Categories
< All Topics
Print

3. Function Portal Sessions Manual

Function Portal Sessions are used to document work completed. Coordinators should be documenting their work as it is done to prevent falling behind on documentation. All calls, visits, and other work done MUST be done in order for it to be verified.

Function Portal Sessions will tell you what is required for each and what other work must be done to complete it. Use the appropriate session type and follow its prompt to complete documentation. 


Introduction

How to create and submit sessions

  1. While in the page of the specific participant you need to document for, select the “Session” tab.
  1. Select the pink circle with the “+” in the bottom right hand corner.
    • This will bring up the “Add Session” box

  1. Select “Session Type” to open the dropdown list of sessions
  1. Select the type of session you’ve conducted.

Regardless of the type of session selected, the session cannot be fully submitted without the following:

  1. Valid Time Range – The start and end time of the session
  2. Answers to all required fields – each session has its own required fields
  3. Required attached documents* – PDF file of the document completed.
    • Not all sessions require attached documents. It will tell you if this is a requirement

Once all the necessary information is documented, the blue button on the bottom right corner of the “Add Session” box will change from ‘Save Draft’ to ‘Add Session

  1. After selecting ‘Add Session’ you will get a summary of the session.
    • The summary will tell you whether or not the session must be copied to Envolve as a general note. 
Example of a session that MUST be copied as a General Note in Envolve

Example of session that does not need to be copied to Envolve

Unscheduled Sessions

Session NameDescription of session
7 and 14 day Follow upUsed to document follow-up calls with participants to ensure services are in place per the service plan from the NPO visit.
– DO NOT USE for non-NPO Participants
COVID-19 QuestionnaireUsed to document/upload COVID-19 Questionnaires prior to F2F visits.
Documentation UploadUsed for uploading miscellaneous documents.
Incident ReportUsed for documenting Critical Incidents and uploading Internal Incident Reports A & B
Incoming Call ReceivedUsed to document any calls received.
Monthly ContactUsed to document successful Monthly Contacts
Office NoteUsed to document any work that does not apply to the other possible sessions.
OPS 8 Outbound CallUsed to document confirmation about missed PAS visits from PHW OPS 8 Report
Outbound CallUsed to document any calls made
RN Health ConsultationUsed to document conversation had with Nurse Irene when discussing participant’s change in PAS hours.
Unsuccessful OutreachUsed to document unsuccessful outreaches to the participant
Welcome CallUsed to document the welcome call made to the participant before an NPO visit
– DO NOT USE for non-NPO Participants

Documenting Sessions

7 and 14 day Follow up

A follow-up call with participants to ensure services are in place per the service plan from the NPO visit. 

DO NOT USE this session for non-NPO PARTICIPANTS

Coordinators MUST follow up 7 days after the NPO visit and complete a 7 day follow up FP session and MCA

If services have not started at the 7 day follow up, then SCs must also follow up 14 days after the NPO visit to confirm if their services have started or not (again), then continue to follow up with Outbound calls until services start. 

  • Session requires:
    • 7 or 14 day MCA
    • Comment describing follow up
    • Copy note to Envolve

Process:

  1. MCA
    • Coordinator must complete MCA in Envolve with “7 or 14 day Follow Up” as Type of Contact
      • Save as PDF for FP
      • Submit in Envolve
  1. Comment – SC should describe the following in the FP Comment
    • Who was contacted for follow up
    • HIPPA verification
      • HIPPA information should ALWAYS be verified. State what was verified (name, DOB, address, phone#)
    • What services were requested in NPO visit; according to the participant, have services started or not
    • Are there authorizations for services on Envolve/Authorization spreadsheet
    • How will SC follow up
    • Copy note to Envolve
      • After selecting “Add session” a summary of the session will come up. Copy the session and paste it into a “General Note” in Envolve


COVID-19 Questionnaire

A review of COVID-19 symptoms and exposure to ensure safety before completing F2F visits with participants

  • Session Requires:
    • Answers to COVID-19 Screening Questions
    • Unscheduled Contact MCA
    • PHW Screening PDF
    • Staff Screening PDF
    • Copy Note to Envolve

Process:

  1. COVID-19
    • Does the participant have any of the following symptoms?
      • Fever
      • Cough
      • Shortness of breath
      • Sore Throat
      • Nausea
      • Vomiting
      • Diarrhea
      • Abdominal Pain
    • Has the participant experienced any of the above in the last 14 days? 
    • Has the participant or family of the household traveled outside of North America in the last 14 days?
    • Has the participant had contact or possible exposure to COVID in the last 14 days?
    • Is the participant on home quarantine or isolation due to possible exposure?
    • Has the participant or anyone in their home been discharged from the hospital due to COVID?
    • Is there a back up plan in case any services are temporarily on hold due to COVID?
      • If so, describe the backup plan
      • If no, has the participant agreed with developing a backup plan?
        • If so, describe the new backup plan
  1. MCA
    • Coordinator must complete an MCA in Envolve with “Unscheduled Contact” as Type of Contact
  1. Screening Tools
    • SC must complete a PHW and Staff Screening PDF and attach it to the session. 
  1. Copy note to Envolve
    • After selecting “Add session” a summary of the session will come up. Copy the session and paste it into a “General Note” in Envolve

Documentation Upload

A session for uploading miscellaneous documents if they could not be uploaded with a more appropriate session. This is primarily used to upload a 1768 form. 

  • Session Requires:
    • Uploaded document
    • Comment
    • Copy note to Envolve


Incident Report

A session for uploading Incident Reports when SC is notified of a critical incident or when they are closing an Incident. 

  • Session Requires:
    • Incident Report Part A
      • If Incident Report Part B was done, then that is required as well
    • Comment describing the Incident
    • Copy session to Envolve

It is important that you upload a copy of the Incident Report, NOT the certificate.

  1. Incident Report Part A
    • SC must complete Incident Report Part A in Docusign (which they receive by request from their SCS), download the filled out report and attach it to the Incident Report Session. 
      1. That way the report can be viewed in FP in the future. 
    • This must be done when completing Incident Reports A and B, together or separately 
  1. Incident Report Part B.
    • When SC completes Incident Reports A&B together, the SC must attach both reports to the Incident Report session. 
    • If the SC does Incident Report Part B separately from Part A, then they must make a new Incident Report session to upload Incident Report Part B. 
  1. Comment
    • SC should be putting in all information from Incident Report into the comment of the session. 

Incoming Call Received

Used to document incoming unscheduled calls. You should discuss the following and document details of the call appropriately.

  • Session Requires:
    • Appropriate answers to all required fields

  1. Call Conditions
  • Visit Type – How are you contacting the participant?
    • Answer should always be Telephone
  • Was the Legal Representative invited to participate? – Did you or the participant try to involve the participant’s Legally Authorized Representative, if there is one at all?
    • Answer is based on if your participant has a rep and invited them or not
    • Based on you answer you may need to answer the following:
      1. Did the Legal Representative participate in the contact?
      2. Did the member request that the legal representative not participate?
  • Where did the visit take place? – Better known as “where did the contact take place?
    • Answer should always be Other
      • Then in Other visit location you should put Telephone
  • Where does the participant currently reside? – Coordinator should be confirming the client’s address and type of residence, then choose the appropriate answer. 
    • If the answer was “Home (with a caregiver)” then the coordinator needs the following information about the caregiver. 
      • Caregiver name
      • Caregiver relationship 
      • Does the caregiver live with member? Answer should be – Yes
      • Does the caregiver provide natural support? – meaning does the caregiver provide informal/unpaid support?
      • Is the caregiver paid?– meaning does the caregiver provide formal/paid support?
    • If the answer was “Other” then the coordinator needs to state what the Other residential location is
    • If the answer was: “AFCH, ALF, Hospice, or Nursing Home” the the caregiver must state what the Residential location facility name
  • Information provided by** – Meaning who did the coordinator speak with during the call. This is also how you may document the call.
    • If information was provided by Enrollee, Authorized Representative, or both, details of the call will be documented under Contact follow-up description in 2) Resolution. 
    • If information was provided by Other or Enrollee and Other, details of the call should be documented in Information provided by other
  • Has the participant expressed the desire to move from an institutional setting to the community? – participants have to be currently residing in an institution, which most of our clients do not.
    • Answer is most likely – Participant has NOT expressed desire…
    • If the answer was “Participant has expressed desire …” the coordinator needs to state the current transition status
  • Did the participant’s demographics change?  – Has any of the information about the participant changed?
    • If there was a change, then the coordinator must state what the changes are. 
  1. Resolution
  • Is follow-up required for the contact?
    • Answer should always be – A follow-up is required
  • Do you need to schedule a visit?
    • If the participant’s visit is already scheduled, or they are NOT due for a visit, then the coordinator should select Do NOT need to schedule a visit. This will prompt Contact follow-up description
      • Contact follow-up description – detail the conversation had with the participant and/or legally authorized representative. 
    • If the participant is due for a visit and you schedule it with them in this call then you need to say Need to schedule a visit and this will prompt follow-up questions on the scheduled visit. 
      • Scheduled Visit – select the type of visit that was scheduled
    1. If the type of visit scheduled is not listed, the coordinator should choose a visit, put in the date and time it is scheduled, but do NOT answer the compliance question.  SAVE the session DRAFT and notify the AVP so that they can put in the correct visit type. 
  • Visit scheduled for – date and time the visit is scheduled for
  • Is the scheduled visit after the compliance due date? – Is the date the visit is scheduled for before the due date?
    1. If the visit is scheduled after the compliance date, this will prompt the last 2 questions to generate
      1. Who were you trying to contact? – Who did you contact/schedule the visit with?
      2. Reason for contact – the type of visit that was scheduled. 

Monthly ContactsA required Monthly phone call to the participant to maintain communication and update client information. You must discuss the following with the participant. Red text indicates mandatory answer.

  • Session Requires:
    • Appropriate answers to all required fields

  1. Visit Conditions
    1. Visit Type – How are you contacting the participant?
  • Answer should always be Telephone
  1. Was the Legal Representative invited to participate? – Did you or the participant try to involve the participant’s Legally Authorized Representative, if there is one at all?
  • Answer is based on if your participant has a rep and invited them or not
  • Based on you answer you may need to answer the following:
  1. Did the Legal Representative participate in the contact?
  2. Did the member request that the legal representative not participate?
  1. Where did the visit take place? – Better known as “where did the contact take place?
  • Answer should always be Other
    • Then in Other visit location you should put Telephone
  1. Where does the participant currently reside? – Coordinator should be confirming the client’s address and type of residence, then choose the appropriate answer. 
    1. If the answer was “Home (with a caregiver)” then the coordinator needs the following information about the caregiver. 
      1. Caregiver name
      2. Caregiver relationship 
      3. Does the caregiver live with member? Answer should be – Yes
      4. Does the caregiver provide natural support? – meaning does the caregiver provide informal/unpaid support?
      5. Is the caregiver paid?– meaning does the caregiver provide formal/paid support?
  1. If the answer was “Other” then the coordinator needs to state what the Other residential location is
  1. If the answer was: “AFCH, ALF, Hospice, or Nursing Home” the the caregiver must state what the Residential location facility name
  1. Information provided by – Meaning who did the coordinator speak with during the call
    1. If the answer involved “Other” then the coordinator needs to state who this other person was and why they spoke to them. 
  1. Has the participant expressed the desire to move from an institutional setting to the community? – participants have to be currently residing in an institution, which most of our clients do not.
  • Answer is most likely – Participant has NOT expressed desire…
  1. If the answer was “Participant has expressed desire …” the coordinator needs to state the current transition status
  1. Did the participant’s demographics change?  – Has any of the information about the participant changed?
    1. If there was a change, then the coordinator must state what the changes are. 
  1. Medical Conditions
    1. What changes to health did the participant report? – Does the participant feel like their health has changed at all?
  1. Was there a change to the participant’s caregiver support system? – Has the participant’s primary or informal caregiver changed?
    1. If there was a change, then the coordinator must state the changes in Caregiver support system changes
  1. Since last visit, has the participant visited any of these? – Has the participant seen their PCP, other medical specialist, or been to an Emergency Room or Hospital, or no?
    1. If there has been a visit the coordinator must state what type of visit and when in Provide details/reasons for the visit and include approximate dates
  1. Does the participant have any special needs? 
    1. If the participant has special needs the coordinator must state what the special needs are in Special needs details
  1. Activities of Daily Living
  • Coordinators must state how much assistance the participant needs with the following ADLs
    • Bathing, Dressing, Grooming, Eating, Transferring, Toileting, and Bladder Management
  1. Does the participant receive informal support for activities of daily living? 
    1. If the participant has informal support then the coordinator needs to state the name, relationship and average minimum and maximum hours of support they provide each day. 
  1. Does the participant have unmet needs for daily living? – Does the participant need any services or devices? 
    1. If the participant has unmet needs then the coordinator needs to put in what these unmet needs are in Describe 
  1. Does the participant use assistive devices/durable medical equipment for activities of daily living?
    1. If the participant feels they would benefit from assistive devices/durable medical equipment then the coordinator needs to state details in Describe
  1. Observations of Participant’s Mood/Behavior
    1. Describe enrollee’s appearance, mood and behavior (happy, pleasant, relaxed, tired, stressed)
  1. Satisfaction
    1. Is the participant satisfied with services and/or providers reflected on their plan of care? 
      1. If the participant is not satisfied with any of their services, the coordinator needs to state what they are doing to address the dissatisfaction
  1. Is the participant receiving adult daycare services? – A common service that participants may receive
    1. If the participant receives ADC services then coordinator must state how satisfied they are with the service
      1. If the participant is dissatisfied with the service, coordinator needs to state the reason they are dissatisfied
  1. Is the participant receiving care coordination services? – All participants receive care coordination so the answer should always be – Participant is receiving care coordination services 
    1. How satisfied is the participant with their Care Coordinator? – Coordinator must state the participant’s satisfaction with Amcord Care. 
      1. If the participant is dissatisfied with the service, coordinator needs to state the reason they are dissatisfied
  1. Does the participant have a health plan? – All participants have a health plan, it is PA Health & Wellness, therefore the answer should always be – Participant has a Health Plan
    1. How satisfied is the participant with their Health Plan? – Coordinator must state the particpant’s satisfaction with PHW.
      1. If the participant is dissatisfied with the service, coordinator needs to state the reason they are dissatisfied
  1. Does the participant have a personal care attendant? – Most participants have a personal care attendant, it is PAS, therefore the answer is likely Participant has a personal care attendant
    1. If the participant receives PAS, then coordinator must state how satisfied they are with the service
      1. If the participant is dissatisfied with the service, coordinator needs to state the reason they are dissatisfied
  1. Does the participant have a transportation provider? – A common service that participants may receive
    1. If the participant receives transportation services then coordinator must state how satisfied they are with the service
      1. If the participant is dissatisfied with the service, coordinator needs to state the reason they are dissatisfied
  1. Quality of Life
  • Coordinators must go through the following and answer honestly
  1. Has the participant received a pneumovax vaccine in the past 5 years
  1. Has the participant received a flu vaccine in the past 5 years
  1. Does the participant have issues with bladder control?
    1. If the participant has issues with bladder control, then SC must answer: bladder control issue frequency
  1. Has the participant had a UTI in the past 3 months?
  1. Does the participant have issues with bowel control?
    1. If the participant has issues with bowel control, then SC must answer: bowel control issue frequency
  1. Does the participant have any skin breakdown?
    1. If the participant has skin breakdown, then SC must answer what type of breakdown there is (bruising, incision, tears, or wounds)
  1. Has the participant had any falls since the last contact?
  • If the participant has had a fall, SC must answer the following:
  1. How many falls has the participant experiences in the last 3 months
  2. Did the falls result in an injury?
    1. If the fall resulted in an injury, then SC must answer Fall injury treatment
  3. Is the participant able to do things they enjoy outside of their home and with whom they want?
  1. Is the participant able to make decisions about their daily routine?
  1. Does the participant feel safe in their home/where they live?
  1. Does the participant have a paid or volunteer job in the community?
  1. Does the participant like where they are living?
  1. Does the participant see or talk to friends and family with whom they do not live?
  1. Schedule
    1. Participant’s PAS schedule – select days of the week that the participant receives PAS
      1. Total amount of hours per week that the participant receives in PAS – If the participant does not receive PAS, then SC should put in “0”
  1. Participant’s ADC schedule – select days of the week that the participant receives ADC
    1. Total amount of hours per week that the participant receives in ADC – If the participant does not receive ADC, then SC should put in “0”
  1. Participant’s Informal Support schedule – select days of the week that the participant receives Informal Support
    1. Total amount of hours per week that the participant receives in Informal Support – If the participant does not receive Informal Support, then SC should put in “0”
  1. Scheduled Visit – If participant is due for a visit, then SC should be scheduling a visit. Otherwise select “no scheduled visits”
  • If a visit was scheduled, select the type of visit scheduled
    • If the type of visit scheduled is not listed, the coordinator should choose a visit, put in the date and time it is scheduled, but do NOT answer the compliance question.  SAVE the session DRAFT and notify the AVP so that they can put in the correct visit type
  1. Visit scheduled for – date and time the visit is scheduled for
  2. Is the scheduled visit after the compliance due date? – Is the date the visit is scheduled for before the due date?
    1. If the visit is scheduled after the compliance date, this will prompt the last 2 questions to generate
      1. Who were you trying to contact? – Who did you contact/schedule the visit with?
      2. Reason for contact – the type of visit that was scheduled. 

Office NoteA miscellaneous session used to document work that does not fit into other sessions

  • DO NOT USE WITHOUT PERMISSION FROM SUPERVISOR


OPS 8 Outbound CallUsed to document calls made to confirm missed PAS visits from PHW’s OPS 8 report. 

  • Session Requires:
    • Appropriate answers to all required fields
      • Including “positive” answers to the reason codes from the PHW report
      • “Negative” answers to the reason codes not mentioned in the PHW report
      • Sufficient details in Resolution about:
        • The health and safety concerns addressed
        • Comments about the participant’s backup plan 
  1. Call Conditions
    1. Visit Type – How are you contacting the participant?
  • Answer should always be Telephone
  1. Was the Legal Representative invited to participate? – Did you or the participant try to involve the participant’s Legally Authorized Representative, if there is one at all?
  • Answer is based on if your participant has a rep and invited them or not
  • Based on you answer you may need to answer the following:
  1. Did the Legal Representative participate in the contact?
  2. Did the member request that the legal representative not participate?
  1. Where did the visit take place? – Better known as “where did the contact take place?
  • Answer should always be Other
  1. Then in Other visit location you should put Telephone
  1. Where does the participant currently reside? – Coordinator should be confirming the client’s address and type of residence, then choose the appropriate answer. 
  • If the answer was “Home (with a caregiver)” then the coordinator needs the following information about the caregiver. 
  1. Caregiver name
  2. Caregiver relationship 
  3. Does the caregiver live with member? Answer should be – Yes
  4. Does the caregiver provide natural support? – meaning does the caregiver provide informal/unpaid support?
  5. Is the caregiver paid?– meaning does the caregiver provide formal/paid support?
  • If the answer was “Other” then the coordinator needs to state what the Other residential location is
  • If the answer was: “AFCH, ALF, Hospice, or Nursing Home” the the caregiver must state what the Residential location facility name
  1. Information provided by** – Meaning who did the coordinator speak with during the call. This is also how you may document the call.
  • If information was provided by Enrollee, Authorized Representative, or both, details of the call will be documented under Contact follow-up description in 2) Resolution. 
  • If information was provided by Other or Enrollee and Other, details of the call should be documented in Information provided by other
  1. Has the participant expressed the desire to move from an institutional setting to the community? – participants have to be currently residing in an institution, which most of our clients do not.
  • Answer is most likely – Participant has NOT expressed desire…
  • If the answer was “Participant has expressed desire …” the coordinator needs to state the current transition status
  1. Did the participant’s demographics change?  – Has any of the information about the participant changed?
  • If there was a change, then the coordinator must state what the changes are.
  1. Missed Dates
    1. PAS Provider – name of the PAS provider on OPS 8 report
    2. Missed dates – all of the dates/date range provided on the OPS 8 report

Reason codes for Missed Visits

  • You must select the “positive” answer for each code mentioned in the OPS 8 report
    • Even if it was not the appropriate reason for missed visit per the participant
  • Select the “negative” answer for all other codes that were NOT mentioned in the OPS 8 report
    • Even if they are the appropriate reason for missed visit per the participant
  1. AR – Participant/Family refused HHA or was unavailable
    1. Did the participant refuse or was unavailable?
      1. Participant refused or was unavailable – positive answer
      2. Participant did NOT refuse or was unavailable – negative answer
  • If selecting the Positive answer, the SC must answer the following:
    • Dates for when the participant refused or was unavailable – All dates mentioned in the OPS 8 report that coincide with the AR reason code
    • Is this a recurring problem for the participant? 
      • If this is the first time choosing this reason code, then you should select “This has NOT been a recurring problem”
      • If this is not the first time choosing this reason code, then you should select “This has been a recurring problem” then provide details in the comment
    • Reason for participant being unable to keep scheduled visits?
    • Follow-up actions being taken
  1. HU – Hospitalization unplanned
    1. Did the participant have an unplanned hospitalization?
      1. Participant had an unplanned hospitalization – positive answer
      2. Participant did NOT have an unplanned hospitalization – negative answer
  • If selecting the Positive answer, the SC must answer the following:
    • Dates for unplanned hospitalizations – All dates mentioned in the OPS 8 report that coincide with the HU reason code
    • Were there HHA/PAS services missed due to an unplanned hospitalization? – If so answer the following:
      • Comment about hospitalization
      • First date of Hospitalization
      • Hospital Name
    • Was the SC made aware of the Hospitalization – If so, leave a comment about how they were made aware and when
    • Was the PCSP adjusted due to the Hospitalization? – If so, leave a comment about what was adjusted and when
    • Has the CHC-MCO/SCE observed a trend of unplanned hospitalizations? 
      • If this is the first time choosing this reason code, then you should select “has  NOT observed a trend of unplanned hospitalizations”
      • If this is not the first time choosing this reason code, then you should select “This has been a recurring problem” then provide details in the comment
  1. UN – Agency was unable to staff the case
    1. Was the agency unable to staff the case?
      1. The agency was unable to staff the case – positive answer
      2. The agency was ABLE to staff the case – negative answer
  • If selecting the Positive answer, the SC must answer the following:
    • Dates for when the agency was unable to staff – All dates mentioned in the OPS 8 report that coincide with the UN reason code
    • Why weren’t the services received? – Reason why the agency was unable to provide staff
      • If selected Other describe the reason provided
    • What did the agency do to address the missed service to ensure the participant wasn’t at risk?
      • If selected Other describe the reason provided
    • Has the issue that caused the gap… been resolved?
      • If NOT then provide comment
    • Was the backup plan initiated? – Describe the backup plan
  1. CV – All other cases where the agency could not staff due to COVID-19
    1. Were there cases when the agency could not staff due to COVID-19?
      1. There were cases when the agency could not staff – positive answer
      2. There were NO cases when the agency could not staff – negative answer
  • If selecting the positive answer, the SC must answer the following:
    • Dates for when the agency could not staff – All dates mentioned in the OPS 8 report that coincide with the CV reason code
    • Did the provider contact the CHC-MCO to report a change? – Provide comment describing the answer
    • Did the CHC/MCO contact the participant? – Provide comment describing the answer
    • Did the missed service cause any health and safety concerns? – If so, describe the health and safety concerns
    • What follow up actions were taken? – describe follow-up actions
  1. FA – Participant is in the hospital or nursing facility due to COVID-19
    1. Was the participant in the hospital or nursing facility due to COVID-19?
      1. The participant was in the hospital or nursing facility due to COVID-19 – positive answer
      2. The participant was NOT in the hospital or nursing facility due to COVID-19 – negative answer
  • If selecting the positive answer, the SC must answer the following:
    • Dates for when the agency could not staff – All dates mentioned in the OPS 8 report that coincide with the FA reason code. 
    • Follow-up call completed date?
    • Discharge planning – describe what plans were made regarding ptp’s discharge from the hospital or facility
    • Is the visit scheduled? – If the visit is scheduled then put in the visit scheduled date
    • Comments –  comment describing the situation
  1. IS – Participant refused due to COVID-19, receiving service through informal supports
    1. Did the participant refuse due to COVID-19, receiving service through informal supports?
      1. The participant refused due to COVID-19 – positive answer
      2. The participant did NOT refused due to COVID-19 – negative answer 
  • If selecting the positive answer, the SC must answer the following:
    • Dates for the participant refusing due to COVID-19 – All dates mentioned in the OPS 8 report that coincide with the IS reason code
    • Is the participant’s informal support able to maintain assistance? – If UNABLE make a comment describing why
    • Are the participant’s needs being met? If NOT describe what needs are not being met
    • Is the reassessment needed? If NOT describe why
  1. SI – Participant refused, self-isolating due to COVID-19, not receiving service
    1. Did the participant refuse while self-isolating due to COVID-19?
      1. The participant refused while self-isolating -positive answer 
      2. The participant did NOT refuse while self isolating – negative answer
  • If selecting the positive answer, the SC must answer the following:
    • Dates for the participant refusing while self-isolating due to COVID-19 – All dates mentioned in the OPS 8 report that coincide with the SI reason code. 
    • How are needs being met without formal services – Describe how participant’s needs are being met
  1. TX – Worker switched to cover another case due to staffing limitations as a result of COVID-19. 
    1. Did the worker switch to cover another case due to staffing limitations as a result of COVID-19?
      1. The worker switched to cover another case – positive answer
      2. The worker did NOT switch to cover another case – negative answer
  • If selecting the positive answer, the SC must answer the following: 
    • Dates for the worker switching to cover another case – All dates mentioned in the OPS 8 report that coincide with the TX reason code
    • Are the participant’s needs being met? – if NOT describe what needs are not being met
    • Was the backup plan initiated? – Describe what was initiated or why it wasn’t
    • Additional Information 
  1. Resolution
    1. How were the health and safety concerns addressed?
  • Describe in detail what major health and safety concerns the participant has and what was done to manage them
  1. Was the participant’s backup plan able to be implemented?
  • Describe in detail what the participant’s backup plan is and how it was implemented, or why a backup plan was not implemented


Outbound CallUsed to document calls made by the service coordinator. You should discuss the following and document details of the call appropriately. Red text indicates mandatory answer

  • Session Requires:
    • Appropriate answers to all required fields

  1. Call Conditions
    1. Visit Type – How are you contacting the participant?
  • Answer should always be Telephone
  1. Was the Legal Representative invited to participate? – Did you or the participant try to involve the participant’s Legally Authorized Representative, if there is one at all?
  • Answer is based on if your participant has a rep and invited them or not
  • Based on you answer you may need to answer the following:
  1. Did the Legal Representative participate in the contact?
  2. Did the member request that the legal representative not participate?
  1. Where did the visit take place? – Better known as “where did the contact take place?
  • Answer should always be Other
  1. Then in Other visit location you should put Telephone
  1. Where does the participant currently reside? – Coordinator should be confirming the client’s address and type of residence, then choose the appropriate answer. 
  • If the answer was “Home (with a caregiver)” then the coordinator needs the following information about the caregiver. 
  1. Caregiver name
  2. Caregiver relationship 
  3. Does the caregiver live with member? Answer should be – Yes
  4. Does the caregiver provide natural support? – meaning does the caregiver provide informal/unpaid support?
  5. Is the caregiver paid?– meaning does the caregiver provide formal/paid support?
  • If the answer was “Other” then the coordinator needs to state what the Other residential location is
  • If the answer was: “AFCH, ALF, Hospice, or Nursing Home” the the caregiver must state what the Residential location facility name
  1. Information provided by** – Meaning who did the coordinator speak with during the call. This is also how you may document the call.
  • If information was provided by Enrollee, Authorized Representative, or both, details of the call will be documented under Contact follow-up description in 2) Resolution. 
  • If information was provided by Other or Enrollee and Other, details of the call should be documented in Information provided by other
  1. Has the participant expressed the desire to move from an institutional setting to the community? – participants have to be currently residing in an institution, which most of our clients do not.
  • Answer is most likely – Participant has NOT expressed desire…
  • If the answer was “Participant has expressed desire …” the coordinator needs to state the current transition status
  1. Did the participant’s demographics change?  – Has any of the information about the participant changed?
  • If there was a change, then the coordinator must state what the changes are. 
  1. Resolution
    1. Is follow-up required for the contact?
  • Answer should always be – A follow-up is required
  1. Do you need to schedule a visit?
  • If the participant’s visit is already scheduled, or they are NOT due for a visit, then the coordinator should select Do NOT need to schedule a visit. This will prompt Contact follow-up description
  1. Contact follow-up description – detail the conversation had with the participant and/or legally authorized representative. 
  • If the participant is due for a visit and you schedule it with them in this call then you need to say Need to schedule a visit and this will prompt follow-up questions on the scheduled visit. 
  1. Scheduled Visit – select the type of visit that was scheduled
    1. If the type of visit scheduled is not listed, the coordinator should choose a visit, put in the date and time it is scheduled, but do NOT answer the compliance question.  SAVE the session DRAFT and notify the AVP so that they can put in the correct visit type. 
  2. Visit scheduled for – date and time the visit is scheduled for
  3. Is the scheduled visit after the compliance due date? – Is the date the visit is scheduled for before the due date?
    1. If the visit is scheduled after the compliance date, this will prompt the last 2 questions to generate
      1. Who were you trying to contact? – Who did you contact/schedule the visit with?
      2. Reason for contact – the type of visit that was scheduled. 

RN Health ConsultationUsed to document conversation had with Nurse Irene when determining if PAS hours increase/decrease is appropriate.

  • Session Requires:
    • Comment regarding discussion
    • Copy note to Envolve


Unsuccessful OutreachUsed to document unsuccessful outreaches to the participant. Coordinators MUST call all other contacts/emergency contact and PAS agency after unsuccessfully reaching the participant in order to document as an Unsuccessful Outreach

  • Session Requires:
    • Appropriate answers to all required fields
  1. Call Conditions
  • Visit Type – How are you contacting the participant?
  • Answer should always be Telephone
  • Where did the visit take place? – Better known as “where did the contact take place?
  • Answer should always be Other
  • Then in Other visit location you should put Telephone
  • Where does the participant currently reside? – Coordinator should be confirming the client’s address and type of residence, then choose the appropriate answer. 
    • If you do not know where the participant currently resides answer “Other”
      • In Other Residential Location put “Unknown due to Unsuccessful Outreach”
    • If the answer was “Home (with a caregiver)” then the coordinator needs the following information about the caregiver. 
      • Caregiver name
      • Caregiver relationship 
      • Does the caregiver live with member? Answer should be – Yes
      • Does the caregiver provide natural support? – meaning does the caregiver provide informal/unpaid support?
      • Is the caregiver paid?– meaning does the caregiver provide formal/paid support?
    • If the answer was “Other” then the coordinator needs to state what the Other residential location is
    • If the answer was: “AFCH, ALF, Hospice, or Nursing Home” the the caregiver must state what the Residential location facility name
  1. Unsuccessful Contact
  • Who were you trying to contact? – which primary contact were you calling
  • Method of contact – What type of contact you were completing (Likely Telephonic)
  • Reason for contact – What type of session were you trying to complete?
  • Reason for contact details – How the call to the emergency contact was completed. 
    • Note: An attempt to the Emergency contact MUST be made
  • Reason for Unsuccessful contact – Result of the contact to the participant
    • Note: If you were able to leave a voicemail, do so with your name, reason for the contact, and Amcord’s phone number. 
  • Reason for contact details – How the call to the PAS agency was completed
    • Note: Almost all participants have a PAS agency. Be sure to check the authorization spreadsheet (while the authorization tab is not functional)
  • Contact attempt number – Number of consecutive unsuccessful attempts that have been made
    • This is done by the system automatically. 

Visit CancelledUsed to document when a participant’s scheduled visit/contact is cancelled for whatever reason. 

  • Session Requires:
    • Appropriate answers to the questions
    • Attached MCA with the appropriate Type of Contact
    • Copy note to Envolve
  1. Scheduled Visit
  • Cancelled Visit – The type of contact that was scheduled and therefore cancelled
  • Visit Cancelled due to – Why the visit is cancelled. 

Welcome CallUsed to document the specific Welcome Call to new waiver participants before the NPO visit. 

  • Do NOT use for non-NPO participants  
  • Session Requires:
    • Answers to all fields
    • MCA with “Welcome Call” type of contact
  1. Welcome Call
  • Does the participant have a preference of a service coordinator?
    • If so, answer what Preferred Language and Other Preferences they have.
  • Comments – any additional comments by the SC or participant.

Scheduled Sessions

Coming Soon!

Previous 2. Services Explained
Next OPS-8 Process Guide
Table of Contents