Standards for private organizations

2020 Edition

Home Care and Support Services (HCS) 7: Care Monitoring

Routine care monitoring ensures delivery of appropriate services.
2020 Edition

Currently viewing: HOME CARE AND SUPPORT SERVICES (HCS)

VIEW THE STANDARDS

Purpose

Individuals who receive Home Care and Support Services obtain a maximum level of independence, functioning, and health, and extend the time it is possible to live safely at home and in the community.
1
All elements or requirements outlined in the standard are evident in practice, as indicated by full implementation of the practices outlined in the Practice Standards.
2
Practices are basically sound but there is room for improvement, as noted in the ratings for the Practice Standards; e.g.,
  • Minor inconsistencies and not yet fully developed practices are noted; however, these do not significantly impact service quality; or
  • Procedures need strengthening; or
  • With few exceptions, procedures are understood by staff and are being used; or
  • For the most part, established timeframes are met; or
  • Proper documentation is the norm and any issues with individual staff members are being addressed through performance evaluations and training; or
  • Active client participation occurs to a considerable extent.
3
Practice requires significant improvement, as noted in the ratings for the Practice Standards. Service quality or program functioning may be compromised; e.g.,
  • Procedures and/or case record documentation need significant strengthening; or
  • Procedures are not well-understood or used appropriately; or
  • Timeframes are often missed; or
  • Several client records are missing important information; or
  • Client participation is inconsistent. 
4
Implementation of the standard is minimal or there is no evidence of implementation at all, as noted in the ratings for the Practice Standards; e.g.,
  • No written procedures, or procedures are clearly inadequate or not being used; or 
  • Documentation is routinely incomplete and/or missing.      
Self-Study EvidenceOn-Site EvidenceOn-Site Activities
  • Care monitoring procedures
  • Documentation procedures 
No On-Site Evidence
  • Interviews may include:
    1. Program director
    2. Relevant personnel
    3. Persons served
  • Review case records

 

HCS 7.01

Follow-up assessments are based on the physical and cognitive needs of the individual and are conducted by a nurse or other qualified professional: 
  1. in person at least every 30 days for cognitively impaired clients, or clients with other special needs;
  2. in person at least every 60 days for clients who are not cognitively impaired and are receiving personal care aide services;
  3. in person at least every 90 days for clients receiving homemaker services only; and
  4. by phone, in addition to the in-person timeframes listed above, when needed.

Interpretation

The organization is responsible for determining the necessary qualifications for staff conducting assessments.

 
Fundamental Practice

HCS 7.02

Care providers:
  1. document all interventions and how the person responds;
  2. monitor and document changes in physical, mental, and emotional status and gains of the individual and their caregivers;
  3. respect and note the individual’s choices;
  4. help individuals make independent choices or assume more responsibility for making decisions;
  5. recognize service gaps and alert applicable service providers to unmet needs;
  6. recognize emergency situations and follow procedures to ensure the safety and well being of care recipients; and
  7. report on plan implementation and progress to a supervisor or case manager at least weekly.

 

HCS 7.03

The care provider and the individual or legal guardian, and his or her family when appropriate:
  1. review progress toward achievement of agreed upon service goals; and 
  2. sign revisions to service goals and care plans.
Examples: Reviews may also include other direct care providers and caregivers when possible and appropriate.

 

HCS 7.04

The worker and a supervisor, or a clinical, service, or peer team review the case quarterly, or more frequently depending on the needs of the individual, to assess:
  1. care plan implementation;
  2. progress toward achieving service goals and desired outcomes; and
  3. the continuing appropriateness of the agreed upon service goals.

Interpretation

When experienced managers are conducting reviews of their own cases, the manager’s supervisor must review a sample of the manager’s evaluations as per the requirements of the standard.