New Participant Orientation

June 3, 2026June 3, 2026| DEVON TUPKIELEWICZ-GOODRICHNew Participant Orientation| 0 Comment| 4:40 pm
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All participants must receive an NPO visit as a brand new participant to the CHC waiver program, lose their eligibility for longer than 60 days in addition to transferring from another Managed Care Organization such as Keystone First or UPMC. The due date for the NPO is within five days of receipt of the participant. Within 24 hours of receipt of an NPO participant, the Service Coordinator must begin making attempts to contact the participant to complete a welcome call and schedule the NPO visit. Once the SC contacts the participant or their Power of Attorney (POA), the SC will document the contact in the “Welcome Call” session in Function Portal. Within this session, there is a NPO section, where the SC documents the date and time the visit is scheduled to take place. Function Portal will then have alerts that the SC just needs to click on to “cancel”, “reschedule”, or “document” the NPO visit.

New Participant Orientation Session

This session is utilized to document new participant orientation contact visits for participants.

  • Session Requires:
    • Appropriate answers to all required questions
  • Corresponding sessions:
    • InterRAI session
    • HEDIS session
    • PCSP session
    • Required Forms session
    • SRT session

Process

  1. Following the scheduling of a NPO in the Welcome Call session, a notification will appear on the right side of the screen prompting the documentation of the New Participant Orientation Session.
  2. When scheduling the NPO assessment, it is best practice to ask the participant to have a list of their diagnoses, medications, PCP information and their insurance cards available.
  3. The SC should make a phone call with the participant BEFORE the assessment to request the medications and diagnoses from the PCP after their welcome call.

Documentation

1) Visit Conditions

  1. Reason for NPO: Select New to Service if this is a brand new PTP to waiver or Transfer from another MCO if PTP is an MCO transfer
  2. Persons present at visit: Check the individuals present at the assessment. If you select “Other”, then the name and relationship of the individual present is required.
  3. Document whether the Legally Authorized Representative (LAR) was invited to participate, if applicable: Based on your 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?
  4. Where did the visit take place?: Select the appropriate option as to the visit location.
  5. The Service Coordinator must select the appropriate current residential setting for the participant.
    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 the member?- Select yes or no.
      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?
    2. If the answer was “Other” then the coordinator needs to state what the Other residential location is
    3. If the setting is an AFCH, ALF, Hospice, or Nursing Home, the facility name must be specified.
  7. NOTE: All residential data must align with the Person-Centered Service Plan (PCSP) and InterRAI assessments.
  9. 2) HIPAA
    1. Identify the individuals interviewed during the assessment: If “Other” is selected, provide the identity of the individual and their title if applicable.
  • Needs to match PCSP in regards to Person Centered Team

3) Demographics Changes

  • Document any changes in the participant’s demographic information since the welcome call.

4) References

  • Responsible Party: Document whichever individuals are listed on the PHI form.
  • Did the participant sign the designated representative (PHI) form?: Select the appropriate choice based on signature status
  • Annual Scheduled Assessment Date: Place a year from the visit date in the text box provided.
    • Note: Your next annual date may differ as you will schedule this at a later time.
  • Was the member referred to Nurtur?
  • Was the member referred to Disease Management?
  • Was the member referred to Behavioral Health?- needs to match PCSP in regards to behavioral plan
  • Is the member a candidate for PDO?- This is a SC judgment question. Do you feel that the participant is a good fit for the Participant Directed Option for PAS services?
  • Ask yourself these questions:
    • Is PTP at risk of forgetfulness?
    • Does PTP have a cognitive impairment that impacts daily functioning?
    • If you answered yes to the above questions, the member is not a good candidate.
  • Did the member have their Health Plan ID Card?- Select based on if the PTP had their ID card present at the assessment.
  • Does the PTP have any advanced directives?- Identify active Advance Directives or document that the importance of directives was discussed if none are in place. Specify the nature of any “Other” Advance Directives documented.
  • What is PTP’s selection for PDO?- If they did not, specify the reason for declination.

Note: This information must align with the PCSP and InterRAI documentation.

5) Informal Supports

  • If the enrollee is not capable of making decisions and does not have a representative, did the CC refer the enrollee to the Public Guardianship Program or other advocacy resource?- Select no if the PTP has an authorized representative or enrollee is capable of making decisions
  • Does TAMARA E have informal supports from family or friends? If selecting yes, the SC will need to identify the type and amount of informal support in addition to who provides it (name of individual, specific tasks, amount on a weekly basis)
    • This information must match the InterRai and the SPG/Time Tasking Tool in addition to the PCSP Service Plan for Informal Support.
    • Example shown below:

6) Coverage of Benefits

  • Does the PTP have insurance other than Medicaid?
    • If there is no other insurance, select No. The section will automatically populate. You will need to enter the remaining information including the policy start/end date from the ID card and the date of the visit in Date TPL verified.
    • If there is additional insurance, additional information regarding the name of the insurance, policy number, member relationship to the policy holder, claims address of the insurance policy, the date of the visit in Date TPL verified and contact number of the insurance policy will need to be obtained from the insurance cards at the assessment.
    • For policy number, policy holder ID number and Member ID number, this is all the same as the ID number listed on the insurance card.

7) Satisfaction

  1. Are you receiving all of the HCBS Services you need? Please answer yes or no. If PTP is an MCO transfer and is requesting a change in services or is a brand new PTP to the waiver program, this will be answered no. You will need to specify what services are needed.
  2. Is enrollee satisfied with their current placement type? Select yes or no based on the participant’s report.
  3. Is the participant receiving adult daycare services? If the participant receives ADC services then coordinator must state how satisfied they are with the service. If the participant is dissatisfied with the service, coordinator needs to state the reason they are dissatisfied and what they are doing to address the dissatisfaction.
  4. Is the participant receiving care coordination services?- Evaluate and document the participant’s satisfaction with Amcord Care services. If the participant is dissatisfied with the service, coordinator needs to state the reason they are dissatisfied and what they are doing to address the dissatisfaction.
  5. Does the participant have a health plan?– Evaluate and document the participant’s satisfaction with their Health Plan (PHW). If the participant is dissatisfied with the service, coordinator needs to state the reason they are dissatisfied and what they are doing to address the dissatisfaction.
  6. Does the participant have a personal care attendant? If the participant receives PAS, then coordinator must state how satisfied they are with the service. If the participant is dissatisfied with the service, coordinator needs to state the reason they are dissatisfied and what they are doing to address the dissatisfaction.
  7. Does the participant have a transportation provider?- If the participant receives transportation services then coordinator must state how satisfied they are with the service. If the participant is dissatisfied with the service, coordinator needs to state the reason they are dissatisfied and what they are doing to address the dissatisfaction.
  8. Does the PTP have Availability of In-Home Services?- Answer Yes or No. If yes, How satisfied are they?
  9. Does the PTP have Wait Times for receiving services?- Answer Yes or No. If yes, How satisfied are they?
  10. Does the PTP have HCBS Employment Services?- Answer Yes or No. If yes, How satisfied are they?

8) Quality of Life

The Service Coordinator must ask questions and document responses accurately.

  1. Has the participant received a pneumovax vaccine since turning 65?
  2. Has the participant received a flu vaccine in the last 12 months?
  3. Has the participant received a shingles vaccine? If yes, please document date of vaccination.
  4. Does the participant have issues with bladder control?- If the participant has issues with bladder control, then SC must answer: bladder control issue frequency.
  5. Has the participant had a UTI in the past 3 months?
  6. Does the participant have issues with bowel control?- If the participant has issues with bowel control, then SC must answer: bowel control issue frequency.
  7. Does the participant have any skin breakdown?: If skin breakdown is present, the specific type must be categorized (e.g., bruising, incisions, tears, or wounds).
  9. Has the participant had any falls since the last contact?
    1. If the participant has had a fall, SC must answer the following:
      1. How many falls has the participant experienced in the last 3 months?
      2. Did the falls result in an injury?
      3. If the fall resulted in an injury, then SC must answer Fall injury treatment
  10. Is the participant able to do things they enjoy outside of their home and with whom they want?
  11. Is the participant able to make decisions about their daily routine?
  12. Does the participant feel safe in their home/where they live?
  13. Does the participant have a paid or volunteer job in the community?
  14. Does the participant like where they are living?
  15. Does the participant see or talk to friends and family with whom they do not live?

Note: All reported documentation here must remain consistent across PCSP and InterRAI documentation.

9) Medical Conditions

  • Where does PTP rate their health? – Ask them to rate on scale of good, fair or poor
    • Needs to match InterRai in instability of conditions section
  • Document if the participant’s diagnosis and symptoms are well managed (details of new diagnoses or health issues must be listed in the InterRAI and PCSP):
    • PTP reports that their diagnosis and symptoms are well managed by medications.
    • PTP reports that their diagnosis and symptoms are not well managed by medications, details of which are listed in InterRAI and PCSP- Option B should ALWAYS be selected for NPO because the SC is adding any new diagnoses or health issues for the first time.
  • Has a doctor or other health care professional told TAMARA E they suffer from memory loss, cognitive impairment, any type of dementia, or Alzheimer’s disease?: If the SC is indicating a cognitive issue in PCSP or InterRai, this should also be documented in this question. 
  • Does PTP have a PCP or specialist managing health conditions?: Select yes or no based on evaluation of PCP involvement.

10) Medical Visits

  • Did PTP have any of the visits in the last 90 days?
    • ER visits, Hospice, Hospital Admission, Medical Professional, Mental Health Facility Visit, Physician, Rehab Admission, Other Visits that don’t apply to above categories
      • If answering yes, please be as detailed as possible including dates and reasons for visits.
      • For hospitalizations, physician visits and ER visits, this needs to match in InterRai and PCSP.

11) Special Needs

  • Does the participant have any special needs?: If special needs are identified, provide detailed documentation in the specified field.

12) Activities of Daily Living

  • Document the level of assistance required for each Activity of Daily Living (ADL).: Bathing, Dressing, Grooming, Eating, Transferring, Toileting, and Bladder Management
  • Does the participant receive informal support for activities of daily living?: 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.
    • This needs to match the above informal support section.
  • Does the participant have unmet needs for daily living? – Does the participant need any services or devices?: Document if the participant has current assistive devices. If the participant has unmet needs then the coordinator needs to put in what these unmet needs are in Describe

Note: All of this information should match the answers provided in InterRAI and PCSP

13) Appearance, Mood and Behavior

  • How was the participant dressed? Were they clean? (nails, hair, clothing): The Service Coordinator must provide detailed clinical observations regarding personal hygiene and attire.
  • How was the participant’s mood?: Select the appropriate emotions based on the SC’s observation.
  • What was the participant wearing?: Select if the participant was wearing dentures, hearing aids, and/or glasses.
  • How were they moving around?: Indicate functional mobility status, including use of assistive devices or if bed-bound.

14) Environment

Document environmental observations and participant’s report. If concerns are identified, specify the nature of the issue using the categories below.

  • Unclean
  • Clutter
  • Infestation
  • Bad Odor
  • Concerns with temperature
  • Deterioration

Note: Environmental concerns must be cross-referenced in the PCSP and InterRAI.

15) Plan of Care

  • Did the PTP/authorized representative sign the plan of care?: Select yes or no based on signature status. If not, the SC must document why the plan of care was not signed.
    • ONLY the PTP, legal representative or POA is allowed to sign the care plan documents. Individuals who are only authorized representatives CANNOT sign on the participant’s behalf.

16) Employment

  • Is the participant aged 21-64?: Please select yes or no.
  • Were benefits counseling and employment materials provided?: If selecting yes, the SC must document details of discussion regarding employment opportunities with the participant.
    • Document discussions regarding vocational rehabilitation services (e.g., OVR/WIPA) by checking off appropriate boxes.
  • Does PTP currently volunteer within the community?: If yes, please describe the volunteering schedule.

17) PCSP

  • How does the participant choose to receive a copy of their PCSP? If PTP wants an electronic copy, the SC MUST obtain the PTP’s email address.
  • Did the member/legal representative, if applicable, sign the PCSP? Select yes or no based on signature status.
  • Did the member request the increase? If PTP is brand new to the waiver program, this would have NO selected since these service requests are first time requests. If PTP is an MCO transfer, select yes or no based on if services are requesting to be increased by the PTP.

18) Loneliness

Ask the participant to rate the questions on a scale of hardly ever, some of the time and often.

  • How often do you feel that you lack companionship?
  • How often do you feel left out?
  • How often do you feel isolated from others?

**This section must match the HEDIS assessment. There are the same questions asked in that assessment.**

19) Final Rule Survey

Please answer all of the questions with the participant and rate on a scale of all of the time, sometimes or rarely. If the question does not apply, answer “not applicable”. 

1. I have access to food and can eat when I want.

2. I can have people visit me when I want.

3. I have the freedom to go wherever I want.

4. I am in charge of my daily schedule to do what I want.

5. I can participate in activities I enjoy outside of this building/location when I want.

6. I can work in the community if I want.

7. I can spend my money on what I want.

8. I can lock up my personal items when I want.

9. I am able to lock the restroom/bathroom door when I want.

10. I am able to change my service provider when I want.

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