Agency-Based Program Nurse Oversight Day-to-Day Program Operation

1. Agency-Based ProgramNurse Oversight Day-to-Day Program Operation

2. Agency Based PAS Provides a choice of in-home services where a qualified Medicaid-enrolled home care agency takes the responsibility for providing quality home-based services • Nurse Supervision • Trained Attendant Staff • Scheduling • And More!

3. What does agency-based PAS cover? • Activities of daily living • Instrumental activities of daily living • Does not provide skilled nursing services • Remember: Unlike SDPAS there is no exemption from the nurse practice act for health maintenance activities!

4. Nurse Supervisor Oversight Tasks

5. Nurse Supervisor or Designee Oversight Tasks

6. Other Tasks to Maintain Quality Services

7. Provider Responsibilities These tasks may be performed by a nurse or other agency staff: • Document and verify Medicaid eligibility monthly • Provide a grievance procedure for consumers • Provide advance notice to consumers who are being discharged • Report serious occurrences in a timely manner • Timely response to the monthly M-PQH inquiry regarding annual review report • Complete an annual consumer survey • Maintain required records • Report changes in contact information to the Department and ACS in a timely manner • Comply with all other policies and procedures as outlined in the manual and Administrative Rules of Montana PAS 602

8. More to come . . . • Break-out sessions will cover provider responsibilities in more detail

9. Agency Based PAS Worker Requirements The nurse supervisor must oversee the following attendant training requirements: • 16 hours of required training prior to entry in the home • Orientation to individual needs of consumer • 8 hours of in-service training per year Don’t Forget: Document, Document, Document

10. Agency Based PAS Training Requirements • Basic 16 hours of training prior to the personal assistant providing care • Mandatory topics as outlined in PAS 706 • 1. orientation to the agency, community and services; • 2. body mechanics, transfer, and assisting with consumer mobility; • 3. personal assistance skills; • 4. care of the home and personal belongings; • 5. safety and accident prevention; • 6. food, nutrition and meal preparation; • 7. health oriented record keeping, including time records; • 8. consumer's rights (including confidentiality); • 9. communication skills; and • 10. basic human needs to provide personal assistants with the knowledge to work with aging and disabled individuals. PAS 706

11. Agency Based PAS Training Requirements Documentation Who, what, when, where and how • Who provided the training and who attended the training • What was covered in the training • When and where did the training occur • How was the competency of the attendees evaluated

12. Types of Training • Video • Quiz • Articles • On the job • Hands-on Demonstration • Discussion • And more . . . Remember the three I’s! • Keep it interesting, interactive and innovative!

13. In-Service Training • Minimum of 8 hours • Develop special skills or knowledge • Advanced training beyond initial basic training • Special population • Provided at the agency or through community education activities PAS 706

14. Waiver of Training PAS 706 Initial training may be waived if the individual can demonstrate competency in the required areas of content included in the basic training Agency criteria for evaluating competency should meet the following 5 requirements: • Designed for individuals with: • CNA certification • Successful training through another PAS agency • One year of experience as a trained personal assistant in a community-based program (i.e. licensed developmental disability group home or licensed assisted living) • Experience solely in the self-direct model or as an informal caregiver does not qualify

15. Waiver of Training cont. PAS 706 2. Include procedures and instruments for evaluating the individual’s competency • Content should be compatible with required basic training • Assesses appropriate skills and understanding 3. Establish the level of competency PRIOR to placement in a home 4. Include a plan for remedial basic training in areas where the individual fails to meet competency 5. Include a mechanism for documenting successful demonstration of competency

16. Waiver of Training Reminders • Once competency is determined a certificate should be issue with the date the attendant was certified • Waiver of training must be supervised by the nurse

17. Attendant Training Documentation • Document 16 hour basic training • What was covered, by whom and length of time • Document passage of competency test • Issue training certificate copy in file • Document first date attendant worked and for which consumer • Document in-service training • 8 hours per year • What was covered, by whom and length of time • Issue training certificate and retain copy in file • Waiver of training • Document reason • Document passage of competency test

18. On The Job Training (OJT) PAS 706 • Effective way to assure that attendants are oriented to consumer specific needs • Nurse Supervisor is responsible for providing or arranging the OJT • May be provided by another attendant when the attendant has extensive knowledge of a consumer’s need Note: You cannot bill Dept. for in-service credit

19. OJT cont. • Time for training is in addition to units authorized on profile • Attendant who is being trained must complete an SDR • Mark time in and out • Check tasks completed • Document in comment section that the time is for training

20. Billing Nurse Supervision • Time spent during intake or re-certification • Change in Condition • Incident Management • Case Conferences* • Charting • Just because you make a visit – doesn’t mean it’s billable PAS/SDPAS 606, 701, 702, 703 MUST HAVE SUPPORTING DOCUMENTATION

21. NOT BILLABLE • Administrative work: • Chart Audits • Surveys • Personnel Issues • Travel time • Non related telephone time. • Billing PAS/SDPAS 414

22. Service Delivery Records(SDR) (PAS 604, 606, 702) Serves two purposes: • Provide necessary documentation of services that are delivered • Documentation for Medicaid billing purposes Reminder: This is a legal document. It proves what was completed in the home.

23. Service Delivery RecordsAgency Review Compare SDRs to duty guide/MPQH authorization/plan of care Look for patterns Review tasks (# of times performed per week) Review hours (per day and per week) Ask? (does this make sense?) Avoid cookie cutter or bottom heavy s.d.r.’s --Follow up and document findings--

24. Service Delivery RecordsAgency Review • Review all Service Delivery Records (SDRs) prior to billing and prior to completing 180 day visits • Make sure: -Tasks marked -Appropriate signatures dated and signed -Principles of charting -Medical escort and mileage documentation

25. Your Friend in the Business When in doubt: • PAS/SDPAS 902 • WHO DOES WHAT, WHEN, & HOW • REFER TO DIRECTIONS • ASK FOR HELP

27. Nurse Supervision Break Out Session

28. Provider Responsibilities: The Role of Nurse Supervision The Nurse must oversee or complete the following: • Complete the intake process • Re-certification done every 180 days • Training attendants prior to working in a consumer’s home • Orient attendants to consumer care plan • Amendments and temporary authorizations • Completion of the quality assurance process

29. SLTC-150 • Intake • 180 Day Eval • Change in Condition • Conference • Amendment • Other

30. Intake Visit PAS 701 Complete the intake process with the required paperwork • explain Department policies, program parameters and philosophy • written and verbal explanation of consumer rights and responsibilities • written and verbal explanation of agency responsibilities • agency’s complaint procedure • Written information regarding advance directives

31. Intake Visit Cont. • Develop an individual plan of care • Instructions for the personal assistance, such as duty guide • identification of the personal assistant’s training needs; and • expected results for the consumer • Establishes a baseline from which to evaluate services • Paperwork: Use form SLTC 150 and keep in consumer file! Include intake progress note- document, document, document!! • Visit must be in-person and on-site (unless in a hospital or nursing home prior to discharge) PAS 701

32. Recertification- 180 day visit (PAS 703) • Prior to the visit review consumer’s SDRs and the consumer’s file! • During the on-site visit • Review the individual plan and profile; • Review functional limitations and need for continued services; • Evaluate the consumer's perception of the quality of services provided by the personal assistant; • Observe the interaction between the consumer and the personal assistant (when appropriate); • Determine any training needs; • Follow-up on issued identified previously; and • Review attendant duty guide • Paperwork: Provide documentation and a detailed summary of current condition and situation via the Nurse Supervision Documentation form (DPHHS-SLTC-150). PAS 703

33. Recertification Timeline • The nurse supervisor must visit during the month the 180th day falls or when significant changes in condition occur. The provider agency is responsible for tracking the timelines of these visits. The visit may occur at any time within the month the 180th day falls. Examples of timing: Example 1: Admit: 1/7/08 • Supervisor visit completed by 7/30/08 Example 2: Admit: 1/7/07 Supervisor visit for change in condition 3/13/07 Next Supervisor visit due 9/30/08 If the 180-day visit is not completed during the required month, a repayment will be required for all services provided after the first of the following month until the date the visit is completed. • Unless the visit cannot be completed as required, documentation must explain the delay. PAS 703, Form SLTC 150

34. SLTC- 150 Nurse Supervision Form Make sure: • Form is always signed by nurse supervisor • Keep original form in consumer file • Distribute form, as necessary • Fax to MPQH if it’s a change in condition that requires an amendment or an amendment-only request

35. Amendments and Temporary Authorizations • High Risk Intakes • Amendments to MPQH • Nurse should provide appropriate level of detail on the form to justify the service and time and sign the forms

36. The SLTC-150 Form Activity • Best Practices • Challenges

37. PAS 902: Who Done It? • What does the nurse have to do? • What does the agency have to do? • Who have you assigned at the agency to do each task? • What system do you have to track these tasks? • What is working and what isn’t working?

38. Questions