Aide signature

24. EMERGENCY RESPONSE SERVICES (ERS) (Always refer to the GENERAL CCSP MANUAL for other requirements) ERS Supervision • Skilled Supervision not required • Supervisor must have • ERS equipment training • Experience • Once a Month Supervision • Member test the system via a personal transmitter of the ERS • Purpose of the supervision • Detect malfunction • To determine member’s ability to use system properly • If unable to reach member for testing • Three attempts must be made within five business days

25. HOME DELIVERED MEALS SERVICES (HDM) (Always refer to the GENERAL CCSP MANUAL for other requirements) HDM Supervision • Skilled Supervision not required • Monthly supervision required • HDM log has three months of supervision on one log • Each month the supervisor • Reviews • Signs and dates the monthly log • The provider is to check • Meal accumulation • Refrigerator/freezer and • Cooking equipment • Meal consumption

26. Very Important • Read Your Manuals • The Information in the Manuals is essential • Manuals are subject to updates quarterly…so check for updates • All CCSP services are required to comply with the Policies and Procedures for Medicaid/Peachcare for Kids, Part I, Chapters 100 through 500, Community Care Service General Manual, Part II, Chapters 600-1000, in conjunction to the specific service manuals • PSS must also comply with Rules and Regulations for Private Home Care Providers, Chapter 290-5-54 manual • ALS must also comply with Rules and Regulations for Personal Care Homes, Chapter 111-8-62, DCH, HFRD and Rules and Regulations for Disaster Preparedness Plans, Chapter 209-5-45, DCH, DPH • PSS must also comply with Rules and Regulations for Private Home Care Providers, Chapter 290-5-54 manual • SNS must also comply with Rules and Regulations for Private Home Care Providers, Chapter 290-5-54 manual

27. UTILIZATION REVIEW (UR) – AREAS OF REVIEW Utilization Review includes the following areas, however this is not an all inclusive work tool. Reviews may include observation and determination in addition to elements listed such as cleanliness, safety, staffing, permits, etc. • Medical Plan of Treatment/Recertification • Sixty (60) Day Summary • Member Care Plan • Supervisory Visits • Clinical Progress Notes • Service Record Form • Medications • Level of Care

28. UTILIZATION REVIEW (UR) – AREAS OF REVIEW (con’t) • Client Assessment Instrument/Initial Care Plan • Comprehensive Care Plan • Services and Frequency of Visits • Using proper billing Codes for Services rendered • Quality of Care • Emergency Procedure Plan • Advance Directives • Directions to Member's Home Non-compliance with required policies and procedures will subject the provider to adverse action up to and including monetary recoupment and termination.