4.12 SCL – Homemaker Personal Care and ISP/PCP Documentation

Policy

The Case Manager/Program Coordinator will prepare documentation that supports the service plan for a individual before providing personal services for the individual. The Case Manager/Program Coordinator will ensure the service plan meets the needs and wants of the individual.

Procedure

1. The Case Manager/Program Coordinator will attend the ISP/PCP meeting and complete all aspects of the Open Door ISP Checklist.
2. The Case Manager/Program Coordinator will be responsible for developing documentation to support the individualized service plan for each individual upon completion of the initial assessment and ISP/PCP meeting.
3. The services offered and planned for each individual will be appropriate to the scope, frequency, need, and preference of each individual.
4. The Homemaker Personal Care Electronic Documentation will reflect the amount of assistance the individual requires in activities for daily living. The agency will provide services to the individual as stated in ISP/PCP.
5. The documentation will contain information regarding any safety concerns or negotiated risks requiring interventions for each individual as identified during My Assessment form and meeting.
6. The ISP/PCP documentation will also indicate a person-centered approach outlining what is important to the individual including personal interests, preferences, and outcomes for personal goals, relationships with family and friends, participation in and/or roles in the community.
7. The ISP/PCP electronic documentation will be utilized as a guide by the employees/caregivers for services.
8. Direct Support Professionals (DSPs) will document all electronic forms in a designated electronic documentation system according to the training manual provided in orientation. Staff are required to document the services provided immediately after service is completed. If a service is not provided, staff shall document an interruption code verifying the reason service was not provided, (ex: on vacation, refused, sick).
9. The Case Manager/Program Coordinator is responsible for initiating other forms that support ISP/PCP needs including, but not limited to, behavior data tracking sheets, menu worksheets, clothing tracking, etc. Copies of these forms are in the shared folder.
10. Documentation of ISP/PCP sheets will be evaluated during random program department audits and through reviews by Case Manager/Program Coordinator. Any deficiencies must be addressed within 14 days of audit finding. The standards of conduct in Policy 2.15 outline corrective action measures for failure to complete documentation to meet standards.

Monthly Summary

The Case Manager/Program Coordinator is required to review and monitor all individual goal plan and service delivery monthly. The assigned Case Manager/Program Coordinator must compile all data to complete the monthly summary documenting progress on all goals. The Case Manager/Program Coordinator must review progress to determine whether to continue, revise, or discontinue goals. Goal progress must be reviewed during ISP/PCP meetings. Monthly summaries are saved on the drive each month to review outcome progress.

Last Revised: 8/25/21