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  • LOUISIANA DEPARTMENT OF HEALTH

    Support Coordination Contact Documentation (SCD)

  • Waiver*
  • Contact Type*

  • Section A: Contact Information

  • Date*
     / /
    2 digit month, 2 digit day, 4 digit year

  • Monthly Monitoring

    Service Activity Code of 41

  • Monthly Remedication

    (Service Activity Code of 41)

  • Annual Monitoring

  • Annual Remediation

  • Name of Individual (s) Providing Response

  • For individual providing response, relationship to participant (check all that apply)*

  • CAPS Review

  • Physical Activities Promotion*
  • Home Environment Optimization*
  • Institutional Risk*
  • Physical Restraints*
  • Date*
     / /
    2 digit month, 2 digit day, 4 digit year
  • Cognitive Loss*
  • Delirium*
  • Communication*
  • Behavior*
  • Abusive Relationship*
  • Informal Support*
  • Date
     / /
    2 digit month, 2 digit day, 4 digit year
  • Social Relationship*
  • Falls:*
  • Pain*
  • Pressure Ulcer:*
  • Cardio Respiratory Conditions:*
  • Under Nutrition:*
  • Date
     / /
    2 digit month, 2 digit day, 4 digit year
  • Dehydration:*
  • Feeding Tube:*
  • Prevention:
  • Appropriate Medications*
  • Tabacco and Alcohol Use:*
  • Date
     / /
    2 digit month, 2 digit day, 4 digit year
  • Urinary Incontinence:*
  • Bowel Conditions:*
  • Date*
     / /
    2 digit month, 2 digit day, 4 digit year

  • Quarterly Plan of Care Budget Review

    List of all services included in the Plan of Care budget in this section. Monitor each service during the quarterly meeting. The SC should review services used in LaSRS to confirm they are being delivered as outlined in the budget. Discuss any service gaps or concerns and document them in the chart or notes.

  • Is service provided as planned in the approved POC?*
  • Is a revision needed?*
  • Is service provided as planned in the approved POC?
  • Is a revision needed?
  • Is service provided as planned in the approved POC?
  • Is a revision needed?
  • Date*
     / /
    2 digit month, 2 digit day, 4 digit year
  • Is service provided as planned in the approved POC?
  • Is a revision needed?
  • Is service provided as planned in the approved POC?
  • Is a revision needed?
  • Based on this quarterly review, is participant in need of a new iHC assessment?*
  • Date
     / /
    2 digit month, 2 digit day, 4 digit year

  • SCD: SECTION D: SIGNATURES

    Signatures for the OAAS SCD Log
  • Date
     / /
    2 digit month, 2 digit day, 4 digit year
  • Date*
     / /
    2 digit month, 2 digit day, 4 digit year

  • Quarterly Packet Signature Page

  • Date
     / /
    2 digit month, 2 digit day, 4 digit year

  • SCD Log: Section B: Participant Questions

    Answer all questions listed below for monthly and quarterly contacts. Obtain answers ONLY from the participant, responsible representative or legally responsible representative. If a question is checked Yes, provide details in the text box following the question.
  • 1. Has the participant had problems receiving services as written in the Plan of Care?*
  • Action Needed, #1
  • 2. Has the participant had problems with goals being met?*
  • Action Needed for #2
  • 3. Has the participant had problems with their preferences being respected (i.e. services being delivered at their preferred times)?*
  • Action Needed for #3
  • 4. Has the participant had problems accessing non-waiver health care services?*
  • 5. Has the participant had problems getting a backup worker when a worker cannot report to work as scheduled?*
  • Action Needed for #5
  • 6. Has the participant had any falls, injuries, and hospitalizations, been restrained and/or been a victim of verbal abuse, physical abuse, neglect or exploitation?*
  • Action Needed #6
  • 7. Has the participant had a substantial change in medical condition?*
  • Action Needed #7
  • 8. Has the participant had a substantial change in the ability to do things for themselves?*
  • Action Needed for #8
  • 9. Does the participant have an identified need for an EAA and/or assistive devices (s)?*
  • Action needed for #9
  • 10. Has the particpant had a change in non-paid caregivers or living situation?*
  • Action Needed for #10
  • 11. Has the participant had a change in who will assist them in the event of an emergency?*
  • Action needed for #11
  • 12. Has the participant had a change in medications/treatement and/or who gives them?*
  • Action needed #12
  • 13. For Self Directed CCW Participants: *Does the home book contain the last 3 months of service logs and progress notes? *Are all other required items, as specified in the CCW Self-Direction Employer Handbook, contained in the home book?*
  • Action Needed
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  • Medication Review: All medications must be visualy inspected and recorded below. *
    Rows
  • Date*
     / /
    2 digit month, 2 digit day, 4 digit year

  • Home Book Review

    The following documents are required to be present in the home book.

  • Current/Approved plan of care is present and includes the follow:

  • Current/Approved plan of care*
  • Provider attachments*
  • Emergency Plans*
  • Back Up Staffing Plans*

  • Other Required Documents

  • Revisions to the plan of care*
  • In-home staff progress notes*
  • Right and Responsibilities*
  • Support Coordinator 24 hour contact form*
  • Waiver Help Line*
  • Self-Direction Payroll Reports*
  • Grievance and Complaint Policy and Procedures*
  • Abuse and Neglect Policy*
  • Authorized Representative Form*
  • Date
     / /
    2 digit month, 2 digit day, 4 digit year

  • Emergency Evacuation Plan Review

    Support Coordinator has reviewed participant's emergency evacuation plan in full during the quarterly home visit.
  • Are changes needed to the emergency evacuation plan?

  • Staff Back Up Plan Review

    Support Coordinator has reviewed participant's' staff back up plan in full during the quarterly home visit.
  • Date of visit*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Are changes needed to the staff back up plan?*
  • Date*
     / /
    2 digit month, 2 digit day, 4 digit year
  •  
  • Should be Empty: