Home and Community-Based Services Information ... - …



SUPPORTS COORDINATION PROCESS:

INDIVIDUAL SUPPORT PLAN MONITORING

Information gathered in this document includes a review of current supports and services identified in the ISP to support health and safety, individual preferences, priorities. This review measures the progress and effectiveness of outcomes and positive approaches identified in the ISP.

|Individual’s Name: | |

|Supports Coordinator’s Name: | |

|Date: | |

You can use the links below to quickly access an area of the Monitoring Tool. Your web toolbar will appear which will allow you to use the [Back] and [Forward] buttons.

Begin Monitoring

Instructions

Health/Safety/Well Being

Medical Information-1

Medical Information-2

Individual Support Plan Status

Incident Reports

Financial Information

Consumer Satisfaction

| |

|SC: INDIVIDUAL MONITORING: SC Monitoring |

|Type of Contact (mark the appropriate one) |

| |Community |

| |Community with Medications |

| |Day Support |

| |Day Support with Medications |

| |Home |

| |Home with Medications |

| |Phone |

| |Phone with Medications |

|Contact Date | |

|Announced | |Yes | |No | |

|Time of Contact | |

|Provider | |

|Person Performing Monitoring | |

Instructions:

In the column labeled Contact Type, the contact type(s) will be listed indicating on which version of the monitoring tool the question appears. Only answer those questions that pertain to the type of monitoring you are completing.

➢ Community – A face-to-face monitoring activity that takes place in a social or recreational environment such as a restaurant, sporting event, or any other location of the consumer’s choice other than the home or the day supports location.

➢ Day – A face-to-face monitoring that takes place wherever funded day supports are provided. (This could include place of employment, adult training facility, or vocational training facility.)

➢ Home - A face-to-face monitoring activity that takes place at the individual’s residence.

➢ Phone – A monitoring activity that takes place through a phone contact.

Unless specifically stated, the Contact Type that is listed represents the contact type both with and without medications. For example, a contact type of Home would indicate that the question should be completed for both the Home without medication and Home with medication.

|Contact Type |Question |Answer |Comments |Issues |

| |

|SC: INDIVIDUAL MONITORING: HEALTH/SAFETY/WELL BEING INFORMATION |

|Community |Are all the individual’s identified health care needs being addressed? | |Yes | | |

|Day | | | | | |

|Home |Document findings by asking the individual and primary caregivers: ask | | | | |

|Phone |about health status or barriers accessing needed health supports. | | | | |

| | | | | | |

| |Review health promotion information in the ISP. | | | | |

| | | |No | | |

|Community |Have there been changes observed in the individual’s overall health | |Yes | | |

|Day |functioning and health status since the last monitoring? (If the | | | | |

|Home |individual is now on medication, please use the medication tool.) | | | | |

|Phone | | | | | |

| |Document changes in weight, sleep habits, appetite, appearance, and | | | | |

| |changes in behavior via SC observation, interviews with individual or | | | | |

| |primary caregivers or review of available medical records. | | | | |

| | | |No | | |

|Community |Necessary appointments were scheduled and kept. | |Yes | | |

|Home | | | | | |

|Phone |Document findings via medical records, interviews with individual and | | | | |

| |primary caregivers, particularly those involved with scheduling and follow| | | | |

| |through. | | | | |

| | | | | | |

| |N/A: No appointments during time period | | | | |

| | | |No | | |

| | | |N/A | | |

|Community with Meds|Have there been any medication changes or has this consumer experienced | |Yes | | |

|Day with Meds |any side effects and/or adverse drug reactions to any medications since | | | | |

|Home with Meds |last monitoring? | | | | |

|Phone with Meds | | | | | |

| |Document finds via medical records, interviews with individual and primary| | | | |

| |caregivers, particularly those involved in helping with medication | | | | |

| |administration. Document any observable changes in physical appearance, | | | | |

| |notes from any medication records that refer to drug interactions, | | | | |

| |information shared by individual or primary caregivers about side effects | | | | |

| |of meds and actions taken. Interview staff (family) as appropriate. | | | | |

| |Review progress notes. | | | | |

| | | |No | | |

|Day with Meds |Medication log is correct, complete and reflective of medication | |Yes | | |

|Home with Meds |administration. | | | | |

| | | | | | |

| |See medication administration training materials for specific guidelines | | | | |

| |and review medication log. | | | | |

| | | | | | |

| |N/A: Persons own home or family home | | | | |

| | | |No | | |

| | | |N/A | | |

|Home |Is the residence clean, hygienic and odor free? | |Yes | | |

| | | | | | |

| |Document observations regarding reasonable cleanliness & sanitary | | | | |

| |conditions. | | | | |

| | | |No | | |

| | | |N/A | | |

|Home |Are the house, site, household furnishings and appliances in good | |Yes | | |

| |condition and is this consumer’s room appropriately individualized and | | | | |

| |appointed? | | | | |

| | | | | | |

| |Focusing on health & safety, document overall condition of furniture, | | | | |

| |appliances, electrical cords, railings, steps, sidewalks, etc. Consider if| | | | |

| |the room is individualized, related to the individual’s interests, | | | | |

| |personal values, etc. | | | | |

| | | | | | |

| |N/A: Persons own home, family home or person does not grant access to room| | | | |

| | | |No | | |

| | | |N/A | | |

|Community |Is necessary adaptive equipment available, in good condition, and being | |Yes | | |

|Day |used? | | | | |

|Home | | | | | |

|Phone |Observe and ask the individual and primary caregivers if needed equipment | | | | |

| |is available, being used, and in good repair. | | | | |

| | | | | | |

| |N/A: No adaptive equipment needed | | | | |

| | | |No | | |

| | | |N/A | | |

|Community |Is the home/setting/community fully accessible as it relates to the | |Yes | | |

|Day |individual’s needs, mobility, vision, etc? | | | | |

|Home | | | | | |

| |Document observations about accessibility for individual, actions taken | | | | |

| |such as adaptations recommended by therapists and interview individual and| | | | |

| |primary caregivers about ease/challenges in getting around. | | | | |

| | | |No | | |

|Day |Is the food handled and stored in a safe and sanitary manner? | |Yes | | |

|Home | | | | | |

| |Observe where, how and the condition of food stored. Is food separate from| | | | |

| |cleaning supplies? Is refrigeration needed? Are odors present?, etc. | | | | |

| | | | | | |

| |N/A: Persons own home or family home | | | | |

| | | |No | | |

| | | |N/A | | |

|Community |Are special diets being followed? | |Yes | | |

|Day | | | | | |

|Home |Review documentation of any orders or recommendations from | | | | |

|Phone |physician/nutritionist. Ask individual and primary caregivers if diet is | | | | |

| |being followed. Look for availability of appropriate foods (low fat, etc) | | | | |

| |and appropriate consistency of food. Does what is available match with | | | | |

| |what is recommended? Has the staff been appropriately trained to | | | | |

| |implement the diet? | | | | |

| | | | | | |

| |N/A: No special diet | | | | |

| | | |No | | |

| | | |N/A | | |

|Contact Type |Question |Answer |Comments |Issues |

|Home |Are there adequate amounts of food? | |Yes | | |

| | | | | | |

| |Observe overall appearance of individual. Look for food available; ask the| | | | |

| |individual and primary caregivers if there is adequate amount of money | | | | |

| |available for food. | | | | |

| | | | | | |

| |N/A: Persons own home or family home | | | | |

| | | |No | | |

| | | |N/A | | |

|Community |Are there any additional health and safety issues or barriers affecting | |Yes | | |

|Day |the person’s wellbeing? | | | | |

|Home | | | | | |

|Phone |Document observations such as anything in residence that would lead you to| | | | |

| |believe the person is in danger, intimidation by staff/others, incidents | | | | |

| |related to individual or site not noted previously, anything that didn’t | | | | |

| |fall into previous categories, ask the individual if he/she feels safe. | | | | |

| | | |No | | |

|Community |Is the individual dressed appropriately and well groomed? Is clothing | |Yes | | |

|Day |available that is appropriate to weather conditions? | | | | |

|Home | | | | | |

| |Observe if clothing is in good repair, appropriate for the occasion/ | | | | |

| |weather/ situation, chosen by the individual, coordinated, and fits | | | | |

| |properly. Individual appearance to include overall cleanliness, evidence | | | | |

| |of brushing teeth, nail and hair care, body odor, clothes washed, etc. | | | | |

| | | |No | | |

| |

|SC: Individual Monitoring: Medical Information-1 |

| |

|(Tools with Med Only) |

|Medication Name | |

|If Other, Please Specify | |

|Diagnosis | |

|Total Daily Dosage | |

|Blood Levels Available | |

|Desired Effect/Comments | |

|Medication Name | |

|Diagnosis | |

|Total Daily Dosage | |

|Blood Levels Available | |

|Desired Effect/Comments | |

To Create Additional Rows for Medications:

1. Highlight the second set of blank rows to be copied from the left hand margin.

Note: If the first row is copy and pasted, the hyperlink from page 2 will no longer go to the first entry for that area of the ISP. Instead, the hyperlink will go to the last set of rows pasted into the section.

2. Click on Edit, Copy.

3. Immediately click on Edit, Paste Rows.

4. Additional rows will appear below the highlighted rows.

5. Continue pasting rows until there are enough rows for the information.

|Contact Type |Question |Answer |Comments |Issues |

| |

|SC: Individual Monitoring: Medical Information-2 |

|Community |Are there any barriers towards accessing medical/behavioral supports? | |Yes | | |

|Day | | | | | |

|Home |Interview individual, family and staff. Check to see if there have been | | | | |

|Phone |any barriers in accessing medical/behavioral supports. | | | | |

| | | |No | | |

|Community with Meds|Is a diagnosis or symptom present for each medication? | |Yes | | |

|Home with Meds | | | | | |

|Phone with Meds |Document findings from medical reports logs, or prescriptions. Ask primary| | | | |

| |caregivers why individual is taking the medication and what it is supposed| | | | |

| |to do. | | | | |

| | | |No | | |

|Community with Meds|Are symptoms still present? If so, what is the follow-up? | |Yes | | |

|Home with Meds | | | | | |

|Phone with Meds |Document findings from daily logs, tracking logs, and/or interview with | | | | |

| |individual and primary caregivers about ongoing symptoms. If medication is| | | | |

| |not working, find out what follow-up is planned if checked yes | | | | |

| | | |No | | |

|Day with Meds |Are blood levels completed and results shared for each medication | |Yes | | |

|Home with Meds |requiring blood levels? | | | | |

| | | | | | |

| |Information may be found in medical logs when blood levels are ordered by | | | | |

| |the prescribing physician, physical/specialty exam summaries, monthly | | | | |

| |medical reviews, lab slips or results of actual test, interview with | | | | |

| |individual and primary caregivers. | | | | |

| | | | | | |

| |N/A: Medication doesn’t require blood levels | | | | |

| | | |No | | |

| | | |N/A | | |

|Community with Meds|Does the direct care staff/caregiver know where to find information | |Yes | | |

|Day with Meds |related to side effects of medication? Does the direct care | | | | |

|Home with Meds |staff/caregiver know how to report observed side effects? | | | | |

|Phone with Meds | | | | | |

| |Interview staff; request to see medication side effects documentation. | | | | |

| |Document findings by asking direct care staff: What would you do if a | | | | |

| |side effect was occurring or reported? | | | | |

| | | |No | | |

|Community |If specialists are involved, is there appropriate and timely communication| |Yes | | |

|Day |between the team and specialists and are specialists’ recommendations | | | | |

|Home |being followed? (i.e. psychiatrist, behavioral consultants, speech | | | | |

|Phone |therapists) | | | | |

| | | | | | |

| |Review documentation of each specialist’s recommendations to determine if | | | | |

| |the recommendations are being followed , time frame between referral and | | | | |

| |follow-through (beyond 30 days should be reviewed/follow-up) | | | | |

| | | | | | |

| |N/A: No specialist recommendations | | | | |

| | | |No | | |

| | | |N/A | | |

|Day |Is an annual physical on site? | |Yes | | |

|Home | | | | | |

| |Review annual physical. The review date should be within 1 year | | | | |

| |(annually). Documents should be in residential, day program, or county | | | | |

| |office or SC entity if the person lives in their own home. | | | | |

| | | | | | |

| |N/A: Not in a residential or day program | | | | |

| | | |No | | |

| | | |N/A | | |

|Day |Annual Physical Review Date. | | | |

|Home |(mm/dd/yyyy) | | | |

|Community |Additional information/comments regarding medical information. | |

|Day | | |

|Home | | |

|Phone | | |

| |

|SC: Individual Monitoring: Individual Support plan status |

|Community |Are there any barriers to service delivery including staffing and | |Yes | | |

|Day |transportation? | | | | |

|Home | | | | | |

|Phone |Interview individual, family and staff to see if there are any delays in | | | | |

| |receiving supports/services. | | | | |

| | | |No | | |

|Day |Is the current Individual Support Plan (ISP) present on site? | |Yes | | |

|Home | | | | | |

| |Document that current ISP is at day program and/or residential program. | | | | |

| | | |No | | |

|Day |Current ISP start date. | | | |

|Home |(mm/dd/yyyy) | | | |

|Community |Have there been any changes in services since the last monitoring? If | |Yes | | |

|Day |there were changes, was a Critical Revision completed? Please describe the| | | | |

|Home |change in the comments box. | | | | |

|Phone | | | | | |

| |Considerations: starting or ending services, new provider, frequency or | | | | |

| |duration changes, setting change, not the specific therapist change, but a| | | | |

| |change in residence/supports. | | | | |

| | | |No | | |

|Community |If the previous question is “YES”, was the individual notified of their | |Yes | | |

|Day |right to appeal? | | | | |

|Home | | | | | |

|Phone |Review protocol with compliance to the Service Preference Bulletin/ County| | | | |

| |Appeal Process. | | | | |

| | | | | | |

| |N/A: No change in services | | | | |

| | | |No | | |

| | | |N/A | | |

|Day |Does the overall staffing reflect what is called for in the approved ISP? | |Yes | | |

|Home | | | | | |

| | | | | | |

| |Document findings by looking at ISP level of supervision (Is Intensive | | | | |

| |Supervision needed?) and in your judgement does the level of staffing | | | | |

| |appear adequate for the individual’s needs? | | | | |

| | | | | | |

| |N/A: Person in supported living with “alone time” | | | | |

| | | |No | | |

| | | |N/A | | |

|Community |Were all services and supports in the individual’s approved ISP received? | |Yes | | |

|Day | | | | | |

|Home | | | | | |

|Phone |Review approved ISP and authorized services, interview individual staff | | | | |

| |and primary caregiver to determine if services are being received at the | | | | |

| |frequency and duration described in the ISP. | | | | |

| | | |No | | |

|Community |Is there evidence that reflects progress is being made toward the desired | |Yes | | |

|Day |outcomes as reflected in the individual’s ISP? | | | | |

|Home | | | | | |

|Phone |Specify evidence present that reflects progress is or is not being made? | | | | |

| |Interview individual, family, staff, review progress notes and quarterly | | | | |

| |reports etc. to determine progress. Evidence can be in the form of | | | | |

| |documentation, family reporting, demonstration, etc. | | | | |

| | | |No | | |

|Contact Type |Question |Answer |Comments |Issues |

|Community |If the individual has more than one service provider, is there evidence of| |Yes | | |

|Day |coordination between them? | | | | |

|Home | | | | | |

|Phone |This includes when one provider provides multiple services. Interview | | | | |

| |individual, family and staff. | | | | |

| | | | | | |

| |N/A: Only one provider and service | | | | |

| | | |No | | |

| | | |N/A | | |

|Day |Is there appropriate staff member/individual interaction? | |Yes | | |

|Home |Observe staff and individual communication, interview individual, family | | | | |

| |and staff. Is the individual being treated with dignity and respect? | | | | |

| | | | | | |

| |N/A: Person has “alone time” during monitoring visit. | | | | |

| | | |No | | |

| | | |N/A | | |

| |

|SC: Individual Monitoring: Incident reports |

|Community |Have there been any incidents since the last monitoring that were not | |Yes | | |

|Day |reported? | | | | |

|Home | | | | | |

|Phone |List incidents, if any occurred but were not reported. Interview staff for| | | | |

| |further clarification on the incident information. Inform provider to | | | | |

| |report any missing reportable incidents. | | | | |

| | | |No | | |

|Contact Type |Question |Answer |Comments |Issues |

|Community |Were all reportable incidents completed, investigated and corrective plans| |Yes | | |

|Day |implemented? | | | | |

|Home | | | | | |

|Phone |Interview staff, review progress notes/incident reports to verify if | | | | |

| |incidents were completed, investigated if required, and corrective action | | | | |

| |plans implemented. | | | | |

| | | | | | |

| |N/A: No reportable incidents | | | | |

| | | |No | | |

| | | |N/A | | |

| |

|SC: Individual Monitoring: financial information |

|Community |Are there any barriers to accessing financial information? | |Yes | | |

|Home | | | | | |

|Day | | | | | |

|Phone | | | | | |

| | | |No | | |

|Home |Are individual’s assets below the established limit? ($2,000 if receiving| |Yes | | |

| |SSI or $8,000 if only receiving SSD) | | | | |

| | | | | | |

| |Review limit with waiver, SSI and Medicaid recipients. For non MA | | | | |

| |recipients, indicate “No” and explain in comments section | | | | |

| | | |No | | |

|Home |Is all appropriate financial documentation of expenses and personnel funds| |Yes | | |

| |available at the consumer’s residence? | | | | |

| | | | | | |

| |Review financial records for compliance with the client funds bulletin. | | | | |

| |There must be a separate record of financial resources including the date | | | | |

| |and amount of deposits and withdrawals. | | | | |

| | | | | | |

| |N/A: Records available but not at residence i.e. with representative payee| | | | |

| |or family member | | | | |

| | | |No | | |

| | | |N/A | | |

|Community |Are personal funds available to the consumer? | |Yes | | |

|Day | | | | | |

|Home |Interview individual, family and staff to determine if funds are available| | | | |

|Phone |to the individual. Review receipts and documentation of spending. | | | | |

| | | |No | | |

|Home |Are the Representative Payee arrangements meeting their obligation to the | |Yes | | |

|Phone |individual? | | | | |

| | | | | | |

| |Interview individual, staff, and family to review financial | | | | |

| |situation/records to determine if obligations are being met. | | | | |

| | | | | | |

| |N/A: No representative payee involved | | | | |

| | | |No | | |

| | | |N/A | | |

| |

|SC: Individual Monitoring: consumer satisfaction |

|Community |Are there any barriers to consumer satisfaction? | |Yes | | |

|Day | | | | | |

|Home |Interview individual, family and staff. Check to see if there have been | | | | |

|Phone |complaints, fair hearings registered or acted upon. | | | | |

| | | |No | | |

|Community |Does the individual feel that the services/supports they receive are all | |Yes | | |

|Day |that they need? | | | | |

|Home | | | | | |

|Phone |Interview individual, family and staff. Review IM4Q satisfaction surveys | | | | |

| |or other external monitoring. If there are substantial unmet needs, | | | | |

| |identify need in comments and a PUNS should be completed. | | | | |

| | | |No | | |

|Contact Type |Question |Answer |Comments |Issues |

|Community | Is the individual satisfied with their current services/ supports? If | |Yes | | |

|Day |not, have other options been explored including a choice of providers? | | | | |

|Home | | | | | |

|Phone |Interview individual, family and staff to determine satisfaction of | | | | |

| |services. Did they have a choice of provider and support coordination | | | | |

| |entity or supports coordinator? | | | | |

| | | |No | | |

|Community |Does the individual know how to report a concern or complaint? | |Yes | | |

|Day | | | | | |

|Home |Interview individual and family or advocate if appropriate, to determine | | | | |

|Phone |if the individual knows how to report a complaint. Check that agency | | | | |

| |procedures are in place for complaints from consumers. Does the person | | | | |

| |want or need an advocate? | | | | |

| | | |No | | |

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