5.C.1.a-f.
The program plan that guides the delivery of the services includes:
- A description of the program including:
- The philosophy or mission statement of the program
- Program scope and goals
- Assurance that adequate resources are available to deliver the services
- Procedures for providing or arranging for crisis intervention services
- Procedures for coordinating and communicating with internal and external service providers
- A process for developing program policies and procedures that:
- Identifies the medical and healthcare competencies required by program staff
- Includes consultation with other medical and healthcare professionals as needed
- A process for the plan to be regularly reviewed and modified as needed
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5.C.2.a-b.
Services are managed by an individual who has:
- The education, training, and experience needed to meet the needs of persons with medically complex needs
- The competencies needed to manage the services
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5.C.3.a-n.
Initial assessments of each person served gather information as appropriate, including his or her:
- Developmental history, such as development age factors
- Motor development and functioning
- Health history and status, including:
- Medical
- Physical
- Mental
- Social/emotional
- Culture/ethnicity, including specific needs and preferences
- Educational history
- Communication functioning, including:
- Speech
- Hearing
- Language
- Visual functioning
- Learning style
- Intellectual functioning
- Family relationships
- Interactions with:
- Peers
- Sexual partner, if relevant
- History of use of alcohol or other drugs
- Current use of assistive devices or technology
- Other information relevant to the person served, as applicable
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5.C.4.a-e.
Assessments are appropriate with respect to the person’s:
- Age
- Development, including physical and cognitive ability
- Culture
- Education
- Functional limitations, if applicable
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5.C.5.a-b.
The program implements written procedures to ensure that assessments are updated:
- At least annually
- As needed:
- According to the specific needs of an individual
- Depending on changes in a person’s functioning
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5.C.6.a-d.
Each person served and his or her family or guardian, as appropriate, have decision-making roles in the following:
- Individual services planning, including planning for transition and/or discharge if appropriate
- Coordination of care
- Referral to appropriate resourced based on the needs and preferences of persons served and their families
- Advance directives
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5.C.7.a-d.
The service delivery team for each person served:
- Provides services that are consistent with:
- The needs and preferences of the person served
- The individual care plan
- Addresses:
- Emergent issues
- Ongoing issues
- Transitions in levels of care as needs change, including identifying the skills necessary to be successful in the next environment for:
- The person served
- Their families/caregivers
- Ensures that, based on ongoing assessments of the person served:
- Treatments change as appropriate
- Resource allocations change as appropriate
- Predicted outcomes change as appropriate
- Considers the impact of changes on:
- The person served and their families/caregivers
- The individual care plan of the person served
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5.C.8.a-b.
The service delivery team for each person served is designed and modified as needed based on:
- The individual services planning process
- Initial and ongoing assessments
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5.C.9.a-c.
There is a designated care coordinator for each person served who ensures:
- That all team members:
- Are aware of the plan of care for each person served
- Exchange information as appropriate
- Implements the plan of care/supports for each person served
- That all changes are communicated to the entire team
- Appropriate communications with:
- The primary care physician of the person served
- Other external stakeholders
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5.C.10.a-e.
Before the person served moves from the program to another service or another level of care, transition planning is conducted and involves:
- The person served
- The family, as appropriate
- Service delivery team members
- Appropriate personnel from the next service, as available
- Consultation from the person’s primary care physician and other healthcare specialists, if applicable
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5.C.11.
The program provides information to families/caregivers and the person served, as appropriate, about options as the person transitions through life stages.
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5.C.12.a-i.
As relevant to the needs of the persons served and the scope of the program, staff members demonstrate competency in the following areas:
- The medical needs of the individuals served, including signs/symptoms requiring immediate response and appropriate actions
- Assistive technology, adaptive equipment, and medical devices used by the persons served
- Methods of communication
- Positive behavior support skills
- Learning styles
- Social, emotional, and sexual needs
- The effects of separation and placement on children and families or as adults transition to different living situations
- Grief and end-of-life support issues
- Other specific needs of the persons served
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5.C.13.
The program collaborates with the healthcare providers who provide specialized medical, psychological/behavioral, and other therapeutic care to the person served.
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5.C.14.
With the permission of the persons served, the program provides advocacy by sharing feedback from the person served regarding from other organizations and professionals providing ancillary services.
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5.C.15.
The program assists families and caregivers to optimize resources and opportunities through involvement in support networks such as peer support groups, local advocacy groups, and self-help groups.
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5.C.16.
If the program is responsible for medical equipment and devices used by persons served, it follows a written schedule according to manufacturers’ specifications for maintenance and/or calibration of the equipment.
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5.C.17.a-c.
If services are provided in the home, the program identifies in-home safety needs of the person served and addresses as appropriate:
- Environmental risks
- Abuse and/or neglect by self or others
- Self-protection skills
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5.C.18.a-e.
As appropriate to the scope of the program, end-of-life planning:
- Is directed by the wishes/desires of the person served and/or guardian
- Includes advocacy of hospice, palliative care, or other end-of-life choices as needed
- Includes spiritual or religious elements, if desired by the person served
- Includes the guidance of a medical professional, if desired by the person served
- Is submitted to the hospital in the required format, if applicable
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5.C.19.a-b.
When a person served dies, opportunities are provided as appropriate to peers, other persons in the program, family/caregivers, and staff members to:
- Express grief and remembrance
- Develop and participate in:
- Memorial services
- Memorial rituals
- Other forms of grief expression, as desired
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5.C.20.a-c.
The living environment provided for persons served is:
- Inclusive and integrated into the community
- Physically supportive to meet the needs of the persons living in the residence
- Psychologically supportive to meet the emotional and social needs of the persons served
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5.C.21.
On-site support is available to meet the individual needs of the persons served.
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5.C.22.a-b.
Persons served have input regarding and access to:
- Nutritious meals and snacks or enteral feedings
- Liquid refreshment on an ongoing basis, as appropriate for the person served
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5.C.23.a-c.
There are separate beds and sleeping areas for persons served according to their:
- Ages
- Genders
- Needs
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5.C.24.a-b.
The program provides for visits, including opportunities for privacy when appropriate, with:
- Family members and significant others
- Friends
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