Form 3599, Habilitation Service Provider Orientation/Supervisory Visits

Effective Date: 9/2013

Availability

Word: 3599.doc

PDF: 3599.pdf

Instructions

Updated: 9/2013

Purpose

To provide a standardized record of habilitation service provider orientation either in person or by telephone and supervisory visits.

Procedure

When to Prepare

The direct service agency (DSA) habilitation service provider supervisor completes Form 3599 when orienting a habilitation service provider by telephone or in person or providing an annual supervisory visit.

Transmittal

The DSA maintains the completed form and provides a copy of the form to the individual/legally authorized representative (LAR).  If the habilitation service provider is oriented by telephone, a copy of this form must be provided to the individual/legally authorized representative within five calendar days of the habilitation service provider orientation.

Form Retention

Keep this form according to record retention requirements documented in the Community Living Assistance and Support Services (CLASS) Provider Manual.

Detailed Instructions

Individual's Name — Enter the individual's name.

Date — Enter the date (month, day, year) of the orientation and/or supervisory visit.

Delegated habilitation service provider — Mark this box if the services being provided are delegated to the habilitation service provider.

Habilitation service provider — Mark this box if the services being provided are included on the Individual Program Plan (IPP).

Special habilitation service provider orientation by telephone — Mark this box if orientation is by telephone for staff that meet requirements of a special habilitation service provider as defined in the CLASS Provider Manual.

Frequency of Supervisory Visits — The supervisor determines the frequency of supervisory visits and enters the frequency (e.g., every 60 days, or every 30 days) at the initial visit as documentation of the plan of supervision.

Habilitation service provider name — Enter the name of the habilitation service provider.

Purpose of Visit — Check the appropriate box to indicate the type of visit:

    • PO  –  Habilitation service provider orientation
    • SV  –  Supervisory visit

Habilitation service provider orientation only: Complete Items 1 through 3D.

Supervisory visit only: Complete Items 4 through 8.

Combined habilitation service provider orientation/supervisory visit: Complete Items 1 through 8.

1. Functional Limitations — Complete this item at every habilitation service provider orientation. If oriented by telephone, this information must be provided during the orientation.

2. Orientation — Complete this item when orienting the habilitation service provider (s). All topics (2-1 through 2-4) must be checked and blanks (2-1 and 2-4) must be completed. Topic 2-3 must include the name, credentials and the telephone number of the supervisor or nurse the habilitation service provider is to contact when specific symptoms of the individual's health problems are observed and must be reported. Describe the specific symptoms of the individual's health problems the habilitation service provider is to report when observed.

Habilitation service provider schedules — Enter the habilitation service provider's schedule and alternate schedule.

3.A. Tasks/Plan of Care: — Indicate tasks to be performed (complete on every visit). During supervisory visits, ask the individual or LAR what tasks are provided by the habilitation service provider.

Frequency — Indicate task frequency as follows: Indicate how often during the day/week/month/year the task is to be provided to the individual.

D—Daily     W—Weekly     M—Monthly     A—Annually     PRN—As Needed

Example: 1D means once a day, 2M means twice a month.

Performance — Observe or ask about performance and indicate if services provided are:

S = Satisfactory    U = Unsatisfactory

Items 3.B. through 5 — Mark the appropriate box Yes, No or N/A.

6.A. through 6.C. — Document any service delivery problems, habilitation service provider training needs or corrective actions.

7. Continued Need for CLASS — Mark the Yes or No box.

8. Additional Comments — Provide any additional comments, as necessary.

Signatures and Dates

Individual/LAR — The individual/LAR signs and dates the form.

Habilitation service provider — The habilitation service provider signs and dates the form.

Supervisor — The supervisor signs and dates the form.

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