4.12 ICF – ADL and PCP Documentation

Policy

The QIDP will prepare documentation that supports the service plan which should also meet the wants and needs for the individual before personal services are provided.

Procedure

1. The QIDP will co-chair the PCP meeting and will be responsible for developing the documentation to support the PCP for each individual upon completion of the initial assessment and meeting.
2. The services offered and planned for the individual will be appropriate to their preference, scope, frequency, and need.
3. The Brittco goals will reflect the amount of assistance the individual requires in daily living activities and the company will provide services as outlined in their PCP. The documentation will also contain information regarding any safety concerns or negotiated risks identified during the life safety assessment and their meeting.
4. The ADL and PCP documentation will indicate a person-centered approach which outlines what is important to the individual including personal interests, preferences, outcomes for personal goals, relationships with family, friends, and participation in the community.
5. The ADL and PCP documentation sheets are located on Brittco. The staff will document for services provided immediately after service is completed. If a service is not provided, staff should document an interruption code verifying the reason service was not provided such as vacation, refused, sick, etc.
6. The QIDP is responsible for initiating other forms on Brittco/JotForm that support the PCP needs which includes but is not limited to: bowel tracking, input/output tracking, menu worksheets, seizure tracking, clothing tracking, etc. Copies of these blank forms are in shared folder.
7. Documentation of ADL and PCP sheets will be evaluated during random program department audits completed weekly by the Residential Coordinator, QIDP, and ICF Systems Manager and through monthly summaries by the QIDP. Any deficiencies must be addressed within 3 days of audit findings; the standards of conduct policy (2.15) outlines disciplinary measures for failure to complete documentation that meet standards.
8. The QIDP is required to review and monitor all documentation systems and service delivery monthly. This data is used to complete a monthly summary which documents progress on all goals. The QIDP reviews the progress to determine whether to continue, revise, or discontinue the goal, and also reviews this during the PCP meetings.

Last Revised: 4/29/22