Staff Action Plan Program and Billing Requirements

ADMINISTRATIVE DIRECTIVE

Transmittal:

18-ADM-09R

To:

Executive Directors of Voluntary Provider Agencies

xecutive Directors of Care Coordination Organizations

evelopmental Disabilities State Operations Offices (DDSOO) Directors

evelopmental Disabilities Regional Office (DDRO) Directors

Issuing

O P W D D Office:

Division of Person-Centered Supports

Date:

May 9

, 2019

Subject:

Staff Action Plan Program and Billing Requirements

Suggested

Distribution:

Habilitation Program/Service Staff

uality/Compliance Staff

Bil

ling Department Staff

ealth Home and Basic HCBS Plan Support Care Managers and Care Manager

Supervisors

Contact:

peoplefirstwaiver@opwdd.ny.gov

Attachments:

Staff Action Plan Template

ADMs/INFs

2002-01

2006-01

2006-04

2012-01

2014-01

2014-04

2015-01

2016-01

2017-03

2018-06R

Releases

Cancelled

18-ADM-09

Regulatory

Authority

14 NYCRR Parts

635, 636, and 686

MHL & Other

Statutory Authority

MHL §§ 13.01, 13.07

Records

Retention

18 NYCRR §504.3(a)

18 NYCRR §517.3

14 NYCRR §635-4.5

PURPOSE:

Effective September 4, 2018, OPWDD issued Administrative Memorandum #2018-09, entitled “Staff

Action Plan Program and Billing Requirements,” describing Staff Action Plan requirements as they

relate to the Life Plan as the Office for People With Developmental Disabilities (OPWDD) transitions

its care management service to the Care Coordination service. This ADM, ADM #2018-09R,

replaces ADM #2018-09 to make certain clarifying revisions. Those revisions are underlined below

and are effective retroactive to September 4, 2018.

When an individual’s ISP is replaced by a Life Plan, the habilitative goals/valued outcomes,

habilitation service provider assigned goals, and individual safeguards/Individual Plan of

Protection (IPOP) is integrated into the Life Plan. The Life Plan is the active document defining

the person-centered habilitative goals/valued outcomes and required individual safeguards/IPOP

needs.

Habilitation providers delivering services reflected in the Life Plan must identify how:

• habilitation staff will assist the individual to achieve his/her defined habilitative

goals/valued outcomes; and

• individual safeguards/IPOP needs identified in the Life Plan will be met.

Habilitation providers accomplish this by creating, developing and implementing a Staff Action

Plan. Individuals must have a Staff Action Plan for each habilitation service they receive. The

overarching protections listed in the individual safeguards/IPOP section identified in the Life

Plan may be further detailed in a Staff Action Plan or internal guidance document created by the

habilitation provider. The Staff Action Plan and/or internal guidance document further details the

individual’s needed safeguards, staff supports, and/or specific/detailed protective oversight

measures to ensure the health and safety of the individual receiving the habilitation service(s). The

Life Plan and/or the Staff Action Plan must specifically reference where the additional detail is

located (e.g., see “Plan of Nursing Services”, see “Behavior Support Plan”, see “Community

Supervision Safeguarding Protocol”).

APPLICABILITY:

During a transition period, July 1, 2018 through December 31, 2019 (“transition period”), both

Individualized Service Plans (ISPs), Life Plans, Habilitation Plans, and Staff Action Plans may be

in effect throughout the Office for People With Developmental Disabilities (OPWDD) service

system. Staff Action Plans are required whether the individual receives care management from a

Managed Care Organization (MCO) or a Care Coordination Organization (CCO) providing Health

Home Care Management/Basic Home and Community-Based Services (HCBS) Plan Support. At

the time of transition to the Life Plan, Habilitation Plans must transition to Staff Action Plans.

Creating and Distributing Staff Action Plans for Individuals New to the OPWDD System

Individuals new to the OPWDD system (i.e., on or after July 1, 2018) do not have ISPs or

habilitation plans in place. Therefore, Staff Action Plans for these individuals must be created

and distributed per the requirements in the “Creating the Staff Action Plan” subsection on page

8. The billing standards requirements apply wholly to these new individuals.

Creating and Distributing Staff Action Plans for Individuals in the OPWDD System

These individuals will have their ISPs transition to a Life Plan during the transition period. For

individuals who have an ISP as their controlling active plan of care, habilitation providers must

continue using a Habilitation Plan for the individual. Habilitation Plans must follow the

Habilitation Plan Requirements in Administrative Memorandum (ADM) #2012-01 until the

individual’s initial Life Plan review date. Once the individual has his/her initial Life Plan review,

the Staff Action Plan should be created and distributed per the requirements in the “Creating

the Staff Action Plan” and subsection on page 8. However, all individuals transitioning from an

ISP to a Life Plan who receive habilitation services must have a Staff Action Plan no later than

March 1, 2020.

DEFINITIONS:

Habilitation Services

Habilitation services are designed to assist individuals in acquiring, retaining, and improving the

self-help, socialization, and adaptive skills necessary to reside successfully in home and

community-based settings. Habilitation services involve habilitation staff teaching skills, providing

supports, and exploring new experiences. Habilitation services include:

• Residential Habilitation in certified sites (Individualized Residential Alternatives (IRA),

Community Residences (CR), and Family Care Homes);

• Day Habilitation;

• Community Habilitation;

• Pathway to Employment;

• Prevocational Services; and

• Supported Employment (SEMP).

Staff Action Plans

Staff Action Plans describe, in detail, what habilitation staff will do to help the individual reach the

habilitation goals/valued outcomes through the habilitation provider assigned goal(s) identified in

the individual’s Life Plan. Habilitation staff are responsible for implementing needed safeguards for

the individual. The Life Plan and Staff Action Plan are important tools to ensure that the habilitative

goals/valued outcomes and the safeguards/IPOP needs of individuals are met by the planning team

and service providers.

Health Information Technology System (HITS)

The Health Information Technology System (HITS) is an electronic information sharing system.

HITS ensures consistent, timely, and comprehensive information sharing between providers and

Care Managers, and must be used if available and accessible.

HITS access is available to the individual, the individual’s family member(s) and/or advocate(s) as

permitted by the individual, and any other parties requested and approved by the individual. If the

individual or family requests access to the Staff Action Plan in a different format, it is the

responsibility of the habilitation provider to provide the document as requested.

If the CCO HITS is not available or accessible, another mechanism for prompt communication

agreed upon by the Care Manager and habilitation provider may be utilized so that the person being

contacted can update the HITS. For the purposes of this ADM, reference to HITS includes both

HITS and any other communication system, if HITS is not available or accessible. For

Basic HCBS service, HITS may be used but it is not required.

DISCUSSION:

A. Coordinating the Life Plan and Staff Action Plan

The individual’s Life Plan drives the development of the Staff Action Plan. Sections II and III of the

Life Plan contain critical information that must be used by the habilitation provider to develop the

Staff Action Plan.

1. Life Plan Section II: Outcomes and Support Strategies

Section II of the Life Plan identifies the goals/valued outcomes of the individual receiving

services and the associated provider. The associated habilitation provider is assigned

goals, supports, and/or tasks, which are identified in the Life Plan as Goals (G), Supports

(S), or Tasks (T).

Below are examples of Goals/Valued Outcomes and Provider Assigned Goals within

Section II of the Life Plan and the corresponding Staff Action Plan(s) that must be

developed based upon the details identified in the individual’s Life Plan (Section II):

CQL POMs

Goal/Valued

Outcome

Goal/Valued

Outcome

Provider

Assigned

(Habilitative)

Goal

Service Type

Staff Action Plan

(Provider Developed

Document)

People live in

integrated

environments

I want to live

independently

in the

community

(G) Teach

person to

identify and

respond to

safety issues

(environmental

safety

concerns, etc.)

Residential

Habilitation

The Residential

Habilitation Staff Action

Plan identifies staff

activities needed to

achieve the goal.

The Residential Staff

Action Plan focuses on

skill development

related to learning

safety skills.

People live in

integrated

environments

I want to live

independently

in the

community

(G) Teach

person to take

public

transportation

Community

Habilitation

The Community

Habilitation Staff Action

Plan identifies staff

activities needed to

achieve the goal.

The Community

Habilitative Staff Action

Plan focuses on

teaching skills for

taking public

transportation.

May appear as PHP/CCO Goal/Valued Outcome in early versions of Life Plans.

CQL POMs

Goal/Valued

Outcome

My Goal/

Valued

Outcome

Provider

Assigned

(Habilitative)

Goal

Service Type

Staff Action Plan

(Provider Developed

Document)

People have

intimate

relationships

Improve the

quality of my

current

relationships

(G) Teach

positive

communication

skills

Community

Habilitation

The Community

Habilitation Staff

Action Plan identifies

staff activities needed

to achieve the goal.

The Community

Habilitation Staff

Action Plan focuses

on teaching

communication skills.

People have

intimate

relationships

Improve the

quality of my

current

relationships

(G) Teach

social skills

Day

Habilitation

The Day Habilitation

Staff Action Plan

identifies staff

activities needed to

achieve the goal.

The Day Habilitation

Staff Action Plan

focuses on social skill

development.

Life Plan Section III: Individual Safeguards/Individual Plan of Protection (IPOP)

Section III of the Life Plan is a compilation of all supports and services needed for the

individual to remain safe, healthy, and comfortable across all settings (including Part 686

regulatory requirements for IPOP). Section III of the Life Plan may include valued

outcomes, goals, or supports. Habilitation providers must include these goals and

supports in the individual’s Staff Action Plan and/or internal guidance document.

Below are examples of Goals/Valued Outcomes and Provider Assigned Goals in Section

III of the Life Plan and the corresponding Staff Action Plan(s) or internal guidance

document(s) that must be developed based upon the details identified in the individual’s

Life Plan (Section III):

Goal/Valued

Outcome

Provider Assigned

(Safeguard) Goal

Service

Staff Action Plan or

Internal Guidance

Document (Provider

Developed

Document)

I need help to take

my medications

(S) Provide total

assistance

See: Plan of Nursing

Services (PONS)

Day Habilitation

The Plan of Nursing

Services (PONS)

defines the supports

needed for the

individual’s ongoing

medication

management needs.

A PONS is developed,

jointly or separately,

by the Day Habilitation

and Residential

Habilitation service

providers. The PONS

is guidance for the

staff providing support.

I need help to take

my medications

(S) Provide total

assistance

See: Plan of Nursing

Services (PONS)

Residential

Habilitation

Goal/Valued

Outcome

Provider Assigned

(Safeguard) Goal

Service

Staff Action Plan or

Internal Guidance

Document (Provider

Developed

Document)

In general, I need this

level of support for

my personal hygiene

(S) Just do it for me,

thanks

Day Habilitation

The detailed staff

actions to provide

support for personal

hygiene must be

identified in the Day

Habilitation and

Residential Habilitation

Staff Action Plans or

internal guidance

documents for the

service related goals,

consistent with the

defined safeguards in

the Life Plan (i.e., Just

do it for me, thanks).

The Day Habilitation

and Residential

Habilitation Staff Action

Plans must identify

staff activities needed

to achieve the goal

(i.e., hand washing

skills).

In general, I need this

level of support for

my personal hygiene

(S) Just do it for me,

thanks

Residential

Habilitation

However, there are

some areas where I

need specific support

or want to be more

independent

(G) Teach hand

washing skills,

provide extensive

assistance

Day Habilitation

However, there are

some areas where I

need specific support

or want to be more

independent

(G) Teach hand

washing skills,

provide extensive

assistance

Residential

Habilitation

Goal/Valued

Outcome

Provider Assigned

(Safeguard) Goal

Service

Staff Action Plan or

Internal Guidance

Document (Provider

Developed Document)

I want to feel better

(regarding my

behavior)

Provide/Implement

Behavior Support Plan

(BSP) with

Documentation of

Replacement Behavior

See: Behavior Support

Plan

Residential

Habilitation

The Behavior Support

Plan (BSP) must be

developed, jointly or

separately, by the

Residential and Day

Habilitation providers.

The BSP must be:

consistent with the

specific needs of the

individual; based on

I want to feel better

(regarding my

behavior)

Provide/Implement

Behavior Support Plan

(BSP) with

Documentation of

Replacement Behavior

See: Behavior Support

Plan

Day Habilitation

appropriate

assessment(s); and

developed with input

from the planning team.

The BSP defines the

staff actions according to

the specific behavioral

support needs of the

individual, including

expectations for person-

centered replacement

behaviors.

Goal/Valued

Outcome

Provider Assigned

(Safeguard) Goal

Service

Staff Action Plan or

Internal Guidance

Document (Provider

Developed Document)

People have the best

possible health, I

want to feel

differently

(S) Provide exercise

program

Community

Habilitation

The Community

Habilitation Staff Action

Plan details the

supports needed to help

the individual achieve

his/her goals.

The Community

Habilitation Staff Action

Plan directs support

staff by further detailing

the safeguards in the

Life Plan.

People have the best

possible health, I

want to feel

differently

(S) Provide diet

counseling

Community

Habilitation

3. Staff Action Plan Program Standards:

The Staff Action Plan Program Standards are designed to provide guidance to

habilitation service providers about the expected level of quality habilitation services.

These program standards are reviewed by OPWDD’s Division of Quality

Improvement (DQI) and may be subject to corrective actions. These program

standards are not considered to be a specific requirement to justify billing. Billing

standards are identified in the Staff Action Plan Billing Standards section below.

Staff Action Plans will be incorporated into DQIPM’s review for the survey cycle following

the transition period.

General Guidance for Developing the Staff Action Plan

1. Staff Action Plan and the Life Plan

When developing the Staff Action Plan, Habilitation staff must follow the

person-centered planning guidance as described in 14 NYCRR Part 636-1.

Staff Action Plans must be developed based on the habilitation provider assigned

goals and supports as outlined in the individual’s Life Plan. Habilitation provider

assigned goals and supports are established by the individual receiving services and

his/her planning team during the Life Plan development process. Staff Action Plans

detail how staff will provide supports and services to help the individual achieve

his/her defined habilitative goals/valued outcomes.

Habilitation provider assigned goals and supports identified in Sections II and III of the

Life Plan meet the requirements for habilitative goals described in the habilitative

provider’s Staff Action Plan. Tasks are a one-time activity assigned in the Life Plan

and are not habilitative in nature. Therefore, tasks do not meet the billing

requirements to be a habilitation goal.

2. Creating the Staff Action Plan

Staff Action Plans must be written by the habilitation provider and must be developed in

collaboration with the individual, his/her advocate, Care Manager, and any other parties

requested and approved by the individual. Additionally, agencies providing Residential

Habilitation must continue to demonstrate the involvement of a Qualified Intellectual

Disabilities Professional (QIDP) in the delivery, management or supervision of

residential habilitation services.

The initial Staff Action Plan must be in place no later than 60 days of the start of the

individual’s habilitation service, or the Life Plan review date, whichever comes first.

Therefore, services that are provided within the first 60 days of the start of the

habilitation service might not have a Staff Action Plan in place. The habilitation provider

must forward the initial Staff Action Plan to the Care Manager via the CCOs Health

Information Technology System (HITS). Staff Action Plans must be provided to the Care

Manager no more than 60 days after

the Life Plan review date.

Reviewing and Revising the Staff Action Plan

The Staff Action Plan must be reviewed at least twice annually and revised as frequently

as necessary based upon the individual’s needs. It is recommended that Staff Action

Plan reviews occur at six-month intervals coordinated with the Life Plan review. At least

annually, one of the Staff Action Plan reviews must be conducted at the time of the Life

Plan meeting. The Life Plan meeting is arranged by the individual’s Care Manager and

is required to include the following parties: the individual, family member(s) and/or

advocate(s) (if permitted by the individual), and all other major service providers. This

review allows the agencies providing services and the individuals receiving services to

reassess the effectiveness of the Staff Action Plan(s) and services.

When reviewing a Staff Action Plan, the habilitation provider must consider the

individual’s progress, including his/her accomplishments and the prevention of

regression since the last review. The review must include discussion about:

•

the services and supports that have been provided since the last review;

•

what challenges have been experienced;

•

what new strategies or methodologies that may need to be implemented; and

•

the individual’s satisfaction with the plan.

Those reviewing the Staff Action Plan should establish objectives to be met before

the next periodic review and establish agreement on those objectives.

Revised Staff Action Plans, written by the habilitation service provider, must be provided

to the Care Manager via the CCOs HITS. Staff Action Plans must be provided to the Care

Manager no more than 60 days after either: (a) a Life Plan review date; or (b) the date on

which the habilitation service provider makes a change to the Staff Action Plan.

Required Sections of the Staff Action Plan

Every Staff Action Plan must include the following three sections:

I. Identifying information. This must include:

• the individual’s name;

• the individual’s Medicaid ID number;

• the name of the habilitation provider;

• the Care Coordination Organization providing care management

to the individual;

• identification of the habilitation service; and

• the date of the Life Plan meeting, or Staff Action Plan review, in

which the Staff Action Plan was developed/reviewed.

II. Individual Habilitative Goals/Valued Outcomes and Provider Assigned

Goals. The individual’s habilitative goals/valued outcomes and habilitation

provider assigned goals are derived from the individual’s Life Plan. The habilitation

service must relate to the individual’s habilitative goals/valued outcomes. Using

the habilitative goals/valued outcomes as the starting point, the details of the Staff

Action Plan must describe the actions that will enable the individual to reach his/her

speci

fic habilitative goals/valued outcomes.

The habilitation service provider must use person-centered planning practices, and

in consultation with the individual and his/her Care Manager, decide which strategies

are to be addressed in the Staff Action Plan. The Staff Action Plan and/or internal

guidance document(s) must be specific enough that new habilitation service staff

know:

• what they must do;

• how to assist the individual to achieve his/her habilitative

goals/valued outcomes; and/or

• how to address the individual’s safeguard/IPOP needs.

The Staff Action Plan must address one or more of the following strategies

for service delivery: skill acquisition/retention; staff support; or exploration of

new experiences.

i. Skill Acquisition/Retention describes the strategies staff will use to

help an individual become more independent in some aspect of life.

Staff assess the individual’s current skill level, identify a method by

which the skill will be taught, and then measure progress periodically.

The assessment and progress may be measured via observation,

interviews of staff and/or others who know the individual well, and/or by

data collection.

Skill acquisition/retention activities should be considered in developing

the Staff Action Plan. Further advancement of some skills may not be

reasonably expected for certain individuals due to various medical

conditions, advancing age, or the determination that the skill has been

maximized due to substantial past efforts. In these instances, based

on an appropriate assessment by members of the habilitation service

delivery team, activities specified in the Staff Action Plan can be

changed to skill retention.

ii. Staff Supports are those actions that are provided by the habilitation

staff when: a) the individual is not expected to independently perform

a task without supervision; and b) are essential to preserve the

individual’s health or welfare, or to reach a goal/valued outcome. For

example, a staff person may assist the individual with personal hygiene,

as opposed to teaching or helping the individual develop that skill.

Staff oversight of the individual’s health and welfare is also a part of the

habilitation service (e.g., when staff accompanies individuals in the

community or provides first aid). The needed staff supports typically

relate to the provision of defined safeguards and can be found within

the habilitation provider’s internal guidance documents, such as the

Plan of Nursing Services, Dining Plan, Behavior Support Plan or other

general support plans. Supports may also be defined directly within the

Staff Acti

on Plan for the habilitative service.

iii. Exploration of new experiences may be part of the Staff Action Plan

when based on an appropriate review by the habilitation service

provider. Learning about the community and forming relationships often

requires an individual to try new experiences to determine life directions

and support greater independence. This trial and error process

eventually allows the individual to make informed choices and identify

new goals/valued outcomes that become part of the individual’s Life

Plan and Staff Action Plan.

III. Individual Safeguards/IPOP. The individual safeguards/IPOP needs described

in Section III of the Life Plan are used as the starting point for the habilitation

service provider to develop the Staff Action Plan safeguard detail, and any

internal guidance documents that outline the individual-specific protective

oversight measures staff need to implement or ensure for the individual.

Safeguards are necessary to provide for the individual’s health and safety while

participating in the habilitation service. All habilitation staff supporting the

individual must have

knowledge of the individual’s safeguard needs.

The individual’s safeguard needs must be immediately identified, and appropriate

supports and services to address the individual’s safeguard needs must be

immediately implemented. Safeguards must be updated based on the individual’s

identified or changed needs. If the individual’s support needs change such that a

change is required in Section III Individual Safeguards/IPOP of the Life Plan, the

service provider must communicate this change to the Care Manager using the

CCOs HITS. This communication ensures Life Plan updates an

d timely

communication of changes to other support givers/providers. Additionally, it is

critical to ensure timely notice of significant support need changes to ensure

health and safety.

i. For individuals receiving IRA Residential Habilitation, the Residential

Habilitation Staff Action Plan or other internal guidance documents that

outline the implementation of specific protective oversight measures

must meet the requirements of the Plan for Protective Oversight in

accordance with 14 NYCRR Section 686.16 and align with Section III

Individual Safeguards/IPOP identified in the Life Plan.

ii. For all other habilitation services, individual safeguards/IPOP needs

from the Life Plan must be identified and addressed in the Staff Action

Plan(s) or references other internal guidance document(s) that outline

the detailed implementation of protective oversight measures. This

guidance on protective oversight measures must align with the

overarching Section III Individual Safeguards/IPOP articulated in the Life

Plan.

Information on the individual safeguards/IPOP needs must be readily

available to the habilitation service provi

der staff. Any change in an

individual’s safeguard/IPOP needs must be addressed immediately and

communicated to the Care Manager and all service providers.

iii. As required in 14 NYCRR Part 633, the medication records are distinct

and separate from the Staff Action Plan. The Staff Action Plan references

the medication records as containing important health related information

when applicable. If the habilitation service provider is teaching the

individual to self-administer medication, this must be listed in the Life

Plan. The activity of self-administering medication and related staff

actions required to teach this skill must appear in the Staff Action Plan.

iv. Providers of Residential Habilitation must have written procedures for

providing back-up supports to individuals when the absence of the

provider’s regularly scheduled staff would pose a threat to the individual’s

health or safety. For IRAs, this information must be included in site-

specific Plans for Protective Oversight and Staff Action Plans, as

appropriate.

Staff Action Plan Format

An optional Staff Action Plan Format has been issued with this memorandum. Providers

may use this format or create their own, so long as the Staff Action Plan includes the

minimum information as described in this ADM. Habilitation providers must write plans

that not only include the information required by this memorandum, but also clearly

communicate information to the habilitation staff and illustrate the steps staff are to take

to address the individual’s needs.

6. Staff Action Plans with Multiple Services

Staff Action Plans may include multiple habilitation services, if all included services are

provided by the same agency.

For Staff Action Plans that incorporate multiple habilitation services, the Staff Action

Plan must have a separate section that describes the supports and services associated

with each service. When the same support/service is delivered in multiple habilitation

services, the service/staff action must be identified in each supports and services

section of the Staff Action Plan.

For each habilitation service described in the Staff Action Plan, one staff from each

habilitation service must assist with writing the plan and include his/her name, title,

signature, and signature date on the Staff Action Plan. Evidence of a Staff Action Plan

review must include a staff signature from each habilitation service.

C. STAFF ACTION PLAN BILLING STANDARDS:

The following standards define the documentation which must be retained to support service

claims by the habilitation provider. Additionally, habilitation providers are responsible for the

documentation standards outlined in the specific service related Administrative Memoranda.

For every habilitation service, an individual must have a Staff Action Plan that contains the:

1) Individual’s name;

2) Individual’s Medicaid Client Identification Number (CIN) (if the individual is enrolled in

the OPWDD HCBS Waiver);

3) Habilitation service provider’s agency name;

4) Name of habilitation service(s) provided (e.g., Residential Habilitation or Day

Habilitation);

5) Date (day, month, and year) of the Life Plan meeting, or Staff Action Plan review,

from which the Staff Action Plan was developed/revised;

6) Identification of the goals/valued outcomes (My Goal) from the individual’s Life Plan;

7) Identification of the provider assigned (habilitative/safeguard) goal(s) and/or support(s)

from the individual’s Life Plan;

8) Description of the service(s) and support(s) and identification of the frequency from

Section II or III of the Life Plan (e.g., teaching laundry skills weekly) the habilitation

staff will provide to the individual;

9) Safeguards (i.e., compilation of all supports and services needed for an individual to

remain safe, healthy and comfortable across all settings) that will be provided by the

habilitation service provider, which may be a reference to internal guidance documents

that further define the safeguards;

10) Printed name(s), signature(s) and title(s) of the staff who wrote the Staff Action Plan;

11) Date (day, month, and year) that staff signed the Staff Action Plan; and

12) Evidence demonstrating the Staff Action Plan was distributed no later than 60 days

after: the start of the habilitation services; the life plan review date; or the development

of a revised/updated Staff Action Plan, whichever comes first (which may include, but is

not limited to: a monthly narrative note; a HITS upload; or e- mail).

There must be evidence that the Staff Action Plan was reviewed at least twice annually.

Evidence of a review may include, but is not limited to a:

1) Review sign-in sheet;

2) Service note indicating a review took place; and/or

3) Revised/updated Staff Action Plan.

Evidence of reviews must include the:

1) Individual’s name;

2) Habilitation service(s) under review;

3) Staff signature(s) from the habilitation service(s);

4) Date of the staff signature(s); and

5) Date of the review.

The initial Staff Action Plan must be in place no later than 60 days of the start of the habilitation

service, or the Life Plan review date, whichever comes first. Therefore, services that are

provided no later than the first 60 days of the start of the habilitation service might not have a

Staff Action Plan in place.

D. RECORDS RETENTION:

New York State regulations require each Medicaid provider to prepare records to demonstrate its

right to receive Medicaid payment for a service. These records must be “contemporaneous” and

retained for six years from the date the service was provided.

All documentation specified above, including the ISP/Life Plan, Habilitation Plan/Staff Action

Plan, and service documentation must be retained for a period of at least six years from the

date the service was delivered or when the service was billed, whichever is later.

E. TECHNICAL ASSISTANCE:

For questions regarding this memorandum, please contact the Division of Person-Centered

Supports, Waiver Unit at: peoplefirstwaiver@opwdd.ny.gov

cc: Leslie Fuld, DQI

Kate Marlay, DPCS

Abiba Kindo, DSD

Jill Pettinger, DSD

Mike Feeney, DSD

Jacquelyn Best, DSD