SHARS: A.R.D. Documentation and SHARS Compliance

1. SHARS:A.R.D. Documentation and SHARS Compliance

2. Areas of Concern • What is SHARS? • Service areas with Documentation issues • ARD Documentation • Medical Necessity • Alignment – PLAAFP, IEP, Supplement • Parental Consent to release information (one-time)

3. 1. What is S.H.A.R.S.? S.H.A.R.S. stands for School Health And Related Services. It is a program that was created by the federal government, that allows a district to bill Medicaid for “direct medical services” provided to “eligible” students by district employed service providers or contracted service providers.

4. 1. What is S.H.A.R.S.? • What are Direct Medical Services? • Direct Medical services are services (other than transportation on the bus) that a district is allowed to bill through the SHARS program. • Assessment and Evaluations • Nursing Services • Nursing Meds • Personal Care Services • PCS - Transportation • Transportation • Audiology • Speech • Occupational Therapy • Physical Therapy • Counseling • Pyschological Services

5. 1. What is S.H.A.R.S.? • Who Qualifies? • What criteria must a child meet in order for the district to bill Medicaid under the SHARS program? • The child must: • be enrolled in a public school’s special education program; • be 20 years of age or younger; • have an ARD/IEP documenting the medical necessity for services • have a disability or chronic medical condition; and • Medicaid eligibility. • The services the child receives at school do not affect the type or amount of Medicaid services the child receives outside the school.

6. Source – TMPPM

7. 2. Service areas with Documentation issues • Personal Care Services – PCS supplement • Personal Care Services Transportation Aide (Bus monitor) – PCS supplement • Nursing – Skilled Nursing supplement • Nursing Meds – Routine Oral Medication Administration – Skilled Nursing supplement • Transportation – Transportation supplement

8. 3. ARD Documentation – Personal Care Services • Individual Education Plan • PCS - Must state needs of the child, including necessary supervision, monitoring, re-direction, prompting and cueing, as well as when and where it’s needed (this includes bus monitor)

9. 3. ARD Documentation – Personal Care Services What is Personal Care Services? There is an entire 8 page section in the SHARS F.A.Q. that covers PCS in tremendous detail. This is the sentence that summarizes best what PCS is: • “PCS include a range of human assistance provided to persons with disabilities and chronic conditions which enables them to accomplish age-appropriate tasks that they would normally do for themselves if they did not have a disability or chronic condition. “ In other words.” You are doing something for the student that they cannot do for themselves due to their disability or chronic medical condition”

10. 3. ARD Documentation – Personal Care Services • Personal care services are provided to help a child with a disability or chronic condition benefit from special education. • Performed on a continuing basis or on episodic occasions provided in a one-on-one or group setting basis • May have limitations in performing these activities because of a functional, cognitive and/or behavioral impairment. • Assistance may be in the form of “hands-on assistance” (actually performing a personal care task for a person) or “cueing” the person so that the person performs the task by him/herself.

11. 3. ARD Documentation – Personal Care Services • Activities of Daily Living (ADLs) • Basic human functioning • eating, bathing, dressing, toileting (including diapering), transferring, maintaining continence, and mobility services • Instrumental Activities of Daily Living (IADLs) • Societal functioning • complex life activities and include personal hygiene, light housework, essential household chores, laundry, meal planning and preparation, transportation, grocery shopping, communication by telephone or other media, medication management, managing finances, getting around and participating in the community, and limited exercises to increase range of motion and flexibility

12. 3. ARD Documentation – Personal Care Services • Goal is not to teach or habilitate, but complete the activity. • Level of assistance is greater than typical child of same age. • Need for assistance is related to disability/chronic condition that affects function. • Supports • Total or partial physical assistance • Prompting or cueing the student to complete the task • Redirection, monitoring, and observation that are medically necessary and an integral part of completing a personal care service

13. 3. ARD Documentation – Personal Care Services

14. 3. ARD Documentation – Personal Care Services • When documenting the need for PCS in the ARD you must state that the “student requires personal care services” as well as answer the following 4 questions: • Is the service provided on an individual basis or group or both • examples of PCS • when/where are the PCS needed • the reason(s) for PCS, such as medical necessity, etc.

15. 3. ARD Documentation – Personal Care Services An example of the correct way to document Personal Care Services is shown below: Doug requires personal care services (1) on a one-on-one basis as well as a group setting when necessary. Doug requires (2) constant monitoring and re-direction of behavior (3) throughout the school day while in the classroom, cafeteria, transition periods between classes and during bus escort between place of residence and school. (4) Doug has been diagnosed as ED and can exhibit behaviors that are dangerous to himself or others without direct supervision.

16. 3. ARD Documentation – Personal Care Services • PCS is a summary of information found in the students IEP • There is not a need to create specific goals and objectives for PCS. The goals and objectives created for other areas such as, Language, Math, Functional Skills should reflect the areas addressed in the PCS Supplement

17. 3. ARD Documentation – Personal Care Services • Toileting, diapering, and escorting do not justify a teacher billing for an entire day • At most 2 hours per day • Must select monitoring, cueing, prompting, redirections and observation which are continual services to be justified for billing all day • Unless a student has a position (e.g., one provider or a rotation of providers) assigned to work with only him/her throughout the day, then PCS is delivered in a group setting • Adaptive P.E., Sign Language Interpretation, Braille Instruction, Community/Vocational Training, Visual Impairment Assistance, Art & Music Therapy

18. 3. ARD Documentation – Personal Care Services • There are two ways to document personal care services (PCS): continuous and non-continuous • These services can be provided in an individual setting (one-on-one) or group setting (more than one). • Student 1 • Student 2 • Student 3 • An example of continuous, group PCS: Lifeskills classroom with multiple students per teacher/aide who require assistance for daily living skills throughout the school day. • Student 4 • Student 5 • An example of non-continuous, group PCS: Two or more students with one teacher/aide that may require assistance in the lunch room at the same time. • Student 6 • An example of a non-continuous, individual PCS: Susie is a paraplegic and requires bathroom assistance periodically throughout the school day. • Student 7 • An example of a continuous, individual PCS: Johnny has bipolar disorder but is mainstreamed; however, in the event of a breakdown, Johnny has an aide with him at all times throughout the school day to observe/monitor his behavior. • In order to bill for individual (one-on-one) PCS, the need for the individual (one-on-one) PCS must be stated in the student’s ARD/IEP. CONTINUOUS G R O U P I N D I V I D U A L 1 2 3 7 4 5 6 INTERMITTENT

20. 3. ARD Documentation – Personal Care Services • Why do we document? • Documentation is necessary in the event that the district is selected for an audit • Keep in mind that the person conducting the audit more than likely has little-to-no experience with: • Special Education • Medical Services • Educational Environment • Explain what is happening so anyone can read it.

21. 3. ARD Documentation – Personal Care Services • Special Education Teachers & Aides • Self-Contained Classrooms • Certain Resource/Inclusion Classrooms • Community Based / Vocational Classrooms • PPCD • Behavior Unit / Classrooms • Visual Impairment Specialists (Direct) • Orientation & Mobility Specialists (Direct) • Sign Language Interpreters • Adaptive P.E. Coaches • Bus Aides/Monitors

22. 3. ARD Documentation – Personal Care Services • Personal Care on the Bus – Aide/ Monitor • The student needs the monitoring, observation, redirecting, prompting, cueing and/or assistance due to the student’s disability or chronic medical condition. • The need for a monitor needs to be justified and documented in the student’s IEP. • PCS Supplement – Necessary! • TR Supplement (Doug doesn’t agree with this at all and I advise against it when I am at schools) • Deliberations

23. 3. ARD Documentation – Nursing Services • Individual Education Plan • Nursing – must identify disability/chronic medical condition that leads to the need for the service • There is a difference between regular nursing procedures and routine oral medication

24. 3. ARD Documentation – Nursing Services • Nursing Services – Medication Administration • Children who have health problems that go untreated may be prevented from reaching their full academic potential. Many students who have a chronic illness or disability must receive medication during the school day. • IDEA mandates that school districts provide health-related services to students with disabilities if it is required in their Individualized Healthcare Plan (IHP)2. These “services” frequently include the administration of medication. • Routine Oral Medication – Pills, liquids, or inhalers only • “Student requires the administration of routine oral medication as prescribed by a physician due to (DISABILTY or CHRONIC MEDICAL CONDITION).”

25. 3. ARD Documentation – Nursing Services • Nursing services are skilled nursing tasks, as defined by the Texas Board of Nursing (BON), that are included in the student’s IEP. • A district can receive Medicaid reimbursement for any nursing service that is determined by the ARD/IEP committee to be needed in order for a Medicaid-eligible student to fully participate in school. • Due to the wide variation in individual needs, it is impossible to develop an all-inclusive list of nursing services.

26. Assessment - Personal Care Services Needed • Assessment - Nursing Services Needed • Blood Pressure • Blood Sugar Check • Catheterization • Chest Percussion Therapy (CPT) • Cough Assist • Diaper Change • Diaper Rash Cream • Dressing Change • E-Cylinder O2 tank check • Empty Ostomy • Exit Site Care • Gastrostomy Care • G-tube Feeding • G-tube Flush • G-tube Medication and Flush • G-tube Site Care • G-tube Vent • Ileostomy Care • Insulin Injection or Pump • Inhalation Therapy • InsulinPump Injection Site Change • Insulin Pump Refill • J-Tube Feeding • J-Tube Flush • Ketone Check • Nebulizer Treatment • Non-Routine Medication Administration • O2 Continuous • O2 Refill • Oxygen Saturation Check • Passy Muir Trach Valve Replacement • Peak Flow Check • Routine Oral Medication Administration • Suctioning • Suctioning with Neb treatment • Trach Suctioning • Trach Tube Replacement • Trach Valve Replacement • Tracheostomy Care • Vagal Nerve Stimulator • Ventilator Monitoring 3. ARD Documentation – Nursing Services

27. 3. ARD Documentation – Transportation • Individual Education Plan • Transportation – Physical adaptation tied to medical need

28. 3. ARD Documentation – Transportation • A specially adapted vehicle is one that has been physically modified due to the • addition of a wheelchair lift; • addition of seatbelts, lap restraints, harnesses; • addition of child protective seating; • addition of air conditioning; and/or • addition of windows being covered or blacked out. • IEPdocumentation explains that • the student requires specific physical adaptation(s) of a vehicle in order to be transported; and • the justification why the student needs the specialized transportation.

29. 3. ARD Documentation • PLAAFP • Currently the area of documentation causing the most problems. • ARD facilitators will make comments talking about the child’s progress without fully explaining the necessary supports that make the progress possible.

30. 3. ARD Documentation • Deliberations • Optional – comments must be in alignment with other areas of documentation, such as the IEP, Supplement and PLAAFP

31. 4. Medical Necessity • Need for service must be linked to an identified Medical Disability or Chronic Medical Condition. • If the child is only LD – we shouldn’t be delivering any services other than instructional services • If the child is Speech only – we should only be delivering speech therapy.

32. 5. Alignment – PLAAFP, IEP, Supplement • The biggest problem we see is that the areas of documentation are not in alignment with each other. Often times they contradict each other. An auditor will always choose the documentation that allows him to “recoupe” revenue.

33. 5. Alignment – PLAAFP, IEP, Supplement • All 3 areas should: TELL THE SAME STORY

34. 6. Parental Consent • As of March 18, 2013, the consent law has changed • Signed consent to release information is one time: PK-12, unless the parent revokes it • Annual notification must be sent to parents, but does not need to be returned or signed.