Willowbrook Case Services/Willowbrook Service Coordination Notes Instructions

Element / Instruction
Month and Year of Service: / Enter the month and year for which WCS is being provided.
Name of Individual: / Enter the individual’s first and last names.
Agency Name: / Enter the name of the agency that is providing WCS.
The sections below must be completed by staff providing the WCS activities
IDT Review
Was theIDTreview of the plan of services conducted this month? / Check “yes” if theIDTreview of the plan of services was convened or check “no” if theIDT review of the plan of services was not convenedduring the service month. If “no” is indicated, the remaining fields in this section are left blank. The plan of services includes the plan for needs and services, persons responsible, data and updates or addendums.
If Yes, Date of IDT review: / If the IDT review of the plan of services was convened within this service month, provide the date of the review.
If yes, describe outcome of review: / Provide WCS Coordinator advocacy, confirmation of active representation status, and summary of discussion on behalf of class member; and follow ups resulting from the review.
Was the Individual Present at IDT review? / Check “yes” if the individual was present at the IDT meeting or check “no” if the individual was not present. The individual should be present at an IDT meeting at least once annually.
If Yes, Date that MHLS notified of review: / If yes, give date that the WCS Coordinator notified MHLS of the IDT review of the plan of services. The date must include the month, day and year.
Active Representation Status
Has active representation status changed during the month? / Check “yes” if the active representation status of the class member has changed during the service month or “no” if there has been no change in active representation.
If yes, date of change anddetails of change / Enter the date that the change was completed in that month. The date must include the month, day and year.
Describe family/advocate
contacts during the months / Description should specify date, by whom and nature of contact initiated by the family/advocate, including but not limited to a phone call, personal contact, visit, email/letter/correspondence exchange. The date must include the month, day and year.
Face-to-Face Contact(s) with the Individual
Date of Contact / Enter the date on which a face-to-face contactwas held with the individual. The date must include the month, day and year.
Purpose and Outcome of Contact / Include a brief description of the WCS activities provided and the outcome of the contact. The purpose of the contact must serve to develop, monitor and/or facilitate implementation of the goals and objectives of the person’s CFA and should not be purely social in nature.
Location of Contact / Describe the location of the face-to-face service meeting (e.g., in the person’s home, day program, or community location)

***Special Instructions forWCS/WSC-10b***

Note: Payment standards below are shaded in grey

p. 1 of 2WCS/WSC 10b- WCS/WSC Notes 11/1/11

SCOR
Was a SCOR completed this month? / Check “yes” if a SCOR was completed or check “no” if there was no SCOR completedduring the service month. If “yes” is indicated, the WCS/WSC Coordinator should provide date and summarize the issues and follow up activities taken. The date must include the month, day and year.
Heath Status
Update on health/medical condition: / Describe the current health/medical condition; whether there were any concerns, i.e., illness, seizures, hospitalization, medication changes, etc. Identify clinic visits and follow up required. List whether emergency services or hospital admission were needed during the month.
Monthly Summary
Monthly Summary / Complete this section to include:
  1. Information about the individual’s satisfaction/dissatisfaction with the supports and services in his or her CFA/plan of services. Any follow-up activities taken by the WCS/WSC Coordinator to address any concerns that the individual may have about his or her supports or services must also be noted.
  2. Significant changes or events in the individual’s life, i.e., incidents, major events, and/or changes in goals/objectives, employment, home, personal relationships, health and other person-centered information. If no changes or events occurred during the month, then this should be noted.
  3. Record review undertaken to confirm the presence of assessments/treatment/habilitation plans; Notice of Rights in the class member’s residential, day and case record; and community inclusion information on behalf of the individual. If a record review was noted, the WCS/WSC Coordinator should note the date/type of review and findings. The date must include the month, day and year. If no record review was completed during the month, then this should be noted.
  4. Any concerns regarding the health and safety of the individual and individual’s environment and actions taken by the WCS/WSC Coordinator to correct the situation. If there were no concerns about the individual’s health or safety during the month, then this should be noted.
The monthly summary may also be used to document outcomes of an IDT or other team review meeting and other relevant information.
Signature: / Sign first and last name
Printed Name: / Printfirst and last name
Title: / Enter title
Date (mth/dy/yr): / Enter the date signed. The date must include the month, day and year. Note by signing the form, staff attests that the activity described on the WCS/WSC-10b form was provided on the dates indicated.

Willowbrook Case Services/Willowbrook Service Coordination Notes Instructions (con’t)

Note: Payment standards below are shaded in grey

p. 1 of 2WCS/WSC 10b- WCS/WSC Notes 11/1/11