Documents and Forms

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This document revised 4/2016

Key

Care Coordinating Agency

Employment/Skill Building

Supported Housing

Staffing Agency/Respite

Residential/AFC

Other Professional Services

Key cont.

The key is used to help guide Providers through the PowerPoint presentation and designates what service provider each slide is applicable to.

Incident Report Training

• All Adult Foster Care (AFC) staff are required to attend training within first 3 months of hire

• Respite, Staffing Agencies, and Supported Housing staff have the option to send all staff or designate a representative who will provide the training to staff

• Training is optional, but recommended for Care Coordinating Agencies (CMH), Supported Employment, Skill Building, and Other Professional Services

*Note: BHPI may request that training be taken or repeated,

if staff fail to follow the Incident Report Policy

Incident Report Training Schedule

• BHPI hosts quarterly trainings on-site at BHPI on Incident Reports to educate Providers and staff about the reporting requirements that are mandated by Licensing, DWMHA, and the Network

• All on-site trainings must be scheduled in advance

• Individuals who attend the training will have the opportunity to complete mock incident reports on real scenarios which helps individuals apply what they have learned in their training

• Individuals will be provided a certificate of completion for their records

• A current schedule of the on-site trainings is posted to the Provider Portal for your convenience

Current Schedule for Incident Report Training

Incident Report Training

• BHPI also offers Incident Report training online through the Provider Orientation Portal which can be accessed at anytime

• Individuals who take the training online will need to complete the post-test afterwards to receive credit

• No certificate of completion will be provided at the end; however, BHPI will receive notification of completion which can then be verified by an employer

*Note: Please refer to the Provider Manual and/or Incident Report training presentation for more

information on the Incident Report Policy Incident Report Training Presentation

BHPI Incident Report Template

• Universal Incident Report form can be used for all settings/services

• You have the option to fill the report out on your computer to print out or you can print the form to fill out manually by hand

BHPI Incident Report Template

Open Letter to DWMHA

• Provides timeline of Recipient Rights training Part 1 & 2

• Provides process if you do not have original face to face training

Click here for Document

Office of Recipient Rights Sanctions

• Providers who do not follow DWMHA policy and fail to have their staff complete face to face Recipient Rights trainings within 120 days of employment, can be fined up to $50 for each employee.

Recipient Rights Sanctions for Untrained Staff

MH WIN New Hire Recipient Rights Registration Instructions

• Presentation serves as a guide for Providers who need to register new staff in MH WIN

• All staff servicing DWMHA consumers must be registered in MH WIN

• Staff must be registered in MH Win to sign up for New Hire Recipient Rights face-to-face training

• Staff who are already registered in MH WIN and are switching homes or have sought employment with another provider must immediately update their information in the system

Office of Recipient Rights - New Hire

Deficit Reduction Act

• Example Deficit Reduction Act (DRA) serves as a template on how providers can create their own

• DRA will need to be typed on agency/provider letterhead

• Each employee will need a copy of the DRA and sign one annually which should be kept in the employees’ file Deficit Reduction Act

Deficit Reduction Act cont.

• Covers Fraud, Waste and Abuse of Medicaid dollars– HITECH Laws– False Claims ACT– Whistleblower Employee Protections

• Individuals may also take Medicare Fraud, Waste & Abuse on VCE Online in lieu of the DRA

For more information please visit: http://www.hhs.gov/ocr/privacy/

Abuse and Neglect Statement

• Statement is required to be signed by all staff who are delivering services at a residential site. This includes AFC staff, Supported Housing, Semi-Independent Living, Staffing Agencies and Respite

• Must be signed and dated by all staff prior to working with any ConsumerLink or CareLink consumers Abuse and Neglect Statement-CareLink

Abuse and Neglect Statement- ConsumerLink

Workforce Background Checks

• All staff under the CMH system including but not limited to, direct care workers, respite staff, CLS staff, skill building staff, case managers, supports coordinators, therapists, etc. are required to have annual background checks

• Staff working with children are also required to undergo annual Central Registry Checks Workforce B

ackground Checks

AFC Fingerprinting Letter

• All AFC staff are required to have their fingerprints taken through the Rap Back process prior to employment

• AFC staff cannot work with consumers until a clearance is received by the State of Michigan

• AFC staff are still required to undergo annual background checks

AFC Fingerprinting Letter

DWMHA Training Grid

• All staff working under the CMH system are required to complete all of the DWMHA training, as appropriate for their job description and in the interval as prescribed

• All staff delivering services to DWMHA are considered “CMH staff”. This includes direct care workers, respite staff, CLS staff, skill building staff, case managers, support coordinators, therapists, etc.

Click here for Document

Staff Training – Residential

• Residential staff is defined as “Any staff who provides services to a consumer in their own home, supported housing, semi-independent living or AFC”

• A staff training checkbox is provided to residential providers to provide a quick overview on essential trainings that is required to help staff be successful in working with consumers

Staff Training – Residential

Staff Training – Clinical

• A staff training checkbox is provided to clinical providers to provide a quick overview on essential trainings that is required to help staff be successful in working with consumers

Staff Training – Clinical

CARF

• All unaccredited Providers are required to review the CARF Unaccredited Providers Training provided on the Provider Portal

• Providers and/or staff will not receive credit for taking the training until they pass the post-test that is given afterwards CARF Unaccredited Provider Training

CARF Documents - Emergency Drill Worksheet

• Template can be used to record various emergency drills such as bomb threat, natural disaster, medical emergency, etc.

• Template cannot be used to record fire drills in AFC homes as licensing has their own form that they provide for recording fire drills Emergency Drill Workshe

et

CARF Documents - Monthly Incident Report Log

• All unaccredited Providers are required to track and trend Incident Reports on a regular basis.

• Template serves as a tool to assist in tracking and trending types of incidents and frequency of incidents occurring

• A copy of the Incident Report Log must be made available for review during monitoring

Monthly Incident Report Review

CARF Documents - Annual Incident Report Log

• Although Incident Reports are already being tracked monthly, this template allows you to aggregate the data which makes it easier for to review a years worth of data at a glance

• Assists Providers’ in

completing their annual CARF report and improve consumer care

Annual Incident Report Review

CARF Documents - Recipient Rights Log

• Unaccredited Providers are required to track all Recipient Right complaints made against them

• If no complaints are made then providers are encouraged to document the month and year and write “No Complaints Made” across the sheet in large bold lettering

• A copy of the Recipient Rights Log must be made available for review during monitoring

Recipient Rights Review

CARF Documents - Grievance Log

• Unaccredited Providers are required to track all Grievances made against them

• If the Provider does not receive any Grievances then providers are encouraged to document the month and year and write “No Grievances Received” across the sheet in large bold lettering

• A copy of the Grievance Log must be made available for review during monitoring

Grievance Review

CARF Documents - Accessibility Plan

• Unaccredited Providers are required to have an Accessibility Plan

• If a Provider has multiple sites and is using only one accessibility plan then the Provider must identify each site under each section of the Accessibility Plan to be clear what site has the identified barriers

• A current copy of the Accessibility Plan must be kept in each home/site to monitor for compliance

Accessibility Plan

CARF Documents - Annual Risk Management Assessment

• This template is provided to assist Providers in creating their own Risk Management Assessment. While this template is only an example of how to complete an assessment, it is not all-encompassing and Providers are encouraged to pull what they need from the template to create their own. Annual Risk Management Assessment

AFC Food Requirements

• AFC Homes are required to have two (2) weeks of food in the home at all times

• Food cannot be locked up, including refrigerator, and consumers must have access to the food

• Home must also have a three (3) day stock of emergency food to provide balanced nutritious meals and in event of an emergency

*Note: Please refer to the Emergency Food Suggestions in the Quality Assurance Resources section to ensure you have all the food necessary to meet Network(s)

standards

AFC Medication Disposal Act

• The Disposal Act fact sheet is provided to ensure Providers are aware of their rights and how they can responsibly dispose of their consumers medication

Medication Disposal ACT

AFC Smoking Ban

• Effective May 1, 2010 smoking was banned from AFC homes

• Homes who have consumers that smoke may designate a smoking area outside and away from the house

Smoking Ban Memo

AFC Monitoring

• AFC homes are reviewed every quarter for compliance with Licensing Rules, DWMHA and Network(s) standards

• To determine compliance, BHPI will review the following:– Environmental Health & Safety– Consumer Charts– Staff Training– CARF Book (for unaccredited Providers only)

• A consumer interview is also completed to ensure consumers are receiving high quality care and are satisfied with services

AFC Monitoring cont.

• Providers will be given the date for their quarterly review three (3) months in advance

• Providers who are not in compliance with all standards will be required to correct deficiencies within five (5) calendar days from date of review

• The review will consist of the following audit tools:– Clinical Review – Residential Provider– Clinical Review – CMH Residential Setting– BHPI Residential Environmental Review– DWMHA Residential Health & Safety– AFC Report Card– Staff Training Tool– CARF Review Tool

Clinical Review- Residential Providers

• The Quality Assurance department at BHPI utilizes the Clinical Review – Residential Providers tool to review progress notes, residential fund sheet, releases and other AFC required documents

• Providers are required to adhere to all standards that are scored in this tool. Fail to do so will require a plan of correction

Clinical Review- Residential Providers

Clinical Review - CMH Documents Residential Setting

• Clinical Review – CMH Documents in Residential Setting tool is used to review the CMH documents in the consumer charts at the home

• Although Providers are required to have all the documents listed in the tool, the Quality Assurance department at BHPI does not score Providers against these standards. However, Providers are required to try and obtain documents from the CMH and should not wait until they are reviewed for compliance to obtain documentation

Clinical Review – CMH Documents in Residential Setting

BHPI Residential Environment Review

• The Quality Assurance team at BHPI conducts quarterly Environmental Health & Safety assessments on all AFC homes

• Tool serves as an “abbreviated” assessment from the annual DWMHA Residential Environmental Health & Safety Review

• Tool is used during 2nd, 3rd and 4th quarter. However, Providers are required and expected to adhere to all Licensing, DWMHA and Network standards at all times, even if they are not being reviewed for a specific standard that quarter

BHPI Residential Environment Review

DWMHA Residential Environmental Health & Safety

• Tool used by the Authority to review AFC homes

• BHPI utilizes tool during annual reviews which is completed during the 1st quarter of every fiscal year

• AFC homes that do not meet the standard of this tool may be subject to a plan of correction, network sanctions and/or contract compliance DWMHA Residential Environmental Healt

h & Safety

AFC Provider Report Card

• After each quarterly review, a Provider Report Card is completed based on how Providers’ scored on the clinical charts, consumer satisfaction, environmental health & safety standards, aesthetics of the home, if Provider has been under Contract Compliance in past year or has received any substantiated Recipient Rights complaints during the fiscal year

• Providers can earn bonus points for being accredited or by having training in Casey Life Skills, Gentle Teaching, and/or having a current CARF book.

• Providers’ who score 22 or above are considered “Premiere Providers” and will be selected first for consumer placement

AFC Provider Report Card

CMH/Agency Reviews

• All Providers are reviewed on an annual basis but may be reviewed more as deemed by the Network(s)

• BHPI uses a variety of tools to measure program and chart compliance. Each tool is tailored for the program being reviewed

• Providers are expected to score a minimum 95% compliance or greater among all programs and staff training

• Providers who score below 95% are expected to complete a plan of correction and show improvement over a specified amount of time

• Providers who score below 95% may also be subject to Network sanctions and/or contract compliance

Staff Review Tool

• Tool used to conduct staff training audits

• Tool used to review all staff regardless of job description

• Staff training is reviewed no less than annually at all Provider sites but may be reviewed more frequently

Staff Review

ACT Case Record

• A sample of consumer charts are reviewed annually across all agencies who provide Assertive Community Treatment (ACT)

• The tool can be used by Providers as a useful resource to help prepare for upcoming ACT reviews

ACT Case Record

ACT Program Review Tool

• The Quality Assurance department at BHPI uses the ACT Program Review tool to score against ACT standards to ensure Providers are adhering to the fidelity of the model

• The tool can be used by Providers as a useful resource to help prepare for upcoming ACT reviews ACT Program

Clubhouse Program Review Tool

• A sample of consumer charts are reviewed annually across all agencies who provide Clubhouse services

• The tool can be used by Providers as a useful resource to help prepare for upcoming reviews

Clubhouse Program

HAB Waiver Review Tool

• A sample of consumer charts are reviewed annually across all agencies who provide HAB Waiver services

• The tool can be used by Providers as a useful resource to help prepare for upcoming reviews

HAB Waiver

Home-Based Children’s Review Tool

• A sample of consumer charts are reviewed annually across all agencies who provide Home-based Children services

• The tool can be used by Providers as a useful resource to help prepare for upcoming reviews

Home-Based Children’s

Infant Mental Health Review Tool

• A sample of consumer charts are reviewed annually across all agencies who provide Infant Mental Health services

• The tool can be used by Providers as a useful resource to help prepare for upcoming reviews Infant Mental Health

Intensive Crisis Stabilization Review Tool

• A sample of consumer charts are reviewed annually across all agencies who provide Infant Mental Health services

• The tool can be used by Providers as a useful resource to help prepare for upcoming reviews

Intensive Crisis Stabilization

Medicaid Claim Verification

• A sample of consumer charts are reviewed annually across all agencies who billed for any Medicaid covered service

Medicaid Claim Verification

Occupational/Physical/Speech & Language Therapy

• A sample of consumer charts are reviewed annually across all agencies who provide Occupation Therapy, Physical Therapy and Speech & Language Therapy

• The tool can be used by Providers as a useful resource to help prepare for upcoming reviews

OT/PT/SL

Outpatient Case Record Review Tool

• A sample of consumer charts are reviewed annually across all agencies who provide Outpatient Therapy

• The tool can be used by Providers as a useful resource to help prepare for upcoming reviews

Outpatient Case Record

Parent Management Training – Oregon Model Review Tool

• A sample of consumer charts are reviewed annually across all agencies who provide Parent Management Training – Oregon Model (PMTO)

• The tool can be used by Providers as a useful resource to help prepare for upcoming reviews Parent Management Training

Partial Hospitalization Program Review Tool

• A sample of consumer charts are reviewed annually across all agencies who provide Partial Hospitalization Program

• The tool can be used by Providers as a useful resource to help prepare for upcoming reviews

Partial Hospitalization Program

Supported Employment Review Tool

• A sample of consumer charts are reviewed annually across all agencies who provide Supported Employment Services

• The tool can be used by Providers as a useful resource to help prepare for upcoming reviews

Supported Employment

Trauma Focused – CBT Review Tool

• A sample of consumer charts are reviewed annually across all agencies who provide Trauma Focused – Cognitive Behavioral Therapy

• The tool can be used by Providers as a useful resource to help prepare for upcoming reviews Trauma Focused - CBT

Wraparound Program Review Tool

• A sample of consumer charts are reviewed annually across all agencies who provide Wraparound services

• The tool can be used by Providers as a useful resource to help prepare for upcoming reviews

Wraparound Program

Office of Inspector General Monthly Checks

• Providers are required to check all their staff on a monthly basis against the Office of Inspector General – Excluded Search database

• BHPI provides detailed instructions for new Providers who have never done this process to make it easier to check their staff

OIG Instructions

Excluded Provider List Systems Monthly Checks

• Providers are required to check all their staff on a monthly basis against the Excluded Provider List Systems database

• BHPI provides detailed instructions for new Providers who have never done this process to make it easier to check their staff EPLS Instructions

CareLink IPOS Training Documentation Form

• All staff working with CareLink consumers are required to be trained on the IPOS of the consumer that they are providing service to

• Form can be used to show evidence that staff was trained on a specific consumers IPOS

CareLink IPOS Training Documentation Form

ConsumerLink IPOS Training Documentation Form

• All staff working with ConsumerLink consumers are required to be trained on the IPOS of the consumer that they are providing service to

• Form can be used to show evidence that staff was trained on a specific consumers IPOS ConsumerLink IPOS Training Documentation Form

Grievance Complaint Form

• Consumers should make a grievance when they are dissatisfied with the services they are receiving

• Staff cannot prevent consumers from making a grievance or retaliate against consumers when they make a grievance complaint

• Grievances are handled by the Member Service department at BHPI and are often resolved without any intervention from the MCPN

Grievance Form

Grievance Complaint Form cont.

• Grievances are handled by the Member Service department at BHPI and are often resolved without any intervention from the MCPN

• BHPI may investigate a grievance if there is just cause and/or concerns about the complaint being made

Links to Useful Documents and Resources

• Choking Poster• Hand Washing Poster• Adult First-aid/CPR/AED Poster• Child First-aid/CPR/AED Poster• Emergency Food Suggestions• Emergency Preparedness• USDA-FDA Cold Storage Chart• Food Product Dating• MDHHS Universal Consent Template• Quality Assurance Provider Manual Section- CareLink• Quality Assurance Provider Manual Section-

ConsumerLink• DWMHA Policies• Licensing Rules