Form 3599, Habilitation Service Provider Orientation/Supervisory Visits

Effective Date: 7/2015

Availability

PDF: 3599.pdf

Instructions

Updated: 7/2015

Purpose

To provide a standardized record of  Community Living Assistance and Support Services (CLASS) habilitation and Community First Choice (CFC) Personal Assistance Services Habilitation (PAS/HAB) service provider orientation either in person or by telephone and supervisory visits.

Procedure

When to Prepare

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

Transmittal

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

Form Retention

Keep this form according to record retention requirements documented in the 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 or delegated CFC PAS/HAB service provider — Mark this box if the services being provided are delegated to the habilitation or PAS/HAB service provider.

Habilitation or PAS/HAB 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  (CLASS only) — 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 or PAS/HAB service provider name — Enter the name of the habilitation or PAS/HAB service provider.

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

    • Provider Orientation  –  Habilitation or PAS/HAB service provider orientation
    • Supervisory Visit

Habilitation or PAS/HAB service provider orientation only: Complete Items 1 through 3D.

Supervisory visit only: Complete Items 4 through 8.

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

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

2. Orientation — Complete this item when orienting the habilitation or PAS/HAB 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 or PAS/HAB 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 or PAS/HAB service provider is to report when observed.

Habilitation or PAS/HAB service provider schedules — Enter the habilitation or PAS/HAB 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 or PAS/HAB 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 or PAS/HAB 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 or PAS/HAB service provider — The habilitation or PAS/HAB service provider signs and dates the form.

Supervisor — The supervisor signs and dates the form.

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