Document (if applies) found in Record Shared Living Contract Shared Living Questionnaire Copy of DSP Certificate Copy Driver's License driver) Copy of HS Diploma or GED Copy of Automobile Registration Copy of Automobile Insurance Copy of Home Owner/Renter's Insurance Proof of Vaccinations for Pets Copy of Member’s Current PCP Copy of CNA-M/CRMA Certificate, SL Medication Certificate, or RN License Name of Individual Completing this Form Document Date listed on Document (if applies) Check off if found in Record Member Information (MaineCare Manual 21.09 Member Records) Progress Notes that identify progress toward goals outlined in the PCP (includes signature) Progress Notes that document the level of services per the PCP Collected requisite daily documentation Collected Medication Administration Reports (MAR’s) Confirmation that the licensee (if applicable) is in good standing with the licensing Agency conducted home visits other month (member present for at least 2 per yr.) Agency conducted phone contact every other month (month the home is not visited)
Shared Living Home Review Tool Shared Living Home Visit Review Tool IV. Residential Record: Indicate areas that have been assessed during the home visit. Additionally, if the area warrants follow-up, mark the appropriate column. Identify the concern/need in the comment section to discuss and plan for response. Record Components Assessed Additional Follow Up Guidelines (In addition to MaineCare requirements, the following prompts may be used as points to consider while assessing for health, safety and good practice) Record Maintenance is in and documents can be located. Documentation reflects provider is following written protocols, MaineCare requirements and best practices. most recent plan is contained in the record. Indication that the guardian is participating in planning (at the minimum signed off on the plan). The plan is individualized for the consumer. The plan identifies all services, unmet needs etc. document progress toward goals outlined in the PCP. document level of services provided according to the PCP. needs are identified and addressed appropriately. documentation of current status, his/her goals, authorized services etc. Documentation reflects efforts to address that the consumer is involved in community life, is in contact with unpaid supports and participates in decision making etc. supports that the Provider is in compliance with Behavior Plans. Current, approved PCP Routine documentation of progress notes are meaningful, reflecting services Services/Supports needs Behavior Plans Comments: Note details of concerns or issues to review for follow-up. Include all steps taken for follow-up on page 7 of tool. Current medical (physical, dental, vision) reflects at least an annual physical exam within the last year, timely dental and other exams. Recommendations are clearly noted & addressed. the consumer is under guardianship, the documentation clearly notes the guardian was contacted prior to the consumer’s appointment/treatment. Provider tracks documentation of consent. reflects that Physician recommendations are being implemented and followed. Physician recommendations Prior consent for treatment Comments: Note details of concerns or issues to review for follow-up. Include all steps taken for follow-up on page 7 of tool. Medication tracking system are stored and tracked appropriately. MAR is used and up to date with current medication regime. Administration policies are in place. doctor’s to prescription on file. provider is following reportable event procedure for missed and/or refused dosages. the consumer is under guardianship, the documentation clearly notes that the guardian was contacted prior to the changes in medications. Provider tracks documentation of consent. Prior consent re:changes to medication regime