STAFF TRAINING COMPETENCY Elements of Service and Documentation

STAFF TRAINING COMPETENCY Elements of Service and Documentation

Hab. Tech. NOTES � � Grids are the forms used to identify goals being addressed and with a key developed that shows intervention/activity provided and a separate key which shows the clients progress toward goals. Grids shall include: � Full date service provided � Goals being addressed � Number or letter as specified in key � Initials of individual reporting service. � Comment section and full signatures of all involved.

Additional Requirements � � Hab. Techs. are to make notes during the day, not at the end of the day. If a service entry is made after 60 working days of the service, it must include “late entry”. (E. g. “late entry on 4/3/16 for 2/4/16). Comments should be made whenever a client does not follow regular schedule (leaves early, has a Dr. appt, etc. ). Hab. Tech. notes are locked in file drawer in coffee room each night.

Documenting Service Records � � All entries should be legible. Made in permanent black ink. Typewritten or computer generated meets this requirement. Each page requires consumer name and record number. Only accepted abbreviations should be used.

Consent for treatment or research � � Consent for treatment shall be signed by consumer or guardian, if there is one. Written consent that grants permission to seek emergency medical care from a hospital or doctor shall be obtained from consumer or guardian, if there is one. Any release must be documented in file. For research purposes, written consent signed by consumer and guardian, if there is one, shall be obtained to authorized consumer’s participation as a subject in research project.

Consent for research, con’t: � Consent must reflect following: � Consumer and/or guardian have been informed of any potential dangers that may exist � Conditions of participation are understood � Consumer has been informed of the right to terminate participation without prejudicing the treatment that he/she is receiving.

Allergies � Any known allergies and adverse reactions should be noted in the consumer file. � Even if there are no known allergies, this should be prominently noted in the file.

Corrections/Alterations � � � No deletions. Single line drawn through entry with black ink. Correction/alteration written in above original. Initials of recorder. Explanation to be written when correction/alteration not clear. If correction explanation won’t fit on same line, put at end of service record. Don’t squeeze it in.

Signatures � � � All entries in service records must be signed. When the staff member is no longer available, their supervisor shall note this in file, with their name/credentials. Electronic signatures are allowed.

Records Retention & Disposition � � History in each consumer file shall be removed from the file and placed into a “history “ envelope. Name of client and dates of paperwork within noted on envelope. Envelope filed in history file drawer. No history shall be shredded. Only current PCP/ISP, goals, authorization, etc. should be in file. Keep all evaluations in the file. Old PCP’s and paperwork go to history.

Hab. Tech. NOTES � � � � � Notes in black ink. No blank spaces Entries made on daily basis. Directly address client goals Brief and to the point Each entry dated and signed Title follow hab. tech. signature Notes written in third person Mistakes not blacked out. Follow correction policy.

Hab. Tech. notes con’t: � � Comment page for additional info or explanations. No judgments made. Describe behaviors only. Every two weeks, turn notes in to Assistant Director. Each afternoon, put hab. tech. notes in locked file cabinet.

Innovation Services � � Can be provided as group or individual service. Can provide both on the same day, but not at the same time. Usually provided Monday through Friday. We cannot provide Innovation services in a consumer’s home.

Innovation Services con’t: � Services and supports include: � Habilitation training Self-direction Money management Daily living skills Socialization Mobility

Personal Centered Plan (PCP) Individualized Service Plan (ISP) � � � Have to be renewed on an annual basis, before it expires. Meeting of all team members. Discuss goals and progress. Plans must be signed by all parties. Copy of plan, signature page, and goals are placed in consumer’s file.

Basic rules for documentation � � � � Accurate Timely Objective Specific, concise, descriptive Consistent Comprehensive, logical and reflective of thought. Clear

Continued… � � � Avoid drawing conclusions. Any remarks by others that indicate bias against a client, are unprofessional and should not appear in client record…unless accompanied by a statement reflecting the need for the documentation. Continuous entries minimize suspicions of inappropriate alterations to the record. Notations in one client’s file shall not identify another client. Use the second client’s initials, record number, etc. Non-client names should only be noted in the record when clinically pertinent and should be reviewed before release. Any copies materials shall include the clients name and record number on each page to provide protection from legal questions regarding copied materials

Continued… � When record content requirements are omitted from the service record due to clinical or other complications, the reason for the omission shall be documented in the record. (e. g. , couldn’t complete assessment due to behavior of client”)

Medicaid Fraud/Abuse � � � � Service is not based on necessity Services are used for staff convenience Poor time-keeping of activities Poor documentation practices Poor judgment Failure to pay back deficiencies. There does not have to be intent to be fraudulent. Lack of knowledge not a defense!