DELMARVA SERVICE SPECIFIC TOOL	Version	11/10 Handbook
Use this information to ensure important areas are covered with the client.

SL- service log	CN- notes	SMU-Status/Medical Update

Top-Topics/Charts	HSH-Health, Safety, Housing Checklist	PCP-Person Centered Planning

QS-Quarterly Summary	AS-Annual Summary	MS-Monthly Summary

SatS-Satisfaction Survey	Demo-Client Demographics	HH-Health History

FCA-Functional Community Assessment	SPA-Service Auth/Cost Plan	SP-Support Plan

IP-Implementation Plan	POL-Signed Policies	IFP-Individual Financial Profile

Lexp - Learning Experiences	CGR-Client-Guardian Release	DP-Disaster Preparedness
SERVICE TOOL	SLC	IHSS	COM	PCA	R HAB	RESP	SEP	BAN	BAS	LOCATION
The provider maintains copies of claims submitted for payment.	x	x	x	x	x	x	x	x	x	N/A until further notice
The provider submits documents to the WSC as required.	x	x	x	x	x	x	x	x	x	receipt/date stamp
The provider has service logs for each date of service that are reflective of the individual's communicated personal goals.	x	x	x	x	x	x	SL, CN, MS, AS, QS
The provider has service logs for each date of service.	x	x	SL
The record includes monthly summaries that reflect progress toward the communicated personal goals.	x	x	x	MS
If the individual is receiving in-home supports and supported living coaching, there is evidence of coordination between the services.	x	SL, CN, Staff Schedule
If renting, the lease (mortgage) is in the name of the individual receiving the service.	x	Lease
Provider or provider's immediate family is not the recipient's landlord or has any ownership of the housing unit.	x	Lease
When the IHSS lives in the individual's home, the IHSS pays an equal share of the room and board for the home.	x	Cleared Checks, paid bills - current
The service is provided in accordance with an outcome on the individual's support plan.	x	x	SP goal = IP goal = SL goal
The provider maintains current service authorization(s) for the service being rendered and billed.	x	x	x	x	x	x	x	x	x	SPA
The provider renders the service in accordance with the service authorization and the Handbook.	x	x	x	x	x	x	x	POL, CN, Scope of Service, job descriptions
The provider addresses the individual's communicated goals.	x	x	x	x	x	x	x	x	x	CN, PCP
The provider addresses the individual's communicated choices and preferences.	x	x	x	x	x	x	x	x	x	CN, Top, SatS, PCP
The provider addresses the person's interests regarding community participation and involvement.	x	x	x	x	x	x	x	Top, SMU, CN
The provider has a system in place to gather historical information about the person's behavioral and emotional health, with the person's/legal representative's consent.	x	x	x	x	x	CGR, SMU, Top
The provider is aware of the person's recent progress towards or achievement of personal goals.	x	x	x	x	x	x	x	x	x	CN, AS, QS, MS
The provider addresses the person's/legal representative's expectations regarding the services he/she is receiving.	x	x	x	x	x	x	x	x	x	CGR
Services are provided at mutually agreed upon times and settings.	x	x	x	x	x	x	x	x	Client-Staff Schedule
Services are rendered in the individual's own home or while the individual is engaged in a community activity (if individual is Tier 4 IHSS, can be rendered in the family home)	x	x	Job Description, CN
Services are rendered in licensed facilities only with specific APD authority.	x	Job Description, CN

The provider renders services to individuals living in their own home or family home.	x	Job Description, CN
If rendered in the family home (child 16-18), the service is directly related to a training goal on the person's support plan.	x	Job Description, CN
If the individual resides in a licensed home, the service takes place only in the community.	x	Job Description, CN
If the service is rendered in the person's own home, the provider is not the landlord nor has any interest in the ownership of the housing unit.	x	Lease, Deed
The provider renders services only in the individual's own home, family home, licensed foster home, group home, ALF, or Home for Special Services.	x	Job Description, CN
The current Implementation/Transition/Employment Plan and all required components are in the record.	x	x	x	IP
The current Implementation/Transition/Employment Plan was completed within the required time frames.	x	x	x	IP
The individual's current Implementation/Employment Plan reflects the individual's communicated personal goals.	x	x	IP Goals
The record includes data to support the current Implementation Plan.	x	CN, AS, QS, MS, Top, SMU, FCA
The initial Housing Survey and ongoing quarterly updates are in the record.	x	HSH
The Functional Community Assessment is in the file (completed prior to the person moving into the supported living arrangement and updated annually thereafter).	x	FCA
The Provider has a current Annual Report (s) on file.	x	x	x	x	AS, QS(4), Top, IFP, SMU, FCA, etc
An annual satisfaction survey (SLC-as described in rule 65G-
5.007 FAC) is in the record.	x	x	SatS
The file includes updated information regarding the demographic, health, medical and emergency information, and a complete copy of the current support plan.	x	SP, Demo, HH, HSH, SMU, HH, DP
The provider addresses the individual's health and health care needs.	x	HH, CN
The individual is provided with education related to his/her own health needs, i.e. medications, side effects of medications, medication reviews, preventive healthcare.	x	CN
The individual see's medical and dental professionals routinely and as needed.	x	CN
The provider is aware of the individual's safety needs and safety skills.	x	SMU, CN, FCA, HSH
The individual is provided with education related to his/her own safety needs, i.e. natural disasters, community safety, home safety, etc.	x	SMU, CN, HSH, FCA, DP
The provider knows which rights are important to the individual.	x	Lexp, Top, SMU
The provider identifies methods for teaching individuals about their rights that are tailored to their learning style.	x	Lexp, Top, SMU
The provider describes how individuals are empowered to make informed decisions regarding their own health.	x	Lexp, SMU
The provider describes how individuals are empowered to make informed decisions regarding their own safety.	x	Lexp, SMU
The provider is aware of the individual's history regarding abuse, neglect, and/or exploitation.	x	Lexp, Top, SMU
The provider is responsive to the individual's definition of abuse, neglect, and exploitation and how the individual would report any incidents.	x	Lexp, Top, SMU
The provider has an on-call system that allows individuals access to services for emergency assistance 24 hours per day, 7 days per week.	x	Pol, IP
Referrals are made to non-HCBS waiver funded resources based upon the individual's expressed need or outcome.	x	CN
The provider maintains daily attendance logs.	x	Attendance Log
The record includes monthly summaries that reflect progress toward the person's goal(s) and if applicable graphic display of acquisition and reduction behaviors related to the implementation plan.	x	MS
When applicable, the provider maintains documentation of LRC review dates and recommendations made specific to the plan and review schedules for the plan.	x	LRC, CN
The provider has a copy of the assessment report completed within 30 days of initially providing services.	x	Assessment
The provider maintains monthly summaries that include graphic displays and a brief description of events affecting the data displayed.	x	MS
The provider has a current Behavior Analysis services plan within 90 days of initially providing services.	x	Behavior Analysis Plan
If the targeted reduction behaviors meet the requirements identified in rule 65G-4.009, F.A.C., the LRC review date, and recommendations made specific to the plan, a review schedule for the plan must be included.	x	Behavior Analysis Plan, LRC, CN
The provider has obtained LRC approval on the current behavior plan.	x	x	LRC approval
The approved behavior plan is being implemented as written and as approved.	x	x	CN
The approved behavior plan identifies a time limit and a plan for fading or discontinuing the service.	x	x	Behavior Analysis Plan
Training for parents, caregivers and staff on the Behavior Plan is documented (when these persons are integral to the implementation or monitoring of a behavior analysis services plan).	x	x	CN
The provider maintains monthly summaries and graphic displays of effects of behavioral service plan.	x	MS
The provider has a current approved Behavioral Analysis services plan in the record prior to claims submission.	x	Behavior Analysis Plan
The responsible Behavior Analysis Services Local Review Committee chairperson or designee approves behavioral Assistant services.	x	LRC approval
The provider has documentation of required monitoring and supervision by the responsible Certified Behavior Analyst.	x	CN
The provider has evidence of documentation, in the form of a letter from Vocational Rehabilitation (VR) Services or a case note detailing contact with a named VR representative, indicating a lack of available VR funding for supported employment.	x	VR Contacts
The provider assists with the acquisition of skills related to accessing and maintaining employment or developing and operating a small business through supports typical to the workplace.	x	CN
The provider assists individuals in securing employment according to their desired outcomes, including type of work environment, activities, hours of work, level of pay and supports needed.	x	CN
The provider assists individuals with retention and improvement of skills related to maintaining employment or developing and operating a small business.	x	CM
The provider includes activities, such as supervision and training, needed for individuals to sustain paid work at or above minimum wage.	x	CM
Services are provided in the individual's place of employment, in the community or in a setting mutually agreed to by the supported employee, the employment coach/consultant and the employer.	x	CN
The provider notifies the support coordinator within five working days of a change in an individual's employment location.	x	CN
Individuals who work an average of less than 20 hours per week or who remain in job development status have at least a quarterly review and documented attempts to increase work hours or secure an appropriate job.	x	CN
The provider addresses the person's interests regarding community employment related outreach, linkage.	x	CN
The provider is able to describe methods for teaching individuals about rights that are tailored to their learning style.	x	CN