Demographics
This document is completed within 365 days and reviews agency/program specific information; such as rights, financial obligations, expectations, and policies.
What is the consumer orientation checklist.
The consumer orientation checklist helps the family understand the expectations of the program. Needs to be updated at a minimum of every 365 days. Q2-3
This section is located in the BPSA and requires perspectives from the individual, family, and clinician viewpoints.
What is SNAP?
Strengths, Needs, Abilities, and Preference. Identify from all three persepctives. Q22
When medications are changed, this document needs to be signed before we can notify the PCP.
What is consent to exchange information or release of information?
PCP's need to be notified when there are changes in medications to ensure coordination of care and to reduce medication interactions. Q81
The purpose of this document (which is to be completed within 365 days of previous one) is to develop an individualized plan to prevent acuity of symptoms, relapse or deterioration of functioning in the future.
What is the relapse prevention plan: which needs combination of quotes and clinical insight/recommendations. Under daily maintenance, need to include why those things are important.
Ex: Sleep- client becomes easily frustrated when he does not get adequate sleep, such as 8 hours minimum. Q69
This document needs to be completed prior to the Input and IPOS.
What is Annual BPSA update and MichiCANS.
The update needs to include a full interpretive summary. It should never state that there are no updates; age, grade, school, functioning, family dynamics, and others are areas that should have changes annually. Q26
This form gives permission to coordinate care with primary care doctor and schools.
What is a consent to exchange information or release of information.
This needs to be done annually to allow coordination with the school, if a client is home schooled, it needs to be noted in the BPSA. Q10
If a release for a PCP is not current, medication letters, program changes, hospitalizations, a health care coordination letters can not be completed. Q9
Health screens and BPSA reviews are completed at this frequency?
What is 365 days?
The health screen and the BPSA update needs to be completed prior to the IPOS to justify medical necessity and continued services. Q12, Q23
The timeframe that coordination with client's educational settings should occur.
What is 30 days of admission, annually and as needed. When going to the school to see a youth, should document speaking to a teacher, social worker, principal regarding client. This demonstrates coordination along with annual letters. Q87
1. The time frame that the IPOS and secondary treatment plans are reviewed, which includes discussion with the consumer about their view of progress made with goals and changes that need to be made.
2. If you can not connect with a family for a quarterly review and they are not keeping appointments, this should be done.
What is 80-90 days interval?
Quarterly reviews must be done within 80-90 day time frames and are stated in the IPOS. This is a good time to review progress from clinician and family perspectives. Give a combination of quotes and ensure there is an update for ALL objectives. This is the same for periodic review notes for treatment plans also. Q71
2. Use of all forms of communication: phone, text, letter and possibly a home or school visit. Coordinate with others on the team to see if family is meeting with someone else and join that meeting. Q60
What needs to be completed when a families' preference can not be honored in the IPOS or in the IPOS meeting (including meeting time and date changes).
Document the reason why in a progress note. Q30/31
Prior to a medication being prescribed, a parent/guardian must sign this form and within this time frame.
What is a medication consent? Q7
And 365 days
When a new medication is prescribed, the consent needs to be signed stating that side-effects and education have been provided regarding the medication.
This is impacted by lack of documentation of needs, appointments cancelled or rescheduled frequently.
What is medical necessity? Q57
This should be a conversation at quarterly reviews and annual time to determine if continued services are needed or need to be adjusted- ongoing assessment.
1. This section of a progess note should be indivualized, describe how the client is presenting and progress made or barriers.
2. This section of a progress note should state what was billed in the session and support to back it up.
What is the Assessment section? Q67
Example: John Doe was attentive in the session, he was able to follow the conversation, he took some responsibility for actions, but still also holds parent responsible for triggering him. Reports that once angered, he can't remember what he did, this is of concern regarding keeping others safe in the home.
2. What is the intervention section? Q66
Targeted Case Management to complete referral for Autism testing.
Individual therapy to process feelings over the weekend that interfered with family outing.
The quarterly review is used to document progress on all the goals/objectives and provides rational to continue, modify or eliminate goals to demonstrate _________.
What is impact of services?
The quarterly review is a time to monitor progress made, barriers to completion (may need to addend the plan) and demonstrate medical necessity. Time to discuss progress made and how services are improving functioning. Can be a time to discuss if services need to be lowered. Q72
Documentation and discussion of self-determination and Independent Facilitation must occur at least this often and in ________document.
What is annually (365 days) and in the Input for IPOS and Orientation Checklist. Q32, Q33
This form needs to be completed within 365 days maximum and also explains the client's what their rights are.
What is Notification of Rights form. Q6
This form needs to be completed when there is a health, home change, safety, or substance use change in a client's case.
BPSA Update
When there is an unexpected change in any of these areas, a BPSA update needs to be completed ASAP instead of waiting for the annual update. An annual BPSA needs to be done within 365 days and include a full interpretive summary.
What is the difference between community inclusion and daily meaningful activities?
Community inclusion is the opportunity to be involved in the community with others that do not have diagnosis. Ex: community events, sporting events, parks, Boy/Girl Scouts
Daily meaningful activities are things that the youth likes to do and should have the opportunity to do regularly. Ex: Ride bikes, crafts, walking Q42, 45
Both need to be in the IPOS and spelled out in detail with examples.
1. These are people that support the client and are not paid to do so. Should be documented in the BPSA/Interpretive Summary and the IPOS.
2. This document is not effective until signed by the parent and describes goals, objectives, interventions, what services will be provided, by whom, and the frequency of services.
What are natural supports?
1. Natural supports include parents, friends, relatives, volunteers, church members that assist in meeting the client/family needs and should be included in the IPOS.
Examples should be specific! WHO it is, WHAT they are doing, WHEN they are doing it Q41
2. What is IPOS? Q62
Therapist will provide family therapy with consumer 90847 once per quarter to process communication styles.
Targeted case management T1017 will be provided 4 units (1 hour) monthly by targeted case manager. Q50, Q51
This discussion encourages strengthening, developing, maintaining natural supports and community connections by inviting family, friends, and allies to participate in the planning meeting to assist in meeting clients' dreams, goals and desires.
What is discussion of natural supports in the Input for IPOS.
Natural supports: list who they are, what they do to support, and how often. Ask about if any of them should be invited to the IPOS meeting. Q29
Consumers cannot be seen without this form being completed within 365 days.
What is Consent for Treatment?
If there is a medical appointment scheduled, case manager or therapist needs to notify prescriber also so that the consumer is not being treated/seen. Q5
This assessment is completed annually and quarterly; it identifies needs such as education, employment, utilities and food concerns.
What is Social Determinants of Health?
SDOH's should be completed annaully and quarterly with your reviews. Any needs that are identified in this assessment, and the family agrees to address, need to be present in the IPOS or addendum Q91
Name three times that documentation of coordination with the consumer's primary care physician should occur.
What is within 30 days of admission, annually and when medications are started or changed. Q80/81
1. If family/consumer is not using services as wrote in the plan, this area is impacted and reasons need to be documented in the quarterly review or an addendum.
2. The IPOS needs to include the _________ that the staff will see the client/family.
What is amount, scope, duration?
The frequency of services, name of services being provided, and the start/end dates of services. Q73
What is frequency? Q51
The time frame that needs to be between the input and the IPOS meeting date, unless you document the client requested it being held sooner.
The form that outlines the family's preferences for location, date, time are participants for the IPOS meeting.
What is 14 days or two weeks? 27
What is the input for IPOS? Q28