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Oregon Project Independence Assessment Tool 2014

Oregon Project Independence Assessment Tool 2014. Logistics. Submit only one completed tool per AAA, not a tool for each of the cases reviewed.

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Oregon Project Independence Assessment Tool 2014

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  1. Oregon Project Independence Assessment Tool 2014

  2. Logistics • Submit only one completed tool per AAA, not a tool for each of the cases reviewed. • The review should not be completed by the staff person who was assigned to the case. It should be a peer, supervisor, quality assurance staff or other staff person. It should not be someone reviewing their own work! • Completed tools are due to the SUA by end of business on May 23rd. • Email the completed tool to the SUA email box, not to an individual SUA staff person.

  3. Logistics • Provide a brief description of how the review resulted in the “yes” or “no” response. • Example: 20 cases are reviewed and 18 met the standard, the AAA indicated a “yes” because the 2 records that did not meet the standard were not indicative of a systemic issue.

  4. Part 1: Agency Review • # of intakes includes the number of individuals that have been evaluated for the program, regardless of whether or not they ultimately receive services from OPI • The 2012 OPI Client survey available at: http://www.oregon.gov/dhs/spwpd/sua/docs/OPI-client-satisfaction-survey.pdf

  5. Part 2: Case auditInitial Assessment Review

  6. Case Audit Parameters • Review 15% of current OPI cases to a maximum of 40 cases. • If 15% is less than 20 cases, then review all cases.

  7. OPI Case Audit Person Search Information Instructions on how to search for a particular client in ACCESS. To search for a client you will preferably need their Prime Number or Social Security number. But if you only have their name, you can also conduct a case search, but it may be more involved.

  8. OPI Case Audit Additional information Begin at the ACCESS opening page and click on the Person Search button.

  9. OPI Case Audit Additional information Enter the person’s name, or Soc. Sec number, or Prime number and hit search.

  10. OPI Case Audit Additional information You will then get a list of people with the branch number in the last column. Use the view person button on the bottom left > then view case > then case details.

  11. Part 2: Case Audit Question #6 • #6. CAPS assessment is complete and current (within last 12 months) for all reviewed records. • “All reviewed records,” means all reviewed OPI cases. • Case managers conduct annual reviews that include a CAPS assessment. You will audit to ensure that there has been at least one CAPS assessment done in the last 12 months.

  12. Part 2: Case Audit Question #6 From this Face Page, go to the tool bar at the top of the page and select the CAPS “Book” icon. This will take you to a CAPS Menu window.

  13. Part 2: Case Audit Question #6 • Steps to view CAPS assessment dates for OPI: • 1. Open ACCESS and double click on the individual’s name. This will open the person’s case to the face page. • (Note: The example case used in this training is a fictional case and no information viewed belongs to a real person)

  14. Part 2: Case Audit Question #6 From the CAPS Menu, select Assessments by clicking on the Assessment button.

  15. Part 2: Case Audit Question #6 Once the Assessment button has been highlighted, click “Next”

  16. Part 2: Case Audit Question #6 You will now see a list of all the CAPS assessments with the most recent assessment at the top. Don’t worry if there are only one or two assessments listed. The top Assessment should say OPI

  17. Part 2: Case Audit Question #6 The Assessment Status Overview window shows the most current assessment. The type of assessment is shown as OPI and the assessment date in this example is 02/20/2014. The Status should say, “Completed.”

  18. Part 2: Case Audit Question #6 This assessment date should be current (within the last 12 months) If it is current, for each a majority of the cases reviewed, mark the Audit question, Yes.

  19. Part 2: Case Audit Question #7 • #7. Service Priority Level (SPL) is calculated and consistent with the AAA eligibility policy for all reviewed records. • “All reviewed records,” means all reviewed OPI cases. • When a Case Manager conducts a CAPS assessment, the assessment tool shows the resulting SPL. • The Service Priority Level for the OPI Program must be SPL 18 or below.

  20. Part 2: Case Audit Question #7 Question 7 asks for the CAPS Service Priority Level - SPL. The SPL level can be found in the upper right corner of the Overview window. Current OPI rules state SPL must be 18 or below.

  21. Part 2: Case Audit Question #7 If the SPL Level is 18 or below for a majority of the cases reviewed, mark the Audit Tool question, Yes.

  22. Part 2: Case Audit Question #8 • #8. Client has at least one diagnosis on Diagnosis List for all reviewed records. • “All reviewed records,” means all reviewed OPI cases. • When a Case Manager conducts a CAPS assessment, diagnosis information is gathered and entered in the Client Details section of the ACCESS case. • You are looking for at least one diagnosis to be listed.

  23. Part 2: Case Audit Question #8 Go to the tool bar at the top of the page and select the CAPS “Book” icon. This will take you to the selection window you have seen before. Click on “Client Details,” and then click on the “Next” button.

  24. Part 2: Case Audit Question #8 The Client Details page will open up and you will see a list of folders on the left hand column. Select the Diagnosis folder by double clicking on the folder.

  25. Part 2: Case Audit Question #8 The Diagnosis window will open up and you will see a list of the client’s diagnosis. Do not be concerned with dates. You are looking to see if there is at least one diagnosis listed for each OPI client audited.

  26. Part 2: Case Audit Question #8 If there is at least one Diagnosis listed for the majority of the cases audited, mark the audit question box, Yes.

  27. Part 2: Case Audit Question #9 • #9. Narration verifies CAPS was completed face-to-face for all reviewed records. • “All reviewed records,” means all reviewed OPI cases. • When a Case Manager conducts a CAPS assessment, that assessment is conducted face-to-face in the person’s home • You are looking for narration that confirms the CM visited the person’s home and spoke with them to conduct the CAPS OPI assessment.

  28. Part 2: Case Audit Question #9 To find the narration record, go to the toolbar and click on the Narration icon as shown.

  29. Part 2: Case Audit Question #9 The Narration record will open and you will see the most recent narration appear at the top. All narrations are date stamped at the lower left and contain the name of the worker who entered the record in the lower right.

  30. Part 2: Case Audit Question #9 To navigate the narration record and view all narrations, use the Slide Bar on the right side. Using the Slide Bar you can access previous narrations. You may need to extend the date range to find a narration.

  31. Part 2: Case Audit Question #9 Tip: Search narrations by date as you scroll down to find the narration you are looking for.

  32. Part 2: Case Audit Question #9 To find the narration for question 9 that details the face-to-face home visit; note the date of the last OPI assessment. (Found on the Assessment page we used previously)

  33. Part 2: Case Audit Question #9 The narration for the face-to-face home visit should be dated within a few days of the assessment date, so this is a good place to start. (The assessment date in this example is 2/20/14)

  34. Part 2: Case Audit Question #9 Question 9 asks you to verify a face-to-face assessment. Case managers will not usually use the words “face-to-face,” in the narration. Here is an example of a face-to-face narration.

  35. Part 2: Case Audit Question #9 Sample narration: Home visit 03/24/2014 for OPI assessment. I met with client in his home in Salem. We sat in the living room for the assessment and his daughter Wilma, was also present for the assessment. Client was seated in a recliner for the interview and had a four wheel walker in front of him. Client complains of osteoporosis pain that limits mobility. He is asking for bathing assist, since that is difficult for him and he prefers not to have his daughter help him. Client was a good historian of his concerns. CAPS complete today and client is SPL 13 and qualifies for OPI. Today called Ermo to let him know the results and he requested a HCW list. One was mailed to him today. 03/26/2014 11:33:43 Worker Name (branch #) As you can tell from the sample narration, there has been a home visit and the Case Manager did meet personally with the client and his daughter for an OPI assessment on 3/24/14 Answer Audit Question

  36. Part 2: Case Audit Question #10 • #10. Client record supports the assessment decision for all reviewed records. • Now that you have viewed the OPI assessment date, SPL level, diagnosis, and narration for each OPI case you are auditing – does all this information support the assessment decision that the individual client is qualified for the OPI Program?

  37. Part 2: Case Audit Question #10 • If the majority of the cases reviewed support the OPI eligibility decision, you can answer the audit question, Yes. • If a substantial amount of the cases do not seem to support the OPI eligibility decision, answer No, and provide comments. End of Part 2

  38. Part 3: Case Audit Question #11Narration Review #11 Narration is objective, factual, free from personal bias/opinions for all reviewed cases. • Follow the previous instructions to view the Narration Record. Read several narratives and evaluate for the following:

  39. Part 3: Case Audit Question #11Narration Review • Did the case worker narrate facts and rely on verifiable evidence, free from their own individual opinions or feelings? Did the case worker avoid biased statements? Factual: “Person expressed the desire to have more housekeeping assistance.” Opinion: “I think this consumer is trying to get more hours by pretending to be needy in some ADL’s.”

  40. Part 3: Case Audit Question #12Narration Review #12 Narration has proper grammar, spelling, sentence structure etc. • Proper: “I called and spoke with Joan today by phone. She has enlisted a HCW to begin work 3/1/14.” • Problems: “I called and spike with Joam today by phone. She has enlisted a HCW 3/1.” • It is ok for workers to use abbreviations and acronyms.

  41. Part 3: Case Audit Question #13Narration Review #13 Narration was completed at time of contact/activity or within 3 business days. • It is a requirement that narration be entered by a case worker within 3 working days of the contact or activity. • Compare the narration date stamp (this is the date the narration was entered), to the narrated date.

  42. Part 3: Case Audit Question #13Narration Review For Example: “Home visit on 03/12/14. Met with Mrs. Smith and her spouse, in their home in Dallas.” 03/18/2014 11:39:14 Case Worker Name In this example the date stamp of 3/18/14 is 5 business days from the date of visit 3/12/14. The 3 day narration requirement was not met.

  43. Part 3: Case Audit Question #14Narration Review #14 Chronological record of all contacts and activities includes: • Who initiated the contact • Who was present if a home visit or meeting was made • What was the purpose of the contact • When and where the contact took place • What changed

  44. Part 3: Case Audit Question #14Narration Review • What and why actions were taken • When actions became effective • What the plan was • What follow up is needed

  45. Part 3: Case Audit Question #14Narration Review These narration examples show the essential components of narration are present: • “I called Mrs Smith to make a home visit appointment for an OPI assessment.” (who initiated and what the purpose was) • “Visited Mrs Smith in her home today for a CAPS assessment. Her son James was also present.” (where contact took place, who was present, what the purpose was)

  46. Part 3: Case Audit Question #14Narration Review • “CAPS is complete and Mrs Smith is SPL 18 and qualified for OPI. Mrs Smith needs to hire a HCW before the case can be opened.” (what actions taken and when actions are effective) • “Mailed Mrs Smith a HCW list so that she can interview and hire a HCW. I will contact her in 3 days to see if she has made any progress.” (what actions taken and follow-up needed)

  47. Part 3: Case Audit Question #15Narration Review #15 Narration of medical information is present only if it is relevant to the service request. • Narration is audited to ensure that private medical information is not needlessly entered into a record that could potentially be viewed by many people. Our goal is to protect the person’s medical information by disclosing only what is relevant to the request for services in the home.

  48. Part 3: Case Audit Question #15Narration Review Example: • Information about a fused ankle that causes mobility needs is relevant information to assessing mobility. • Information about bariatric reduction surgery may not be relevant to assessing ADL’s or IADL’s.

  49. Part 3: Case Audit Question #16Narration Review #16 Quotations are only used to reflect direct client statements. • Narration should not represent a person’s direct words, unless they are actually a direct quote and demonstrated by quotation marks. • Example: Client said, “I’m not sure I want to continue my home delivered meals. They have too much sodium for me.”

  50. Oregon Project Independence Assessment Tool 2014 End of Part 3 Narration review

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