Documentation
The type of documentation that you must complete for each individual at the end of every shift you work by the end of that shift.
What is a progress note?
These should be entered under ISP Data > "Daily Training Record and Progress Notes"
The section on Therap where you locate Behavior Plans and/or Individual Service Plans (ISP's)
What is Individual Home Page > Go to > Consent List?
Note: Behavior plans can also be located under the Plans tab on the Individual Home Page.
Who takes out the garbage and when?
The overnight is responsible for taking the garbage to the curb by 5am on garbage pickup days, which vary by group home. Pickup day can be found either posted or on group home calendar.
Once an appointment is completed, how do you proceed with documenting?
1) All files (such as prescriptions, consultation forms, referrals, full medical discharge papers) should be scanned to the group home computer.
2) To the best of your ability, document in a t-log what is written on the consultation form. Attach the files to the t-log.
3) In the t-log, include any relevant details such as follow-up appointments or medication changes.
4) Document the information from the t-log in the results box on Therap for that specific appointment.
What do you do if you run out of supplies at the group home?
All supply lists for the month should be sent to purchasing@capitol-care.org and include enough supplies for the whole month. If you notice supplies are getting low and will likely be exhausted prior to the scheduled delivery, you must notify purchasing via email immediately.
When you call 911, where in the incident report do you indicate that notification was made?
Always input if 911 was called in the "Notifications" section on the incident report, under where it asks "Were any outside agencies notified?" Always include the exact time that 911 was called.
NOTE: After calling 911, complete a UIR and t-log. No phone calls to leadership are necessary.
Who is responsible for filling the gas tank on company vehicles, and when should it be refilled?
The staff driving the vehicle is responsible for refueling before returning to the group home. The fuel level should never go below half a tank.
You cleaned the group home, the van, and took out the garbage that the overnight staff did not. To t-log or not to t-log?
NO! Your daily responsibilities should not be t-logged as these are a part of your everyday tasks. If one of your co-workers do not complete their daily responsibilities, this should not be t-logged, but your Residential Manager should be notified.
The amount of time someone has in the home and/or in the community without staff supervision.
What is unsupervised time?
Note: Unsupervised time is located in the "Home and Community" sections of the ISP, as well as noted under Guidelines in the Individual Home Page. Unsupervised time may also be referred as alone time.
Which shift is responsible for cleaning the group home?
The overnight shift is responsible for completing the primary cleaning tasks for common areas (sweeping, mopping, deep cleaning bathrooms, and checking for expired food). However, all shifts are responsible for maintaining cleanliness, and if a task was missed by a previous shift, the current shift is expected to complete it.
NOTE: If you notice that the shift prior to yours continues to neglect their daily tasks, please report to your Residential Manager.
An individual refuses to take their medication. What do you do?
1) Attempt to encourage compliance throughout the full medication administration window
2) If continued refusal, contact Tarrytown to determine any potential for serious side effects. Document who you speak with.
3) Submit an incident report for medication refusal and document all information including reason for refusal as stated by the individual, strategies attempted for encouraging compliance, all details of conversation with Tarrytown including the name of who you spoke with.
NOTE: It is our job to encourage compliance with medication administration, but individuals do have the right to refuse medication. When implementing strategies to encourage compliance, ensure you are not violating their rights through bribery, threats, etc.
What happens if an individual has IHP funds left over from the previous week?
This does not include special request money (which should be held by staff) or money that was given to the individual by friends and family (gift cards or cash) which they may keep on hand and spend at their discretion.
How do you refer to staff and individuals in an incident report?
Use full names and titles for staff. Use full names for all individuals involved. After a staff or individual is mentioned once, they may be referred to by their first name afterwards. Do not refer to anyone as "staff", "client", "this writer", or by initials in an incident report. Use legal names and do not use nicknames.
An individual purchases Burger King while you are on a community outing. The individual leaves empty wrappers in the car but you do not see them. Your coworker sees it on the next shift and reports it to the Residential Manager. What was done wrong?
What was done wrong in this situation:
1) There is no eating or drinking in vehicles. You will likely need to remind individuals of this each time food is purchased on an outing.
2) After the community outing, you should do an inspection of the van to see if any garbage was left behind. You should encourage the individual to take their garbage with them, but if they refuse to clean up after themselves it is your responsibility to clean it up. (Note: if individuals refuse to clean up after themselves or eat in the van despite redirection and reminders, this needs to be documented in t-logs and progress notes).
3) If you find a mess in the van from the previous shift, you are still responsible for cleaning the van. If a co-worker consistently neglects van cleanliness, please report to your Residential Manager.
The three departments that do not read t-logs.
What are maintenance/transportation, finance/purchasing, and Navitend (IT)?
Instead:
1) submit facility maintenance request via dashboard (notify Director of Grounds & Maintenance or Director of Transportation if urgent)
2) email the appropriate finance staff for financial related questions, and email purchasing@capitol-care.org for any questions regarding supplies, groceries, etc.
3) submit IT request by emailing service@navitend.com
Then: Document what occurred and who was contacted in a t-log, as well as any next steps.
One of the verbal strategies to use for crisis intervention, and an example of how you would use it.
What is:
1) Persuade: reminding of positives, review member handbook, reminder of natural consequences
2) Praise: give positive feedback, reminder of individuals' strengths,
3) Model:
4) Ignore:
5) Give direction:
6) Use redirection:
7) Use distancing:
You wake up sick and need to call out of your shift. Who do you contact and what do you do?
1) Call the group home at least one hour prior to the start of your shift to notify them you will be calling out. If it is a weekend, ask which Residential Manager is on call
2) Go into Time America and submit a request for sick time off
3) Email your Residential Manager (or the Residential Manager on call) notifying them that you are calling out
NOTE: if you are on shift and the staff coming in after you calls out, you are responsible for finding coverage. Begin making calls from the sub list for your group home (located on dashboard). If you are still unable to find coverage, call your Residential Manager. If they are unable to find you coverage, you must stay and work the double shift. If you are going into a third shift, call your Residential Manager and they will arrange for your relief.
An individual informs you that they have a headache. What do you do?
Ask if the individual would like a PRN/OTC medication. If they do, administer the medication only as prescribed on the MAR and document the administration on both the MAR and in a t-log.
After administering, check back with the individual within an hour to see if the medication was effective and document the effectiveness and time in a follow-up t-log.
Reminder:
PRN/OTC medications may only be given exactly as ordered on the MAR. Do not give a higher dose than prescribed (e.g., if the MAR lists one Tylenol, administer one—even if the individual requests two).
What is the difference between IHP funds and PNA shopping?
PNA shopping is done once per month. Each individual is allotted $40 per month for personal needs such as shampoo, toothpaste, deodorant, feminine products, etc. Staff should email at the beginning of each month with what each individual needs, including the hyperlink to each month and/or the product description such as brand, flavor, scent, etc. (NOTE: it is very important to review each individual's inventory prior to placing the PNA order)
What is an example of workplace misconduct that would necessitate an incident report?
If you observe a coworker doing any of the following:
1) Utilizing personal electronics while on shift
2) Completing personal errands while in the community with individuals
3) Utilizing group home resources to complete personal tasks such as laundry
4) Using vulgar or inappropriate language about a coworker and/or to an individual
Workplace misconduct is NOT disagreements between staff or anything that occurs outside of the workplace. Interpersonal issues between staff should be discussed with your Residential Manager who will provide direction.
NOTE: Workplace misconduct is considered internal. If you witness a coworker engaging in misconduct that involves or directly affects an individual, it should be reported immediately as abuse, neglect, or exploitation
When should vehicle mileage logs be completed and what information needs to be included?
Staff need to ensure the Vehicle Mileage Logs are filled out completely and accurately, including all page totals and monthly totals in the provided boxes. These logs should be emailed to Transportation Manager by the 1st of each month. All information must be completed, and there should be no mileage gaps or incomplete trip totals.
Let's Rephrase That! "as usual, yet again, they do this all the time, here we go again, this happens everyday, this is a constant behavior, nothing ever changes, this is how they are, they have a bad habit of..."
This is a known behavior, this is a previously documented behavior, this is observed to be a repetitive behavior, this is a recurring issue, this appears to be a pattern, staff has observed this on multiple occasions, individual has done this three times in the past hour, etc.
The criteria that needs to be met to justify the use of a PCT
1) An individual is hurting themselves
2) An individual is hurting others
3) An individual is engaging in property destruction that could hurt themselves or others
4) An individual is in a dangerous environment and needs assistance in relocating
NOTE: The need for a PCT is not always in response to an individual's behavior. For example, if an individual is not responding to a fire alarm, a lead-along may be necessary for safe and timely evacuation
If there a missed medication or non-emergency medical issue, who do you call?
1) For missed medication or other med errors, call Tarrytown to determine potential side effects, or if medication can still be administered outside of the window slots
2) Submit an incident report
3) Email the Director of Medical Compliance
4) Document what occurred in a t-log
An individual requests an appointment with their PCP, but the provider is only available at a time when group home staff cannot provide transportation. What should you do?
Check the medical scheduling calendar on Outlook to confirm availability. There are only two medical runners on staff available for transportation. If you see two appointments scheduled at the same time on the medical calendar, assume both medical runners are booked.
If both runners are booked and group home staff are unable to transport, contact the provider’s office to request an alternate appointment time and notify Director of Medical Compliance via email of the scheduling issue. Document in t-log.
What is a special request and how do you submit it?
A special request must be submitted for funds needed outside of normal IHP or PNA funds. Special requests must be submitted at least two weeks in advance and approval is based on the individual's budget and staff availability for transportation (if needed).
The special request form (available on dashboard) must be completed in its entirety. One form should be submitted for each individual.
The special request form should be emailed to both the Residential Manager for that group home and finance team (Stephanie and Tracey).
If the special request is for an item to be purchased online, the link to the item must be included in the email with the special request form.
NOTE: Special request funds should always be held by staff and not given to individuals. Staff should make the purchase and keep all receipts and change in the envelope to be returned to the finance team.When there is an allegation of abuse, neglect, or exploitation, who is required to be notified and in what time frame?
Guardians and Support Coordinators must be notified within 2 hours of the incident being reported to staff.
NOTE: Sometimes an individual who is their own guardian will have appointed someone as their Stephen Komnino's contact. This is listed on their Individual Home Page in the "Profile" tab under "Active Contacts", and should always be checked when an A/N/E allegation is made.
How do you report vehicle issues?
Vehicle issues should be reported electronically on the dashboard system rather than by email. While email reports are acceptable in some cases, logging the issue in the system ensures proper tracking, history, and cost documentation. NOTE: Transportation does not read t-logs. While vehicle issues may be important to document in t-logs for purposes of informing your colleagues, it must be reported on dashboard.
What's Wrong With This T-Log?
Jane asked if we could go to the dollar store but I told her it's only me here because the other staff called out and nobody else wants to go so we have to stay home. Jane freaked out and started bugging on me using racial slurs and spitting in my face. She was completely out of control and it was really scary. Jane does this every time she doesn't get her way. It's impossible to deal with her and nobody is doing anything about it. I told Jane if she doesn't calm down I'm calling the cops. This is ridiculous.
There are several things wrong with this t-log:
1) It is not objective
2) It is not professional
3) It is judgmental and does not use person-centered language
4) It discloses staffing information that is unnecessary
5) It does not include any strategies staff utilized to address the situation
6) Threatening to call the cops as punishment is a rights violation
What is the difference between these two statements:
1) "We aren't going out if you don't clean your room"
2) "We will go out as soon as you're done cleaning your room"
1) This is a rights violation as you are restricting access to the community contingent upon the individual cleaning their room
2) This is not a rights violation because it simply explains the order in which things will happen
NOTE: If an individual still refuses to clean their room, you should still take them into the community as planned. The only exception is if the mess in the room is a safety hazard.
An individual informs you that they have been having suicidal thoughts and scratched themselves. They show you the cut and the skin is broken with minor bleeding. Who do you contact?
1) Address immediate medical needs.
If you reasonably believe that immediate medical attention required, call 911. If no, inspect the wound and provide appropriate first aid per training. Take a picture of the wound with the van phone to be used in documentation.
2) Check for imminent risk.
Ask whether the individual has a plan or intent to act on their suicidal thoughts. If they report having a plan or intent, call 911 immediately. If they do not, support the individual by engaging in appropriate coping strategies and supervision as directed by the care plan.
3) Notify leadership and complete incident report.
Inform your Residential Manager as soon as possible via email and complete an incident report. If 911 is not needed but you are unsure how to proceed, contact your Residential Manager for guidance.
Important Reminder:
If an incident appears life-threatening, call 911 immediately before contacting anyone else. Review ISP's and/or Behavior Plans for all the individuals you work with to understand who has a history of self-harm so you are prepared to handle these situations appropriately.
You receive an email from Tarrytown stating that medication refills have been denied. What are the three main steps you should take?
1) Contact Tarrytown immediately.
As soon as you receive the email, contact Tarrytown to confirm what steps they have already taken, including which provider was contacted and when. Document all details (including the name of the Tarrytown employee you speak with) in a t-log.
2) Contact the prescribing provider immediately after call with Tarrytown.
Reach out to the provider to request the refill. Document the names of anyone you speak with, what was discussed, and any next steps in a follow up t-log. If you leave a message, document that and follow up the next business day. If the provider’s office is closed during your shift, document this in a t-log for the 8–4 shift to follow up.
3) Complete follow-up until refill is received.
Follow up with Tarrytown within 24 hours to confirm the refill was received and processed. If it has not been completed, contact the provider again. If needed, follow up daily until the refill is processed and received.
Important Reminder:
Medication refill emails must be addressed promptly. Delays can result in individuals running out of medication, which may be considered medical neglect.
1) Look in the menu to see what is needed for the following week, including alternatives
2) Look in the kitchen (including cabinets and chest freezer) to see what is available
3) Only add items to the cart if they are listed on the menu and there is not enough supply in the group home for the following week
4) Additional items such as snacks that can be shared between all individuals may be added (within reason). Special request for food items for occasions such as holidays and birthdays will be approved, with at least 2 weeks advanced notice emailed to purchasing
Other important notes:
- Menu for the current week must be posted on the fridge at all times
- You may only make what is on the menu for each meal, or a designated alternative
- Any changes must be communicated to purchasing and updated on the posted menu
- If individuals would like to change any meals on the menu, purchasing must be contacted and at least 2 weeks given for finance team to approve and make adjustments
- If an item is purchased through the group home ShopRite order, it belongs to everyone in the group home
- Soda and other "junk food" items will need to be purchased with their own money and will not be approved if added to the ShopRite order
- Food cannot be locked
- If an individual refuses to eat what is on the menu, it should be documented in t-log and progress notes
- Purchasing does not read t-logs. All updates should be communicated via email
An individual is having a behavior and strikes you. You are unable to de-escalate the individual and have to call 911. When completing the incident report, are you listed under Persons Involved, Witness, or Victim?
Even if you are struck by an individual, you are not considered a "victim" in the incident report. The individual would be listed under Persons Involved as a Perpetrator (or Perpetrator/Victim) if they were injured in any way, and you would be listed as a Witness.
After snowstorms, what are you responsible for cleaning?
1) Direct Support Professionals are responsible for shoveling all fire egress routes (as designated on fire evacuation plan) with a safe pathway to the safety meeting place. This would also include sliding doors onto porches.
3) Remove all snow from vehicles. If your group home has a garage, please park the group home vehicle in the garage prior to snow. If there is room, also park your personal vehicle in the garage to make it easier to plow the driveway.
You are not responsible for shoveling the driveway unless otherwise communicated to you.
NOTE: Salt the pathways when you are done removing the snow. You may need to salt throughout the week if there is residue of snow and/or ice on the walkways.