Title: Service Monitoring Policy and Implementation Guidelines

Division Directive Number 3.020 Effective Date: September, 2002

Anne S. Deaton, Ed.D., Director

Application: Applies to Regional Centers and Senate Bill 40 Boards

Purpose: To prescribe service monitoring standards for services funded through the Division of MRDD

Service Monitoring Policy Service coordinators must conduct monthly face-to-face visits with individuals in residential settings funded by the Division and/or processed through the DMH billing system, and quarterly face-to-face visits with individuals participating in on-site day habilitation programs. If an individual receives both residential and day habilitation services, service coordinators do not have to visit the residential site during the quarterly day habilitation visit. Individuals participating in off-site day habilitation will have quarterly face-to-face visits with at least one annual visit at the off-site location where the service is received.

Service coordinators must conduct quarterly face-to-face visits with individuals residing in their natural homes who receive personal assistance or out-of-home respite care as well as individuals living in nursing homes or residential care facilities. Less than quarterly face-to-face visits may be requested by the individual/guardian. The service coordinator must agree to any reduction in frequency and document it in the person-centered plan.

Service coordinators will conduct at least an annual face-to-face visit and quarterly phone contacts with all other individuals (people living in their natural home, people not receiving a funded service, etc.). Each phone contact or a minimum of three (3) attempts to make contact with the individual/guardian/parent must be documented in case notes. If contact is not achieved after three (3) attempts by phone, the service coordinator will send a letter including offers of assistance with phone number, dates, and times that attempts to contact were made.

In all of the above contact situations/expectations, if no contact is received from the consumer/family after 90 days of a letter being sent, another letter needs to be sent to the consumer/family indicating they will be discharged from services if no contact is received within 30 days.

The above “frequency of visits” guideline is a minimum standard. It is expected that service coordinators will exercise professional judgment and increase visits according to the individual needs of consumers.

Service Monitoring Policy-Revision 3-24-03 Page 1 of 6 Frequency of Visits Overview

Monthly Face to Face Annual Face to Face Quarterly Face to Face & (All residential services funded by Quarterly Contact the Division and/or processed through the DMH Billing System except for Nursing Homes)

. Individuals Group Homes . On-site Day Habilitation . Individuals living in Natural Home not . Individuals in ISLs . Off-site Day Habilitation –once receiving funded service annually at site of service listed in other categories . Individuals in Foster Homes delivery

. Individuals living in Natural Home receiving personal assistance or respite care

. Individuals living in Nursing Homes and Residential Care Facilities

Service Monitoring Implementation Guidelines

Definitions:

Agency Action Plan Tracking System: A Regional Center database designed to track issues identified through the Quality Management Functions that require action. Issues tracked will be identified though indicators categorized by health, safety, rights, services, and money, in addition to the Missouri Quality Outcomes.

Day habilitation: Service provided in a non-residential setting to enable individuals to increase their independent functions. Day Habilitation may be provided to individuals or to groups and may be provided either on-sit in a center based setting or off-site in the individual’s own home or community. On-site group and off-site individual are how this service is typically provided; the other two types of services are for specific situations. Examples of on-site day habilitation would include cognitive skills training, socialization, and functional skills training. Examples of off-site day habilitation include house cleaning, money management (budgeting and bill paying), menu development, and cooking, shopping, laundry, first aid, and community inclusion.

DMH (Department of Mental Health) billing system: All services/supports authorized and paid through DMH regardless of where the revenue originated from, including DMH general revenue funds, Medicaid Waiver match, SB (Senate Bill) 40 Waiver match and non-waiver funds, shared unit agreements, DFS (Division of Family Services) or CPS (Comprehensive Psychiatric Services) agreements.

Face to face visit: A service coordination visit with the person & staff in their home and / or day program.

Indicator: A key value or quality characteristic used to measure, over time, the performance, processes, and outcomes of an organization or some component of service delivery.

Integrated Quality Management Function: Prescribes the systematic process for how information from all quality management functions is integrated and synthesized to evaluate the performance of the service delivery system. This

Service Monitoring Policy-Revision 3-24-03 Page 2 of 6 process assures the health and welfare of consumers, while meeting their needs and supporting them to achieve personal goals.

Interpretive guidelines: questions, examples of how to gather information in the review areas

Issues: Area reviewed where a problem is identified, interpretive guideline where problem is identified. A critical issue is where the health and/or safety of an individual are in jeopardy.

Log note / Case notes: Include answers to these questions, who, what, where, when & why.

One-time concern: Issue identified during a visit and resolved before the end of the visit, something that has not been a concern before, an isolated incident.

Outcome: An agreed upon result of action to be taken as outlined in the Quality Management Plan, or other intervention, that resolves issues, prevents reoccurrence and increases opportunities for implementation of the Missouri Quality Outcomes.

Quality Management Function: A process to monitor and effect services being provided, focusing upon health and welfare of consumers, meeting their needs and supporting them to achieve personal goals. The Regional Center Statewide Quality Management Functions are: Service Monitoring, Incident Response System, Fiscal Review, MOAIDD Visit, Health Inventory Planning System (Nursing Review), Death Review, Personal Plan Review, and Licensure and Certification Survey. There are other quality management functions that are local or from outside the Division.

Quality Management Plan: Written outcome-based strategies outlining actions formulated from the integration or synthesis of information gathered utilizing the Agency Action Plan Tracking System. Quality Management Plans are written for the provider, Regional Center, and Division of MRDD for the purpose of increasing performance above current levels

QM (Quality Management) Referral Form: A document describing issues, concerns and findings identified, with recommendations and immediate action taken following a Quality Management Function.

QM (Quality Management) Team: Regional Center staff designated by the Regional Center Director to perform statewide Quality Management Functions.

Residential habilitation: Service provided in a residential setting including group homes, residential centers, semi- independent living situations and Individualized Supported Living arrangements, which includes support and training provided by direct support staff as well protective oversight, where needed. Examples of residential habilitation include assistance with routine household chores, transportation to and from appointments, accompaniment to activities or into the community, the provision of care, skill training, home management, and community inclusion.

Routine documentation of visits: Written documentation that the visit occurred, what was reviewed during the visit and any progress on outcomes, documentation is written in log notes / case notes within 5 working days of visit.

Service Monitoring Checklist: An optional tool that service coordinators may use to assist in reviewing the five Indicators or areas of service specified in the Service Monitoring Guideline. It describes identified issues/concerns and findings, with recommendations and immediate action taken following a service monitoring visit.

Service Monitoring Guidelines: The tool that specifies the five Indicators or areas of service to be reviewed, and interpretive guidelines for each area. The five indicators are Health, Environment/ Safety, Money, Rights, and Service /Staff.

Service Monitoring Implementation Guidelines: Outlines the procedure for conducting service monitoring, and appropriate follow-up for identified issues.

Service Monitoring Policy-Revision 3-24-03 Page 3 of 6 Process for Identification, Communication and Resolution of Issues:

. During face-to-face visits with individuals, service coordinators will review the areas of Environment/Safety, Health, Services and Staff, Money and Rights identified in the Service Monitoring Guidelines. The Service Monitoring Guidelines Checklist is an optional tool that service coordinators may use to assist in the review. . If service coordinators identify or learn of incidents of abuse and/or neglect during a visit, they shall report the incident according to Department Operating Regulation 2.210. Service coordinators who work for County Boards or Affiliated Community Service Providers shall follow Department Regulation 9 CSR 10-5.200. . Should a service coordinator find no issues during a visit, documentation of the visit and other pertinent information should occur in routine ways (log notes, case notes, etc.) and any other manner required by agency management. . If a situation is identified during a visit that the service coordinator deems critical (e.g. dangerous or harmful), the service coordinator shall remain on site until adequate safeguards are in place and their supervisor approves their leaving. . If the service coordinator identifies an issue(s) during a visit that can be quickly resolved or the issue is a one- time concern, the service coordinator should resolve and document the issue and resolution in routine ways (log notes, case notes, etc.). The service coordinator must also complete either the Quality Management Referral Form or the Service Monitoring Guidelines Checklist indicating that the issue has been resolved and submit the document to their supervisor. The service coordinator supervisor will then give the documentation to the Quality Management Team within five working days for data entry in the Agency Action Plan Tracking System (AAPTS). . If the following issues occur during a visit, the service coordinator must complete the Quality Management Referral form or the Service Monitoring Guidelines Checklist:  Multiple guideline issues occurring at one time.  Issues occurring over an extended period of time (more than two months). An issue is not just a one-time instance, unless deemed critical.  Non-life threatening issue(s) that re-occurs after correction. Issue(s) does not appear to be consistently resolved over time.  Significant health changes in the person they are supporting. A significant health change is defined as any change in a person’s mental or physical health that causes a significant change in the life of the person and/ or the people around him/her.  Anytime the service coordinator needs assistance from the Quality Management Team. The service coordinator shall notify their service coordinator supervisor, the person involved and the provider’s responsible QMRP within 5 working days. The service coordinator supervisor or other designated staff shall give the Quality Management Referral Form or the Service Monitoring Guidelines Checklist to the member of the Quality Management Team (QMT) designated to work with the agency. The QMT member must ensure follow-up and resolution of identified issues. All issues/concerns will be entered in the AAPTS for tracking and trending. The service coordinator will continue to monitor the issue(s) during routine visits. . The Regional Center Quality Management Team will combine the issues/concerns identified through service monitoring with issues/concerns from a variety of regional center quality management sources (e.g. MOAIDD visits, Nursing Reviews, Incident reporting, Personal Plan reviews, etc.) including positive outcomes as outlined in the Missouri Quality Outcomes document. This is the basis for the development of provider plans according to the Division’s Integrated Quality Management Function.

County Boards and Affiliated Community Service Providers (ASCP) who provide Targeted Case Management must follow, at a minimum, the Service Monitoring Policy and Guidelines for conducting face-to-face visits. They must also establish and implement written procedures for prompt resolution of issues and concerns identified during service monitoring visits. Following each visit, the County Board or ACSP must document issues and concerns on the Quality Management Referral Form or Service Monitoring Guidelines Checklist and submit the documentation to their respective regional center for centralized data tracking and trending purposes.

Service Monitoring Policy-Revision 3-24-03 Page 4 of 6 Service Monitoring Guidelines

During face-to-face visits with the individual, the service coordinator shall review, according to the Service Monitoring Guidelines, the areas of Environment/Safety, Health, Services and Staff, Money and Rights each time they visit a person in a setting funded by the Division (group homes, ISLs, foster homes, day programs). The Guidelines provide a framework to promote effective and efficient provisions of services and supports in enabling the individual to achieve his or her personal goals.

ENVIRONMENT / SAFETY INTERPRETIVE GUIDLEINES applies to all settings  Cleanliness of home / facility  Is the home/ facility clean? Look for dirt, insects, rodents, pests, trash. *Unclean is defined as anything that may represent a health or safety threat for the people living there.  Odors  Are there any unusual odors present (urine, feces, spoiled food, natural gas)?  Temperature  Is room temperature too hot or cold? Is water temperature too hot or cold?  Maintenance of the home / facility  Is the home / facility in good repair? No broken windows, doors, walls, plumbing, electrical, etc. All appliances are in working order, all steps &railings are in good condition, all furniture is clean and in good repair.

 Adaptations  Is the home / facility adapted for the person? Can the person get out in case of an emergency?  Soap & towels  Are these items present in the bathroom(s) and kitchen? Are people and staff using them?  Smoke detectors and fire  Are these items present? Ask the person and staff if they work. extinguishers HEALTH applies to residential settings unless INTERPRETIVE GUIDELINES otherwise indicated  General well-being  Talk to the person and staff; ask how the person is feeling today? Has the person had any recent injuries or illness? Has the person been to the Doctor and if so, what was the result?  Appearance  Is the person clean? Are clothes and shoes clean, in good condition and the correct size?  Weight change  Observe and ask questions if there seems to be a weight change.

 Special dietary needs  Are staff and the person aware of any special dietary needs? Ask the person what he / she had for lunch, dinner, etc. Ask about grocery shopping. Have the person show the contents of the refrigerator and /or pantry  Medications  Are medications present? Look at the bubble packs, have pills been missed? Are the medications locked & secure?  Doctor’s Orders  Are the orders present, signed and current?

 MAR’s (does not apply to day  Are there blanks? Are they signed? habilitation if no medication is given.)  Adaptive equipment  Is the equipment clean, in good repair and is it being used as prescribed? Do the person and staff know how to use the equipment? Is it the right Service Monitoring Policy-Revision 3-24-03 Page 5 of 6 equipment?  Physical, vision and dental exams  Are the exams current and in the home record? *Physical exam must be (a copy of the physical is not completed annually required for day habilitation if the person does not receive residential services) SERVICES & STAFF applies to all settings INTERPRETIVE GUIDELINES  Staff  Observe! Are staff interactions respectful, attentive and positive? Are staff teaching and mentoring people?  Services authorized  Are the services authorized in the plan being provided, is when, where and by whom documented? Are staffing ratios being met?  Staff Documentation  Is the documentation present and meaningful? Are incident and injury reports being completed and forwarded to the Regional Center in a timely manner? Do daily activity records that staff complete describe the activities & services the person participated in? MONEY applies only to residential settings INTERPRETIVE GUIDELINES  Spending money  Where is the money kept? How much money does the person have access to? What is the balance? Ask the person if they have bought anything they wanted lately?  Bills  Are the bills paid? Who pays them?

 NAFS / Personal accounts  Have there been any purchases? If so, does the person have the purchased item? RIGHTS applies to all settings INTERPRETIVE GUIDELINES  Control  Observe: Who answers the door and phone? Do people appear to ask staff for permission frequently? Do people choose who visits in their home? Are staff taking care of personal business while at work (errands, children at work, phone calls, etc.)? Can people talk privately? Do people have privacy for daily activities that are typically private (dressing, bathroom, etc.)?  Choice  Ask the person, do you choose what you eat & when? Do you choose what to buy with your money? How do you decide what to do everyday?  Rules  Ask if there are any rules? If so, who made up the rules?

 Restrictions  Are there any restrictions? Are there places in the home that are off- limits (other than bedrooms)? Is the refrigerator off-limits or restricted? Are there alarms on the doors, etc.? If there are restrictions in the person’s plan, does the person know how to have their right restored? Are efforts being made to teach the person how to have their rights restored?

Authority:

Targeted Case Management Manual- 000022 Quality Enhancement Waiver Manual 13.4.A Service Coordinator Monitoring County SB 40 Technical Assistance Manual for TCM, Section V. Services Quality Enhancement Inter-Governmental Agreement to Provide Case Management Services Between Providers And the Division of Mental Retardation and Developmental Disabilities

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