Adult Foster Care Program Details and Referral Process in MA

GAFC PROGRAM GAFC PROGRAM Group Adult Foster Care

GAFC CONTRACTS GAFC CONTRACTS ADVANCED GAFC Peabody Properties Inc.

Peabody Properties Inc. Peabody Properties Inc. PPI PPI PPI is a vendor/contract with Advanced Home Care Advanced accepts GAFC referrals/transfers Referrals/Transfers are accepted depending on area and HHA availability All referrals are approved for 7 hours a week; additional hours are added later on by RSC. There s a maximum of 2 hours per day (3 hours a day are not permitted).

Advanced GAFC Program Advanced GAFC Program ADV GAFC ADV GAFC Advanced GAFC is our program directly with the state of MA Advanced obtain referrals via emails, phone calls, or CM marketing system CM informed DN and CC of potential referral via email. DN confirms RN availability and CC confirms HHA availability in the area. All referrals are approved for 7 hours a week; additional hours are added later on by CM; which in most cases are Temporary. There s a maximum of 2 hours per day (3 hours a day are not permitted).

New Referrals/Transfers New Referrals/Transfers For PPI, there are two types of referrals: New Referrals and Transfer For Advanced GAFC, there only one type of referral; which is New Referral 1. New referral documentation: Referral form, PSF, Med List and Diagnosis List. 1. CM is responsible for completing the necessary documents for new referral 2. Transfer documentation: Referral form, last MDS, and ISP with med list and diagnosis list 2. Once the documents are singed by potential client, additional documents like the PSF with med list and diagnosis list are requested from potential client PCP 3. RN is provided with the documentation; who will complete an Initial MDS if the potential client is a new referral or a PRN visit if the potential client is a transfer 3. Once received, RN scheduled and completes the Initial MDS 4. PPI RSC will information Advanced Home Care if the New Referral was approved for services 4. Paperwork is received by CC; who keeps a copy and provide original to CM 5. Approval is confirmed by RSC; who forwards the information to CC at Advanced 5. CM add the information from Initial MDS to Coastline Website and receives approval in a week 6. CC then schedules an Admission with RN, RSC, Client and HHA (introduction to the GAFC Program) 6. Approval is confirmed by CM; who forwards the information to CC 7. Transfer are coming from another vendor with completed admission and the RN only needs to follow up with regular visits after the PRN 7. CC then schedules an Admission with RN, CM, Client and HHA (introduction to the GAFC Program)

GAFC Documents GAFC Documents All documents are scanned into the Shared Drive and a folder under client s name is created Documents are scanned and named what they are with completed date Original documents are mail or safe for RSC/CM pick up Timesheets are created and uploaded into HCIT

Timesheets Timesheets PPI Timesheets are created by CC; who adds the care plan on the slips for the aide to follow (CP is found in the ISP). ADV GAFC - Timesheets are created by CC; who adds the care plan on the slips for the aide to follow (CP is found in the ISP). Add: Name, address and care Plan Add: Name, address and care Plan

Payroll Payroll - - Timesheets Timesheets Payroll expiration dateline for timesheet are 90 days. Our payroll team bills PPI on the 15thof every month for timesheets visits and weekly for ADV GAFC. Anything after 90 days is not billable to PPI or ADV GAFC. Aide will lose the hours and payments for that week. However, CC is responsible for making sure timesheet are provided to Advanced office weekly. Helpful: Ollyve, emails a list of all unconfirmed visits for previous month. Check and follow up if either PPI or ADV GAFC timesheets are on the list

RN Visits RN Visits Both PPI and ADV GAFC have the same type of RN visits Those include: 1. Initial MDS 2. Annual MDS 3. Individual Services Plan ISP/Semiannual 4. Admission 5. 24 hours Post Hospital 6. 2 Week 7. 4 week 8. 60 day 9. PRN and Transfer

Payroll Payroll RN Visits RN Visits RN are responsible of their own schedule. However, CC can remind RN of visits due or not yet completed. Payroll expiration dateline for RN visits are also 90 days as well. Our payroll team bills PPI on the 15thof every month for RN visits. Anything after 90 days is not billable to PPI or ADV GAFC. RN will lose the hours and payment for that week. However, if allowed, an exception can be apply and RN visit can be pay under NS-NB (only for those over 90 days) which means; the visit is not billable to PPI or ADV GAFC but payable to the RN.

RN Visits: Initial MDS RN Visits: Initial MDS Initial MDS is completed once the necessary paperwork are provided by RSC/CM. CC is responsible for notifying the RN and making sure that she/he completed the Initial MDS. Initial MDS are schedule in HCIT under NS 2 hours. The Initial MDS include the following documents: RFS - 2 Pgs. MDS - 5 Pgs. Diagnosis - 1 Pg. Meds - 1 Pg.

RN Visits: Annual MDS RN Visits: Annual MDS Annual MDS Completed annually by RN for continuation of services. Annual MDS are schedule in HCIT under NS-YA 2 hours. The Annual MDS include the following documents: MDS-5 Pgs. Add l Diagnosis - 1 Pg. Add l Med - 1 Pg.

RN Visits: ISP/ Semiannual RN Visits: ISP/ Semiannual ISP Are completed every 6 months by RN. Semiannual - RSC provides an updated semiannual document with diagnosis and medication list from PCP before RN completes the ISP (CC provides faxed or emailed documents to RN). ISP/Semiannual are schedule in HCTI under NR 1 hour. The ISP/Semiannual include the following documents: ISP 3 pgs. Semiannual 1pg + PCP Doc.

RN Visits: Nursing Progress Notes RN Visits: Nursing Progress Notes The following RN visits are all completed in the Nursing Progress Notes: Admission, 24hrs Post Hospital, 2 week, 4 week, 60 day and PRN/Transfer RN must checked-off the type of visit completed RN must write and signed her name on the Nursing Progress Notes RN must date the Nursing Progress Notes. Any of the above three statements missing on the Nursing Progress Notes can result on a delay of payment.

RN Visits: Nursing Progress Notes RN Visits: Nursing Progress Notes The Nursing Progress Notes include the following document:

RN Visits: Admission RN Visits: Admission Admission A first day introduction to the services. CC schedule the admission with CM/RSC, RN, client and aide. It s not necessary to scheduled all four people at once but services must be provided by aide. RN and CM/RSC can visit client on the same day at a different time. Admission visits can be rescheduled if all parties need to attend. Admission are schedule ONCE in HCTI under NA 1 hour.

RN Visits: 24hrs Post Hospital RN Visits: 24hrs Post Hospital 24hrs Post Hospital Are due once client has been discharged from hospital. Either the CM/RSC, RN, Client or Aide will notify you once he/she has been release from the hospital. Follow up with CM/RSC as well as RN if client or aide provided the information. A RN needs to schedule a visit within 24hrs of being discharged from hospital. If due to scheduling conflict, RN is unable to visit client within 24hrs, the visit becomes a PRN. However, RN can visit client another day but sign note on discharged date at their discretion. 24hrs Post Hospital are schedule in HCIT under NR 1 hour.

RN Visits: 2 week RN Visits: 2 week 2 week this visit is completed 2 weeks after an Admission and after a 24hrs Post Hospital date. A follow up visit by RN regarding the client status after starting services or being discharged from hospital. RN schedule visit 2 weeks after Admission and/or 24hrs Post Hospital. 2 week visit are schedule in HCIT under NR 1 hr.

RN Visits: 4 week RN Visits: 4 week 4 week this visit is completed 4 weeks after an Admission and 24hrs Post Hospital date. A follow up visit by RN regarding client s services as well as health status, additional comments or request more hours, schedule and review care plan. RN establish a report regarding those changes. RN reminds the client the RN visits will continue but every two months/60 days. 4 week visit are schedule in HCIT under NR 1 hour.

RN Visits: 60 day RN Visits: 60 day 60 day this visits are completed by RN every two months. Usually completed by RN from the date of 4 weeks visit or from the last 60 days visit. A follow up visit by RN to obtain updates from client services during the last two months as well as changes in health, schedule, additional comments or request and care plan. RN establish a report regarding those changes. RN will continue to schedule and visit client every 60 days unless there s any discrepancies like hospitalization or vacation; which can affect or change the date of the visit. 60 day visit are schedule in HCIT under NR 1 hour.

RN Visits: PRN and Transfer RN Visits: PRN and Transfer PRN this visits are completed if needed. If client goes away for a short period of time and missed a 60 day visit. If client had an accident a fall or injury and he/she refused to go to the hospital Transfer this visit is completed when a client is transfer from a vendor to Advanced Home Care Services LLC. PRN/Transfer visit are schedule in HCIT under NR- 1 hour.

RN Visits: Dates RN Visits: Dates Dates on RN Notes are better important. RN are allow to date their completed NR Notes 2 days before or 2 days after the due date. RN can also make additional note stating the reason why the RN Notes was completed on a different date. All billing should be reflected on the date the RN Note was completed by RN not the date it s due.

Home Care I.T. Home Care I.T. All Nursing Progress Notes need to be entered in HCIT. Each visit must be bill under their code: NA, NR, NS, NS-YA and NS-NB If visit is not available under Authorization, create or restart the visit with the same RN note date. Once created/restarted, schedule visit under Assignment. Under assignment, each visit needs a start and end date. Time does not matter. Once completed, submitted and add on Notes, date completed, type of visit and completed by who. For example; 07/28/21 60 days visit completed by RN Daviela Perez

GAFC Platform GAFC Platform All RN Note completed and paid for need to be entered here. Search client either by first or last name (do not type both) Select client s name and double click to open Once open, add the date the RN Notes visit was completed Under corresponding visit Please keep GAFC Platform organize and make it make sense.

Case Coordinator Case Coordinator Report, report, Report! If an aide called regarding a client not being home or taken to the hospital, contact CM/RSC and RN. If services are stopped due to whatever reason notify CM/RSC and RN. If client canceled services notify CM/RSC. If there s changes in schedule or aide notify CM/RSC. If client contact office with request or comments notify CM/RSC. If client move to different address notify CM/RSC and RN. If aide reports an issue about client notify CM/RSC. Please update HCIT

Questions Questions If you still have any questions after reviewing this information, please contact Nurgul, Denise and Daviela