New Hire Test #3: Mental Retardation Client Care

The Mental Retardation Community Waiver (MR Waiver) in Virginia provides a way to pay for certain long-term services in communities instead of in institutions. In order to allow this, Virginia applied to the Centers for Medicare and Medicaid Services (CMS) for a waiver of specific federal Medicaid requirements. Since Virginia’s application was first approved in 1991, the waiver has provided funding to allow many individuals who would have required institutional services to receive a variety of needed services and supports in the community. Virginia’s MR Waiver is built upon the idea of individualized supports. Services are developed and funded based on a person-centered approach, which allows each individual to have different types and levels of supports based on each individual’s goals, choices and needs. People can get either agency services where the provider hires the staff to work with the person or consumer-directed services where the individual (or her family) employs the staff person. They can even get different combinations of both agency-directed or consumer-directed services. The following types of services are available through the MR Community Waiver:
– residential support,
– day support,
– personal assistance,
– respite,
– companion
– consumer-directed personal assistance, respite and companion services
– assistive technology,
– environmental modifications,
– therapeutic consultation in the areas of psychology, behavior, speech, occupational therapy, physical therapy, recreation therapy and rehabilitation engineering,
– personal emergency response systems (PERS),
– crisis stabilization,
– skilled nursing,
– prevocational, and
– supported employment.

In order to be eligible for services funded through the MR Waiver, a person must have mental retardation, or if under six years old, he or she must be at developmental risk. Developmental risk means the child is likely to have mental retardation or another disability, such as autism or cerebral palsy, but she’s still too young for us to know yet. Once the child turns six, if she does not have mental retardation, she may need to get services from a different Waiver called the Developmental Disability Waiver. The person must also meet financial eligibility criteria for receiving Medicaid and show the need for Waiver services by meeting specific level of care criteria. Eligible individuals for whom a slot is available must be allowed to choose whether they want to participate in the Waiver program, what services they will receive, and who the service provider(s) will be. There are a limited number of slots for MR Waiver services, so not everyone who is eligible gets to start services right away. Each person who is enrolled in an MR Waiver slot is assigned a case manager by the Community Services Board (sometimes called a Behavioral Health Authority) that serves the area in which the individual lives. The case manager works with the individual to develop a Consumer Service Plan (CSP). The CSP addresses the person’s strengths, goals, and support needs in important life areas such as residential, education, vocational/work, and recreation/leisure. The case manager is responsible for linking the individual with service providers, coordinating and monitoring the person’s services. All Waiver services must be pre-authorized, which means that the case manager must review service plans and request authorization from the Office of Mental Retardation Services for services to be provided at the levels determined to be appropriate for the individual.

SERVICE PLANNING
All MR Waiver services must be delivered according to a written Individual Service Plan (ISP). The ISP has to include an assessment of the person’s strengths and needs in relevant areas. Based on assessment information and the individual’s desires, long-term goals and short-term objectives are developed. Strategies must be identified for achieving the goals and objectives, and the ISP must be reviewed on a regular basis (usually once every three months). Documentation (written information) is required to show that services are delivered as outlined in the ISP and to provide ongoing evaluation of the appropriateness of the services. Following is a description of each component of the service planning process and documentation requirements.

Assessment
Each service provider is required to learn about the individual’s strengths, interests and support needs using approved assessment tools. Formal assessment tools usually contain checklist information regarding the person’s skills and support needs in specific service areas. Assessments should be functional. That means that information is gathered through a variety of means in order to determine the individual’s current abilities in day-to-day community life skills. The best way to learn about a person’s strengths, interests and needs is to spend time with her in many different settings, seeing what she can and cannot do, what she likes and doesn’t like and by talking to her and others who know her well. The individual’s desires are important in identifying strengths and needs. For example, there’s no reason to train an individual for years and years how to tie his shoes if he can wear shoes with Velcro and manage them independently. When completing assessments and presenting what you’ve learned about the individual, it’s also more valuable to discuss what the individual can do rather than what he can’t do. The emphasis in planning should be placed on identifying an individual’s strengths and interests and building upon them.

Service Planning Team
ISPs are developed by a service planning team with the individual as the central team member. Other members of the team include family members and/or friends of the individual, the case manager, and service providers. The team must meet at least once a year to develop the ISP with the individual. These meetings should be informal, with all team members helping the individual feel comfortable expressing his desires and worries about services and supports. Team members present what they’ve learned about the individual and make recommendations related to the individual’s goals, objectives and services to be provided in the upcoming year. Service plans are developed based on team agreement.

Individual Service Plans
In addition to addressing the individual’s needs/desires, ISPs must be written to follow various regulatory and funding agency guidelines. Goals, objectives, strategies, and reviews must be written in a way that follows these guidelines.
– Long-range goals address the person’s desires and other team members’ recommendations for personal achievements in 3 – 5 years time.
– Short-term objectives provide steps for working toward the individual’s long- range goals. They are usually things the individual can accomplish in a year or less.
– Strategies give staff directions for providing the needed supports (training, assistance) toward meeting objectives.
– Quarterly Reviews: Plans must be reviewed at least quarterly to evaluate whether the individual is satisfied with services and if any changes should be made to reflect changing needs and desires of the individual.

Documentation
Each provider must maintain documentation which shows that services were delivered as outlined in the ISP. Additionally, each provider must have documentation which shows that the plan is being reviewed on a regular basis and that changes are made according to progress and/or the individual’s changing needs. Formats and styles for this documentation vary from agency to agency. Specific requirements for the agency where you work will be explained to you by your supervisor.

Your Role — What Can You Do?
1. Keep accurate documentation. Never “fudge” on required documentation. If you don’t understand how to document something, ask your supervisor.
2. Be sure to sign and date all entries in staff notes, logs, etc.
3. Learn to write objectively. Write down what you see, hear, or otherwise observe. Do not include your conclusions or opinions in documentation that is intended to be factual. If you have an idea or a hunch about something, such as why he might be behaving a certain way, make sure you write it as your opinion.
4. Know what’s in the ISPs of individuals with whom you work. You are responsible for providing services as outlined in the plan. In addition, when you know what both you and the individual are supposed to be doing, your documentation will reflect this knowledge.
5. If you are unsure or question why a piece of documentation is needed, ask your supervisor to explain. You will be more likely to complete better documentation if you understand the reason for the requirement.
6. As you get to know an individual, share your ideas for changes that might make the ISP better match the person’s strengths, interests and support needs.
7. Remember that all documentation is subject to review by licensing and funding agencies and, in some cases, could be subpoenaed for an appeal hearing or other legal action. Provide accurate, clear, detailed information. Never use white-out or erase ink. Mark through errors and sign and date any changes to the record.
8. Record information regarding personal likes and dislikes as well as other input from the individual receiving services in appropriate places in his record.