Cabinet for Health and Family Services
Department for Community Based Services
Division of Protection and Permanency
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4F APS ONGOING SERVICES
Introduction
4F.1 ONGOING CASE PLAN
4F.2 PLACEMENT AND MOVEMENT OF ADULTS
SOP 4F
R.11/15/05
APS ONGOING SERVICES
INTRODUCTION:
A case plan is developed for the provision of all on-going services to adults. The ongoing case plan is based on an Adult CQA no older thanthirty(30)calendardays. The ongoing case plan and Adult CQA are updated when a significant change occurs and at least every six (6) months from a prior assessment.
The FSOS assigns all requests for placement and movement of adults to a SSW for assessment. The decision to place or move the adult does not rest with the Department, but assistance is provided within budgetary and personnel limitations. The assessment is initiated within three (3) working days of receipt of the request for services and is documented in the record. The assessment may include, but is not limited to contact and interview with the adult in need of placement and movement and interviews with family members, caretaker(s) and collaterals, as appropriate.
Division of Protection and Permanency
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SOP 4F.1
R.11/15/05
ONGOING CASE PLAN
COA STANDARDS:
- G9.1 Service Delivery - Service Delivery Processes
LEGAL AUTHORITY:
- 42 U.S.C. 1397 includes the provision of adult protection services in the State's plan.
- KRS 209.030 Rules and regulations - Reports - Cabinet actions
- 922 KAR 5:070 Adult Protective Services
PROCEDURES:
1.When providing on-going case services to an adult the SSW:
(a)Has personal contact with the adult on at least a monthly basis (every thirty (30) calendar days);
(b)Establishes with the adult the expectation of such contacts and documents such in the case plan;
(c)Documents all identified on-going services to be provided by the SSW as tasks in the FLO or ILO; and,
(d)Documents all contacts with the client or on behalf of the client within five (5) working days of the contacts in the case file and in the appropriate TWIST screens, as outlined inSOP 1A.2 Documentation.
2.Ongoing alternate care services provided by the SSW may include:
(a)Protective services referrals to CommunityMentalHealthCenters, Home Health Agencies, and other resources for:
(1)Counseling to help the resident and family members;
(2)Adjusting to the placement,
(3)Understanding grief and loss issues,
(4)Understanding changes in social economic status;
(5)Adjusting to loss of functional abilities, and
(6)Alleviating conflict;
(b)Assistance in budgeting the monthly personal allowance;
(c)Explanation of DCBS service responsibility;
(d)Education on the aging process and methods for dealing with special needs and behaviors;
(e)Assistance in securing information about proper nutrition, medical services, budgeting, and recreational activities;
(f)Assistance in arranging special health services;
(g)Assistance in arranging transportation for medical and social activities; and
(h)Assistance in securing volunteers or community organizations for social activities, outings, or other supportive services in the facility.
SOP 4F.2
R.11/15/05
PLACEMENT AND MOVEMENT OF ADULTS
COA STANDARDS:
- G9.1 Service Delivery - Service Delivery Processes
LEGAL AUTHORITY:
●42 U.S.C. 1397 includes the provision of adult protection services in the State's plan.
- KRS 209.030 Rules and regulations - Reports - Cabinet actions
- 922 KAR 5:070 Adult Protective Services
PROCEDURES:
Alternate Care Placement:
1.As part of the assessment, the SSW determines, in conjunction with the care team, the appropriate level of placement in alternate care. The SSW completes the assessment and submits it to the FSOS for approval. The SSW first considers alternate care settings, which are registered, certified or licensed by Cabinet for Health and Family Services including:
(a)Certified Assisted Living;
(b)Registered Boarding Homes;
(c)Personal Care Homes (PCH);
(d)Family Care Homes (FCH);
(e)Nursing Facilities (NF);
(f)Skilled Nursing Facilities (SNF);
(g)Intermediate Care Facilities for the Mentally Retarded/Developmentally Disabled; and
(h)Supports for Community Living (SCL).
2.The SSW may provide family members with information on unlicensed, non-registered, or non-certified facilities or agencies and may suggest that the family of the adult contact such facilities or agencies.
3.The SSW may assist in placement by:
(a)Considering the needs of the adult identified on the Adult CQA;
(b)Identifying vacancies in facilities at the appropriate level of care; and,
(c)Suggesting a pre-placement visit by the family to the facilities;
4.If no one else is available to assist when the adult is accepted for placement, the SSW may, with permission of the adult, guardian or legal representative:
(a)Arrange transportation; and,
(b)Notify appropriate agencies, i.e. Social Security Administration, Division of Family Support, or the U.S. Postal Service.
5.The SSW does not contact out-of-state facilities for the purpose of placement. Contact may be interpreted as a state agency placement as defined by Federal regulations, which specify Medicaid residency conditions. Direct contact by DCBS staff with an out-of-state facility, which results in placement, obligates Kentucky’s Medicaid program for care reimbursement. If the adult, family, guardian or other legal representative desires out-of-state placement, the worker may:
(a)Provide out-of-state facility or agency information;
(b)Suggest that the family of the adult contact such facilities or agencies; or,
(c)Consult the Family and Adult Consultative Services Branch for assistance.
6.When an adult is certified for a Medicaid placement, the adult may be placed in a Medicaid facility and the SSW:
(a)May assist in locating placement in the appropriate level of care;
(b)May refer the adult or family member to the Division of Family Support for the determination of Medicaid eligibility;
(c)May tell an adult, or guardian of an adult, who has a mental illness or mental retardation diagnosis that a Pre Admission Screening and Record Review (PASARR) evaluation will be conducted prior to admission in a Medicaid facility. The Division of Mental Retardation administers the PASARR evaluation;
(d)Considers every available community resource that may assist the adult to remain at home or return home during the placement process; and
(e)May follow up within thirty (30) calendar days to determine that the adult’s care needs are being met and the adult is adjusting to the placement.
When an adult is decertified, he loses Medicaid eligibility. If requested, the SSW assists with relocation of an adult to a non-Medicaid Facility within ten (10) calendar days from the date of decertification. If appropriate placement is not located or accepted by the adult or responsible party within the ten (10) days, Medicaid is discontinued and the resident is placed in private pay status.
Alternate Care Facility Closure:
1.The SSW assists in the closure of a facility when:
(a)The Center for Medicare and Medicaid Studies (CMS) or the Office of the Inspector General determines that the facility will be closed;
(b)A court order is issued to close a facility; or,
(c)There is an emergency voluntary closure.
2.In the closure process the SSW:
(a)Assesses the resident’s needs;
(b)Notifies family member(s),guardian or payee of the closure and discusses placement options; and,
(c)Assists in locating placement for each resident;
3.As part of this process the SSW may:
(a)Copy and send to the new facility the following items from the medical record:
(1)Face sheet,
(2)Advance directives,
(3)PASARR, if appropriate,
(4)TB Testing,
(5)Physician's orders,
(6)Hospital discharge summary,
(7)History and physical;
(8)Other information requested by the receiving facility;
(b)Contact the adult's payment source to advise of the new address;
(c)Arrange transportation of the adult;
(d)Arrange for packing and transfer of personal belongings;
(e)Arrange for packaging and transfer of medications; and,
(f)Complete a master register of all the adults who were placed as a result of the closure.
4.The SSW may coordinate the closure process with other agencies, i. e. the Long Term Care Ombudsman, Department for Medicaid Services, Division of Family Support, and the Office of the Inspector General.
Division of Protection and Permanency
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