6214 Nursing Home Transition Required Contacts

Georgia State Seal

Georgia Division of Aging Services
Access to Services Manual

Chapter:

6000 Community Transitions

Effective Date:

Section Title:

Nursing Home Transition Required Contacts

Reviewed or Updated in:

MT 2018-02

Section Number:

6214

Previous Update:

Summary Statement

Nursing Home Transition agencies document required contacts for Nursing Home Transition using the DAS Data System.

Basic Considerations

NHT agency staff make required contacts with NHT clients to support their transitions. These contacts will be documented according to the following guidelines:

  • Harmony Notes (case notes) use the appropriate Note Type and sub-type (Harmony for MFP/NHT User Guide).

  • Documentation uses the minimum amount of abbreviations to assure full understanding of the note. Common acronyms and medical abbreviations are acceptable abbreviations. Other abbreviations should be used sparingly, if at all.

  • Monthly Contacts must be documented using the Monthly Contact Script in the DAS Data System.

DAS Procedures

DAS staff review Notes as part of the following activities:

  • Case staffing

  • Technical Assistance

  • Monitoring activities

  • Desk Audits

  • Quality Assurance initiatives

  • Other business needs

NHT Agency Procedures

NHT agency staff make required contacts and utilize the Harmony Notes in accordance with the following requirements:

Face to Face (FtF) Visits:

  • Initial FtF is made by MDSQ Options Counselor

  • 1st Home Visit, within three (3) business days of transition

  • 2nd Home Visit, between thirty (30) and sixty (60) calendar days from date of transition

Remote Contacts (Phone, Video Chat, e-mail, etc):

Additional remote contacts must be made directly with the client. Remote contacts must be made monthly after the 2nd home visit through the 6th month following the transition date.

Mandated TC-initiated calls may be discontinued after the 6th month post-transition call.

TC Agencies must have a written remote contact policy identifying how many remote contacts are attempted before a home visit is required. Attempted remote contacts may include a welfare check from the client’s local law enforcement agency and/or an attempt to contact letter to the client’s address. If remote contact cannot be made, an unscheduled home visit must be attempted within the same calendar month.

If a client is unable to be contacted either remotely or by unscheduled home visit for two (2) consecutive months, the client should be terminated from the NHT program. See NHT Termination Policy, Chapter 6221.

TCs must remain available and responsive to client-initiated contacts for the duration of the client’s 365-day participation period or until the client is terminated from the program.