SCL Questions and Answers

Questions Related to Documentation
Q.
According to the regulation, the Day Training monthly summary must include “an analysis of the efficacy of the service provided including recommendations and identification of additional support needs.”

Since most Day Training staff who write monthly summaries have a high school diploma or GED or neither, can you please give specifics on what reviewers will be looking for regarding this requirement.
A.
This is a basic description of how the person has benefited from Day Training Services during the month and identifies any changes or support needs that should occur. The person who works with the participant the most should have valuable input to document and share with the team about whether the Day Training piece of the person-centered POC is working.

The Direct Support Professional most involved will have the clearest insight about why or why not a particular approach, teaching mechanism or opportunity is helping a person achieve the person's outcome. That same person is also in the best position to notice when something needs to be changed, to recommend changes, or to celebrate accomplishments.

907 KAR 12:010, Section 1, (22) Direct support professional… (e) has the ability to 1. Communicate effectively with a participant and the participant’s family; 2. Read, understand, and implement written and oral instructions; 3. Perform required documentation; 4. Participate as a member of the participant's person centered team if requested by the participant.
Q.
We have encountered a lot of problems with getting doctors to write out prescriptions. Almost all have moved to e-scripts (which allows a lower liability on their part by not having their signature floating around), which has caused us a lot of problems of obtaining written-out and signed prescriptions.

Furthermore, pharmacies have been unwilling to allow us to have copies of the prescriptions as well. How is DDID moving forward with this? We are already VERY limited in the number of doctors that will see our individuals due to their insurance. We have also encountered doctors stating that this is our problem and that we should consider ourselves lucky that we see them.
A.
E-Scripts printed out and signed by the doctor is acceptable. Carewise Health will accept a pharmacy printout of E-Scripts with the electronic signature of the physician.

The Board of Pharmacy considers the E-Script as the original and that no other script should be printed. So, DDID staff will not be looking for a handwritten prescription if an E-Script exists.

Please contact your agency DDID Nurse if you have further questions.
Q.
Can we get a specific response on this as to what the division expects to see in a record on an annual dental exam and/or what you would consider best practice?
A.
The SCL Regulation requires that providers maintain a record for each participant served that contains the results of an annual dental exam. With or without teeth, oral health is an important component of a person’s overall well-being.

Even if a person is edentulous, the person should have his or her mouth and gums checked by a professional in that field, not only for gum care and hygiene reasons, but for specific oral health and disease prevention. Dentists are frequently the first to identify mouth cancers. Early diagnosis of mouth and throat cancer is crucial because these cancers caused by HPV and tobacco are so frequently fatal if diagnosed at late stage.

The regulation does not specify that the requirement for dental exams only applies to people who have teeth. Also, dentists do recommend that people who are edentulous still have routine exams. If a general practitioner checks the person's gums during the physical exam, this should be documented by the physician.
Q.
Could the Department please clarify what is the Summary Sheet and what elements should be present within that document?

Please discuss and clarify the expectations for the participant summary.
A.
The Participant Summary is intended to be a quick-reference document that captures the most critical need-to know information from the participant’s plan of care. It should combine the critical elements previously included in Crisis Prevention Plans (ALL health/safety/welfare issues) with more general information about the individual’s preferences and needs.

The Participant Summary should include all the information a direct support staff person needs to know to provide quality supports for the participant, including items that are important to and for the person.

This should be person centered and may include items like:
  • I prefer to take a shower in the morning. I do not like to take a bath.
  • Don't expect me to talk to you before I've had my morning coffee. I like it to be quiet and peaceful in the morning, so please don't turn on the TV until at least after breakfast.
  • It is important to me to watch XXX on TV every Monday night. If you, as a staff person, really want to watch football, then you should ask to take Mondays off during football season.
  • I do not like to eat green vegetables, but will agree to have a small portion if you remind me that the doctor said it is important to eat a balanced diet.
  • I attend YYY church every Sunday. It's important to me to arrive early so I can have coffee with my friends there. That means we need to leave the house no later than 9:15.

Under the Crisis Prevention Plan system, people who don't display disruptive behavior when their preferences are not honored did not consistently have their preferences written down or communicated to staff. The broader Participant Summary is intended to ensure that direct support staff know each person's preferences and interests, which will improve quality of life.
  • Each agency should have a policy addressing the participant summary.
  • The participant summary must be current and updated as changes occur.
Q.
Can DDID clarify if this document will include aspects of what would formerly be known as the crisis plan and can it also incorporate other documents currently utilized, such as the Face Sheet and Picture requirements?

And to build on this question, wouldn't preferred items and communication and some of those items you are describing be on the new narrative form?
A.
Yes, the Participant Summary Sheet should include the health/safety/welfare items that would previously have been included in a Crisis Prevention Plan. If an agency elects to also incorporate the participant's picture and information it would previously have included in a Face Sheet (date of birth, MAID number, etc.), that is an acceptable practice. The Participant Summary is intended to serve as a quick reference sheet that includes all the information a direct support staff person needs to know to provide quality support for the participant, which includes information about what is important to the person in addition to health/safety/welfare issues.

It is true that the new Narrative form also includes information about the individual's preferences. The Participant Summary Sheet should include information that can be found in other documents in the participant's record, including but not limited to a Positive Behavior Support Plan, Physician's Orders and/or Protocol, Rights Restrictions, the Life Story, clinical assessments such as a Physical Therapy Assessment, and the Narrative. The Participant Summary is intended to be a summary of the critical information each direct support staff person needs to know to be effective in providing supports for that person, collected into one document.
Q.
Our agency has been told that CM is required to sign the CPP/participant summary sheets. I thought it was up to each agency to develop their own participant summary sheet. If this is required, where is this requirement in regulations?
A.
The Participant Summary Sheet is required to be maintained in the participant’s record. The regulation does not specify that each agency must develop its own. Since it is part of the person centered planning process, the full support team should be involved in the development of the participant summary, and that summary should be maintained in the record of each agency supporting that person.

Each document in the participant's record should be dated and signed by the person who generated the document.
Q.
What paperwork do other providers need for their notebooks and charts?
A.
The following items are required to be in the primary record for all SCL providers.From 907 KAR 12:010, Section 3:

  • (3) An SCL provider shall:
    • ...
    • (p) Maintain a record for each participant served that shall:
      • ...
      • 10. Contain the following:
        • a. The participant summary sheet;
        • b. The participant’s name, Social Security number, and Medicaid identification number;
        • c. The Supports Intensity Scale Assessment Form;
        • d. The results of a health risk screening performed using a Health Risk Screening Tool which shall:
          • (i) Be administered by trained personnel at least annually and updated as needed;
          • (ii) Assist in determining a participant’s areas of vulnerability for a potential health risk; and
          • (iii) Be provided in accordance with the health risk screening tool requirements established in the Supports for Community Living Policy Manual;
        • e. The current person centered plan of care;
        • f. The goals and objectives identified by the participant and the participant’s person centered team which facilitates achievement of the participant’s chosen outcomes as identified in the participant’s POC;
        • g. A list containing emergency contact telephone numbers;
        • h. The participant’s history of allergies with appropriate allergy alerts;
        • i. The participant’s medication record, including a copy of the signed or authorized current prescription or medical orders and the medication administration record (MAR) if medication is administered at the service site;
        • j. A recognizable photograph of the participant;
        • k. Legally adequate consent, updated annually, and a copy of which is located at each service site for the provision of services or other treatment requiring emergency attention;
        • l. The participant’s individual educational plan or individual family service plan, if applicable;
        • m. The participant’s life history updated at least annually;
        • n. The results of an annual physical exam;
        • o. The results of an annual dental exam;
        • p. The Long Term Care Facilities and Home and Community Based Program Certification Form, MAP-350 updated annually;
        • q. A psychological evaluation;
        • r. A current level of care certification;
        • s. The prior authorization notifications; and
        • t. Incident reports, if any exist;


Additionally, in Section 4 specific documents are required as documentation for each service.

If a separate program book is maintained (such as at a Residential or Day Training site), the following information is required:
  • Participant Summary.
  • Plan of Care .
  • Photo (recognizable).
  • Consent for Emergency Treatment.
  • Allergy Alerts.
  • Behavior Support Plan, if applicable.
  • Rights Restrictions, if applicable.
  • Prescription or physician's order for any medication administered at the site.
  • Medication Administration Record .
  • Current documentation for the service provided, such as in and out times for Day Training, daily notes, and implementation of outcomes.
Q.
Do SCL2/PDS clients have to have the same documentation as SCL2 clients? I have been told by many Case Managers that SCL2/PDS clients are not required to have physicals and dental exams. Is this true?
A.
This is not true. People in SCL who chose to participant-direct (PDS) some or all of their SCL services should have dental and physical exams provided by the appropriate professional entity that specializes in that service.
Q.
I understand if a participant has transferred to SCL2 with no Residential Goals, that we are only to do daily notes as outlined in the new regs. However, it asks that we document in the monthly summary how the participant is working toward outcomes, analysis of progress toward outcomes, and a projected plan to achieve the next step in achievement of an outcome. If a participant doesn't have outcomes in the POC, how do we document this correctly?
A.
The monthly summary should have information that indicates that the case manager is monitoring the service, identifying barriers, and taking action as needed. Even without formal outcomes the regulation lists what residential services might include based on the individual’s needs which are:
  • 1. Adaptive skill development.
  • 2. Assistance with activities of daily living, including personal assistance.
  • 3. Community Inclusion.
  • 4. Social and Leisure development.
  • 5. Adult educational supports.
  • 6. Protection and oversight.
  • 7. Transportation. The agency providing residential supports is responsible to arrange for or provide transportation between the participant’s place of residence and other service sites and community locations.
  • 8. Medical and Health Care Services that are integral to meeting the person’s daily needs.
The monthly summary would discuss the provision of the residential service based on the above expectations. It would include any problems noted and steps taken to remedy the situation.

This also includes the individual’s satisfaction with his or her service, the location of the home, staffing, housemates, transportation, opportunities for socialization and participation in the broader community.
Q.
After many different free iPad apps and signing up for a trial of Microsoft 365 to utilize their Excel app, I and my colleagues have not been able to find an app that allows for full functionality of the new Focus Tool. What app is the tablet-friendly version able to be opened in?
A.
For full functionality you must have the complete Microsoft Office. The trial version does not allow for use of the Focus Tool.