W7291 each billed day this may be an Specialist must use a monthly progress note to – W7293 Family Living 1-Individual Home attendance roster, a progress note, a determine Adult (Licensed under 55 Pa. MAR, etc. An affirmative Whether the service is being provided as Code Chapter 6500)-TD (service confirmation that documents the specified in the ISP; provided by a RN) and TE person was present rather than Whether the service is meeting the (service provided by a LPN). assumes the person was present is participant’s assessed needs and essential. preferences; Family Living 2-Individual Home Whether is progress toward ISP Adult (Licensed under 55 Pa. The provider must retain time specified outcomes and actions; and Code Chapter 6500)-TD sheets (including ESignatures or When there is an identified lack of electronic time sheets) that progress, how the lack of progress will be demonstrate the staffing ratio addressed. specified in the ISP. Progress notes must document substantive Exceptions include Therapeutic Leave issues that impact the participant’s which requires start and end times Health; on the day of absence and return, Safety; and Medical Leave which requires Preferences; admission and discharge date from Priorities; and medical center. Routine. In addition: Documentation needed upon occurrence as License Type RN or LPN, required by Pa. code, including, for example – Title but not limited to reportable events. A service note must be included for each one day unit that describes what the nurse did to address any health/medical interventions performed by the nurse. Based upon the diagnosis of the participant, the nurse should document activities around assessment, intervention,
W7291 W7293 Family Living 1-Individual Home Adult (Licensed under 55 Pa. Code Chapter 6500)-TD (service provided by a RN) and TE (service provided by a LPN). Family Living 2-Individual Home Adult (Licensed under 55 Pa. Code Chapter 6500)-TD each billed day – this may be an attendance roster, a progress note, a MAR, etc. An affirmative confirmation that documents the person was present rather than assumes the person was present is essential. The provider must retain time sheets (including ESignatures or electronic time sheets) that demonstrate the staffing ratio specified in the ISP. Exceptions include Therapeutic Leave which requires start and end times on the day of absence and return, and Medical Leave which requires admission and discharge date from medical center. In addition: License Type – RN or LPN, Title A service note must be included for each one day unit that describes what the nurse did to address any health/medical interventions performed by the nurse. Based upon the diagnosis of the participant, the nurse should document activities around assessment, intervention, Specialist must use a monthly progress note to determine Whether the service is being provided as specified in the ISP; Whether the service is meeting the participant’s assessed needs and preferences; Whether is progress toward ISP specified outcomes and actions; and When there is an identified lack of progress, how the lack of progress will be addressed. Progress notes must document substantive issues that impact the participant’s Health; Safety; Preferences; Priorities; and Routine. Documentation needed upon occurrence as required by Pa. code, including, for example but not limited to reportable events.
Technical+Guidelines+3-27-17.docx