A. | Please refer to the Exceptional Supports Protocol (see Related Links or visit http://chfs.ky.gov/dms/incorporated.htm#12).
The SCL Exceptional Supports Request Fax Form is located on the SCL2 Home Page (see Related Links or visit http://dbhdid.ky.gov/ddid/scl2.aspx).
Supporting Documentation should include:
- 1. A cover letter stating:
- The participant is currently in institutional setting and transitioning to the community; or
- The participant is at risk of not maintaining their life, friends, home and work in the community; and
- The assessed needs of the participant based upon the SIS and/or HRST indicate an intense level of supports is required to promote health, wellness and stability.
- 2. Team-approved Plan of Care documenting:
- The enhanced service delivery needed (e.g., specific enhanced training requirements or credentialed employee, time of day enhanced staffing ratio required, number of hours of professional staffing, or oversight required), including any support needs for which enhanced professional treatment and oversight are warranted (to include dietary, psychological or positive behavior support services).
- The frequency of the data review by the team and consideration of criteria for reduction of these, and information about alternative measures attempted.Cost analysis or projected budget for the supports provided for participant.
- 3. Request for additional supports needed in the area of skilled nursing shall include the following additional documentation:
- Specification of hours of necessary RN direct support required for delivery of identified nursing care not delegable per 201 KAR 20:400.
- Plan to obtain and monitor clinical outcome data with criteria for reduction as relevant to medical condition.
- Specification of additional direct support staffing requirements in amount and time of day with criteria for reduction of these supports, including completion of the expanded requirements for credentialed DSP in the areas of Health Support if appropriate; and
- Assessed exceptional needs documented by the SIS and the HRST with a copy of the physician’s orders when applicable.
- 4. Request for exceptional supports based on the exceptional behavioral health or behavioral supports needs of the participant must also include the following (as applicable):
- Documentation of completion of the expanded requirements for the direct support professional (DSP) credentialed in the area of positive behavior supports.
- Documentation of the providers' ability to support people with exceptional behavioral health or behavioral support needs which may include implementation of specialized programs, established arrangements with network of community supports. This documentation pertains to a provider’s overall or system wide capacity to provide these types of supports.
- A functional assessment and any supports developed based on that assessment, to include a Positive Behavioral Support Plan.
- Any notes from HRC and BIC for plans reviewed.
- The form of communication utilized and, as appropriate, specified communication techniques/use of technology. Include a description of efforts toward functional communication.
- Quantitative data in the form of frequency, rate or duration should be provided for each target behavior identified in the Positive Behavior Support Plan. This data must include the most recent three-month period of the continuous data collection for each targeted behavior or behavioral health symptom. Data should be in an objective, numerical and graphical form.
- Documentation which may include clinical notes, to indicate that ongoing behavioral health services are necessary to achieve the desired outcomes specified in the POC.
- Behavioral Health Plan, Crisis Prevention Plan and notes from debriefing sessions of the CMHC and ICF/IID Mobile Crisis Services.
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