ConsumerLink Progress Note Training

Progress Note Training

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This document revised April 2016.

Why do we need Progress Notes?

• To ensure provision of Medicaid Authorized services according to Medical Necessity, including Scope, Duration and Frequency as outlined in the IPOS and to support the level of services authorized

• To ensure completion of IPOS identified clinical interventions and action steps in order to support the person in achieving goals.

• Provide clarity to Provider Staff of specific goals / actions for documentation related to CLS

Why do we need Progress Notes?

• To monitor progress and/or concerns related to the person’s achievement of goals

• To improve the collaboration/coordination/and communication between the SC and the staffing provider

• Shift notes did not capture the actual service time connected with providing clinically meaningful activities

• To meet the contract requirements for a “clean claim”

“Clean Claim” Standards

DWCMHA “Clean Claim” Standards

• A “clean claim” paid by the MCPN to any subpanel provider organization for which the MCPN (ConsumerLink) has submitted data/cost encounter into the Agency (Wayne County) for reimbursement, SHALL MEET ALL OF THE FOLLOWING CRITERIA:

– A covered service defined in the Person’s applicable benefit plan, as contained in the Agency’s “Covered Benefits Policy” guideline (Note: this is why we have the Out of Benefit process in place);

– The Person meeting the Agency’s “eligibility” criteria for the benefit plan (e.g. Medicaid or General Fund) on the date of service delivery, as defined in the

Agency’s “Covered Benefit Policy” guideline;


• A “clean claim” … shall meet all of the following criteria:

– The Person having an assessed need completed by a qualified credentialed practitioner, with supporting evidence contained in the medical record;

– The covered service is documented in the person’s “Person-Centered Plan” (and IPOS), as an authorized medically necessary service;

– Documentation in the medical record that details what covered services were provided to the individual on the date of the service;



– Documentation in the medical record that the covered service was provided by an appropriately credentialed practitioner, qualified to render the covered service (Note: in the case of CLS, staff must have current training and meet the standards in the Medicaid manual);

– Documentation in the medical and/or administrative records that the Provider Organization maximized all applicable first and third party payments due prior to submitting a claims encounter to the MCPN and…



– Assurance that the claim encounter was submitted timely and in accordance with the Agency/MCPN claims payment protocols

Role of the Supports Coordinator or Therapist

• Completes top portion of provider progress note regarding:

– Member information

– Relevant expected outcome, goal statement from IPOS and/or FAST

• Completes top portion of provider progress note regarding:

– Interventions and action steps indicated in IPOS/FAST pertaining to expected delivery of Community Living Supports, Personal Care and/or Respite.

– Faxes a copy of the progress note with completed top section to the staffing provider.


• Clear outcomes, goals and action steps are essential to treatment success

– The Person’s expected outcome or goal provides a baseline for measure of progress for the provider and future review

– Interventions and action items from the IPOS show the provider the activities they must assist the Person to complete/learn to meet their goals.


• Clear outcomes, goals and action steps are essential to treatment success

– All CLS goals should be clearly defined and describe scope, duration and intensity on the FAST tool. The FAST is an addendum to the IPOS.

– The Supports Coordinator should never indicate on the FAST that the reader should “see PCP”.

– The CLS goals and objectives from the FAST will then be transferred to the Progress Note for clear tracking.

– Personal Care goals should only be created and transferred to the Progress note for people in licensed, specialized residential settings only


• Provides in-service/orientation to the staffing provider staff within 30 days of the IPOS or service authorization effective date and reviews expected service delivery areas in the IPOS and as described in the provider progress note.

• Reviews provider progress notes monthly for provision of services identified in IPOS and progress toward identified outcomes and updates the PCP/IPOS as needed.

• Initials progress notes to indicate review (7 days).


• Incorporates and summarizes information and data reviewed in provider progress notes into the supports coordination progress notes monthly and status reviews as indicated in IPOS.

• Reports concerns about amount, scope or delivery of expected provider services to provider management staff and supports coordinating agency supervisor.

• Ensures that a copy of the IPOS, including the current FAST, and any plans related to ancillary staff (psychology, occupational therapy, dietary, etc.) are available on site for staff review at supported housing and specialized residential sites.

• For Community Living Supports provided in the family home (H2015) or In-home Respite services (T1005), documents listed above should be made available at the staffing provider’s office.


• Provides copies of progress notes for review by supports coordinator a minimum of monthly, during site visits or upon request of documents for review if CLS is being provided in the family home (H2015).

• Contacts Supports Coordinator or Supports Coordinator Supervisor with concerns about delivery of services according to IPOS defined scope, duration and frequency or changes in level of need.

• Contacts the Supports Coordinator’s Supervisor if no Progress Note is provided for their use.


Role of Staffing Provider

• Delivers and describes services according to Medicaid service definitions:

– Community Living Services (CLS)

– Personal Care (PC)• Completes one progress note daily on each CLN

member indicating:

– Start and stop time of delivery of each service provided (CLS, Personal Care and/or ancillary plan interventions)

• Times do not have to be back to back• Entries can indicate CLS services not connected to a

goal but evident from the FAST assessment tool as a skill that the person needs to develop.


• When documenting time you should reflect actual time spent as closely as possible

• Avoid rounding up

• Identifies Task and/or intervention completed for each area from action items on the progress note or from ancillary plans from the IPOS

• Marks objective from IPOS (uses codes provided on the Progress Note)

• Example: Under CLS Joan has 3 areas she is working on under Safety. “B” is to work on learning to identify risk factors in the home. You work with Joan for 20 minutes on this area. You would document “CLS “B”) under the “Objective Area from IPOS” column of your Progress Note.


• Indicates Progress based on measurable outcome identified and/or intervention described by marking the correct box (Decreased, Same, or Improved).

• Provides additional Comments as needed on the progress note

• Signature and initials of each staff completing the progress note should be present.

• Provides documentation that is legible.

• Provides documentation of all services delivered as reflected in the IPOS, FAST or ancillary service plans

• Reviews IPOS / FAST and plans from ancillary staff regularly

to ensure implementation of action steps and incorporates into progress notes.


Documenting Shifts• Daily notes should always consistently show average

hours of services to match FAST/IPOS during a 24 hour period.

• Notes should reflect IPOS/FAST identified needs and priorities related to both CLS and Personal Care if in a specialized residential facility.

Documenting Overnight Shifts• If staff are present during sleeping hours and the

IPOS states specific need for nighttime monitoring or interventions – Progress notes should show this.


Warning!!Not providing services in accordance with the authorization and medical necessity stated in the IPOS/FAST can result in:• Requirement to pay back funds• Possible Rights violations for failing to

provide services according to the plan

Definition of CLS

• Community Living Supports are used to increase or maintain personal self-sufficiency, facilitating an individual’s achievement of his goals of community inclusion and participation, independence or productivity.

• Coverage includes:– Assisting, reminding, observing, guiding and/or

training in the following activities:• Coverage includes:

– Assisting, reminding, observing, guiding and/or training in the following activities:• meal preparation• laundry• routine, seasonal, and heavy household care and

maintenance• activities of daily living (e.g., bathing, eating, dressing,

personal hygiene)• shopping for food and other necessities of daily living

Definition of CLS

• Staff assistance, support and/or training with activities such as:

– money management– non-medical care (not requiring nurse or

physician)– socialization and relationship building– transportation from the beneficiary’s residence to

community activities, among community activities, and from the community activities back to the beneficiary’s residence

Definition of CLSand What to Document

• Staff assistance, support and/or training with activities such as:

– participation in regular community activities and recreation opportunities (e.g., attending classes, movies, concerts and events in a park; volunteering; voting)

– attendance at medical appointments– acquiring or procuring goods, other than those

listed under shopping, and– Reminding, observing and/or monitoring of

medication administration

What to Document

• CLS or Personal Care activities documented in the progress note should be reflective of what was captured in the FAST as supports needed by the person (even if these items were not chosen as goals to be worked on during the current reporting period).

• If additional CLS or Personal Care supports appear to be needed on an ongoing basis, the provider should request the completion of an updated FAST.

CLS vs. Personal Care /Home Help

• CLS services may not supplant state plan services, e.g., Personal Care (assistance with ADLs in a certified specialized residential setting) and Home Help or Expanded Home Help (assistance in the individual’s own, unlicensed home with meal preparation, laundry, routine household care and maintenance, activities of daily living and shopping).

• Please do not document Personal Care activities as CLS

CLS vs. Personal Care /Home Help

• If a person you are assisting is receiving Home Help dollars and you are providing that service --

• Remember that you will need to track this activity on a separate progress note.

Respite

• Respite services are provided to assist in maintaining a goal of living in a natural community home by temporarily relieving the unpaid primary caregiver.

• Provided during those portions of the day when the caregivers are not being paid to provide care.

• Not intended to be provided to enable the caregiver to work somewhere else.

• Not intended to extend CLS services.

Respite

• Respite services are available for CLN members only.

• The Respite provider should never provide Respite for other (none CLN) family members.

• Can be provided to more than one CLN member residing in the same home at the same time, however, the services must be documented on separate progress notes and it must be part of all the Plans.

Exceptions for Respite & CLS

• Respite and CLS services are not available to paid foster parents in a licensed foster care placement through ConsumerLink. These services are available to them through their foster care agency.

• Respite services may be available through ConsumerLink to children living in a family foster care home, unless the child is receiving Therapeutic Foster Care as a Medicaid SED waiver service because this is considered in the bundled rate (April 1, 2013).

ConsumerLink’s Role

• Conducts audits and reviews of provider progress notes related to specific members or sites for verification of services delivered in amount, scope and duration identified in IPOS/FAST.

Healthcare

ConsumerLink Progress Note Training