6212 Nursing Home Transition Mandatory Documentation

Georgia State Seal

Georgia Division of Aging Services
Access to Services Manual

Chapter:

6000 Community Transitions

Effective Date:

Section Title:

Nursing Home Transition Mandatory Documentation

Reviewed or Updated in:

MT 2018-02

Section Number:

6212

Previous Update:

Summary Statement

Nursing Home Transition (NHT) agencies will provide, at minimum, the mandatory documentation required by the Division of Aging Services.

Basic Considerations

The following documentation standards must be followed for Nursing Home Transitions to ensure accurate record keeping, and allow quality assurance and analysis:

DAS Data System

  • NHT Screening

  • Determination of Need/Revised (DON-R)

  • Triage Risk Assessment (Attached in Notes)

  • Monthly Contact Script (when required)

  • Care Plan, Planned Services, & Authorizations

  • Care Plan Activities

  • Quality of Life Assessment

  • Notes (when required)

DAS Procedures

DAS NHT Staff reserves the right to review all NHT documentation for monitoring and quality assurance purposes at any time, without prior notification to the NHT agency.

NHT Agency Procedures

NHT agency staff are to complete documentation at the appropriate benchmark in the transition process. Benchmarks and associated documentation are listed below:

Client Intake / Eligibility Determination

  • NHT Screening

  • DON-R

  • Triage Risk Assessment

  • Release of Information (Form 5459, Appendix D, Manual 5600)

  • Legal Status Affidavit (Appendix D, Manual 5600)

Transition Planning

  • Pre-Transition Contacts

  • Care Plan

  • Planned Services

  • Authorizations

  • Activities

  • Quality of Life Assessment (Baseline)

Post-Transition

  • Additional Planned Services, Authorizations, and/or Activities

  • Monthly Contact Scripts

  • Quality of Life Assessment (1-Year)

DAS may require additional documentation/information on a case-by-case basis.