|
|
|
PDF
Version
STATE OF NEVADA SERVICE SPECIFICATIONS CASE
MANAGEMENT Any
exceptions to these Service Specifications must be requested in advance in
writing and approved by the Administrator. SERVICE DEFINITION: This service is a process by which client needs are
identified, and services to meet those needs are located, coordinated, and
monitored. SERVICE CATEGORIES AND UNIT MEASURES: The following service categories and unit measures
established by the Administration on Aging (AoA) must be used to document the
amount of service provided: Case Management:
Assistance either in the form of access or care coordination in
circumstances where the older person and/or their caregivers are experiencing
diminished functioning capacities, personal conditions or other characteristics
which require the provision of services by formal service providers. Activities
of case management include assessing needs, developing care plans, identifying
available providers, follow-up and reassessment, as required. One unit equals one hour of service. GENERAL REQUIREMENTS: A.
Case managers may also be Licensed Social Workers and would therefore
meet the requirements of NRS Chapter 641B, Social Workers. SPECIFICATIONS: 1.
Eligibility: 1.1
Client must be functionally impaired to be eligible for case management
services. Eligibility is based on an individual’s ability to perform
activities required for daily living (ADL). These activities include eating,
transferring, ambulation, dressing, bathing, toileting, and controlling bladder
and bowel. In addition, the client’s ability to perform instrumental
activities of daily living (IADL) will be considered. These activities include
meal preparation, housekeeping, laundry, shopping, medication management,
telephone, accessing transportation, and financial management. 2.
Required Services: 2.1 A written screening procedure must be used to assess the appropriateness of the client referrals for the case management program. 2.2
The designated case manager must act as an advocate on behalf of the
client/client’s family with agencies and service providers. 2.3
Clients who appear to be eligible for the Division for Aging Services'
Community Home-Based Initiatives Program (CHIP) must be referred. 3.
Optional Services: 3.1
Transport of clients to apply for needed services may be provided as part
of the case management service. The grantee must verify that caseworkers
maintain a valid Nevada Driver’s License and automobile insurance per NRS
485.185. The grantee must also
require a current (within 1 year) DMV driver record and must have a background
check completed on each case manager. 4.
Service Prohibitions: 4.1
Staff shall not accept tips, gifts, fees, loans or anything of value from
clients. 4.2
Staff shall not visit clients after the grantee’s business hours
without the supervisor’s approval. 4.3
Staff shall not operate as the client’s legal guardian or executor 4.4
Staff shall not investigate suspected elder abuse, but must refer
suspected abuse to the appropriate agency within 24 hours. 5.
Assessment: 5.1
A standardized multi-dimensional assessment of the client must be
completed and must document: 5.1.a
An appraisal of the client’s support system; 5.1.b
a description of the client’s physical/mental health and ability to
perform Activities of Daily Living (ADLs) and Instrumental Activities of Daily
Living (IADLs); and 5.1.c
a description of home environment and client’s financial resources. If the initial assessment is
conducted in a setting other than the client’s place of residence, a home
assessment must be completed within 30 days. 5.2
A care plan must be developed with the client/client’s representative
that incorporates the client’s goals and choices. The care plan must contain
specific actions designed to meet the established goal, including the type,
amount, frequency, duration, and sources of services to be arranged or provided.
The care plan must be signed and dated by the client/caregiver and case manager.
A copy of the completed care plan must be provided to the client or caregiver. 5.3
Amendments to the care plan must be made as necessary. At a minimum, a
new care plan must be established annually. 5.4
A reassessment must be conducted at least every six months to assess any
changes in the client’s physical health, mental health, and/or support
systems. The reassessment must include the following: 5.4.a
A description of the client’s ability to perform ADL’s and IADL’s; 5.4.b
an evaluation of the services provided and the progress toward the goals
established in the client’s care plan; 5.4.c
an assessment of the client’s mental/physical condition and support
system; 5.4.d an assessment of the services needed; and 5.4.e
a summary of any changes to the client’s condition since the last
assessment, if any. 5.5
The client’s condition must be monitored monthly by phone or in person.
A home visit or a visit in an adult day care setting is required no less than
every six months. When a client receives case management service in an adult day
care setting, a visit in the day care program is required no less than every six
months. The purpose of monitoring is to determine the appropriateness and
quality of the service and the status of the client’s condition. Documentation
must be maintained in the client’s file. 6.
Documentation Requirements: 6.1
In addition to the client assessment, care plan, monthly monitoring case
notes, and reassessment, the file must include: 6.1.a
Client referral information, including a minimum documentation of: date,
name of agency contacted, name and title of person handling the referral, and
the reason for the referral. Follow-up on referrals must occur within 30 days
and note the outcome of the referral. 6.1.b
Case narrative notes that document each contact with, or on behalf of,
the client, including referrals and outcomes. Narrative notes must also include
date of entry, brief summary of pertinent information, initials, and title of
person making the entry. 6.1.c
Statement of Understanding which explains the client’s rights and
obligations under the program (including grievance rights) and indicates the
client’s desire to receive services. The client must read this document or
have it read to him/her. The form must be signed and dated by the client/client
representative and the case manager. The client/client representative must
receive a copy of the Statement of Understanding form. 6.1.d
All applications completed on behalf of the client. 7.
Operating Procedures: 7.1
A waiting list is to be established only after all other measures for
improving the efficiency of the service delivery system have been examined and,
when feasible, implemented. Grantees are required to establish a waiting list
policy that will be activated in the event that demand for service exceeds the
program’s capacity. Waiting list documentation must include, at a minimum: 7.1.a
The client’s name, address, and telephone number; 7.1.b
the date the client was placed on the waiting list; and 7.1.c
the description of each client’s need for service. Clients with the greatest needs
are to receive priority consideration. The program must establish a procedure
for updating the continued service needs of clients placed on the waiting list. 8.
Training: 8.1
Any person providing case management services who is not licensed in
accordance with NRS 641B, et sec., must receive at least 10 hours of
training annually in areas related to case management. 9.
Quality Improvement: 9.1
The program shall establish an annual method to determine consumer
satisfaction with service through questionnaires or some other means. The
results of the quality improvement review must document any program deficiencies
and contain a plan of correction. 10.
Special Compliance Requirement: 10.1 Grantees must have current commercial and professional liability coverage as appropriate. |
Questions or Comments for the Division for Aging? Last Updated: 09/05/08 Disclaimer Search Regional Offices/Contact |
