response, and any planned next steps. W7037 Community Residential Same as above: Progress Notes W7039 Rehabilitation--Unlicensed 1, 2 Documentation that indicates a In accordance with 55 PA Code, Chapter W7078 Individual Family Living Home contact with the participant is 51.16, the Provider must use a monthly W7080 required to confirm presence for progress note to determine W7082 Residential Habilitation-- each billed day this may be an Whether the service is being provided as – Unlicensed 1, 2, 3 Individual attendance roster, a progress note, a specified in the ISP; Home MAR, etc. An affirmative Whether the service is meeting the confirmation that documents the participant’s assessed and person was present rather than preferences; assumes the person was present is Whether is progress toward ISP essential. specified outcomes and actions; and When there is an identified lack of The provider must retain staff time progress, how the lack of progress will be sheets (including ESignatures or addressed electronic time sheets) that demonstrate the staffing ratio Progress notes must document substantive specified in the ISP. issues that impact the participant’s Health; Exceptions include Therapeutic Safety; which requires start and end times Preferences; on the day of absence and return, Priorities; and and Medical Leave which requires Routine. admission and discharge date from medical center. Documentation needed upon occurrence as required by Pa. code, including, for example but not limited to reportable events. W7070 Supplemental Habilitation 1:1, 15 In addition to residential habilitation Progress Notes W7084 2:1 minutes billing documentation requirements, The progress note completed for Residential service must include Habilitation should address progress in W7086 Additional Individual Staffing Start and end times for Supplemental Habilitation. 1:1, 2:1 supplemental/additional staff; and
response, and any planned next steps. W7037 W7039 W7078 W7080 W7082 Community Residential Rehabilitation--Unlicensed 1, 2 Individual Family Living Home Residential Habilitation-- Unlicensed 1, 2, 3 Individual Home Same as above: Documentation that indicates a contact with the participant is required to confirm presence for 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 staff time sheets (including ESignatures or electronic time sheets) that demonstrate the staffing ratio specified in the ISP. Exceptions include Therapeutic 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. Progress Notes In accordance with 55 PA Code, Chapter 51.16, the Provider 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 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. W7070 W7084 W7086 Supplemental Habilitation 1:1, 2:1 Additional Individual Staffing 1:1, 2:1 15 minutes In addition to residential habilitation billing documentation requirements, service must include Start and end times for supplemental/additional staff; and Progress Notes The progress note completed for Residential Habilitation should address progress in Supplemental Habilitation.
Technical+Guidelines+3-27-17.docx