3021 Initial and Monthly Contacts

Georgia State Seal

Georgia Division of Aging Services
Public Guardianship for Adults Manual

Chapter:

3000 Case Management

Effective Date:

06/30/2023

Section Title:

Initial and Monthly Contacts

Reviewed or Updated in:

MT 2023-03

Section Number:

3021

Previous Update:

MT 2023-01

Summary Statement

A Department of Human Services (DHS) representative shall make face-to-face contact with guardianship clients for whom DHS has been appointed guardian on a monthly basis unless otherwise specified in policy and procedure.

Basic Considerations

The guardian shall treat the person under guardianship with dignity. In doing so the guardian has the responsibility to:

  • Establish contact with and develop a regular pattern of communication. Each contact with the person under guardianship should be purposeful and strategic.

  • Communicate to the person the role of the guardian and explain the rights retained by the person

  • Ensure that provision is made for the support, care, comfort, health, and maintenance of the person

  • Ensure that the person is living in the most appropriate environment that addresses the person’s goals, needs, and preferences

  • Continuously assess the person’s physical and social situation, the person’s educational, vocational, and recreational needs, the person’s preferences, and the support systems available to the person

  • Regularly examine and monitor all services

  • Fully identify, examine, and continue to seek information regarding options that will fulfill the person’s goals, needs, and preferences

Case Management

Face-to-Face Visits

An initial face-to-face visit with the person under guardianship must be made within 5 business days of case assignment. For emergency appointments, the initial face-to-face visit must be within 48 hours of case assignment.

A face-to-face monthly contact must be completed by the 20th calendar day of each month. As a rule, for persons under guardianship who participate in a day program, monthly face to face visits should alternate between the day program and the person’s residence. However, up to two doctor’s visits a year with the client may serve as a monthly contact in place of a home visit or day program visit. Additional doctor’s visits can count as contacts but are not to be substituted for home or day program visits. More than one visit a month is allowable.

Monthly visits must be unannounced.

If the Client has left their placement and contact is limited to phone calls, emails, texts from the client, the case manager must document all efforts to encourage the client to return to their previous placement or to cooperate with attempts at a new placement. If the client is known to be in another state, the case manager must document efforts to locate the client for the purpose of establishing guardianship where the client is residing.

Telephone conversations or electronic communications with the person under guardianship are also considered contacts but do not take the place of required face-to-face visits. Collateral contacts include telephone conversations, electronic communications, or face-to-face meetings with the person’s family member(s), significant other(s) or providers from which the person under guardianship receives or may receive services.

Purposeful and strategic contact includes:

  • The assessment to determine service needs, including activities that focus on needs identification and to determine the need of any medical, education, social or other services, to include:

    • Taking client history

    • Identifying the needs of the individual and completing related documentation

    • Gathering information from other sources such as family members, medical providers, social workers, and educators, if necessary, to form a complete assessment of the eligible individual

    • (for initial visit) Completing the Client assessment

    • (for Clients living at home) Completing the medication checklist during the initial visit and updating as needed

    • (for Clients residing in a host home, group home, personal care home, assisted living facility or nursing home or attending day services) Reviewing the chart and other available and pertinent information

  • Development of a specific care plan based on the information collected through assessment; specifies goals and actions to address the medical, social, educational, and other services needed

  • Referral and related activities to help an individual obtain needed services, including activities that help link eligible individuals with medical, social educational providers or other programs and services that are capable of providing needed services, such as making referrals to providers for needed services and scheduling appointments for the individual

  • Monitoring and follow-up activities, including activities and contacts that are necessary to ensure the care plan is effectively implemented and adequate. Contact may be with the individual, family members, providers, or other entities. At contact, review:

    • Whether services are being furnished in accordance with the person’s care plan,

    • Whether the services in the care plan are adequate

    • Whether there are changes in the needs or status of the person under guardianship and, if so, make necessary adjustments in the care plan and/or service arrangements with providers

Documentation

The following must be maintained in the person’s record:

  • Current comprehensive service plan which identifies the medical, nutritional, social, educational, transportation, housing, and other service needs which have not been adequately accessed and a timeframe to reassess service needs.

  • Documentation of all contact with the person under guardianship and collaterals

  • Description of the services provided and outcome Case managers must follow documentation standards.

Meaningful Contacts

The following are steps to ensure that contacts are meaningful:

Step 1

Review the current care plan before the visit.
Step 2

Discuss with the person under guardianship and/or caregiver the care plan steps that have been achieved and areas where progress has been experienced.
Step 3

Discuss with the person under guardianship and/or caregiver the steps or goals that will be the focus of the next contact or the area of greatest need that must be addressed.

Document the contact in the case record no later than the fifth business day after the contact is made.