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Medicaid Waiver Services Documentation Requirements

The following information is also available as presentation on given June 28, 2012 in PPT or as a PDF document for quick review.

Documentation Requirements for Day Habilitation

Functional Analysis

Develop a functional analysis of the individuals capabilities with in the first month and annually.

Develop an ISP that includes the following:

  • The individuals interest
  • Choices
  • Measurable outcomes

Submit quarterly reports to the individual, family/guardian, and Service Coordinator on the programming and support provided to achieve the outcomes in the ISP.

In-Home Day Habilitation

Day Habilitation provider must provide written documentation that in-home service  are necessitated by the individual’s medical or safety needs.

The Day Habilitation provider are responsible for developing the ISP goals and activities. The plan should include transitioning the individual to the community to the extent possible.

Documentation Requirement for Prevocational services

Prepare Vocational Assessments

Vocational assessment within the 90 days of intake and annually. The vocational assessment must include the following:

  • Employment-related strengths and weaknesses
  • Available natural/community supports
  • Individual concerns and preferences
  • Accommodations and supports that may be required on the job.

Develop an ISP

The ISP includes the following:

  • The person interest
  • Specific measurable outcomes for the development of vocational skills that are consistent with the goals
  • Activities shall be functional.

File Quarterly Reports

Submit quarterly reports, no later that the 15th day of January, April, July, and October. The quarterly reports will include the following:

  • Name of the person
  • Community inclusion opportunities
  • Volunteer activities
  • Prevocational facility and non-facility-based activities
  • Progress to achieving outcomes from IHP.

Documentation Requirements for Supported Employment

Complete a comprehensive vocational assessment.

The vocational assessment includes the following:

  • Employment-related strengths and weakness
  • Available family and community supports
  • Personal concerns
  • Accommodations and supports that may be required on the job
  • If specific job or entrepreneurial efforts has been targeted the assessment may include:
  • Individualized training needs
  • Anticipated level of interventions that will be required by the job coach.
  • Type of integrated work environment
  • Supports that are needed to improve potential for employment.

Provide written justification ten business day prior to the prior authorization expires to request an extension.

Maintain service records that accurately link the services billed to the ISP/POC.

The documentation includes:

  • Individual’s name
  • Staff person’s name
  • Date(s) of activities
  • Start and end times of activities
  • Purpose of activities
  • Location of activities
  • Occurrences or behaviors that impede the progress of the group or individual participants
  • Any unusual circumstances or events that impact the stability of the group or individuals participant
  • Any incidents
  • Actions take to address behaviors or unusual circumstances

Submit quarterly reports that include the following:

  • Individual’s name
  • Confirmation that wages exceed minimum wage
  • Average hours a week worked by each person
  • Hours of activities for each person if not engage in employment
  • Aggregate calculation of wages earned, hours worked and hours of activities for person not engaged in employment.

Documentation Requirements for Supported Living and Residential Habilitation

Develop a functional analysis of the individual’s capabilities with the first month.

Develop a support plan with measurable outcomes using the functional analysis, ISP/POC, and other information to develop and maintain skills to remain in the community while maintaining the individual’s health and safety.

Maintain a participants attendance roster on a daily basis.

Maintain weekly progress notes or more frequently.

Progress notes include:

  • Progress in meeting each goal in the ISP assigned to the supported living and residential habilitation provider.
  • A list of all community activities and the individual’s response to each activity.
  • Any health events, side effects to medication, change in health status, behavioral event, use of restrictive procedures or unusual incidents.
  • Each visitor the person receives, special events, and any situation or event requiring follow up.

Quarterly reports that include the activities and support provided to help the individual achieve his/her identified outcomes and progress to date.

Maintain current financial records of expenditures.

Documentation Requirements for Respite

Provider must maintain documentation the following information:

  • Date and amount of time the service is delivered
  • Record the activities engaged in
  • Individual’s response to those activities
  • Unusual events or circumstance involving the individual’s health and welfare while respite services were delivered.

Documentation Requirements for Host Homes

Develop a functional analysis of the individual’s capabilities with the first month.

Develop a support plan with measurable outcomes using the functional analysis, ISP/POC, and other information to develop and maintain skills to remain in the community while maintaining the individual’s health and safety.

Maintain weekly progress notes or more frequently.

Progress notes will include the progress in meeting each goal in the ISP assigned to the Host Home provider.