Day Activity Health Services (DAHS) Forms

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∗ In March 2012,DADS began working on revisions to Form 3050, including a decision to develop a separate health assessment form.

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Background

DAHS Forms ∗ Changes were made to the following three forms;

which are used by DADS to determine whether the individual meets the medical eligibility criteria to receive DAHS.

∗ Form 3049, DAHS Health Assessment ∗ Form 3050, DAHS Individual Service Plan ∗ Form 3055, DAHS Physician’s Orders

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∗ During internal policy meetings, DADS DAHS policy staff, including two registered nurses, evaluated the efficacy of Form 3050.

∗ A decision was made to separate Form 3050 into two forms, Form 3049, DAHS Health Assessment and Form 3050, DAHS Individual Service Plan.

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Background

∗ Reasons for creating a separate health assessment form: ∗ Using check boxes for most of the assessment

information did not provide enough detail about the individual’s condition (especially medication administration).

∗ The assessment and service plan elements combined in one form made it difficult to determine what specific treatments were being administered at the DAHS Facility.

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Background

∗DAHS policy and rule were revised to emphasize consistency between the individual service plan and the physician’s orders.

∗Frequency of service delivery is now required documentation.

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Background

∗ Copies of the health assessment, individual service plan and physician order forms were shared during DADS DAHS stakeholder meetings in July of 2012 and again in July of 2013.

∗ Revised Forms 3049, 3050 and 3055 were posted for use by DAHS providers in October 2013.

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Background

Form 3049: DAHS Health Assessment

∗ The health assessment from Section II of the old Form 3050 was moved to new Form 3049.

∗ Form 3049 is completed by the DAHS facility nurse for DAHS applicants/individuals: ∗ who need initial prior approval; ∗ who transfer from one facility to another; ∗ when the licensed nurse determines an individual needs to be

reassessed based on changes on Form 3050, DAHS Individual Service Plan.

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∗ The new Form 3049 must be completed for all individuals receiving DAHS through a DADS contract by June 30, 2014.

∗ Form 3049 is used for initial assessments and is updated as determined by the DAHS Facility nurse.

∗ When Form 3049 is completed for initial enrollment into the DAHS program, it is considered a comprehensive assessment.

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Form 3049: DAHS Health Assessment

DAHS Health Assessment

∗ Licensure information: ∗ DAHS facility staff are reminded to consult the Texas

Board of Nursing website at http://www.bne.state.tx, for guidance on all issues regarding the maintenance of nurse licensure.

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Form 3050: DAHS Individual Service Plan

∗ Form 3050 consists of only the individual service plan.

∗ Form 3050 is developed using the information from new Form 3049.

∗ Form 3050 should reflect treatments that will be provided based on information collected during the health assessment and information received from the individual’s physician documented on Form 3055.

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∗ Form 3050 is completed by the DAHS facility nurse for DAHS applicants/individuals: ∗who need initial prior approval; ∗who transfer from one facility to another; or ∗when the licensed DAHS nurse determines an

individual needs a new service plan developed.

Form 3050: DAHS Individual Service Plan

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∗ Once the initial Form 3050 is implemented, DAHS facility nurses enter additional documentation on Form 3050 as changes to the individual’s service plan occur.

∗ A new Form 3050 is not needed as long as the: ∗ Revised Form 3050 documentation does not become

difficult to read or to determine the individual’s most current service plan.

Form 3050: DAHS Individual Service Plan

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∗ The revised DAHS Form 3055 must be implemented immediately for all new DAHS applicants.

∗ The revised Form 3055 must be completed for current-ongoing DAHS individuals by June 30, 2014.

When to prepare Form 3055 Physician’s Orders

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∗ After the rollout phase of the revised Form 3055 is complete this form is completed: ∗ For initial approvals for DAHS; and ∗ If the facility nurse determines a new Form 3055 is needed.

∗ If the individual receives supplemental physician orders, a revised Form 3055 may be completed or the DAHS Facility nurse may accept signed orders from the physician that are attached to the current Form 3055.

When to prepare Form 3055 Physician’s Orders

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∗ The current medical diagnosis on Form 3055 was added to Forms 3049 and 3050 to ensure assessment and service plan documentation accurately reflect the current medical diagnosis listed on Form 3055.

∗ Form 3050 includes new sections on frequency for treatments, medications and therapies taken from revised Form 3055 to ensure individual’s plan of care accurately reflect current physician’s orders.

Additional DAHS Forms 3049, 3050 and 3055 Revision Highlights:

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∗ Form 3055 includes revised documentation sections on all prescribed and over-the-counter (OTC) medications to avoid issues with adverse side effects due to contraindications of medications.

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Additional DAHS Forms 3049, 3050

and 3055 Revision Highlights

∗ Form 3050 is a living document.

∗ This means changes in the individual’s condition can be made on Form 3050 to match supplemental physician orders without revising the entire form.

∗ The form must be legible and contract monitoring staff must be able to determine what services the DAHS Facility is providing.

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Additional DAHS Forms 3049, 3050

and 3055 Revision Highlights

∗ Documentation to support service delivery: ∗ Assistance with activities of daily living (non-skilled

care) can be documented monthly. ∗ For example, Mrs. Smith needs assistance with

toileting while attending DAHS. The DAHS facility nurse or designee can document Mrs. Smith received assistance with toileting each day she attended DAHS in the month of June.

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Documentation Requirements

∗ Medication administration and skilled care must be documented each time they occur. ∗ For example: The DAHS facility nurse monitors Mrs.

Smith’s blood pressure and administers the noon dose of blood pressure medication each day Mrs. Smith attends DAHS.

∗ Records must show a blood pressure reading and indication medication was given each time these activities occur. Dates must be included and match DAHS attendance records.

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Documentation Requirements

∗ The DAHS Provider Manual was updated to provide information about the revised forms and documentation requirements.

∗ The DAHS Provider Manual can be found at: ∗ http://www.dads.state.tx.us/handbooks/dahs/

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Provider Manual Revisions

∗Questions about DAHS Policy may be sent to: PDOMailbox@DADS.state.tx.us

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DADS Contact Information