SUPPORT COORDINATOR RECORD REVIEW …...support coordinator provides choices of non-waiver supports and services. 12 Support Coordinator supports the person to make informed choices

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SUPPORT COORDINATOR RECORD REVIEW FOCUSED OUTCOME AREA (FOA)

(NOTE: Those indicators in red are key to Intensive Support Coordination)

Person Centered Practices

Expectation: Person’s needs are identified through person centered thinking and planning

Indicator Scoring Guide Present Not Present

Reasons Not Present – Marion modify this section based on indicator and scoring guide

N/A

1 Documentation demonstrates pre-ISP activities/meetings are held with the individual, family (if available), and service providers for the development of the ISP. Part III, Chapter 600, 603, 1.a., pg. VI-5

Review the support notes and Outcome Reviews to determine if information is collected prior to the ISP meeting from the individual, family and service providers to assess the needs and goals of the individual. This should include information about what is working and not working with the current plan. This could include review of the SIS, HRST, discussion on goals, etc. This should occur within 90 days prior to the ISP meeting.

Documentation does not demonstrate any pre-ISP meetings with the individual/family.

Documentation does not demonstrate any pre-ISP meetings with the service providers.

Documentation does not demonstrate during pre-ISP meetings how the Support Coordinator is assessing the person’s needs.

Documentation does not demonstrate during pre-ISP meetings how the Support Coordinator is assessing the person’s future goals/objectives.

Documentation does not demonstrate the SC is reviewing what is working/not working with the current ISP.

Documentation does not demonstrate pre-ISP discussions occurred within 90 days prior to the ISP meeting date.

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2 Documentation demonstrates how all selected providers or other supports are assisted in understanding the full implementation of the ISP, including goals and intent for all planned services. Part III, Chapter 600, 603, 1.f., pg. VI-5

Review Outcome Reviews to determine if the Support Coordinator is determining whether the providers/support staff and other natural supports understand the goals for the person and intent for all supports and services. If the response is “no” for this question in the Outcome Review, the Support Coordinator educates the support person or shares this with provider management so training can occur. NOTE: Review whether a coaching/referral was opened.

Documentation does not demonstrate the support coordinator is determining whether the providers/support staff and other natural supports understand the goals for the person and intent for all supports and services.

If the response is “no” to this questions in the Outcome Review, a coaching and referral was not opened to address this issue.

If the response is “no” to this questions in the Outcome Review, documentation does not demonstrate the Support Coordinator is explaining to paid providers selected to implement services, the goals for the person.

If the response is “no” to this questions in the Outcome Review, documentation does not demonstrate the Support Coordinator is explaining to paid providers selected to implement services, the intent of the services and supports for the person.

Documentation does not demonstrate the Support Coordinator is explaining to any non-paid natural supports selected to implement services, the goals for the person.

Documentation does not demonstrate the Support Coordinator is explaining to any non-paid natural supports selected to implement services, the intent of the services and supports for the person.

Expectation: A personal outcome approach is used to design person centered supports and services.

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Reasons Not Present N/A

3 Documentation demonstrates evaluation of the Individual Service Plan’s (ISP) implementation. Part III, Chapter 600, pg. VI-2

Review support notes and Outcome Review forms demonstrating the evaluation of the implementation of the ISP. This would include documentation that the support coordinator is evaluating ISP implementation. This includes direct observation, review of documents and any needed follow up.

Documentation does not demonstrate an evaluation of the implementation of the ISP.

Documentation does not demonstrate the evaluation includes observation of services provided.

Documentation does not demonstrate the evaluation includes a review of provider documentation.

If there is any indication that services are not provided according to the ISP, there is no documentation the support coordinator has followed up on this issue.

4 Documentation demonstrates how the Support Coordinator is evaluating that services have the intended effect and approaches. Part III, Chapter 600, pg. VI-2

Review support notes and Outcome Review forms demonstrating evaluation of services to determine if the person is benefiting from the services as implemented. This includes direct observation, discussions with the person/family, review of documents and any needed follow up.

Documentation does not demonstrate the Support Coordinator is evaluating the effectiveness of the service delivery.

Documentation does not demonstrate discussions with the person/family regarding the effectiveness of the services.

Documentation does not demonstrate the review of provider documentation to evaluate the effectiveness of the services being provided.

Documentation does not demonstrate any identified follow up if changes to approach in supports and services are needed to better benefit the person.

If changes to service delivery are needed, documentation does not demonstrate how this was addressed to resolution.

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5 Documentation demonstrates review with the individual’s progress or lack of progress of the ISP goals/objectives. Part III, Chapter 600, pg. VI-2

Review the support notes, and Outcome Review to determine if the support coordinator is reviewing the individual’s progress on goals/objectives. Look for descriptions of the individual’s progress and if the person is not making progress what are the contributing factors.

Documentation does not demonstrate discussions with the individual on progress on goals/objectives.

Documentation does not demonstrate the review of the individual’s progress or lack of progress on goals/objectives in the ISP.

Documentation does not include the specific description of the individual’s progress or lack of progress.

Documentation only states the individual made progress on goals but does not include what specific progress was made.

Expectation: Supports and services change as progress is made and as the person’s wants and needs change.

Indicator Scoring Guide Likert Scale

6 In response to the support coordinator becoming aware of changes in condition or circumstance, the support coordinator responds by assisting the individual with identifying needed changes to services and supports.

Review the support notes to determine if there was a change in condition or circumstance for the person. As a result, determine if the SC discussed this with the person and discussed options related to changes to supports and services. The decisions made based upon these discussions should be documented.

Documentation does not demonstrate the support coordinator responded to a change in condition or circumstance by offering the person options related to changes to supports and services.

Based upon changes in condition or circumstances, documentation does not demonstrate the decisions made regarding changing supports and services.

Score N/A a if no changes in condition or circumstance.

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7 Based upon changes to condition or circumstance that would impact the current services, documentation demonstrates changes are made to the ISP.

Review the support notes to determine if there was a change in condition or circumstance for the person. If there was a change required in quantity or in type of service, the support coordinator documents this change in the ISP. If the need is for an increase in current services or additional services, a STAR was submitted to the Field Office.

Based upon changes to condition or circumstance that would impact the current services, documentation did not demonstrate changes were made to the ISP.

Based upon changes to condition or circumstance that would increase current services, documentation does not indicate a STAR was submitted to the Field Office.

Score N/A if no changes in condition or circumstance.

8 Documentation demonstrates modifications are made to the person’s Action Plan based upon the results of reviews of progress or lack of progress. Part III, Chapter 600, pg. VI-1

Review the support notes, and Outcome Reviews to look for evidence the support coordinator modifies the Action Plan of the ISP if the person is not making progress on goals/objectives or if the person has met a goal/objective. These modifications should be based upon the preferences and defined outcomes of the person and support the person towards maximum independence.

There is no documentation demonstrating a review of progress or lack of progress on the goals/objectives of the Action Plan.

Based upon results of reviews of progress or lack of progress on goals/objectives, documentation does not demonstrate modifications are made to the individual’s Action Plan of the ISP.

CHOICE

Expectation: Person actively participates in all of life’s decisions.

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9 If a person/guardian is dissatisfied with service providers, documentation demonstrates discussions about options of other service providers or the option of participant-direction services. Part III, Chapter 600, pg. VI-2

If a person is dissatisfied with service providers, look for documentation the support coordinator has provided options related to service providers or participant-direction if warranted.

Dissatisfaction with service providers is noted but there is no documentation demonstrating the support coordinator offers options of other service providers.

Dissatisfaction of traditional services is expressed but there is no documentation demonstrating participant-direction was provided as an option.

Score NA if the person does not express dissatisfaction is service providers.

10 If the Support Coordinator identifies the service providers are not providing services according to the person’s preferences or needs, documentation demonstrates discussions with the provider in delivering supports and services according to the person’s preferences or needs. Part III, Chapter 603, 2.a., pg. VI-5

Review support notes to determine if support coordinator discussed with the service provider the support needs and preferences of the person. Determine if the support coordinator is arranging and coordinating meetings with the individual/family or representative and the provider.

Documentation does not demonstrate the support coordinator is discussing with the provider how supports and services should be rendered to meet the person’s needs and preferences.

Documentation does not demonstrate the support coordinator is arranging and coordinating meetings with the individual/family or representative and the provider.

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11 Documentation demonstrates the support coordinator provides options of non-waiver supports and services available. Part III, Chapter 603, 3.a., pg. VI-5

Review support notes and Outcome Review to determine if documentation demonstrates the support coordinator provides options of non-paid supports and services available. This could include but not be limited to such natural supports as a neighbor, friend, family member, church organization, etc. or GVRA, social security, Medicaid State Plan, Children’s Intervention Services, Autism State Plan, Waiver Supplemental Services (co-pays, glasses, dental, etc.), etc..

Documentation does not demonstrate the support coordinator provides choices of non-waiver supports and services.

12 Support Coordinator supports the person to make informed choices about life’s decisions including living environments, meaningful day activity and employment throughout the year.

Review support notes and Outcome Reviews to determine if documentation demonstrates the support coordinator provides options related to living environments, meaningful day activity and employment.

Key Quality Indicator

EXCEEDS: Documentation demonstrates the support coordinator is providing information, options, and resources regarding living environments, meaningful day activity and employment throughout the year.

MEETS: Documentation demonstrates the support coordinator is providing information, options, and resources regarding two of the three areas listed throughout the year.

NEEDS IMPROVEMENT: Documentation demonstrates the support coordinator is providing information, options, and resources regarding one of the three throughout the year and the other areas listed at least annually.

UNSATISFACTORY: Documentation demonstrates the support coordinator is not providing information, options, and resources regarding any of the areas listed.

Expectation: Person’s choices are valued.

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13 Documentation demonstrates the support coordinator respects and acts upon the person’s choices. Quality Indicator

Review support notes and Outcome Reviews to determine if documentation demonstrates the support coordinator is soliciting the person’s choices and respects and acts upon the choices of the individual. If risk is involved look for evidence the support coordinator is helping educate the person on risks. If family or representatives are not supporting the individual’s choice, look for evidence the support coordinator is advocating on behalf of the individual.

Documentation does not demonstrate the support coordinator is soliciting the person’s choices.

Documentation demonstrates the support coordinator does not honor or act upon the person’s preferences or choices.

Documentation demonstrates the support coordinator does not advocate for a person’s preferences.

If the person’s choice presents a risk to the person’s health, safety or well-being, documentation does not demonstrate the support coordinator is educating the person on these risks.

Expectation: Person is satisfied with supports and services.



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14 Documentation demonstrates any dissatisfaction the person expresses relating to supports and services, including support coordination, is addressed to resolution. Part III, Chapter 603, 4.d., pg. VI-6

Review support notes and Outcome Reviews to determine if the support coordinator is determining the person’s satisfaction with supports and services through discussions with the person/family and observations of service delivery. If dissatisfaction is expressed, look for documentation how this is being addressed (through mitigation or dispute resolution) and whether it is resolved.

Documentation does not demonstrate the support coordinator determines the person’s satisfaction with supports and services.

Documentation does not demonstrate how expressed dissatisfaction with supports and services are addressed.

Documentation does not demonstrate how the support coordinator addressed identified barriers to resolve any dissatisfaction.

Documentation demonstrates how expressed dissatisfaction with supports and services were addressed but there is not documentation demonstrating follow up to the issue to determine if it was resolved.

Score N/A if no dissatisfaction expressed in the past 12 months.

COMMUNITY

Expectation: Person actively participates in the community.



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15 Documentation demonstrates how the support coordinator is taking active measures to gather information and share with the person and providers regarding opportunities for presence in community settings. Part III, Chapter 603, 3.a., pg. VI-5

Review support notes and Outcome Reviews to determine if documentation demonstrates the support coordinator is gathering information and coordinating services and supports to promote participation and provide opportunities in day to day community activities (e.g., bank, grocery store, pharmacy, barber).

Documentation does not demonstrate efforts on behalf of the support coordinator to gather information regarding day-to-day community activities available in the person’s community.

Documentation does not demonstrate efforts on behalf of the support coordinator to promote participation in day-to-day community activities.

Documentation does not demonstrate efforts on behalf of the support coordinator to coordinate services and supports to provide opportunities in day-to-day community activities.

Documentation demonstrates the support coordinator does not make efforts to address any barriers to the person’s participation in day-to-day community activities.

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16 Documentation demonstrates the support coordinator’s efforts to help link the person with social or educational providers or programs and services. Part III, Chapter 603, 3.b., pg. VI-5

Review support notes and Outcome Reviews to determine if documentation demonstrates the support coordinator’s efforts to help link the person with social (groups, clubs, advocacy groups, etc.) or educational providers or programs and services. The efforts of the support coordinator could include such activities as providing resources or information and education to the person or provider. These programs and services should be based upon the person’s needs, preferences and goals.

Documentation does not demonstrate efforts on behalf of the support coordinator to link the person with social programs and services based upon the person’s needs, preferences or goals.

Documentation does not demonstrate efforts on behalf of the support coordinator to link the person with educational providers or programs and services based upon the person’s needs, preferences or goals.

Documentation demonstrates the support coordinator does not make efforts to address barriers to the person’s participation in social programs and services.

Documentation demonstrates the support coordinator does not make efforts to address barriers to the person’s participation in educational programs and services.

17 Documentation demonstrates the support coordinator’s efforts to offer choices related to supported employment or competitive employment. Quality Indicator

Review support notes and Outcome Reviews to determine if documentation demonstrates the support coordinator’s efforts to offer choices related to supported employment or competitive employment including referrals to GVRA.

Documentation does not demonstrate efforts on behalf of the support coordinator to offer choices related to supported employment or competitive employment.

Documentation demonstrates the support coordinator does not make efforts to address barriers to the person’s participation in supported employment or competitive employment.

Expectation: Person develops and maintains valued social roles (e.g., employment, family member, community group).

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18 Documentation demonstrates the support coordinator is coordinating services and supports to promote opportunities for the person to maintain or develop valued social roles. Quality Indicator

Review support notes and Outcome Reviews to determine if documentation demonstrates the support coordinator’s efforts to promote opportunities for the person to maintain or develop valued social roles. This could include but not be limited to coordinating with service providers or natural supports to increase opportunities for the person to participate in valued activities at a frequency that promotes maintenance of social connections. If barriers exist, the support coordinator is addressing these. Efforts to develop social roles could include resources, information or education to the person and provider or family. Support in maintaining social roles could include coordination with a provider/natural supports to ensure resources are available for the person to continue those connections to others.

Documentation does not demonstrate efforts to promote opportunities for the person to maintain valued social roles.

Documentation does not demonstrate efforts to promote opportunities for the person to develop valued social roles.

Documentation does not demonstrate efforts to address barriers in maintaining valued social roles.

Documentation does not demonstrate efforts to address barriers in developing valued social roles.

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WHOLE HEALTH

Expectation: Health related needs have been addressed.



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19 Documentation demonstrates the support coordinator evaluates service delivery to determine if there are any unmet health needs. Part III, Chapter 603, 4.b., pg. VI-6

Review support notes and Outcome Review to determine if documentation demonstrates the support coordinator evaluates service delivery to determine if there are any unmet health needs that could include preventative health (e.g.: annual physical, dental, eye or hearing exam, female/male health) or specialty medical (e.g.: neurologist, endocrinologist, gastroenterologist) health needs.

Documentation does not demonstrate the evaluation of the person’s overall health needs during contact with the person.

Documentation does not demonstrate the evaluation of the person’s overall health needs during contact with service providers.

Documentation does not demonstrate a review of the individual’s medical documentation to determine if a person’s overall health needs are being met.

Documentation does not demonstrate the evaluation of the person’s preventative health needs during contact with the person.

Documentation does not demonstrate the evaluation of the person’s preventative health needs during contact with service providers.

Documentation does not demonstrate a review of the individual’s medical documentation to determine if a person’s preventative health needs are being met.

Documentation does not demonstrate the evaluation of the person’s specialty medical health needs during contact with the person.

Documentation does not demonstrate the evaluation of the person’s specialty medical health needs during contact with service providers.

Documentation does not demonstrate a review of the individual’s medical

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documentation to determine if a person’s specialty medical health needs are being met.

20 Documentation demonstrates the support coordinator evaluates if there are any emerging health risks. Part III, Chapter 603, 4.b., pg. VI-6

Review support notes and Outcome Review (free text section) to determine if documentation demonstrates the support coordinator evaluates if there are any emerging health risks that could include preventative health needs or emerging health related issues. This could include but not be limited to the review of health tracking forms completed by the provider, review of critical incidents to identify trends, repeated illnesses, etc..

Documentation does not demonstrate the evaluation of the person’s health risks during contact with the person.

Documentation does not demonstrate the evaluation of the person’s health risks during contact with service providers.

Documentation does not show evidence the support coordinator is reviewing health protocols or health tracking logs (e.g., glucose monitoring, blood pressure, bowel elimination, fluid/food intake, weight) during face-to-face visits.

Documentation does not show evidence the support coordinator is reviewing critical incidents for potential emerging health risks.

Documentation does not show evidence the support coordinator is reviewing reasons for doctor visits to help identify potential emerging health risks.

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21 Documentation demonstrates the support coordinator coached the person or service providers related to any identified health risks. Part III, Chapter 603, 4.a., pg. VI-5&6

Review Outcome Review follow up documentation to determine if the support coordinator entered follow up actions to address any identified health risks. At minimum, monthly follow-ups are required by policy until the risk is mitigated.

Documentation does not demonstrate coaching with the person to address any health risks.

Documentation does not demonstrate coaching with service providers to address any health risks.

Documentation does not demonstrate at a minimum monthly follow up regarding the identified health risk until the risk was mitigated.

Score N/A if there are no identified health risks in the last 12 months.

22 Documentation demonstrates the support coordinator evaluates the effectiveness and quality of services that address health needs identified in the ISP. Part III, Chapter 600, pg. VI-1 and Part III, Chapter 603, 4.e., pg. VI-6

Review support notes and Outcome Review to determine if documentation demonstrates evaluating the effectiveness and quality of health services (i.e.: nursing services, therapy assessments, medical specialists, mental health services) as outlined in the ISP. If issues/barriers are identified, look for evidence the support coordinator addresses (ensure needed referrals or actions are taken to mitigate the problem/barrier) them to completion.

Documentation does not demonstrate ongoing evaluation of a person’s health services to determine effectiveness in addressing the health concern(s) or diagnoses identified in the ISP.

Documentation does not demonstrate ongoing evaluation of quality for health services identified in the ISP.

Documentation does not demonstrate ongoing evaluation of the health services identified in the ISP.

Documentation does not demonstrate any issues/barriers to the effectiveness of health services are being actively addressed.

Score N/A if the person does not have any identified needed health services.

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23 Documentation demonstrates the Intensive Support Coordinator’s efforts to work closely with the person’s physician(s), other healthcare providers and service providers in the management of the person’s complex health issues. Part III, Chapter 700, pg. VII-2

Review support notes and Outcome Review to determine if documentation demonstrates the Intensive Support Coordinator is contacting and following up with physicians, healthcare providers and service providers to help manage a person’s complex health needs and concerns.

Documentation does not demonstrate efforts to contact the person’s physician(s).

Documentation does not demonstrate efforts to coordinate efforts or share information with the person’s physician(s).

Documentation does not demonstrate efforts to contact the person’s other healthcare providers.

Documentation does not demonstrate efforts to coordinate efforts or share information with the person’s other healthcare providers.

Documentation does not demonstrate efforts to contact the person’s service providers related to health.

Documentation does not demonstrate efforts to coordinate efforts or share information with the person’s service providers.

Score N/A if the person does not receive Intensive Support Coordination.

Expectation: The person has assessments and health protocols as needed.



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24 Documentation demonstrates the Service Change/Technical Assistance Request form was submitted when additional services or technical assistance were needed in response to health risks. Part III, Chapter 603, 4.c., pg. VI-6

Review support notes and Outcome Review to determine if documentation demonstrates the support coordinator made the necessary referrals due to changes in health status or potential health risk. These additional services could be clinical or traditional to address the needs of the person.

Documentation does not demonstrate the support coordinator made the needed referral for technical assistance to address any identified changes in health status or potential health risk using the Change/Technical Assistance Request form.

Documentation does not demonstrate the support coordinator made the needed referral for additional clinical services to address any identified changes in health status or potential health risk using the Change/Technical Assistance Request form.

Documentation does not demonstrate the support coordinator made the needed referral for additional services to address any identified changes in health status or potential health risk using the Change/Technical Assistance Request form.

Score N/A if there are no identified need for a referral in the last 12 months.

25 Documentation demonstrates the support coordinator reviewed the most current clinical evaluations and responded by coordinating action responsive to the recommendations. Part III, Chapter 603, 5.c., pg. VI-6

Review support notes and Outcome Review to determine if documentation demonstrates the review of clinical evaluations. If needed, the support coordinator assists responsible parties (family, providers, individual, etc.) in coordinating action responsive to the recommendations.

Documentation does not demonstrate the support coordinator reviews any clinical evaluations conducted in the last 12 months.

Documentation does not demonstrate the support coordinator assists responsible parties in coordinating follow up to any clinical recommendations.

Documentation does not demonstrate the support coordinator addresses any barriers to taking action on any clinical recommendations.

Score N/A if there are no clinical evaluation with recommendations for follow up in the last 12 months.

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26 Documentation demonstrates the review of healthcare plans and supporting health protocols or tracking systems to ensure they meet the health care plan’s requirements. Part III, Chapter 603, 5.d., pg. VI-6

Review support notes and Outcome Review to determine if documentation demonstrates the review of healthcare plans and supporting health protocols or tracking systems to ensure they meet the health care plan’s requirements.

Documentation does not demonstrate the support coordinator reviews any health care plans.

Documentation does not demonstrate the support coordinator reviews health protocols.

Documentation does not demonstrate the support coordinator reviews health tracking systems.

If the protocol or tracking system does not meet the health care plan requirements, there is no documentation the support coordinator addressed the issue.

Score N/A if the person does not require a health care plan.

Expectation: Person is managing his/her own health.



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27 Documentation demonstrates the support coordinator promotes the person’s preferences for managing health. Quality Indicator

Review support notes and Outcome Review to determine if the support coordinator is speaking to the person about managing health. Look for evidence the support coordinator identifies the person’s preferences for managing own health. Look for documentation the support coordinator ensures the person’s preferences in this area are being implemented.

Documentation does not demonstrate the support coordinator’s efforts to learn about the person’s preferences for managing personal health.

Documentation does not demonstrate the support coordinator’s awareness of the person’s preferences for managing personal health.

Documentation does not demonstrate the support coordinator is advocating for the person to manage health according to preferences.

Documentation does not demonstrate the support coordinator is ensuring the person is learning skills and increasing abilities to manage personal health.

Documentation does not demonstrate efforts to ensure a person’s preferences for managing personal health are being supported.

28 Documentation demonstrates the support coordinator advocates for the person to have a voice in healthcare decision-making. Quality Indicator

Review support notes and Outcome Review to determine if the support coordinator is ensuring the person is involved in decisions regarding healthcare. This could include areas like choosing a doctor, setting up an appointment on a date/time convenient for the person, giving consent to take a medication, education on responsibilities of decisions, etc..

Documentation does not demonstrate the support coordinator determines what decisions the person is involved in related to healthcare.

Documentation does not demonstrate the support coordinator is advocating for the person to be involved in making healthcare decisions.

Documentation does not demonstrate the support coordinator educates the person on responsibilities relating to decisions about healthcare.

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SAFETY

Expectation: Safety related needs have been addressed.



29 Documentation demonstrates the support coordinator evaluates supports and service delivery to determine if there are any unmet safety needs. Part III, Chapter 603, 4.b., pg. VI-6

Review support notes and Outcome Review to determine if documentation demonstrates the support coordinator evaluates service delivery to determine if all safety needs are met and if there are any unmet safety needs.

Documentation does not demonstrate the evaluation of the person’s safety needs during contact with the person.

Documentation does not demonstrate the evaluation of the person’s safety needs during contact with service providers.

30 Documentation demonstrates the support coordinator evaluates if there are any emergent safety risks. Part III, Chapter 603, 4.b., pg. VI-6

Review support notes and Outcome Review to determine if documentation demonstrates the support coordinator is discussing safety with the person during visits and with the family as applicable. Evidence that safety is also discussed with the service providers should be evident. Look for evidence the support coordinator evaluates critical incidents, reviews provider’s documentation to determine if there are any emerging risks or safety issues.

Documentation does not demonstrate the evaluation of the person’s potential safety risks during contact with the person.

Documentation does not demonstrate the evaluation of the person’s potential safety risks during contact with service providers.

Documentation does not demonstrate the support coordinator is reviewing provider’s documentation to determine if there are any emerging safety risks.

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31 Documentation demonstrates evaluating the effectiveness and quality of safety/crisis and/or behavior plans as warranted. Part III, Chapter 600, pg. VI-1 and Part III, Chapter 603, 4.e., pg. VI-6

Review support notes and Outcome Review to determine if documentation demonstrates evaluating the effectiveness and quality of safety/crisis and/or behavior plans as outlined in the ISP. Look for documentation the support coordinator is ensuring they are in place, utilized, and monitored as required.

Documentation does not demonstrate ongoing evaluation of a person’s safety/crisis and behavior plans to determine effectiveness in addressing the health concerns or diagnoses.

Documentation does not demonstrate ongoing evaluation to determine the quality of safety/crisis and behavior plans identified in the ISP.

Score N/A if the person does not have any identified safety/crisis and/or behavior plans in place.

32 Documentation demonstrates the support coordinator coached the person or service providers as needed to address any identified safety risks. Part III, Chapter 603, 4.a., pg. VI-5&6

Review support notes and Outcome Review to determine if documentation demonstrates the support coordinator entered follow up actions to address any identified health risks. At a minimum, monthly follow-ups are required by policy until the risk is mitigated.

Documentation does not demonstrate coaching with the person to address any safety risks.

Documentation does not demonstrate coaching with service providers to address any safety risks.

Documentation does not demonstrate at a minimum monthly follow up regarding the identified safety risk until the risk was mitigated.

Score N/A if there are no identified safety risks in the last 12 months.

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33 In the event a person accesses crisis services, documentation demonstrates the Intensive Support Coordinator’s efforts to evaluate any changes that may be needed to the person’s services and supports. Part III, Chapter 704, 5., pg. VII-10

Review support notes and Outcome Review to determine if documentation demonstrates the Intensive Support Coordinator is continuously evaluating any changes in the person’s well-being (safety and behavioral concerns) that need intervention, including coordination of crisis services, reassessment and revisions to the ISP. The support coordinator has documentation of actions taken to arrange or ensure supports are in place to address the safety needs of the person. There is documentation the ISP is updated as required.

Documentation does not demonstrate efforts to continuously evaluate any changes in the person’s well-being (safety and behavioral concerns).

Documentation does not demonstrate actions to arrange or ensure supports are in place to address changes in the person’s well-being (safety and behavioral concerns).

Documentation does not demonstrate efforts to coordinate efforts or share information regarding crisis services.

Documentation does not demonstrate efforts to solicit services to have the person reassessed as warranted.

Documentation does not demonstrate actions taken to ensure supports are put into place to address the safety needs of the person.

Documentation does not demonstrate efforts to update the ISP based upon changes to the person’s safety needs.

Score N/A if the person does not receive Intensive Support Coordination.

34 In the event a person is admitted to a crisis support home, the Intensive Support Coordinator took a primary role in discharge planning efforts to coordinate services and supports needed for the person’s return to the community. Part III, Chapter 704

If a person accessed crisis home services in the last 12 months, review progress notes and Outcome Review to determine if there is documented evidence the intensive support coordinator helped coordinate services and supports identified in the person’s discharge plan.

Documentation does not demonstrate efforts to coordinate services and supports identified in the discharge plan.

Documentation does not demonstrate efforts to address any barriers to accessing services and supports identified in the discharge plan.

Score N/A if the person was not admitted to a crisis support home in the last 12 months.

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Expectation: The person has safety or behavior plans as needed.



35 Documentation demonstrates the Service Change/Technical Assistance Request form was submitted when additional services or technical assistance were needed in response to increases in behavioral support needs. Part III, Chapter 603, 4.c., pg. VI-6

Review support notes and Outcome Review to determine if documentation demonstrates the support coordinator made the necessary referrals due to changes in safety status or potential safety risk. These additional services could be clinical or traditional to address the needs of the person.

Documentation does not demonstrate the support coordinator made the needed referral for technical assistance to address any identified changes in behavioral status or potential behavioral risk using the Change/Technical Assistance Request form.

Documentation does not demonstrate the support coordinator made the needed referral for additional clinical services to address any identified changes in behavioral status or potential behavioral risk using the Change/Technical Assistance Request form.

Documentation does not demonstrate the support coordinator made the needed referral for additional services to address any identified changes in behavioral status or potential behavioral risk using the Change/Technical Assistance Request form.

Score N/A if there are no identified need for a referral in the last 12 months.

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36 Documentation demonstrates the review of any current behavioral assessments and coordinating action responsive to the recommendations. Part III, Chapter 603, 5.c., pg. VI-6

Review support notes and Outcome Review to determine if documentation demonstrates the review of clinical evaluations related to safety, crisis or behavioral supports. If needed, the support coordinator assists responsible parties (family, providers, individual, etc.) in coordinating action responsive to the recommendations.

Documentation does not demonstrate the support coordinator reviews any clinical evaluations conducted in the last 12 months.

Documentation does not demonstrate the support coordinator supports responsible parties in coordinating follow up to any clinical recommendations.

Documentation does not demonstrate the support coordinator addresses any barriers to following up on any clinical recommendations.

Score N/A if there are no clinical evaluation with recommendations for follow up in the last 12 months.

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37 Documentation demonstrates the review of safety or behavior plan’s tracking systems to ensure they meet the plan’s tracking requirements. Part III, Chapter 603, 5.d., pg. VI-6

Review support notes and Outcome Review to determine if documentation demonstrates the review of safety or behavior plans identified tracking systems (i.e.: type, content, timeframes)to ensure they meet the plan’s tracking requirements.

Documentation does not demonstrate the support coordinator reviews any safety plan to ensure they address the person’s needs.

Documentation does not demonstrate the support coordinator reviews any behavior plan to ensure they address the person’s needs.

Documentation does not demonstrate the support coordinator reviews tracking systems to ensure they meet the tracking requirements (type, content, timeframes, etc.) of the plan.

If the safety or behavioral plan does not meet the person’s needs, there is no documentation the support coordinator addressed the issue.

If the tracking system does not meet the plan requirements, there is no documentation the support coordinator addressed the issue.

Score N/A if the person does not require a safety or behavior plan.

Expectation: Person is managing his/her own safety.



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38 Documentation demonstrates the support coordinator advocates for the person to maintain own safety. Quality Indicator

Review support notes and Outcome Review to determine if documentation demonstrates the person’s preferences for managing safety and efforts the support coordinator has advocated for the person to maintain own safety. Look for documentation the support coordinator ensures the person’s preferences in this area are being implemented.

Documentation does not demonstrate the support coordinator’s efforts to learn about the person’s preferences for managing personal safety.

Documentation does not demonstrate the support coordinator’s awareness of the person’s preferences for managing personal safety.

Documentation does not demonstrate the support coordinator is advocating for the person to manage safety according to preferences.

Documentation does not demonstrate the support coordinator is ensuring the person is learning skills and increasing abilities to self-preserve.

Documentation does not demonstrate efforts to ensure a person’s preferences for managing personal safety are being supported.

Expectation: Free from abuse, neglect and exploitation. NOT SURE IF YOU WANT TO KEEP THIS EXPECTATION.



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39 Documentation demonstrates the support coordinator addresses abuse, neglect and exploitation, according to policy.

Review incident reports and support notes and Outcome Review to determine if there is any suspicion of abuse, neglect or exploitation. If so, look for evidence the support coordinator reported the event according to DBHDD’s policy.

Documentation does not demonstrate the support coordinator evaluates if there is any suspected abuse, neglect or exploitation.

Documentation does not demonstrate the support coordinator reported any suspected abuse, neglect or exploitation according to DBHDD policy.

Documentation does not demonstrate the support coordinator addressed the person’s needs if allegations have been made.

RIGHTS

Expectations: Rights are being upheld.



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40 Documentation demonstrates the support coordinator advocates for the person, with other stakeholders, to support the person to exercise rights. Quality Indicator

Review support notes and Outcome Review to determine if documentation demonstrates the support coordinator’s efforts to advocate for the person to exercise rights.

Documentation does not demonstrate the support coordinator knows rights that matter most to the person.

Documentation does not demonstrate the support coordinator is aware of the person’s preferences for exercising rights.

Documentation does not demonstrate the support coordinator evaluates whether rights important to the person are being exercised and respected by stakeholders.

Documentation does not demonstrate the support coordinator advocates to ensure providers/natural supports are supporting the person to exercise rights.

Documentation does not demonstrate the support coordinator advocates to ensure the person is being treated with dignity and respect.

Documentation does not demonstrate the support coordinator advocates for dignity of risk.

41 Documentation demonstrates the support coordinator provides education to the person on the dignity of risk to support informed choice. Quality Indicator

Review support notes and Outcome Review to determine if documentation demonstrates the support coordinator’s efforts to educate the person on the dignity of risk to support informed choice.

Documentation does not demonstrate the support coordinator’s efforts to provide education to the person on the dignity of risk.

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42 Documentation demonstrates the support coordinator evaluates any plans in place to reinstate any rights that have been restricted for safety or legal reasons. Quality Indicator

Review support notes and Outcome Review to determine if documentation demonstrates the support coordinator’s efforts to advocate for plans to be in place to reinstate any rights that have been restricted for safety or legal reasons.

Documentation does not demonstrate the

support coordinator is aware of any rights

restriction in place.


support coordinator is advocating for

plans to be in place to reinstate any

restriction of rights.


support coordinator’s evaluation of plans

to determine progress on reinstatement of

rights.

Score N/A if there are no rights restrictions identified

Expectation: Person is able to identify rights.



43 Documentation demonstrates the support coordinator supports the person to understand how to exercise rights and understand responsibilities that come with certain rights. Quality Indicator

Review support notes and Outcome Review to determine if documentation demonstrates the support coordinator’s efforts to support the person to understand how to exercise rights and understand responsibilities that come with exercising rights.

Documentation demonstrates the support coordinator only reviews rights information with the person once a year.

Documentation does not demonstrate the support coordinator takes advantage of moments to reinforce rights and responsibilities with the person.

Documentation does not demonstrate the support coordinator evaluates if providers are offering rights education to the person and providing experiences to exercise rights.

Documents

SUPPORT COORDINATOR RECORD REVIEW …...support coordinator provides choices of non-waiver supports and services. 12 Support Coordinator supports the person to make informed choices