CHAPTER 1100 DOCUMENTATION AND RECORDS

1101. General
This chapter specifies the general requirements for documentation and records for COMP providers. The Part III Services Manual for the Comprehensive Supports Waiver specifies documentation and record requirements specific to individual waiver services. Chapter 700 of this manual includes any documentation and record requirements for screening, and the initial and reevaluations regarding level of care.
1102. Individualized Service Planning and Implementation
The intent of the development of the Individual Service Plan (ISP) is a process that focuses on the individual’s hopes, dreams and vision of a “life well-lived”. Information included within this individualized plan should be presented as a single plan describing the individual’s service/support needs within a daily life versus a daily service. Support networks should work closely together to identify issues of risk and needed supports to address those risks while never losing sight that the individual is at the center of the planning process and included in all discussions. Individualized service planning produces an organized statement of the proposed services to guide the provider(s) and participant throughout the duration of service. Chapter 700 of this manual covers the process of development of the initial Individual Service Plan. This section describes the process for updating subsequent Individual Service Plans.
A. Annual Individual Service Plan Document: After the initial Individual Service Plan (ISP), the participant’s support coordinator is responsible for the development of the annual ISP document. It is the responsibility of the support coordinator to discuss service options with the participant, his/her family and others as appropriate over the course of the year. Annual ISP meetings will use the participant’s date of birth as a guide to annual review.
B. Choice of Service Options and Providers: The ongoing discussion on the range of service options is repeated at the annual review At this time, it is the Support Coordinator’s responsibility to discuss service options based on the participant’s assessed support needs, with the participant, his/her family and others as appropriate in order to identify social, education, and other needs. These needs may indicate Medicaid and non-Medicaid covered services. The support coordinator works with the participant and/or family/representative to determine their choices among the service options for the participant and available providers prior to the formal Individual Service Plan meeting with the chosen provider(s).
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C. ISP Meeting Participants and Documentation: The participant’s support coordinator facilitates the ISP development. The support coordinator works with the participant (and his/her representative) to determine whom he or she wants to include in the ISP development meetings and the formal ISP meeting and invites those identified. Individuals participating in these meetings should include people who best know the participant outside the service system and from other agencies and resources as deemed appropriate, with the participant or legal representative’s consent. The support coordinator informs the participant that he or she can have a representative to help with the ISP development process. The support coordinator documents the occurrence of all ISP development meetings with the participant, his/her family and others as appropriate.
D. ISP Document: The planning process produces an organized statement of proposed services to guide the service provider(s) and the participant throughout the duration of service. The organized statement, or Individual Service Plan (ISP), is based on what is important to/for the participant and includes the following:
a. Desired outcomes of services (goals);
b. The services to be provided, including the frequency and amount;
c. Known medical conditions, allergies and medication summaries
d. Diagnoses to ensure treatment of medical conditions such as obesity and diabetes
e. Behavioral Health conditions and connections to community mental health services as appropriate.
f. Needed connections to primary care physicians and specialty medical providers.
g. The provider responsible for each service or the name of the service element and type of professional staff that is responsible for service (e.g., Registered Nurse);
h. Consideration of the following:
1) The participant’s support systems; and
2) The community resources available to be used
i. Wellness of individuals is facilitated through:
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1) Advocacy
2) Individual care practices
3) Education
4) Sensitivity to issues affecting wellness including, but not limited to:
 Gender;
 Culture; and
 Age.
5) Incorporation of wellness goals within the individual plan.
a. The intent of the development of the ISP is a process that focuses on the individual’s hopes, dreams and visions of a “life well-lived.” Information included within this individualized plan should be presented as a single plan that addresses residential and all other paid supports that the individual receives. The Support networks should work closely together to identify issues of risk and needed supports to address those risks while never losing sight that the individual is at the center of the planning process and included in all discussions. If the individual receives residential services, the residential provider has the primary responsibility in conjunction with the support coordinator or state services coordinator to assure a holistic (i.e., integrated) support plan for all services identified as a need for the individual.
E. ISP Listing of Services: The ISP must list the services to be provided, the frequency of the services, and the name of provider to deliver the services. No service will be reimbursed which is not listed on the Individual Service Plan approved by the Regional DBHDD Intake and Evaluation Team. Assurance is made that goods and services provided by the waiver are not covered under the Medicaid State Plan when applicable.
F. Participant’s Involvement and Acceptance in Developing ISP Document: The participant’s involvement and acceptance, if applicable, in developing the ISP must be documented.
1. The participant’s signature on the ISP signifies this acceptance.
2. If a participant declines or is unable to sign the ISP, it is documented in the participant’s record.
G. Family Involvement: Unless clinically or programmatically contraindicated, participants are asked to consent to the family’s involvement in the service planning and service delivery processes. Contraindications, if present, and the participant’s refusal, if permission is not given, are documented in the record or ISP.
H. ISP Annual Review and Amendments: Each ISP must be reviewed and modified annually, or more often as needed to reflect all life changes, progress or lack of progress, to identify changes in outcome, review changes in medical psychological or social services, and to identify new problems or goals.
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Circumstances warranting more frequent reviews would include, but are not limited to, significant changes in participant functioning, increases or decreases in services, change of provider(s), changes in medical, social or behavioral statuses, family crisis, and reduction in funding.
Individualized plans or portions of the plan must be reassessed as indicated by the following:
a.. Changing needs, circumstances and responses of the individual, including but not limited to:
i.Any life change;
ii.Change in provider;
iii.Change of address;
iv.Change in frequency of service.
b. As requested by the individual;
c. As required for re-authorization;
d. At least annually;
e. When goals are not being met.
I. The Organization Maintains a System of Information Management that Protects Individual Information and that is Secure, Organized, and Confidential
1. The organization has clear policies, procedures, and practices that support secure, organized and confidential management of information, to include electronic individual records if applicable.
2. Maintenance and transfer of both written and spoken information is addressed:
a. Personal individual information;
b. Billing information; and
c. All service related information.
3. The organization has a Confidentiality and HIPAA Privacy Policy that clearly addresses state and federal confidentiality laws and regulations, including but not limited to federal regulations on “Confidentiality of Alcohol and Drug Abuse Patient Records” at 42 C.F.R. Part 2 (as applicable) and state laws at O.C.G.A. §§ 37-3-166 (MH), 37-4-125 (DD) and 37-7-166 (AD) as applicable. The organization has a Notice of Privacy Practices that gives the individual adequate notice of the organization’s policies and practices regarding use and disclosure of their Protected Health Information (PHI). The notice should contain mandatory elements required by the Health Insurance Portability and Accountability Act of 1996 (HIPAA, Title II). In addition, the organization should address:
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1) HIPAA Privacy and Security Rules, as outlined at 45 CFR Parts 160 and 164 are specifically reviewed with staff and individuals;
2) Appointment of the Privacy Officer;
3) Training to be provided to all staff;
4) Posting of the Notice of Privacy Practices in a prominent place; and
5) Maintenance of the individual’s signed acknowledgement of receipt of Privacy Notice in their record;
6) Provision of the rights of individuals regarding their PHI as defined in federal and state laws and in HIPAA, including but not limited to:
i. Right to access to one’s own record.
ii. Right to request an amendment.
iii. Right to request communications by alternative means.
iv. Right to request restriction of access by others.
7) Identification of its Business Associates, and obtaining Business Associate agreements with Business Associates, in compliance with HIPAA requirements.
8) Identification of violations of confidentiality or HIPAA and follow up to include compliance with all requirements of HIPAA at 45 C.F.R. sections 164.400 through 164.414:
i. Reporting of violations to the Privacy Officer.
ii. Risk assessment of the violation as required by HIPAA provisions.
iii. Determination of whether the violation constitutes a “breach” as defined by HIPAA.
iv. Notifications of breaches to the individual(s) affected, to the Secretary of Health and Human Services, and if necessary to the media, in compliance with HIPAA requirements.
9) Corrective Actions for sanctions of employee(s) as necessary, mitigation of harm to any individual and preventing risks to PHI
5. A record of all disclosure of Protected Health Information (PHI) should be kept in the medical record, so that the organization can provide an accounting of disclosures to the individual for 6 years from the current date. The record must include:
1) Date of disclosure;
2) Name of entity or person who received the Protected Health Information;
3) A brief description of the Protected Health Information disclosed;
4) A copy of any written request for disclosure; and
5) Written authorization from the individual or legal guardian to disclose PHI, where applicable.
5. Authorization for release of information is obtained when Protected Health Information of an individual is to be released or shared between organizations or with others outside the organization. All applicable
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DBHDD policies and procedures and HIPAA Privacy Rules (45 CFR parts 160 and 164) related to disclosure and authorization of Protected Health Information are followed. Information contained in each release of information must include:
a. Specific information to be released or obtained;
b. The purpose for the authorization for release of information;
c. To whom the information may be released or given;
d. The time period that the release authorization remains in effect (reasonable based on the topic of information, generally not to exceed a year); and,
e. A statement that authorization may be revoked at any time by the individual, to the extent that the organization has not already acted upon the authorization.
6. Exceptions to use of an authorization for release of information are clear in policy:
a. Disclosures may be made if required or permitted by law;
b. Disclosure is authorized as a valid exception to the law;
c. A valid court order or subpoena are required for mental health or developmental disabilities records;
d. A valid court order and subpoena are required for alcohol or drug abuse records;
e. When required to share individual information with the DBHDD or any provider of treatment or services for the individual under contract or LOA with the DBHDD; or
f. In the case of an emergency treatment situation as determined by the individual’s physician, the chief clinical officer can release Protected Health Information (PHI) to the treating physician or psychologist.
7. The organization has written operational procedures, consistent with legal requirements governing the retention, maintenance and purging of records.
a. Records are safely secured, maintained, and retained for a minimum of six (6) years from the date of their creation or the date when last in effect (whichever is later).
b. Protocol for all records to be returned to or disposed of as directed by the contracting regions after specified retention period or termination of contract/agreement; and
c. Compliance with HIPAA Security Rule provisions to the degree mandated by or appropriate under the Security Rule to protect the security, integrity and availability of records.
E. The organization has written policy, protocols, and documented practice of how information in the record is transferred when an individual is relocated or discharged from service to include but not be limited to:
a. A complete certified copy of the record to DBHDD or the provider who will assume service provision, that includes
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individual’s Protected Health Information, billing information, service related information such as current medical orders, medications, behavior plans as deemed necessary for the purposes of the individual’s continuity of care and treatment;
b. Unused Special Medical Supplies (SMS), funds, personal belongings, burial accounts; and
c. The time frames by which transfer of documents and personal belongings will be completed.
9. Assessments, ISPs, and documentation required by Medicaid are to be retained in the individual’s records for six years.
J. Medication Oversight and Monitoring
1. A copy of the physician(s) order or current prescription dated and signed within the past year is placed in the individual’s record for every medication administered or self-administered with supervision. These include:
a. Regular, on-going medications;
b. Controlled substances;
c. PRN (as needed) Over-the-counter (OTC) medications;
d. PRN medications (does not include standing orders for psychotropic medications for symptom management of behavior); or
e. Discontinuance order.
2. Anti-psychotic medications must be prescribed by a psychiatrist or psychiatric nurse practitioner unless the medication is prescribed for epilepsy or dementia and there is documentation that includes:
a. Informed consent for the medication is obtained and a signed copy is maintained in the clinical record. It is the responsibility of the physician/designee to complete the informed consent;
b. The treating psychiatrist or psychiatric nurse personally examines the individual to determine whether this person has the capacity to understand to consent for herself or himself;
c. If the individual does not have the capacity to consent for herself or himself, an appropriate substitute decision maker is identified based on the Order of Priority outlined in Georgia Medical Consent Law;
d. The risks/benefits is explained in language the individual can understand;
e. Medication education provided by the organization’s staff should be documented in the clinical record; and
f. Education regarding the risks and benefits of the medication is documented.
3. The organization has written policies, procedures, and practices for all aspects of medication management including, but not limited to:
a. Prescribing:
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i. The physician’s order or current prescription is defined as a prescription signed by one authorized to prescribe in Georgia; and
ii. Electronic prescriptions (E-scripts and Sure scripts), if practiced
b. Authenticating orders: Describes the required time frame for obtaining the actual or faxed physician’s signature for telephone or verbal orders accepted by a licensed nurse.
c. Ordering and Procuring medication and refills: Procuring initial prescription medication and over-the-counter drugs within twenty-four hours of prescription receipt, and refills before twenty-four hours of the exhaustion of current drug supply.
d. Medication Labeling: Describes that all medications must have a label affixed by a licensed professional with the authority to do so. This includes sample medications.
e. Storing: Includes prescribed medications, floor stock drugs, refrigerated drugs, and controlled substances.
f. Security: Requires safe storage of medication as required by law including single and double locks, shift counting of the medications, individual dose sign-out recording, documented planned destruction, and refrigeration and daily temperature logs. All controlled substances are double locked and there is documented accountability of controlled substances at all stages of possession.
g. Dispensing: Describes the process allowed for pharmacists and/or physicians only. Includes the verification of the individual’s medications from other agencies and provides a documentation log with the pharmacist’s or physician’s signature and date when the drug was verified. Only physicians or pharmacists may re-package or dispense medications:
i. This includes the re-packaging of medications into containers such as “day minders” and medications that are sent with the individual when the individual is away from his residence.
ii. Note that an individual capable of independent self-administration of medication may be coached in setting up their personal “day minder”.
h. Supervision of individual self-administration: Includes all steps in the process from verifying the physician’s medication order to documentation and observation of the individual for the medication’s effects each time supervision of individual self-administration occurs. Makes clear that staff members may not administer medications unless licensed to do so, and the methods staff members may use to supervise or assist, such as via hand-over-hand technique, when an individual self-administers his/her medications. Where medications are self-administered, protocols are defined for training to support individual self-administration of medication.
i. Administration of medications: Administration of medications may be done only by those who are licensed in this state to do so.
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j. Recording: Includes the guidelines for documentation of all aspects of medication management. This includes adding and discontinuing medication, charting scheduled and as needed medications, observations regarding the effects of drugs, refused and missing doses, making corrections, and a legend for recording. The legend includes initials, signature and title of staff member.
k. Disposal of discontinued or out-of-date medication: Includes via an environmentally friendly method of disposal by pharmacy.
l. Education to the individual and family (as approved by the individual) regarding all medications prescribed and documentation of the education provided in the clinical record.
m. All PRN or “as needed” medications will be accessible for each individual as per his/her prescriber(s) order(s) and as defined in the individual’s ISP. Additionally, the organization must have written protocols and documented practice that ensures safe and timely accessibility that includes, at a minimum, how medication will be stored, secured or refrigerated when transported to different programs and home visits.
4. Organizational policy, procedures and documented practices stipulate that:
a. The use of Proxy Caregivers for Health Maintenance Activities must be in accordance with requirements as specified in Chapter 900, Section 909 of this manual.
b. There are safeguards utilized for medications known to have substantial risk or undesirable effects, to include:
i. Obtaining and maintaining copies of appropriate lab testing and assessment tools that accompany the use of the medications prescribed from the individual’s physician for the individual’s clinical record, or at a minimum, documenting in the clinical record the requests for the copies of these tests and assessments, and follow-up appointments with the individual’s physician for any further actions needed;
ii. For individual in residential services, there is documentation of a review of polypharmacy usage in order to ensure that intra-class and inter-class polypharmacy use for psychiatric reasons are justifiable, if applicable, using the following monitoring criteria:
a) Intra-class Polypharmacy monitoring reports includes individuals who are on more than one psychotropic medication in the same single class of medications (2 or more antipsychotics, antidepressants, mood stabilizers), e.g., the use of 2 anti-depressants to treat depression.
b) Inter-class Polypharmacy monitoring reports include individuals who are on 3 or more different classes of medications (antipsychotics, antidepressants, mood stabilizers), e.g., the use of an antipsychotic, an antidepressant and mood stabilizer to treat someone with Schizoaffective Disorder.
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c. There are protocols for the handling of licit and illicit drugs brought into the service setting. This includes confiscating, reporting, documenting, educating, and appropriate discarding of the substances.
d. The organization defines requirements for timely notification to the prescribing professional regarding:
i. Medication errors;
ii. Medication problems;
iii. Drug reactions; and
iv. Refusal of medication by the individual.
e. There are practices for regular and ongoing physician review of prescribed medications including, but not limited to:
i. Appropriateness of the medication;
ii. Documented need for continued use of the medication;
iii. Monitoring the presence of side effects. (Individuals on medications likely to cause tardive dyskinesia are monitored at prescribed intervals using an Abnormal Involuntary Movement Scale (AIMS) testing.);
iv. Monitoring of therapeutic blood levels, if required by the medication such as Blood Glucose testing, Dilantin blood levels and Depakote blood levels.
v. Ordering specific monitoring and treatment protocols for Diabetic, hypertensive, seizure disorder, and cardiac individuals, especially related to medications prescribed and required vital sign parameters for administration;
vi. Maintain medication protocols for specific individuals in:
a) Epinephrine for anaphylactic reaction;
b) Insulin required for diabetes;
c) Suppositories for ameliorating serious seizure activity; and
d) Medications through a nebulizer.
vii. Monitoring of other associated laboratory studies.
f. For organizations that secure their medications from retail pharmacies, there is a biennial assessment of agency practice of management of medications at all sites housing medications. An independent licensed pharmacist or licensed registered nurse conducts the assessment. The report shall include, but may not be limited to:
i. A written report of findings, including corrections required;
ii. A photocopy of the pharmacist’s license or a photocopy of the license of the Registered Nurse; and
iii. A statement of attestation from the independent licensed pharmacist or licensed Registered Nurse that all issues have been corrected.
5. The “Eight Rights” for medication administration are defined with detailed guidelines for staff to implement within the organization to verify that right:
a. Right person: Check the name on the order and the individual and include the use of at least two identifiers.
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b. Right medication: Check the medication label against the order.
c. Right time: Check the frequency and time to be given of the ordered medication and double check that the ordered dose is given at the correct time. Confirm when last dose was given.
d. Right dose: includes verification of the physician’s medication order of dosage amount of the medication; with the label on the prescription drug container and the Medication Administration Record document to ensure all are the same.
e. Right route: Check the order and appropriateness of route ordered and confirm that the individual can take or receive the medication by the ordered route.
f. Right position: The correct anatomical position for the medication method or route to ensure its proper effect, instillation and retention. If needed, individual should be assisted to assume the correct position.
g. Right Documentation: Document the administration/supervision after the ordered medication is given on the MAR; and
h. Right to Refuse Medication: includes staff responsibilities to encourage compliance, document the refusal, and report the refusal to the administration, nurse administrator, and physician.
6. A Medication Administration Record is in place for each calendar month that an individual takes or receives medication(s):
a. Documentation of routine, ongoing medications occur in one discreet portion of the MAR and include but may not be limited to:
i. Documentation by calendar month that is sequential according to the days of the month;
ii. A listing of all medications taken or administered during that month including a full replication of information in the physician’s order for each medication:
a) Name of the medication;
b) Dose as ordered;
c) Route as ordered;
d) Time of day as ordered; and
e) Special instructions accompanying the order, if any, such as but not limited to:
1. Must be taken with meals;
2. Must be taken with fruit juice;
3. May not be taken with milk or milk products.
iii. If the individual is to take or receive the medication more than one time during one calendar day:
a) Each time of day must have a corresponding line that permits as many entries as there are days in the month;
iv. All lines representing days and times preceding the beginning or ending of an order for medications shall be marked through with a single line;
v. When a physician discontinues (D/C) a medication order, that discontinuation is reflected by the entry of “D/C” at the date and
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time representing discontinuation; followed by a mark through of all lines representing days and times that were discontinued.
b. Documentation of medications that are taken or received on a periodic basis, including over the counter medications, occur in a separate discreet portion of the MAR and include but may not be limited to:
i. Documentation by calendar month that is sequential according to the days of the month;
ii. A listing of each medication taken or received on a periodic basis during that month including a full replication of information in the physician’s order for each medication:
a) Name of medication;
b) Dose as ordered;
c) Route as ordered;
d) Purpose of the medication; and
e) Frequency that the medication may be taken.
iii. The date and time the medication is taken or received is documented for each use.
iv. When ‘PRN’ or ‘as needed’ medication is used, the PRN medications shall be documented on the same MAR after the routine medications and clearly marked as “PRN” and the effectiveness is documented.
c. Each MAR shall include the legend that clarifies:
i. The identity of the authorized staff’s initials using full signature and title;
ii. The reasons that a medication may not be given, is held or otherwise note received by the individual, such as but not limited to:
“H” = Hospital
“R” = Refused
“NPO” = Nothing by mouth
“HM” = Home Visit
“DS” = Day Service
K. Service Environment
Respectful Service Environment (To include Host Homes and Day Services Sites)
1. Services, supports, care or treatment approaches support the individual in:
a. Living in the most integrated community setting appropriate to the individual’s requirement, preferences and level of independence;
b. Exercising meaningful choices about living environments, providers of services received, the types of supports, and the manner by which services are provided;
c. Obtaining quality services in a manner as consistent as possible with community living preferences and priorities; and
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d. Inclusion and active community integration is supported and evident in documentation.
2. Services are provided in an appropriate environment that is respectful of individuals supported or served. (For Host Homes and Community Access Services Sites refer to Operational Standards for Host Homes/Life Sharing and Physical Environment NOW/COMP Part III, Chapter 1700 for Community Access Services). The environment is:
a. Clean;
b. Age appropriate;
c. Accessible (individuals who need assistance with ambulation shall be provided bedrooms that have access to a ground level exit to the outside or have access to exits with easily negotiable ramps or accessible lifts. The home shall provide at least two (2) exits, remote from each other that are accessible to the individuals served);
d. Individual’s rooms are personalized;
e. Adequately lighted, ventilated, and temperature controlled;
f. There is sufficient space, equipment and privacy to accommodate;
g. An area/room for visitation; and
h. Telephone use for incoming and outgoing calls that is accessible and maintained in working order for persons served or supported.
3. The environment is safe:
a. All local and state ordinances are addressed:
i. Copies of inspection reports are available;
ii. Licenses or certificates are current and available as required by the site or the service;
iii. An automatic extinguishing system (sprinkler) shall be installed per city/county requirements for residential settings excluding host homes not governed by other federal, state and county rules and regulations, if applicable; and
iv. Approved smoke alarm shall be installed in all sleeping rooms, hallways and in all normally occupied areas on all levels of the residences per safety code. Smoke alarms especially in the bedrooms shall be tested monthly and practice documented. The facility shall be inspected annually to meet fire safety code and copies of inspection maintained.
b. Installation of Fire alarm system and inspection of equipment meets safety code.
c. Fire drills are conducted for individuals and staff:
i. Once a month at alternative times; including
ii. Twice a year during sleeping hours if residential services;
iii. All fire drills shall be documented with staffing involved;
iv. DBHDD maintains the right to require an immediate demonstration of a fire drill during any on-site visit.
4. When food service is utilized, required certifications related to health, safety and sanitation are available. A three day supply of non-perishable emergency
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food and water is available for all individuals supported in residences. A residence shall arrange for and serve special diets as prescribed.
5. Policies, plans and procedures are in place that addresses Emergency Evacuation, Relocation, Preparedness and Disaster Response. Supplies needed for emergency evacuation are maintained in a readily accessible manner, including individuals’ information, family contact information and current copies of physician’s orders for all individual’s medications.
a. Plans include detailed information regarding evacuating, transporting and relocating individuals that coordinate with the local Emergency Management Agency and at a minimum address:
i. Medical emergencies;
ii. Missing persons;
a) Georgia’s Mattie’s Call Act provides for an alert system when an individual with developmental disabilities, dementia, or other cognitive impairment is missing. Law requires residences licensed as Personal Care Homes to notify law enforcement within 30 minutes of discovering a missing individual.
iii. Natural and man-made disasters;
iv. Power failures;
v. Continuity of medical care as required;
vi. Notifications to families or designees; and
vii. Continuity of Operation Planning (COOP) to include identifying locations and providing a signed agreement where individuals will be relocated temporarily in case of damage to the site where services are provided. COOP must also include plans for sheltering in place (for more information go to:
http://www.georgiadisaster.info/PersonsWithDisabilities/disasterpreparedness.html ; and
http://www.fema.gov/about/org/ncp/coop/templates.shtm).
b. Emergency preparedness notice and plans are:
i. Reviewed annually;
ii. Tested at least quarterly for emergencies that occur locally on a less frequent basis such as, but not limited to flood, tornado or hurricane; and
iii. Drilled with more frequency if there is a greater potential for the emergency.
6. Residential living support service options:
a. Are integrated and established within residential neighborhoods;
b. Are single family dwellings;
c. Have space for informal gatherings;
d. Have personal space and privacy for persons supported; and
e. Are understood to be the “home” of the person supported or served.
7. Video cameras may not be used in the following instances:
a. In an individual’s personal residence;
b. In lieu of staff presence; or
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c. In the bedroom of individuals, as it is an invasion of privacy and is strictly prohibited.
8. There are policies, procedures, and practices for transportation of persons supported or served in residential services and in programs that require movement of persons served from place to place:
a. Policies and procedures apply to all vehicles used, including:
i. Those owned or leased by the organization;
ii. Those owned or lease by subcontractors; and
iii. Use of personal vehicles of staff.
b. Policies and procedures include, but are not limited to:
i. Authenticating licenses of drivers;
ii. Proof of insurance;
iii. Routine maintenance;
iv. Requirements for evidence of driver training;
v. Safe transport of persons served;
vi. Requirements for maintaining an attendance log of persons while in vehicles;
vii. Safe use of lift;
viii. Availability of first aid kits;
ix. Fire suppression equipment; and
x. Emergency preparedness.
L. Infection Control Practices are Evident in Service Settings:
1. The organization, at a minimum, has a basic Infection Control Plan which is reviewed bi-annually for effectiveness and revision, if needed. The Plan addresses:
a. Standard Precautions;
b. Hand Washing Guidelines;
c. Proper storage of Personal Hygiene items; and
d. Specific common illnesses/infectious diseases likely to be emergent in the particular service setting.
2. The organization has policies, procedures and practices for controlling and preventing infections in the service setting. There is evidence of:
a. Guidelines for environmental cleaning and sanitizing;
b. Guidelines for safe food handling and storage;
c. Guidelines for laundry; and
d. Guidelines for food preparation.
3. Procedures for the prevention of infestation by insects, rodents or pests shall be maintained and conducted continually to protect the health of individuals served.
4. No vicious/dangerous animals shall be kept. Any pets living in the service setting must be healthy and not pose a health risk to the individual supported. All pets must meet the local, state, and federal requirements to include the following:
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a. All animals that require rabies vaccinations annually must have current documentation of the rabies inoculation;
b. Exotic animals must be obtained from federally approved sources; and
c. Parrots and Psittacine family birds must be USDA inspected and banded.
M. Oversight of Contracted/Subcontracted Providers/Professionals by the Organization
1. The organization is responsible for the Contracted/Subcontracted Provider/Professional compliance with:
a. Contract/Agreement requirements, documented and maintained for review;
b. Standards of practice and specified requirements in the Provider manual for the Department of BHDD, including Community Standards for All Providers;
c. Licensure requirements;
d. Accreditation or Community Service Standards Quality Review requirements; and
e. Quality improvement and risk reduction activities.
2. There is documented evidence of active oversight of the Contracted/Subcontracted Provider/Professional capacity and compliance to provide quality care to include monitoring of:
a. Financial oversight and management of individual funds;
b. Staff competency and training;
c. Mechanisms that assure care is provided according to the plan of care for each individual served; and
d. The requirement for a Host Home Study when contracting with a Host Home provider.
3. A report shall be made quarterly to the agency’s Board of Directors regarding:
a. Services provided by Contracted/Subcontracted Provider/Professional ; and
b. Quality of performance of the Contracted/Subcontracted Provider/Professional.
4. A report shall be made to the DBHDD Regional Office prior to the end of the first quarter and third quarter of the fiscal year that includes:
a. Name and contact information of all contracted providers;
b. The specific services provided by each contracted provider;
c. The number and location of individual supported by each contracted provider; and
d. Annualized amount paid to each contracted provider.
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1103. Provider Intake
Service providers, except for providers of participant-directed services, conduct an intake for participants at the beginning of waiver services. This section specifies requirements related to that intake. Requirements for providers of participant-directed services are covered in Chapter 1200 of this manual.
A. The service provider intake consists of basic identifying information, including information that the Georgia Department of Behavioral Health and Developmental Disabilities requests for the statewide participant data reporting system, appropriate consents to service, and other standardized agency forms. A release of information form will be obtained as needed, and will be time, agency, and event specific.
B. The participant is to be informed of projected duration of service, hours of service, rules of conduct, involvement of family members and participant rights and responsibilities.
1104. Individual Service Plan (ISP) Goal Progress Documentation
Providers are required to document progress towards moving the participant towards independence by meeting the participant’s ISP, which includes person-centered goals, desired outcomes in the participant’s action plan, and the amount/type of assistance/support in the Current Service Summary and the Health and Safety sections of the ISP. This section covers ISP progress documentation for providers, except for providers of participant-directed services. The Part III, Policies and Procedure Manual for the New Options Waiver specifies documentation and record requirements specific to individual waiver services. Chapter 1200 of this policy manual specifies documentation requirements for providers of participant-directed services.
A. Activity Notes/Learning Logs are formulated to document progress or lack of progress towards moving the participant towards independence by meeting the participant’s ISP, which includes person-centered goals, desired outcomes in the participant’s action plan, and the amount/type of assistance/support in the Current Service Summary and the Health and Safety sections of the ISP.
B. Activity Notes/Learning Logs document the actual implementation of the planned services, strategies or interventions and reflect the course of service received by the participant and participant’s response to the service provided.
1. Activity Notes/Learning Logs (which may include charts, tracking sheets, narratives, etc.) are a chronological record that reflects the direct contact, other direct and indirect services rendered to attain the expected participant outcomes. Justification for ISP modifications and reviews must be documented in the activity notes.
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a. Activity Notes/Learning Logs must be dated and signed by the provider staff making the entries on the date of the occurrence/service.
b. Activity Notes must document provision of services, as indicated on the current ISP and correspond to progress towards moving the participant towards independence by meeting the participant’s ISP, which includes person-centered goals, desired outcomes in the participant’s action plan, and the amount/type of assistance/support in the Current Service Summary and the Health and Safety sections of the ISP.
c. Notation of communications from family, significant others and other community agencies that address the condition or needs of participants must be entered in the record.
d. Appointments missed or canceled by the participant or staff is to be documented along with appropriate follow-up attempts to reschedule.
e. Services for which Medicaid is billed must be accurately reflected in the services documented in the participant’s record.
f. Activity Notes/Learning Logs must be kept readily available for review by the Department for purposes of audit or monitoring.
2. Other than as noted above for providers of participant-directed services, there are no exceptions to activity note documentation in detailing service delivery to the COMP participant. Failure to adequately record service documentation to justify reimbursement claims may result in a request for refund by the Department when Utilization Review or other focused audits are conducted.
Provider staff must document the service provided to a participant each time service is delivered (See Appendix S of this manual for examples of documentation). If any form is used that includes staff initials, a key for the initials must be in the participant’s record. A daily service, such as Community Residential Alternative Services, must be documented each day the service is provided. The daily documentation must include the required elements listed below. Except for providers of participant-directed services, all providers must document the following in the record of each participant each time a waiver service is delivered:
 Specific activity, training, or assistance provided;
 Date and the beginning and ending time when the service was provided;
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 Location where the service was delivered;
 Verification of service delivery, including first and last name and title (if applicable) of the person providing the service and his or her signature;
 Progress towards moving the participant in the direction of independence by completing the participant’s ISP, which includes person-centered goals, desired outcomes in the participant’s action plan, and the amount/type of assistance/support in the Current Service Summary and the Health and Safety sections of the ISP.
1105. Maintenance of Records
Providers, with the exception of providers of participant-directed services, must maintain written documentation of all level of care evaluations and reevaluations in the individual’s case record for a period of six (6) years. Copies of these evaluations must be made available to the State upon request. Maintenance of records requirements for providers of participant-directed services are covered in Chapter 1200 of this manual.
The organization has written operational procedures, consistent with legal requirements governing the retention, maintenance and purging of records. Records are safely secured, maintained, and retained for a minimum of six (6) years from the date of its creation or the date when last in effect (whichever is later).
1105.1 Documentation
1. The individual record is a legal document, information in the record should be:
a. Organized;
b. Complete;
c. Current;
d. Meaningful;
e. Succinct; and
f. Essential to:
i. Provide adequate and accurate services, supports, care and treatment;
ii. Tell an accurate story of services, supports, care and treatment rendered and the individual’s response;
iii. Protect the individual; their rights; and
iv. Comply with legal regulation.
g. Dated, timed, and authenticated with the authors identified by name, credential and by title:
i. Notes entered retroactively into the record after an event or a shift must be identified as a “late entry”;
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ii. Documentation is to be done each shift or service contact by staff providing the service;
iii. If notes are voice recorded and typed or a computer is used to write notes that are printed, each entry must be dated and the physical documentation must be signed and dated by the staff writing the note. Notes should then be placed in the individual’s record; and
iv. If handwritten notes are transcribed electronically at a later date, the former should be kept to demonstrate that documentation occurred on the day billed.
h. Written in black or blue ink;
i. Red ink may be used to denote allergies or special precautions;
j. Corrected as legally prescribed by:
i. Drawing a single line through the error;
ii. Labeling the change with the word “error”;
iii. Inserting the corrected information; and
iv. Initialing and dating the correction.
2. At a minimum, the individual’s information shall include:
a. The name of the individual, precautions, allergies (or no known allergies – NKA) and “volume #x of #y” on the front of the record;
i. Note that the individual’s name, allergies and precautions must be flagged on the medication administration record.
b. Individual’s identification and emergency contract information;
c. Financial information;
d. Rights, consent and legal information including but not limited to:
i. Consent for service;
ii. Release of information documentation;
iii. Any psychiatric or other advanced directive;
iv. Legal documentation establishing guardianship;
v. Evidence that individual rights are reviewed at least one time a year; and
vi. Evidence that individual responsibilities are reviewed at least one time a year.
e. Pertinent medical information;
f. Screening information and assessments, including but not limited to:
i. Functional, psychological and diagnostic assessments.
g. Individual service plan, including:
i. Identified outcomes or goals (in measurable terms);
ii. Interventions or activities occurring to achieve the goals;
iii. The individual’s response to the interventions or activities (progress notes, tracking sheets, learning logs or data);
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iv. A projected plan to modify or decrease the intensity of services, supports, care and treatment as goals are achieved; and
v. Discharge planning is begun at the time of admission that includes specific objectives to be met prior to decreasing the intensity of service or discharge.
h. Discharge summary information provided to the individual and new service provider, if applicable, at the time of discharge includes:
i. Strengths, needs, preferences and abilities of the individual;
ii. Services, supports, care and treatment provided;
iii. Achievements;
iv. Necessary plans for referral; and
v. A dictated or hand-written summary of the course of services, supports, care
and treatment incorporating the discharge summary information provided to the individual and new service provider, if applicable, must be placed in the record within 30 days of discharge.
i. The organization must have policy, procedures and practices for Discharge/Transfer/ immediate transfer due to medical or behavioral needs of individuals in all cases. Agency employees, subcontractors and their employees and volunteers who abandon an individual are subject to administrative review by the contracting Regional Office(s) representing DBHDD to evaluate for recommendations to the Department of Community Health concerning increasing new admission capacity further or continuing the relationship with the provider agency.
j. All relocation/discharge of individuals within or outside the agency must have prior approval from the DBHDD Regional Office. A copy of the approval must be maintained in the individual record.
k. Progress notes or Learning Logs (for DD individuals) describing progress toward goals, including:
i. Implementation of interventions specified in the plan;
ii. The individual’s response to the intervention or activity based on data; and
iii. Date and the beginning and ending time when the service was provided.
l. Event notes documenting:
i. Issues, situations or events occurring in the life of the individual;
ii. The individual’s response to the issues, situations or events;
iii. Relationships and interactions with family and friends, if applicable;
iv. Missed appointments including:
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a) Findings of follow-up; and
b) Strategies to avoid future missed appointments.
m. Records or reports from previous or other current providers; and
n. Correspondence.
3. The individual’s response to the services, supports, care and treatment is a consistent theme in documentation.
a. Frequency and style of documentation are appropriate to the frequency and intensity of services, supports, care and treatment; and
b. Documentation includes record of contacts with persons involved in other aspects of the individual’s care, including but not limited to internal or external referrals.
4. There is a process for ongoing communication between staff members working with the same individuals in different programs, activities, schedules or shifts.
1106. Management and Protection of Participant Funds
The personal funds of an individual are managed by the individual and are protected.
Policies and clear accountability practices regarding individual valuables and finances comply with all applicable DBHDD policies and Social Security Guide for Organizational and /or Representative Payees regarding management of personal need spending accounts for individuals served.
Providers are encouraged to utilize persons outside the organization to serve as “representative payee” such as, but not limited to:
 Family
 Other person of significance to the individual
 Other persons in the community not associated with the agency
The agency is able to demonstrate documented effort to secure a qualified, independent party to manage the individual’s valuables and finances when the person served is unable to manage funds and there is no other person in the life of the individual who is able to assist in the management of individual valuables or funds. Individual funds cannot be co-mingled with the agency’s funds or other individuals’ funds.
1107. Monitoring
All ISPs for recipients of services under the COMP Waiver will be reviewed and monitored by the State through the Regional DBHDD Office, the DCH Program Integrity Unit’s Utilization Review Team, and through desk reviews of the services provided. When DCH utilization reviews result in deficiencies, the
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provider must submit a Corrective Action (CAP) to the Department of Community Health within fifteen (15) calendar days of the date of utilization review reports. Failure to comply with the request for a corrective action plan may result in adverse action, including suspension of referrals or termination from the program.
Each Community Living Support (CLS) provider agency under COMP must provide a current Private Home Care Provider License from the Department of Community Health, Healthcare Facility Regulation Division (HFR), to the Regional DBHDD Office if providing covered PHC services as defined by HFR.
It will be the responsibility of the Regional DBHDD Office to assure that all CLS provider agencies providing PHC covered services as defined by HFR have and maintain a current PHC license. In the event that HFR should take action to change the provider license/permit from a permanent licensure or permit to a provisional status, the COMP CLS provider agency is at risk of being discharged as a Medicaid provider. Failure to adhere to maintaining a current PHC license will require that the agency repay all funds collected for CLS services rendered by a non-licensed CLS provider agency providing PHC covered services as defined by HFR.
1108. Multi-Purpose Information Consumer Profile
The Georgia Department of Behavioral Health and Developmental Disabilities is implementing a new comprehensive data collection and utilization management system titled the Multi-Purpose Information Consumer Profile (MICP). The MICP will be used to capture data regarding basic consumer demographics and service detail on all consumers served by the Division. This new form is being implemented in order to streamline and consolidate multiple data collection processes for registration, authorization, and reporting of publicly funded services.
The Division sponsors consumer satisfaction surveys for all adult populations. These surveys generally require no direct action from service providers. However, providers are expected to make their facilities and consumers available to teams who gather the survey responses.
NOTE: This is meant to cover access to consumers and facilities for the NCI Consumer Surveys (currently completed by the Support Coordination Agencies).
Providers of developmental disability services who serve ten or more waiver or state funded adults in residential, day or employment services (including subcontractors) are expected to complete – on an annual basis — the National Core Indicators Provider Staff Turnover and Board Membership Survey. The survey instrument and instructions for completion will be sent directly to providers.

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