June 1, 2011
As a first step in the service authorization process, the ADvantage Service Plan Authorization Analyst checks every service plan packet for health and safety risk indicators. Should an indicator be identified during this preliminary screening, the packet is forwarded to an ADvantage RN Clinical Review Analyst for an in-depth clinical review.
Below you will find the specific indicators as well as the process used by the Clinical Review Nurse to determine if the service plan and service plan goals address the health and safety needs of the Member.
1. Is MSQ over 18 per current UCAT?
- Does member actually need and/or have 24-hour support?
- Is 24-hour support addressed in Service Plan and Goals?
2. Is MSQ over 12 and does Member live alone?
- Why is MSQ over 12? Which items were missed? Does other documentation such as UCAT Summary and/or RN Evaluation indicate that Member can function with intermittent safety supervision?
- Is intermittent safety supervision needed / provided?
- Is intermittent or 24 hour safety supervision addressed in goals?
3. Is there documentation of falls (either current or prior history)?
- Fall prevention should be addressed in the Service Plan Goals of every Member.
- May use Fall Prevention Guide on OKDHS Website, may use other websites or develop fall prevention goals; should be Member specific.
4. Is there evidence of current wounds?
- Is wound management needed / addressed in goals?
- If wound is identified anywhere in UCAT, RN Evaluation or other documentation it is expected that wound management will be addressed in Service Plan and Goals.
- If wound is healed by the time Service Plan is developed this needs to be noted in documentation submitted.
5. Are medication issues identified?
- Is medication management needed / addressed in goals?
6. Is Member ventilator dependent, have a catheter, ostomy, tracheotomy, feeding tube, etc?
- Is management of device addressed in goals?
- Who provides routine care related to use of the device?
7. Is there evidence of existing or potential mental health conditions?
- Is need for mental health management indicated?
- Is specific management addressed in goals (psychiatric care, counseling, etc.)?
- If Member declines, is there a goal indicating that mental health status will be monitored at each visit?
8. Are environmental issues identified?
- Is intervention needed?
- Is a plan for intervention addressed in goals?
- If an environmental issue is identified but has been resolved, please update UCAT accordingly and submit with packet.
- If Member declines intervention, do the goals address ongoing monitoring of
9. Is Member unable to use phone?
- How will he / she summon emergency assistance?
- Member specific emergency action plan should be addressed in the goals of all Members!
10. Is Member unable to transfer independently?
- How does Member complete routine transfers?
- How will Member exit the home in the event of an emergency?
- Is Member specific emergency action plan addressed in goals?
- Is risk negotiation addressed in goals?
11. Has the need for 24 hour support been identified (by assessor)?
- Is 24-hour support addressed in Service Plan, Goals and Cost Sheet?
- Has APS been contacted if needed 24-hour support is not available?
- Do goals reflect high-risk monitoring of situation?
- Do goals reflect ongoing coordination of services with APS to assure services are appropriate and adequate to meet the Members needs in addition to reviewing other alternatives if the plan does not work?
12. Is Health Assessment scored as High-Risk?
- Is specific disease management addressed in goals?
- Is 24-hour support needed / provided and addressed in goals?
- Is high-risk case management addressed in goals?
If you have any questions or concerns regarding the information provided above, please feel free to contact us via email at Provider Questions.