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340:100-5-26. Health and wellness

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Revised 5-15-09

(a) Purpose. Services and supports promote health and well-being.

(b) Scope and applicability. OAC 340:100-5-26 applies to service recipients receiving services funded by Developmental Disabilities Services Division (DDSD) or Home and Community-Based Services (HCBS) Waivers.

(1) Oklahoma State Department of Health (OSDH) guidelines for universal precautions, and infection control practices are used to prevent the transmission of communicable diseases.
(2) DDSD staff and contract providers implement procedures to promote the health and wellness of each service recipient, including procedures related to:
- (A) accessing emergency medical intervention;
- (B) initiating first aid and cardio pulmonary resuscitation (CPR);
- (C) promoting disease prevention;
- (D) addressing issues associated with aging;
- (E) medication administration per OAC 340:100-5-32;
- (F) health related services per OAC 340.100-5-26.3;
- (G) assisting the service recipient to access medical and dental services when needed; and
- (H) identifying and addressing service recipient needs per OAC 340:100-5-50 through 340:100-5-58.

(1) The right of a service recipient to refuse service is respected per OAC 340:100-3-11. However the:
- (A) Personal Support Team (Team) meets to discuss the service recipient's decision;
- (B) service recipient must cooperate with assessments and provide documents necessary to continue eligibility to receive HCBS waiver services;
- (C) service recipient must cooperate with the case manager and provider to obtain necessary assessments and physician orders if assistance by a paid HCBS waiver provider is identified in the Individual Plan (Plan); and
- (D) except as provided for in OAC 340:100-5-22.5; the service recipient is responsible for health and medical costs including:
  - (i) over-the-counter medications, and other medications not covered by insurance;
  - (ii) health insurance co-payments;
  - (iii) dental treatments and appliances not covered by dental insurance or within the allowable annual limits of the HCBS waiver, if eligible;
  - (iv) medical treatments not covered by health insurance;
  - (v) dietary supplements, including but not limited to:
    - (I) vitamins; and
    - (II) herbal and dietary treatments;
  - (vi) treatment supplies not medically necessary for:
    - (I) nutrition;
    - (II) incontinence;
    - (III) respirator or ventilator care;
    - (IV) decubitis care;
    - (V) catheterization;
    - (VI) health conditions;
    - (VII) infection control; or
    - (VIII) not within the allowable limits of the HCBS waiver.
(2) The service recipient or his or her family will assume the responsibility for making appointments when residing in his or her own home or family home.

(d) Assessment of needs. The DDSD case manager ensures an individual assessment is completed for each service recipient per OAC 340:100-5-51. • 1-4

(e) Planning and implementation requirements.

(1) Health and wellness support and services and the roles of various individuals are specifically noted in the service recipient's IP per OAC 340:100-5-50 through 340:100-5-58.
(2) For a service recipient who receives minimal services to maintain residence in his or her own home, family home, or to maintain employment, the service recipient and his or her Team determines the appropriate roles for members of the Team per applicable policy.
(3) For a service recipient who receives residential, group home or extensive health supports to remain in their own home, family home, or maintain employment, the team will identify specific roles and protocols necessary to provide support as listed in (A) – (H) of this paragraph.
- (A) The Team identifies desired health care outcomes through the Team process.
- (B) Health issues identified through health care evaluations and assessments that impact the service recipient's life are incorporated and integrated by the Team into the Plan through goals and objectives.
- (C) Health care services are addressed in terms of individual outcomes, not units of clinically specific service.
- (D) When assessing health care services or implementation strategies involving discipline-specific services, a representative from that discipline participates in at least a consulting role.
- (E) Any invasive or intensive professional service or procedure is reviewed by the Team, including participation from any other service provider as appropriate. Consent is assessed per OAC 340:100-3-5.
  - (i) Team review of an invasive or intensive service or procedure includes discussion, prior to implementation, of the proposed service or procedure, and of possible alternatives.
  - (ii) Invasive procedures reviewed by the Team comprise both scheduled and emergency procedures, that include but are not limited to:
    - (I) tracheotomy;
    - (II) orthopedics;
    - (III) gastrostomy;
    - (IV) jejunostomy;
    - (V) multiple dental extractions;
    - (VI) amputation; or
    - (VII) consideration of permanent sterilization.
  - (iii) An invasive or intensive professional service or procedure implemented on an emergency basis must be reviewed by the Team as soon as possible, but within five working days. Emergency procedures subject to review include, but are not limited to emergency:
    - (I) surgery; or
    - (II) behavioral intervention including mechanical or chemical restraints.
- (F) The residential or group home provider has an obligation to assure health coordination activities are implemented.
- (G) The Team identifies a health care coordinator (HCC) to ensure implementation and coordination of health care services for the service recipient. The HCC:
  - (i) is a person who has an understanding of the service recipient's health care needs and lifestyle, and may be the service recipient, service recipient's family member, foster parent, companion, residential provider staff, or other person who is familiar with the service recipient's needs;
  - (ii) receives DDSD required training;
  - (iii) documents that health concerns are addressed, monitored, and communicated;
  - (iv) supports the person to directly communicate to the physician the reason for the medical consultation whenever possible, or communicate on the service recipient's behalf;
  - (v) keeps the physician advised of medical status and data regarding any target symptoms;
  - (vi) communicates physician orders to core Team members and other service providers as appropriate;
  - (vii) presents Form 06HM005E, Referral Form for Examination or Treatment, for HCBS Waiver recipients to the physician at the time of the visit.
    - (I) Form 06HM005E is completed by the HCC prior to the visit.
    - (II) The HCC requests the physician to complete a short written summary of the findings.
  - (viii) When employed by a contract provider, the employer develops and implements a procedure to ensure appropriate backup if the HCC is unable, for any reason, to perform these duties; and
  - (ix) completes health status and medication reviews each month using Form 06HM006E.
- (H) For HCBS Waiver service recipients, the DDSD case manager makes a referral for a clinical pharmacy review by a clinical pharmacist or physician:
  - (i) upon request of a Team member or clinician participating with the Team;
  - (ii) when a review performed by the assigned DDSD case manager and nurse determines a referral to an independent clinical pharmacist or physician is indicated. The DDSD case manager submits a clinical pharmacy review annually or as needed when the service recipient:
    - (I) receives five or more medications;
    - (II) has an unusual physical sign or symptom during the month in review that is not resolved through other medical interventions;
    - (III) uses a p.r.n. medication routinely for more than three months with an average use of three per week or ten per month;
    - (IV) takes two or more psychotropic medications per OAC 340:100-5-26.1; or
    - (V) takes three or more anticonvulsant medications used for a seizure disorder.

(f) Implementation procedures for HCBS waiver skilled nursing services.

(1) Skilled nursing services are implemented per OAC 317:30-5-390 through 317:30-5-394.
(2) Community service workers are trained and carry out implementation strategies addressing health care outcomes.
(3) Accurate and current medical and program information is maintained in the home record by the residential provider and available for review by authorized OKDHS staff.

(g) Case management monitoring responsibilities for HCBS Waiver service recipients.

(1) The case manager monitors implementation of the plan per OAC 340:100-5-52 and 340:100-3-27.
(2) For the purpose of monitoring and evaluation, designated DDSD staff have access at all times to the service recipient's medical and programmatic information.
(3) The case manager monitors the service recipient's access to medical and dental services.
(4) The case manager may assist the service recipient in locating health care providers.

INSTRUCTIONS TO STAFF 340:100-5-26

Revised 5-15-09

1.  The Developmental Disabilities Services Division (DDSD) case manager completes Form 06HM007E, Physical Status Review, for service recipients of the Homeward Bound Waiver or those in the Community Waiver who receive residential supports or group home services.

(1) Form 06HM007E is a review tool that identifies a service recipient's functional ability to attend to activities of daily living based on past and present health history and current treatment modalities.

(2) The PSR assesses the service recipient's needs in the areas of:

(A) functional abilities;

(B) behaviors;

(C) physiological needs;

(D) safety considerations; and

(E) frequency of service.

(3) To complete Form 06HM007E, the case manager communicates with the service recipient or someone who knows the service recipient's medical history, current trends in overall health and behavior, daily care needs, medical or nursing treatments, the past year's medical incidents, emergency room visits, hospitalizations, and medication regimen.

2.  Form 06HM007E is completed annually, no more than 60 days prior to   the annual Team meeting.

3.  When a significant change in the service recipient's function or health treatment occurs that requires additional staff training or health care services, the case manager completes a new Form 06HM007E and revises the Plan as necessary.

4.    The PSR identifies a health care level.

(1) A DDSD nurse reviews the responses documented by the case manager.

(A) Level I, service recipient ordinarily has no body system compromised. The service recipient is assisted or has the ability to access the health care system.

(B) Level II, service recipient ordinarily has a chronic condition, but the health status is stable.

(C) Level III, service recipient ordinarily has two or more chronic co‑existing conditions with no occurrences within the past year.

(D) Level IV, service recipient ordinarily has two or more existing health conditions that require close observation for symptoms and specialized health training.

(E) Level V, service recipient ordinarily meets all criteria for Level IV and has health needs that require licensed nursing treatment one or more times daily.

(F) Level VI, service recipient ordinarily has several existing health issues that are unstable and require treatment by a nurse more frequently than every two hours over a 24-hour period.

(2) Based on the review and responses from the PSR, the DDSD RN makes health related training and service recommendations for Team consideration.

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