Agency Name:
1. Number of Active Charts Randomly Selected for Review: |Assigned
Caseload = |Active
Caseload = | | | |
| | | |Woman |Total |
| |Performance |# of Charts |Number |# Done |% Compliance |Quarterly Data from Cornerstone |
| |Standard |Reviewed |Expected | | |Report % |
|2. Risk Assessment (707G) |100% | | | | | |
|I. 630.20e Monitoring: At least annually, appropriate health care personnel of the Division and its consultants shall review each project for appropriateness of services and quality of care furnished to recipients|
|in accordance with the project plan. |
|I. Agency Requirements and Provider Qualifications |
|A. The provider provides intensive case management |Contract: |Assessment tool | | | | |
|services to pregnant women meeting specific Department |Attachment | | | | | |
|criteria. |Scope of | | | | | |
| |Services Section | | | | | |
| The agency must agree to help |Section |All Kids log | | | | |
|program participant apply for |Code: |Case Notes | | | | |
|benefits under the All Kids Health |630.220B2 | | | | | |
|Insurance Program or refer them to |Contract | | | | | |
|the closest application agent. | | | | | | |
| | | | | | | |
| | | | | | | |
|Staff employed to provide TIPCM are |Contract: |Proof license | | | | |
|registered nurses who either have a |Attachment |Educational | | | | |
|B.S.N. with an emphasis on maternal- |Scope of Services |qualifications; Degrees| | | | |
|child health, community health |Section | | | | | |
|nursing, or public health, or a Master |MCH Code 630.220 |Policy/Procedure | | | | |
|of Social Work with emphasis on | |Interview with manager | | | | |
|services for women and children; and | |DHS Waiver letter for | | | | |
|experience in working with young | |exceptions | | | | |
|women and children | | | | | | |
| | | | | | | |
|Case loads for TIPCM do not exceed |Contract Attachment |Cornerstone | | | | |
|40 clients per case manager. (If |Scope of Services |Caseload Reports | | | | |
|exceeds 40, explain in “Comments” |Section |HSPR0202; | | | | |
|Section. | |Participant Events: | | | | |
| | |HSPR0604 | | | | |
| | |Policy/Procedure | | | | |
| | | | | | | |
| | | | | | | |
|II. Clinical Record: The participant’s medical record shall contain but not be limited to: |
|General Case Management Activities: |
|A. Documentation of: | | | | | | |
|Missed appointments and attempts to follow-up on missed | |Policy/Procedure | | | | |
|appointments of those participants the case manager or | |Manual | | | | |
|physician have identified as non-compliant. | |Chart Review | | | | |
|Client needs to have a primary care provider or a | |All Kids Log | | | | |
|medical home designated | |(optional) | | | | |
|Each service rendered by the case |Code: |Cornerstone Screens: | | | | |
|manager |630.220d |Enrollment (PA03) | | | | |
| |Cornerstone |Program Info (PA15) | | | | |
| |Manual |Medicaid screen (PA05) | | | | |
| | |Most recent Cornerstone| | | | |
| | |Quarterly Reports | | | | |
|Release of information to providers of necessary |Code: |Release of Information | | | | |
|services |630.220d |Consent | | | | |
| |Cornerstone | | | | | |
| |Manual | | | | | |
| |Code: |Case Notes CM04 | | | | |
|4. Coordination of care |630.220d |Service Entry SV01 | | | | |
| |Cornerstone |Activity EntrySV02 | | | | |
| |Manual |RF01/03 | | | | |
| | | | | | | |
| | | | | | | |
| The provider uses the Cornerstone |TIPCM |Policy/Procedure: | | | | |
|Management Information System to |Contract Agreement |C-Stone Screens | | | | |
|Record demographic health status |Attachment Section A|PA01 | | | | |
|and service delivery information |2nd paragraph |PA02, PA03 | | | | |
|about each client receiving TIPCM | |PA15, PA05 | | | | |
|services. | |PA06, SV01, | | | | |
| | |PA07, PA08, | | | | |
| | |PA10; | | | | |
| | |Assessments | | | | |
| | |700-General | | | | |
| | |(questions 1-40) | | | | |
| | |701-Other Service | | | | |
| | |Barriers | | | | |
| | |703 Psychosocial Stress| | | | |
| | |Mgt., | | | | |
| | |704-Alcohol and | | | | |
| | |Substance Abuse, | | | | |
| | |705-Violence | | | | |
| | |706-Home | | | | |
| | |707D-Prenatal Nutrition| | | | |
| | |707G-Risk Factors | | | | |
| | |SV01-Service Entry | | | | |
| | |SV04-Time Entry | | | | |
|Outreach efforts are conducted to |MCH Code |CM04-Case Notes, | | | | |
|identify and recruit high-risk pregnant |630-220b5 |CM02-Participant | | | | |
|women to participate |Contract attachment |Goals, CM03 – | | | | |
| |13 paragraph |Planned Service | | | | |
| | |Summary, RF01-Referrals| | | | |
| | | | | | | |
| | |Discussion with | | | | |
| | |manager/staff; | | | | |
| | |policy/procedure | | | | |
| | | | | | | |
|III. 630.220c1 and 630.220.131 Case Management Process |
|A. Assessment of needed health and social |Code: 630.220e1a & |Policy & Procedures | | | | |
|services assessment(s) to determine need |630.220e1e |Assessments : | | | | |
|for health, mental health, educational, |Performance Standard|(AS01) | | | | |
|vocational, substance abuse treatment, |90% Contract |General: 700 | | | | |
|child care, transportation, oral health, |TIPCM |(questions: 1-40) | | | | |
|prenatal and postpartum depression |Contract |701-Other service | | | | |
|screening and other services (must |Attachment |barriers | | | | |
|include: risk assessment) |Paragraph 2 C-Stone |703 Psychosocial/ | | | | |
| |TIPCM Flow Chart |Stress Mgt. | | | | |
| | |704-Alcohol/ | | | | |
| | |Substance Abuse | | | | |
| | |705 Violence | | | | |
| | |706 Home | | | | |
| | |707D Prenatal Nutrition| | | | |
| | |707G Risk | | | | |
| | |710 Prenatal Educ. | | | | |
| | |PA11 Birth Data | | | | |
| | |SV01 | | | | |
|TIPCM clients are entered in the |TIPCM |C-Stone Program | | | | |
|“Targeted Intensive Prenatal Case |Contract |Information Screen | | | | |
|Program” on the Program |Attachment |(PA15) | | | | |
|Information Screen (PA15) in the |TIPCM | | | | | |
|Cornerstone Information System: |C-Stone Flow Chart | | | | | |
|(The client is active in two programs, | | | | | | |
|Targeted Intensive Prenatal Case | | | | | | |
|Management and Family Case | | | | | | |
|Management) | | | | | | |
|Frequency of Contacts: |TIPCM |C-Stone: Case Notes | | | | |
|A minimum of two face-to-face |Contract |(CM04) Service Entry | | | | |
|contacts with each client each month |Attachment |Screen (SV01) Activity | | | | |
|(from enrollment to termination of the |Paragraph 1 |Entry Screen (SV02) | | | | |
|pregnancy). | | | | | | |
| | | | | | | |
| | | | | | | |
| | | | | | | |
|Half of the face-to-face contacts |TIPCM |Care Plan: | | | | |
|occur in the client’s home |Contract |Goals (CM02) | | | | |
| |Attachment |Participant Services | | | | |
| |Paragraph 1 |(CM03) | | | | |
| | |Cornerstone: | | | | |
| | |Case notes (CM04) | | | | |
| | |Service Entry Screen | | | | |
| | |(SV01) | | | | |
| | |Activity Entry Screen | | | | |
| | |(SV02) | | | | |
|All prenatal visit dates for each client |TIPCM |Cornerstone | | | | |
|are recorded on the Cornerstone |Contract |Service Entry Screen | | | | |
|Service Entry Screen (SV01) with |Cornerstone |(SV01) | | | | |
|Code 802. |Flow chart | | | | | |
| | | | | | | |
| | | | | | | |
| | | | | | | |
|EPDS prenatally and postpartum |Perinatal Mental |SV01 code 825 | | | | |
| |Health Disorders | | | | | |
| |Prevention and | | | | | |
| |Treatment Act | | | | | |
| | | | | | | |
| | | | | | | |
| | | | | | | |
| | | | | | | |
|B. Development of an Individual Care Plan |
|List of all service providers involved |Code: |Policy & Procedures | | | | |
| |630.220e1b & |Chart review | | | | |
| |630.220e2 |Cornerstone screens: | | | | |
| |Performance Standard|Care Plan | | | | |
| |90% |Goals-CM02 | | | | |
| | |Planned Services-CM03 | | | | |
| |Contract |Case Notes- | | | | |
| | |CM04, RF01, RF03 | | | | |
|List of agencies participant referred to | | | | | | |
| | | | | | | |
| | | | | | | |
| | | | | | | |
| | | | | | | |
| | | | | | | |
| | | | | | | |
|Problem list and plans for resolution | | | | | | |
| | | | | | | |
| | | | | | | |
| | | | | | | |
| | | | | | | |
| | | | | | | |
|Includes evidence of review, updated information and | | | | | | |
|follow-up activity | | | | | | |
| | | | | | | |
| | | | | | | |
| | | | | | | |
| | | | | | | |
| | | | | | | |
| | | | | | | |
| | | | | | | |
|Referrals as appropriate documented on the RF01/03 with status of follow-up documented under RF01 comments field: |
|Health |Code: 630.220e1c |Cornerstone screens: | | | | |
|Mental health | |Case Notes— | | | | |
|Substance abuse treatment | |CM04 &/or | | | | |
|Smoking cessation services | |Service Provider | | | | |
|Domestic violence services | |Selection (RF01, 03) | | | | |
|Family planning |Contract |CM02, CM03 | | | | |
|Housing | |RF01 | | | | |
|Educational/vocational | |SV01 | | | | |
|Child care | |Code 813 medically | | | | |
|Transportation | |necessary | | | | |
|Oral health and other services | |transportation | | | | |
|WIC | | | | | | |
|Food bank | | | | | | |
|Clothing | | | | | | |
|Other services | | | | | | |
|Referrals kept appropriately documented | | | | | | |
|D. Client Education |
|Provide Healthy Start/Grow Smart |Contract |Anticipatory Guidance | | | | |
|brochures from HCFS post delivery |Code: |Screens, SV01 Service | | | | |
| |630.210.D |Entry | | | | |
| |630.210.E |Case Notes | | | | |
| | | | | | | |
|Post information on accessing free | | | | | | |
|Transportation | | | | | | |
| | | | | | | |
|All Kids | | | | | | |
| | | | | | | |
| | | | | | | |
|Prenatal Care | | | | | | |
| | | | | | | |
|E. Postpartum Information |
|Each child’s birth data is entered on | | | | | | |
|the Cornerstone Infant Birth Data |C-Stone |PA11 | | | | |
|Screen (PA11) |TIPCM |Cornerstone | | | | |
| |Flowchart |Infant Birth Data | | | | |
| |TIPCM Contract |Screen | | | | |
| |Attachment | | | | | |
| | | | | | | |
|After the infant’s birth, the |TIPCM Guidelines |Cornerstone Program | | | | |
|Targeted Intensive Prenatal Program | |Information Screen | | | | |
|Record (the PA15 is closed on all | |(PA15) | | | | |
|clients | | | | | | |
|Corrective Action Plan Please email to: |
|Please respond within 20 working days to the following required actions by: _________________________________ |
|(Date) |
| |
|See attached Review Findings and CAs Summary |
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