ISP Monitoring 2014 - Lesson 3 Printable Version PD

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Course Number: 005-15-03

1ISP Monitoring 2014 - Lesson 3

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Hello, my name is Sonya Hipple, Supports Coordination Organization Lead (SCO) for the Office of Developmental Programs. Welcome to Lesson 3 of ISP Monitoring 2014.



Issues and comments were discussed in the Introduction to ISP Monitoring course; in this lesson, we’ll expand our understanding of the difference between issues that require immediate action to address risk and issues that require longer‐term planning by the team to resolve. We’ll talk about the steps SCs need to take to respond to issues.

The lesson will include information about how documentation of an issue is to be done – from the point when it’s identified until the issue is resolved.

We’ll make the point that the SC is not acting alone in resolving issues by talking about responsibilities of SC Supervisors, SCO Administration, Providers, AEs, and ODP.

We’ll also talk about the ways SCOs use comments to track important information. We’ll talk about roles and responsibilities when issues are identified and as I do, keep in mind what we discussed in the first lesson about the collaborative nature of monitoring. We’ll also discuss ways to link documentation from the point an issue is identified to actions taken to address it, through resolution of the issue.

Amy Hines from the Office of Developmental Programs Consulting System will be your narrator.



Thanks, Sonya.

We’re turning to the Supports Coordination Services Bulletin to begin discussion of issues and comments. The Bulletin establishes that the outcome of the monitoring process is to identify and resolve issues and comments. In this lesson, we’re going to distinguish issues from comments, and talk about issues that require immediate action versus those that require planning over time to address. We’ll include ways that SCOs use comments – for example, as one method to record information that SCs want to refer to at a future monitoring visits.

We’ll talk about the importance of clear documentation of an issue to ensure that a reader can easily follow the issue from the point of identification to resolution.



The first thing to know when thinking about issues and comments is ODP’s expectation that every question must have more than a yes or no answer.

Even when the question does not reveal an issue, a yes or no response without more information really doesn’t tell a reader anything about what’s going on in the individual’s life. When conducting monitoring, SCs should practice the habit of writing notes on the Annotated ISP Monitoring Tool so information can be included when entering monitoring in HCSIS. During the conference calls in February 2014, SCOs put forward some practical ways they use comments to track information they want to remember to bring up at future visits; for example, pace of service utilization or notes about progress toward outcomes. We’ll give you more detail about what SCOs said about using comments later in the webcast.

When an issue is identified, the issues box must include enough information so that a reviewer knows the nature of the issue and the response by the team. We’ll talk more about documenting issues later in the webcast.



The next thing is to be clear about the difference between issues and comments. The Bulletin states that there are two important components of an issue: first, issues warrant action to correct the situation and second, the response should be timely.

Comments, on the other hand, don’t contain the same strong language about correction and timeliness. Comments could include a note about something that’s going well, or it may be something out of the ordinary that the SC feels is important to document perhaps for reference at a future monitoring. At the end of this lesson, we’ll provide some examples that SCOs said they use comments to track information from one visit to the next.



Let’s go into more detail about issues.

The Bulletin gives three examples of issues. It’s significant that the first is circumstances that negatively impact quality of life. This is a reminder of the importance of a person‐centered focus in monitoring. Quality of life could include many circumstances, such as limited opportunity to experience community life, lack of control or choice, or inadequate attention to health or medical care.

We’ve talked previously about the direct connection between monitoring and the ISP that answers the question: are services being received as the individual and team expected when they developed the ISP?

The individual’s subjective feelings about how services are delivered are also included as a fundamental focus of monitoring. Satisfaction should always be from the perspective of the individual receiving services.



When an issue is identified during monitoring, the SC must first determine if the risk is imminent. Issues of imminent risk are identified by a sense of urgency to act when it is reasonable to conclude that failing to do so will cause the individual to suffer serious injury or harm. For example, if during monitoring the SC learns that the individual has inadvertently been taking or has been given double doses of a medication that can cause serious or life‐threatening side effects, there may be an immediate risk to the individual’s health. When issues represent an imminent risk, the responsibility of the SC is first to coordinate a response to address the risk. The response should include people responsible to support the individual, the SC Supervisor for support and, in some cases, if the issue represents an emergency or suspected criminal activity, emergency medical support or law enforcement.



Situations of imminent risk call upon an SC to exercise good judgment about how to intervene. If we were crossing a busy street together and I saw that you were stepping in front of a speeding car, I would react by pulling you out of its path. Another type of risk may require the SC to coordinate involvement of emergency medical intervention or police because of physical abuse. Every situation of imminent risk is unique but the immediate nature of imminent risk means that a response must be quick.

In addition to immediate responsiveness in addressing the imminent risk, the SCO has a responsibility to inform the AE and ODP of any imminent risk that is discovered.



Notice that the nature of non‐urgent issues is not really all that different than issues of imminent risk. We’re talking about essentially the same things: health, safety, and well‐being. The distinction is in immediacy. Non‐urgent issues imply that the team needs to look for strategies that may take time to put in place.

For example, choices that pose risk may not be imminent but, they still need to be addressed from a person‐centered perspective. For example, reasons for over‐eating need to be understood and strategies that support the individual in making better choices may take time to find and implement. If the individual identifies that he or she is not satisfied with a particular service and wants to consider other options, the SC and team will need to look for alternatives, support the individual while making choices, advocate for the new service or support, and revise the ISP at the right time. Over time, the individual’s choice and control will help guide the team’s direction.

Other examples include loss of skills over time or diminished involvement in community life. Neither of these situations happened abruptly and they may need time to improve – but they are still issues that must be addressed within the context of the team’s planning.

Problems with the individual’s environment or adaptive or other equipment are also issues that need to be documented and addressed. They are usually not acute in nature and require collaboration to resolve; although some environmental concerns or problems with equipment may pose more immediate risk and must be addressed right away.



Whether an issue represents imminent risk or is non‐urgent (requiring solutions that are developed over time) the SC follows the same response sequence. First, assess the situation when an issue arises. Then, determine if action to address the issue needs to occur immediately or unfold over time.

The SC will enlist support, depending on the nature of the issue: imminent risk may require support from team members or even local authorities, while support to resolve non‐urgent issues usually means coordinating the efforts of the individual, and team including service providers, and perhaps, the Administrative Entity.



Every issue requires a plan, whether it is one of imminent risk or a non‐urgent issue that is addressed over time. The SC is responsible for facilitating planning to reduce or eliminate the causes of the issue or make changes and find alternatives the individual finds satisfactory, ensure referrals are made, advocate for and coordinate services and supports, and then close the loop by monitoring implementation and effectiveness of the plan. Providers are responsible for implementing the plan.



We’re going to wrap‐up discussion of SC responsibilities when issues are identified by talking about documentation on the monitoring form and in service notes.



Think about the fact that issues are rarely, if ever, identified and resolved immediately. Instead, resolution of an issue can unfold over days, weeks, or months. The SC may first document the issue on the monitoring form, but will almost always need to continue documenting actions to address and resolve the issue in subsequent service notes and, often, on the monitoring form at the next visit and sometimes, even subsequent visits.

An example is an issue that is non‐urgent in nature: it would appear first on the monitoring form but the team meetings to plan and strategize would be reflected in several service notes. So, think of documentation of issues and resolution as one continuous story that connects from beginning to end, even though the chapters are documented in different places over time.



There are several references that support the need for complete documentation of issues. The SC Services Bulletin states that issues and resolution – including a provider’s corrective action plan and remediation of the issue – are to be documented in the Home and Community Services Information System, or HCSIS. The Chapter 51 Home and Community‐Based Services regulations, in the section about SC services, also state the need for complete documentation of issues and resolution in HCSIS.

Documentation in HCSIS includes the ISP Monitoring Form itself, but it also refers to service notes. Let’s look at how documentation in the monitoring form and service notes in HCSIS work together.



The beginning of the story is when the issue was identified during a monitoring visit and documented in HCSIS on the Monitoring Form. Remember, SCs always write an accompanying service note for monitoring visits. The monitoring form contains a description of the issue and the response, while the service note includes details to describe the issue, immediate actions taken, and the plan for next steps.



The middle of the story describes the actions taken to address the issue over time. The SC would record the actions in subsequent service notes over the days and weeks following monitoring. But, think about a reader trying to follow the story. How does he or she find the service note that tells them the next part of the story? Use HCSIS to your advantage: begin notes that refer to the issue with the date of the monitoring at which it was identified and include a short phrase that identifies the issue. Then, include current information remembering the structure of service notes: “who, what, when, where,” and “next steps.”



The subsequent monitoring visit is the next chapter of the story. As before, the monitoring form and the service note for the monitoring visit would both be used to document the current status of the issue. Perhaps the issue is resolved, and the monitoring form and service note describe the resolution. Or maybe the issue is still being addressed in planning with the team. In either case, using the original date the issue was identified and the same short phrase to describe it will connect this chapter to previous actions and information.



The documentation may continue over several monitoring visits and in service notes until the issue is resolved. When it is, make sure you clearly note that the story of this particular issue is ended and include the date of the monitoring that the issue was initially identified so a reviewer knows the issue is resolved.



When dealing with issues, the SC is not acting alone. The Supports Coordination Services Bulletin, SCO Monitoring Guidelines, and the Chapter 51 Regulations outline specific roles for SC Supervisors, SCOs, Providers, AEs, and ODP.



When there is imminent risk to health and welfare, the Bulletin states that the SCO should inform the AE, ODP Regional Program Manager, and Service Provider. The Bulletin is clear that notification of imminent risk should happen immediately. Each SCO should have a clear process for SCs to follow so they can meet the notification expectation, including issues that occur after typical work hours.



The SCO Monitoring Guidelines outline responsibilities for SC Supervisors and SCO Administration when SCs identify issues in monitoring (whether an issue poses an imminent risk or is less urgent and will be addressed by the team over time): Supervisors and SCO Administration are to provide oversight as the SC and the team take action to resolve the issues. The Guidelines specify that oversight to determine the effectiveness of action to address issues happens in discussion with the SC and also in SC supervisor and SCO administration review of documentation. The Chapter 51 Regulations reinforce the responsibility of SC Supervisors and SC Administration to assess the impactof risk mitigation strategies when issues are identified in monitoring.



Think back to the point I made earlier about planning when an issue is identified. A sound planning process not only identifies what actions will occur to resolve issues – a plan also includes the timeframe of when the issue is expected to be resolved. If SC Supervisor’s and SCO Administration’s oversight of follow up actions shows that issues remain unresolved past the time that corrective actions were to be completed, the SC Services Bulletin specifies that the SCO must notify the AE.



Let’s round out discussion of issues and comments. First, remember I said earlier that a “yes” or “no” response is not sufficient and that some detail needs to be included for each question, even if it’s brief. If things are going well and there are no issues revealed during monitoring, an SC will be writing comments to provide general observations taken during the monitoring visit. When the individual is satisfied with services and supports, the ISP is being implemented as outlined, and there are no issues of health or safety, it might be tempting to fall into a pattern of writing things like, “No concerns noted” or “No changes needed.” But some SCOs found practical and useful ways to use comments and including descriptive comments which are preferred.



Think of comments as a way to provide continuity from one monitoring visit to the next. Most SCs follow the practice of reviewing previous monitoring forms before going to the next monitoring visit. If I purposefully wrote comments in the last monitoring that I need to follow up on next time, I don’t have to remember or keep notes somewhere else; I can just read what I wrote and be prepared to follow up.

For example, at the last monitoring visit, the caregiver told the SC that she may be having surgery in the next couple months and, if it’s scheduled, will need respite. A brief note in comments will serve to remind the SC to ask about respite at the upcoming visit. Another way SCs have used comments is to provide enough detail about progress toward outcomes so that they can more efficiently assessed at future visits. There’s still a need to determine current status of progress, but having notes about where things stood previously saves time trying to remember what was occurring last time. Some SCOs ask SCs to include service utilization information in comments. Think about a service that is less predictable in the pace of how it’s used, such as respite. If the pace of how a family is using respite is a little quicker or slower than the team anticipated, having detail about utilization at hand can help the SC have a more structured conversation with the family during the monitoring visit.

Documenting comments follows the same patterns as we discussed for documenting issues. If the comment requires follow‐up before the next monitoring visit, document the follow‐up in service notes. Then, if the comment is still pertinent at the next monitoring visit, include the current status. Continue connecting documentation until the reason for the comment no longer needs to be included.



We’ll conclude this lesson by emphasizing that, while a vital role of an SC is to identify issues and coordinate a plan to address them, the SC is not solely responsible for resolving the issues. Within the waivers and ODP policy and bulletins are numerous expectations for Providers, AEs, and ODP in identification and mitigation of risk and responsibility to respond to individuals’ needs and satisfaction.



This webcast has been developed and produced by the Office of Developmental Programs Consulting System on behalf of the Pennsylvania Department of Public Welfare, Office of Developmental Programs.

Thank you for participating in this lesson.



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ISP Monitoring 2014 - Lesson 3 Printable Version PD