Division of Aging Services Adult Protective Services Case Review Guide – Ongoing Services | APS-5500-MANUAL

Region:

Review Date:

Name of Supervisor:

Client ID:

Name of Client:

Name of Caseworker(s) Assigned to Case:

Name of Family Service Worker (if applicable):

APS On-Going Services

1. Does the documentation in the DAS Data System Investigation Determination indicate the ongoing need for adult protective services?

(Critical)

APS Investigation – Determination Reason, Determination Notes

2. Is there a current DON-R?

(Critical)

A DON-R must be completed on the client to indicate functional capacity and identify areas of unmet need.

(Completed during the APS Investigation and annually or when significant change occurs in the client’s ADL’s/IADL’s.)

Consumer – Consumer Assessments: DON-R (DON-R completed during Investigation can be transferred to ongoing, however the data has to be entered in a new DON-R within Consumer Record section)

3. Are the duration dates of the current case plan in the DAS Data System correct?

(Procedural)

Consumer – Consumer Assessments: APS Service Plan

4. Is there a signed copy of the current APS Case Plan in the DAS Data System and is it documented in the DAS Data System that the case plan was signed by the client?

(Procedural)

A signed case plan must be uploaded into the Electronic Data Record.

The DAS Data System must indicate why the APS Case Plan was not signed by the client.

Consumer – Consumer Assessments: APS Case Plan (Signature Section)

Consumer - Notes

5. Is there documentation to support client involvement in the development of the case plan (either the initial case plan or at the time of redetermination)?

(Procedural)

The documentation in the DAS Data System must indicate at least one case management visit where the case plan was discussed and developed with the client and that he/she agreed to the goals/steps in the case plan, or there must be documentation in the case management notes regarding why the client did not participate in the case plan.

Consumer - Notes

6. Does the case plan include strategies to eliminate or reduce the risk of abuse, neglect, exploitation?

(Critical)

The case plan must indicate how the case manager and/or others will eliminate and/or reduce the risk of ANE. This includes, but is not limited to, strategies regarding how unmet needs identified in the DON-R and the APS ANE Risk

Assessment will be addressed. Each goal and related steps must indicate who is responsible (client, CM, service provider, FSW, etc.) for the goal, what will be done and timeframes for beginning and completing the steps and the goal.

APS Investigation – Documentation: APS ANE Risk Assessment

Consumer – Consumer Assessments: APS Case Plan and DON-R

7. Does the DAS Data System documentation support that a minimum of one monthly face to face contact occurred between the case worker (or Supervisor) and the client?

(Critical)

Consumer - Notes

8. Does the DAS Data System documentation support that a minimum of one quarterly face to face contact occurred between the case worker (or Supervisor) and the client in an alternate setting?

(Critical)

A minimum of one APS Case Management face to face contact occurred with the client, outside of the case address and must be documented in the Electronic Data Record. If the client is receiving services outside of the home then one quarterly visit must be made at that setting. If client receives no services outside of the home, then mark this question N/A

Consumer - Notes

9. If the CM identified safety issues in the home while providing APS on-going services (e.g., loaded guns in the house, rugs or other conditions of the flooring that may lead to falls, etc.), did the CM document that he/she addressed all issues with the client and/or caregiver that have the potential for serious injury and/or unexpected death during the reporting period?

(Critical)

The CM must document any safety issues found and what steps were taken to address those issues. Note: If no safety issues were found, mark N/A for this question.

Consumer - Notes

10. Were collateral contacts (minimum one per month) made to individuals mentioned in the case plan and/or others (e.g., service and/or medical providers, neighbors, friends, etc.) to assess if risk of A/N/E is still present and/or case plan goal(s)/step(s) were being achieved?

(Critical)

The documentation must indicate that collateral contacts were made to individuals mentioned in the case plan and/or others who are involved with the client. The CM must document if the collateral source is aware of additional risk factors and/or if case plan goal(s)/steps that involve the collateral source are in progress and/or have been achieved. Note: In the case that a case plan goal that involved a collateral is not achieved within the time specified in the case plan, the CM should document the reason(s) why it was not achieved.

Consumer - Notes

10. Terminations: If APS services were terminated for the client, was the criteria met for termination and documented in the Electronic Data System? If there is no termination in the review month, mark N/A.

(Procedural)

11. Terminated Cases: Is there evidence of supervisory concurrence and approval prior to case termination? If client was not terminated in the month of review, mark N/A.

(Procedural)

The APS Termination “statement” must indicate that the APS Supervisor has reviewed the case and agrees with terminating the client from APS services. The APS Supervisor will enter a Consumer – Note that the case has been reviewed and agreement with termination

Look at the Consumer – Notes to see if there is an entry from Supervisor indicating Termination review and concurrence

12. Terminated Cases: Was the client notified of the termination? If client was not terminated in the month of review, mark N/A.

(Procedural)

The APS Case Management Notes, entered prior to or no later than the effective date of the termination of the client, must indicate that the client was notified of the termination, and/or the termination statement addresses client notification. Notification can be made in person or by telephone or mail. If the client was not notified, there is a note in the Harmony Consumer record to indicate why the client was not notified.

Look at the Consumer – Notes - Termination Statement to see if a statement is that shows that the client was notified of the termination

1. Is there documentation in the DAS Data System to indicate the need for ERF?

Consumer – Notes

Consumer – Consumer Assessments: APS ERF Application and Approval Form

2. Is the ERF request/authorization documented in the Electronic Data Record?

Contact and Documentation Standards 3.16 [P]

A copy of the APS ERF Application and Approval Form, ADPOR (Authorization for Disbursement/Purchase Order) to DFCS Regional Accounting, along with all required and supporting documentation is in the Electronic Data Record.

The Supervisor, the District Manager and/or State Office Representative has approved the request by completing the ERF Decision in the DAS Data System and signing off on the APS ERF Application and Approval Form, ADPOR to DFCS Regional Accounting, and supporting documentation.

Consumer – Notes

Consumer – Consumer Assessments: APS ERF Application and Approval Form

3. Was an income worksheet completed and in the Electronic Data Record?

Contact and Documentation Standards 3.16 [P]

The Income Worksheet was completed and provides justification or supporting need for ERF.

Consumer – Notes