Team Leader (TL)

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PROCEDURES

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Job DESCRIPTION———————————————————————————2

pOSITION oVERVIEW——————————————————————————4

COMMUNICATION———————————————————————————-5

tRAINING———————————————————————————————6

inDEPENDENCE & aSSIGNING tASKS——————————————————–8

rETRAINING pROCESS—————————————————————————-9

TRAINING SUPPORT RECORDS—————————————————————–9

SCHEDULING—————————————————————————————11

CLIENTS REFUSALS——————————————————————————-11

reVIEWiNG dOCUMENTATION—————————————————————-12

Medication assistance & Administration——————————————12

MEdication check-in PRocedures—————————————————–16

mEDICATION prOFILES————————————————————————-16

MEdication disposal————————————————————————-16

MEdicATION AVAILABILITY——————————————————————–17

inVENTORY OF oRDERING sUPPLIES AND mEDICATION—————————–17

mEDICATION cHANGES————————————————————————-18

nARCOTIC bOOKS———————————————————————————21

hEALTHCARE—————————————————————————————21

APPOINTMENTS————————————————————————————22

UPDATES THERAP———————————————————————————27

RELEASES OF INFORMATION——————————————————————-28

POLST————————————————————————————————-29

MEDICAL EQUIPMENT—————————————————————————32

PSYCHOTROPIC MEDICATIONS—————————————————————34

NURSE DELEGATION—————————————————————————–37

HYGIENE———————————————————————————————39

GENERAL EVENT REPORTS———————————————————————39

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PERSON CENTERED SERVICES PLANS (PCSP)———————————————-41

OVERSIGHT FOR AREAS OF RESPONSIBILITY (AOR)————————————–43

TIMESHEETS—————————————————————————————–43

MILEAGE———————————————————————————————44

COMMUNITY INTEGRATION——————————————————————–44

CLIENT FINANCES———————————————————————————45

VEHICLES——————————————————————————————–46

WORKSITE SUPPLIES—————————————————————————–47

SAFETY CHECKS AND DRILLS——————————————————————47

TEAM MEETINGS———————————————————————————-48

ARCHIVING—————————————————————————————–49

JOB DESCRIPTION

Job Title: Team Leader- TL

Supervisor: Client Services Coordinator

Wage:

Team Leaders work alongside Direct Support Professionals to lead a team in providing individuals with disabilities the support needed to live full and meaningful lives.

We are looking for those that understand the needs of individuals with developmental disabilities and can undertake the level of responsibility necessary to maintain exceptional client services.

Employment Qualifications:

*Must be at least 18 years old *High school diploma or equivalent *Pass an FBI background check * Valid driver’s license *CPR certification and all other state required trainings * Comfortable working independently and can consistently make good judgements that ensure the health and safety of clients *Flexible, with a keen ability to handle stress well *A friendly disposition with a positive ‘can-do’ attitude *Enjoys working with developmentally disabled individuals to improve their quality of life *Can quickly manage stressful situations responsibly and effectively *Strong interpersonal skills *Ability to move and stand for prolonged periods and frequently perform physically demanding tasks (e.g. lifting 35 lbs., twisting and bending, Hoyer, tie- downs, repositioning and PC care/showing needs)

Team Lead Qualifications:

  • One-year DSP experience or equivalent
  • Display professionalism in speech, written work and with employees, clients, volunteers and outside agencies
  • Driving:
    1. Have a vehicle every day that you work
    2. Meet and maintain Kokua’s driving requirements
    3. Ability to drive all Kokua vehicles to client appointments and community integration activities regardless of location or distance
  • Flexibility to work a day/swing/grave shift based on agency need
  • Carry Kokua’s on-call phone on a rotating basis

Ability To:

• Mentor, coach, and train new DSPs • Supervise and monitor the work of DSP staff in a fair and consistent manner• Organize and meet timelines; • Exercise discretion and judgement and make sound decisions under pressure; • Communicate sufficiently to explain protocols, procedures and individualized support plans to DSPs; • Implement person centered practices.

Responsibilities:

  • Maintaining an environment that ensures the health and safety of clients
  • Advancing clients decision-making, productivity, and participation in a range of activities that nurtures their needs, self-expression and goals
  • Assisting with and working to strengthen client’s daily living needs including but not limited to: nutrition, hygiene, exercise, communication and socialization skills
  • Delivering individualized training, encouragement and care in compliance with healthcare professional’s instructions.

Expectations

  • Uphold Kokua’s Code of Ethics
  • Uphold your mandatory reporting responsibility
  • Be knowledgeable of all Kokua policies and procedures
  • Follow the safety training guidelines to assure a safe workplace environment
  • Actively seek support and training when needed
  • Contact Kokua’s On-call system or your Client Services Coordinator with all client health and safety concerns
  • Oversee staff scheduling and review staff timesheets for accuracy
  • Attend team leader meetings and actively participate to improve client services
  • Maintain a positive line of communication between the work team and the Service Coordination Team.

The above description is intended to describe the general nature and level of work performed by employees in this position. It is not intended to be an exhaustive list of all of the duties, responsibilities and qualifications of employees assigned to this job.

Funding for this position: 100% ISS DSP JD updated Feb. 2019

 

“True leadership lies in guiding others to success–in ensuring that everyone is performing at their best, doing the work they are pledged to do and doing it well.” –Bill Owens

Overview of Position

A Team Leader is both a challenging and rewarding position. You are tasked with having a key role in overseeing the well-being of clients while promoting and cultivating a positive working environment for staff. You are not doing this alone but rather as part of team of support staff and supervisors. A Team Leader is not expected to complete every task independently, but rather to collaborate with direct team members and provide oversight to their team to ensure all necessary tasks are completed and provide optimal care for each client. In addition to performing all DSP duties as needed, you will be responsible for onsite management of the worksite and function as the direct supervisor of the DSP and Float staff. Your job performance and attitude are setting an example and standard for the staff you work with and supervise. You are to uphold all policies and procedures.

Time Management: See DSP Schedule Section. After staff are fully trained (completed peer coaching demonstrating independence with tasks) is when you delegate out work to other team members. They need to be completing the tasks outlined in their AOR to allow time for you to oversee medical care, goal planning, documentation, and the cleanliness of the worksite. You will need to rely on your staff to fulfill their job duties for you to have time for yours. It is essential to allow time in your day for documentation and overseeing the documentation of your team. All paperwork must be completed on time, accurately and thoroughly as this is our record of the care, we are providing to the individuals we support.

Time Off: See Kokua Policy 3.3. Employee Leave; See Above Sections Time Off (Vacation or Unplanned) & Requesting Scheduled Time Off. If you are taking a day off and have coverage arranged, please alert the client Service Coordinator and for any changes to you schedule. This will avoid scheduling confusion and you receiving communication during scheduled time off. Complete the Schedule Change form sheet that is in the house Staff Log to verify the shift change. Also complete the Time Off Request form when you are taking more than one planned day off.

Setting Boundaries: In addition to having professional boundaries with clients setting and keeping boundaries with the staff you supervise is equally important. You will need to treat each staff equally, fairly, and be neutral in your interactions.

One boundary you will need to uphold and enforce is not accepting communication from your staff when you are not at work and not on-call. If you are to receive a call or other communication like a text message redirect the staff to contact the Kokua On-Call after business hours. Staff are also explained the expectation during new employee training.

Schedule: When you start employment with Kokua Team Leaders are scheduled the primary day shift Monday-Friday. The position does require flexibility to work different schedules when staffing needs arise. You will work closely with the assigned Client Service Coordinator, Program Manager(s), Client Programs Director, the Scheduling Coordinator, and Human Resources as needed regarding your schedule.

Communication

The key to a well-functioning work team and resulting good client care is communication. Team Leaders need to effectively communicate orally and in writing and follow all documentation expectations when completing paperwork. Your supervisors and other Kokua employees involved in the client’s care, review documentation to keep updated. When anything occurs outside of the routine, day to day running of the worksite contact the assigned Client Services Coordinator who needs to be informed of what happens with the client, staffing concerns, or issues with the safety of the client’s home. When there is clear and prompt communication the rest of the team will be able to provide appropriate support.

Communication with non-Kokua Staff: As described previously in the Confidential Information section of the DSP section, you will need to communicate with providers, friends, family, and legal representatives of the individuals you work with. When the client has a legal representative they are asked to complete a Contact Preference form detailing how and under what circumstances they would like to be notified of what happens with the client. The preferences forms are available in the Client’s Individual Data section on Therap and in the Authorization section of the Medical and Medication Details binder. Read through the forms and refer to them when you have questions about when it is appropriate to contact a guardian or other legal representative. These forms are sent out once a year for review. You may also talk with the assigned Client Services Coordinator with questions regarding guardian contact. See Contact Preference Form.

Phone Calls and SCOMMS: See Phone Messages in DSP section of manual. Phone messages need to be checked at least once a shift. This does not have to be done by you. As part of shift change check the message book for any message written while you were off shift. Check the phone to see if there is an indication of voicemail messages. SCOMMS are checked at shift change and you need to make time to check SCOMMS during your shift, as this is how Kokua employees mainly communicate with each other. SCOMMS are also part of shift change. The expectation is you will respond within 1 business day. When you receive a phone call, receive a voicemail or SCOMM that you do not know how to respond to you must notify your supervisor during your shift. When you receive a call and do not know the answer at the time let the caller know you will need to look into it and will call them back (name a realistic time frame). What’s key is you acknowledge the communication, not ignore.

Communicating with Direct Support Professionals: Have check in conversations with staff routinely about how they feel their job duties are going and if they have any questions or concerns. Some staff will be forthcoming with sharing information as it comes up and others may not. It is your job to monitor the team and address any issues promptly, especially those related to a client’s quality of care.

Training

Training for the Team Leader Position

  • Before you will assume your role as Team Leader you will receive the following training:
    • New employees Orientation(See Overview section of Manual)
    • Training
    • QuickMAR
    • DSP Position
    • Client and agency specific training
      • Training with various Service Coordination Team Members-this typically occurs as a 1 to 2 days in office training. Including HR, Training, Health, Financial, Business Operations, and Client Enrichment.
    • Accountability Training
    • Additional 1:1 training with the Client Service Coordinator of your assigned worksite.
    • Nurse Delegation: You may assume some of your duties without this complete training. When you can become delegated is contingent on how long the Department of Health (DOH) takes to process your NAR credential request.
    • As soon as possible you will enroll in the Peer Coaching course led by Kokua. After successful completion of this course you are qualified as a peer coach. This allows you to sign off that the staff has demonstrated independence in all areas in the peer coaching packets. You will still help train new staff but will not be able to sign off on the packet verifying the staff understands and has demonstrated independence, without a certificate from the course.
    • On-Call: You will enter the on-call rotation schedule after 90 days employment as a Team Leader. A Client Service Coordinator, Program Manager, or the Programs Director will complete an in-person training of the expectations when you are on-call.

Additional Training: At any time, you would like additional training, which may include a review of a topic, task or further explanation about a client’s IISP contact the assigned Client Service Coordinator during business hours to discuss your needs and request support. You are expected to ask for assistance when needed. The Client Service Coordinator will be in close communication with you for mentoring, supervision, and support, however you will need to ask for additional resources or support when needed.

Training Staff: You play a key role in training and mentoring staff including new and long-term employees. Putting time and effort into fully training your staff leads to a more capable and self-sufficient team, which is the goal. Training is also referred to as Peer Coaching. You are the example for staff of following the appropriate procedures, polices, and best practices.

New Staff Training Schedule: The training department and, or the Onboarding Coordinator puts together a schedule for new staff of all required training. A member of the training department will contact you to set up the initial day of peer coaching for the staff. After that date, you are responsible for arranging the training schedules that you deem most effective for the new staff to learn about the clients, and what happens on different shifts at the worksite. The recommendation is to have the staff start by working day shifts with the Team Leader for training. After work swings, and a grave to have a better understanding of the client’s needs and routine of each shift. Work with your Client Service Coordinator for support and any additional staffing needs you foresee when setting up the training schedule. Staff needs to know and understand how to perform all DSP duties, even if they may be working a shift where that task is not needed. Due to many of our clients having complex medical conditions care needs may change quickly, which necessities staff schedule changes. 

Training Approach: While training keep in mind that everyone has different learning styles, strategies, and works at a different pace. When you model tasks and coach staff check in regularly to see if they have questions and to gage understanding of the task or skill you are working on at the moment. You are there to share knowledge and experience. Patience is needed and the ability to adapt to how you share and teach new skills based on the learner is critical for successfully training your staff members.

Peer Coaching Packets: Completing the Peer Coaching packet with the new staff is a mandatory training requirement. A staff completes a peer coaching checklist, referred to as a packet, for each client at the worksite. A separate checklist is required for the orientation of the worksite. For each topic in the packet that applies to the client, the staff is trained, the staff and coach will sign off verifying that the new staff understands, and can independently complete the tasks. After the staff has completed the packet, review for accuracy, and all required signatures before submitting it to the Training Department. The deadline for the staff to complete peer coaching is on the first page of the checklist. Refer any questions on how to complete the checklists to the Training Department. When an existing client moves to a different household within the Kokua program or a brand new household is established, each staff needs to complete a worksite orientation form and submit it to the training department. Direct questions regarding Peer Coaching to the Training Department.

Client’s Role in Training: Depending on the client’s preference and functional ability, they will be involved in different degrees in the training of their staff. Clients are the best sources of information on what works for them and how they like things done in their home. They need to be included as much as possible during the process. Remind and instill in staff the importance of observing the client’s routines, how they do things around the house, and their reactions to learn what works. Especially for our individuals who communicate in ways other than verbally, this is a form of communication that is not familiar to many new staff.

Independence and Assigning Tasks

Ensure staff understands the task being asked of them by observing their work, requesting they show you how to do the tasks, and allowing staff the time to ask questions to ensure they are fully aware of the expectation. Do not assign a staff a task until you are confident in their ability to do the work. Refer to the Peer Coaching Packet checklists, which for each learning area uses the following process, model the appropriate way to complete the task, guide the new staff as they practice, and observe their demonstrated independence with completing the task. As new job duties are assigned to an employee you will need to follow the same process outlined above when teaching. If you have made attempts to teach the skills or task and the staff are not able to complete correctly, contact your Client Service Coordinator for assistance during business hours as they can provide additional support or refer you to the most appropriate department. If assistance is needed after hours contact the Kokua On-call system. Refer to the Retraining Process below for more details.

Accountability: One of your main responsibilities as a Team Leader is to uphold a high standard of work for yourself and those you oversee. The goal is always deliver the best client centered care possible. When staff are not meeting standards (following best practices, agency policies, procedures, WAC, or DDA policies and procedures) you will provide mentoring and retraining when needed.

Explaining Your Role in Training to Staff.  When a staff begins training with you, let them know their success is important to you. As a Team Leader, you need to have direct conversations with your staff explaining you have a responsibility to mentor and teach. In that role, you evaluate their performance and when you see or hear their work is not at an acceptable standard first you will talk with them and show the correct way to do the task. You need to always directly ask the staff if they understand the task or expectation. Also, ask the staff, “Will you do it correctly from this point forward?” Being open and honest with staff will help the person to feel supported and sets the expectation from the beginning that issues will be addressed promptly.

Refer to Team Leader Accountability Training for more instructions and examples.

Mentoring and Training needs to occur anytime a staff has breached (not followed or followed correctly) any of the following:

    • Policy
    • Procedure
    • WAC (Washington Administrative Code)
    • IISP
    • PCSP
    • Client protocols
    • All client care plans
    • Team Agreements
    • Kokua Code of Ethics

The Retraining Process

  1. Mentoring-Verbal Refresher-Explaining and demonstrating the applicable task, policy, etc. Ask staff directly if they understand and if they will complete the task or follow the policy, etc. from this point forward. Document mentoring on a Training Support Record. Alert the assigned Client Service Coordinator that mentoring was completed. Provide the name of the employee and topic.
  2. Team Leader Level Retraining: When there is still poor performance after mentoring, do a retraining with the staff. Again, review the policy, skill, task, etc. that the staff is not meeting the set standard. Training needs to include staff actively participating such as, re-reading a client’s care plans or demonstrating a skill correctly. Perform the training with the staff in the applicable area or refer to the Training Department. Ask the staff directly if they understand and if they will complete the task or follow the policy, etc. from this point forward. Document retraining on a Training Support Record. Alert the assigned Client Service Coordinator that a retraining was completed via phone or SCOMM as soon as reasonably possible. Provide the name of the employee and topic.
  3. Client Service Coordinator Level Retraining: When there is still poor performance after the Team Leader has completed a retraining with the staff you will alert the assigned Client Service Coordinator who will need to meet with the staff to do a retraining, including a Training Support Record. Alert via phone or SCOMM as soon as reasonably possible.
  4. Human Resources (HR) Written Warning: When there is still poor work performance after the employee has been re-trained by the Client Services Coordinator, alert the assigned Client Service Coordinator and HR of the issue. Alert via phone or SCOMM as soon as reasonably possible. HR is responsible for completing and reviewing a written warning with the staff. HR will work with the employee to determine what barriers to successful performance may be present.
  5. Human Resources (HR) Final Warning. When there is still poor work performance after the employee has received a written warning alert the assigned Client Service Coordinator and HR of the continuing issue. HR will work with the staff on a final warning regarding their work performance. Alert via phone or SCOMM as soon as reasonably possible.
  6. Termination: If there is still poor work performance after the staff has received a final warning of the need to improve, alert the assigned Client Services Coordinator and HR. Alert via phone or SCOMM as soon as reasonably possible

Training Support Records-Mentoring

Training Support Records are how we prove the training and mentoring has occurred to support an employee to correct their work performance. The form documents what the training consisted of, the staff’s understanding of the training, the staff’s cooperation, or refusal to participate in the process. The Training Support Records are filed in the employee’s training file and personnel file.

Below is an overview of how to complete each section of the Training Support Record

Mentoring Level: Check the refresher or TL box depending if this is the first or second time you have addressed a specific work performance issue with the employee. See Training Support Record.

Topic or Policy Being Addressed: Explain what the subject of the training is. For example, Code of Ethics, Policy 2.4 Medication Procedures

Brief Outline of Issue/Infraction: Explain how the standard, policy, or procedure is not being upheld by the employee. For example, not all required client documentation has been completed during your shift. Including signing MARS, writing a T-log and documenting client’s elimination as required by their bowel protocol. This happened 4 out of the last 6 shifts you worked.

Overview of Expectation: Be Specific. You can take the information directly from Kokua’s Policies and Procedures, the job description, Code of Ethics, client protocol or IISP, etc. Use whatever document is applicable depending on what the nonadherence was. For Example, if the 5 Rights of Medication Administration plus documentation have not been completed 100 % of the time write “In addition to all employees following the 5 Rights of Medication Administration each individual is expected to complete accurate, thorough and timely documentation of medications administered. Any medication missed by a client for any reason requires a GER to be completed and submitted by the end of your shift.” Also, if there are documents that would be helpful to the staff to know about and use for reference cite those for example. “Follow the MAR training document in the Staff Log for documenting administering meds.”

Specific Correction/Improvement: List or describe briefly what needs to change in order for staff to be meeting the expectation. For example, if a staff has not been completing all documentation on a client’s MAR explaining what needs to be present such as: “Initialing/signing bottom of each MAR sheet(s) if any meds were administered; initialing for all meds. Administered, having complete entries when PRN medications are administered-all columns complete, full signature and credentials.”

Training Requested or Available: Ask the staff, “What other training would be helpful to you to understand your duties and the expectations?” When an employee requests any specific training or materials write down exactly what they asked for. You may also recommend or require a training. For example, as that the staff meet with a trainer to review the Core Curriculum chapter on Medication Administration. Set a deadline for completion and write the deadline on the Training Support Record.

Signatures After completing the retraining ask the employee to read the entire form and sign if they are in agreement with what has been written. If they refuse to sign ask them to write an explanation on the back. Staff do have the right to refuse. Inform the staff you will alert the Client Service Coordinator so they are aware if a refusal to sign occurs.

What to do with the Training Support Record To ensure the privacy and confidentiality of the staff, do not leave the Training Support Record at the worksite. If you are unable to deliver the document to the assigned Client Service Coordinator the same day, contact them to request assistance picking up the form, which is filed by the Client Service Coordinator as a record of retraining and used as a reference, if any further incidences occur with the staff.

Job Duties

Below is a review of the duties that fall into the scope of the Team Leader job description.

Scheduling: The Team Leader has the first level responsibility of overseeing the staffing schedule for the worksite. To complete this task, do the following:

  • Use the correct schedule for the worksite. If you are unsure if the schedule form you have is current, contact the Scheduling Coordinator or the assigned CSC to verify.
  • Schedule forms are for one-week time periods and include each shift at the worksite.
  • Review the upcoming week’s schedule for any changes, including staff taking time off, check the Temporary Schedule Change record for staff trading shifts, or any client outings, appointments, or meetings that will require additional staffing.
  • Communicate with the assigned Client Services Coordinator promptly when you see additional staffing will result in overtime.
  • Write in the schedule for each day with all the shifts that are covered.
  • Review the schedule for any open shifts. When you have open shifts:
    • Talk with the staff about working additional hours.
    • Contact the fill-in staff on the phone list with the available shift information.
    • Contact the Client Services Coordinator and the Scheduling Coordinator when you have questions about scheduling staff or need support filling open shifts.
  • Submit the schedule to the Scheduling Coordinator and assigned worksite CSC each Tuesday.
  • The assigned Client Services Coordinator and, or the Scheduling Coordinator will communicate any schedule changes they make with you. This may be done orally or via SCOMM.

Refusals: See Client Refusal in Overview section of manual. Team Leaders have the additional responsibility of check each client’s Daily Charting book every shift they work to see if any refusals forms were completed. Also, if you learn of a refusal check to verify a GER was completed with all the necessary information. After reviewing the form to ensure it is accurate and complete provide your signature and work on any needed follow up depending on the natures of the client refusal. Each week submit the refusal forms to the assigned Client Services Coordinator when you turn in timesheets. The Client Services Coordinator completes a second review and files the form in the individual’s record at the Kokua office.

Reviewing Documentation: See Documentation Standards in Overview section. In general, Team Leaders have a responsibility to provide oversight that staff is documenting following all standards, policies, and procedures. Each day you will need to build in time for documentation reviews. You have to complete ongoing monitoring of staff’s work and provide training when staff is not fulling their duties.

Medication Assistance and Administration

Medications: See Medication Assistance and Administration in DSP section; Kokua Policy 2.4 Medication Procedures. WAC and DDA policy dictates what the service provider must do when the client’s PCSP identifies the service provider is involved in assisting a client with their medications.

See WAC 388-101D-0310 Medication assistance; 388-101D-0315 Medication administration—Nurse delegation; 388-101D-0320 Medication administration. See DDA Policy 6.19 Residential Medication Management ; 6.15 Nurse Delegation Nurse De

Medication Administration Records: Kokua is transitioning to an eMAR (electronic medication administration record) system through QuickMAR, which is a company, providing cloud-based healthcare software. QuickMAR connects Kokua with Lincoln Pharmacy services via an interface. You will access the eMAR from a designated laptop at your worksite. Be prepared to use an electronic or paper MAR to pass medications following the 5 rights and to document as verification that the rights are followed. You will be trained on how to use QuickMAR and informed of your permission levels by the Training Department and or the Healthcare Advocate. Login information is assigned at new employee orientation. Additional self-guided trainings are available through the online QuickMAR portal. Per WAC 388-101D-0340 Medications—Documentation. The service provider must maintain a written record of all medications administered to, assisted with, monitored, or refused by the client.

Daily MAR checks ensuring charting is completed and medications administered (part of shift change responsibilities)

At shift change you will review the MAR with the staff that is leaving shift when you arrive and with the oncoming staff when you are leaving shift. This is the opportunity to ensure all medications have been administered and documented appropriately for your shift. Also, before leaving physically check the routine medications packaged in strip packs to ensure all medications have been administered up until the time of shift change.

Completing Weekly MAR and Documentation Reviews

Besides completing a MAR review at shift change, once a week Team Leaders do a thorough review of each client’s Medication Administration Record to check for accuracy and completion. See Daily and PRN MAR Review sheets.

How to Complete a Review: These checks are done at the end of each calendar week and documented on the Daily Medication Administration Review or the PRN Medication Administration Review form. Use the right form for the section of the MAR you are reviewing. Physically look at each page of the client’s MAR, front and back. In the comments section note any errors (see below for what to look for) or concerns you find. If there are no corrections, write in the Comments column, “No corrections needed” for the reviewed week.

Documentation Errors: Write down the error in the Comments column, the name of the responsible staff, and when you contacted them to make corrections. The staff has 24 hours from the time you contacted them to complete the necessary documentation. Any missing or incorrect documentation is also the time to complete mentoring, a verbal refresher training with the staff. If documentation cannot be corrected or completed that needs to be noted in the comments section. For example, if the staff commits the errors is no longer an employee of Kokua write” staff name is no longer employed at Kokua.”

The expectation is that any changes, corrections, or additional documentation are completed before the MAR is submitted to the Health Specialist by the 7th of each month for a second review. After a second review, the Health Specialist communicates any needed corrections to the staff. They must be completed by the end of the last day of the month.

Completing a Feeding & Flush Chart Reviews: When a client has a feeding tube, Team Leaders will also need to be completing reviews of the charting. Follow the same process in the above weekly documentation review and documentation error section. Document on the Feeding and Flush Schedule Review form that is turned in with the Feeding & Flush Schedules each month to the Health Specialist for a second review. See Feeding & Flush review sheet.

Below is a list of what to look for during your MAR reviews. This list will review what needs to be included in proper documentation and also what constitutes a medication error.

  • Review the MAR for initials signifying medication administration.
  • Ensure initials and signatures are present on the bottom, front of MAR pages on each page you have initialed for administering a medication.
  • Look for any blanks on the front of the form when you are completing MAR review at shift change
  • If you have administered a PRN medication, ensure this information is completely documented on back of form. (SEE EXAMPLE).
  • Ensure you are signing the back, bottom left of MAR in the Staff Signature sections when you have done any documentation on back of the MAR. In this section you need to include credentials, initials and signature. (SEE EXAMPLE)
  • Ensure is used for missed medications on front of MAR and is used for refused medications on front of form in the corresponding date boxes. Complete necessary documentation on back of MAR. Write a GER for any missed and/or refused medication. Contact Kokua On-Call to notify of all medication errors.
  • Ensure is used in corresponding date boxes when client is in hospital. Write in reason column on back of MAR “client is hospital.”
  • If you initial in error, circle your initials and write a note on the back of the MAR explaining that you initialed in error and communicate this to the staff that will be passing that medication. The staff who then actually give the med should initial just below the initials that were entered by mistake.
  • Never scribble or scratch out any documentation. If you make an error put a single line through the error and initial. Write the correction below or above.
  • Never cross out another staff’s initials or write over their initials.
  • Ensure appropriate color coding is used for medication times. (SEE CHART) The color should only be applied to the small rectangle where the med time is written.
  • Blue and black are the only acceptable ink colors to use on all paper documentation. The use of white out is never acceptable.
  • Do not use a highlighter to point out to staff missing documentation on MAR. For example, do not highlight empty date boxes or signature lines. Please use another method to indicate to staff where documentation needs to be completed or corrected.
  • After making any entries on the backside of the MAR make sure you sign in the signature column. Initials are not acceptable. You must put your credentials after the signature.

Charting and Medication Administration Errors to Watch for

  • Not administering medications
  • Signing that medication(s) were administered when medications have not been given
  • Not making changes to MAR-not transcribing new orders, dose changes or D/C orders
  • Making changes to the MAR without written orders from pharmacy or licensed prescriber.
  • Not administering medications during approved windows.
  • If a medication is administered outside of a prescribed window with approval, ensure a is used in the corresponding date box. Complete necessary documentation on back of MAR.
  • Giving inaccurate medication (not prescribed medications) Example: Client has a prescription for Tylenol 325 mg and the medication purchased and administered was Tylenol 500 mg.
  • Giving the wrong dose-Giving more or less than prescribed
  • Not calling in refills, leading to missed medications
  • Administering to the wrong client-Clients cannot share medications
  • Administering wrong route Example(s)- Putting a medication prescribed for ear into the eye, administering a medication in G-tube when its prescribed to go in J-tube.
  • Not signing the MAR with initials and full signature (front of MAR) when administration has taken place.
  • Not completing PRN documentation or partial completion (on back of MAR-initials, signatures with credentials and results or responses, time given). On back of the MAR need to complete all columns. You may use N/A if it is applicable for the BMI (Behavior Management Intervention) and MSE (Medication Side Effects) information. Use the Key at the top of MAR when applicable.
  • Documenting inaccurately- Example-in Reason column on the back of MAR writing comment “out of medication” when client refused to take medication
  • Signing for the wrong medication
  • Giving an expired medication. * Please check PRN medications carefully before administering*
  • Improper storage of medications-Examples: Not refrigerating a medication that requires refrigeration. *Look for refrigeration label on packaging* Not locking medication boxes or storing medications in locked boxes.
  • Administering a medication or completing a delegated task when staff is not delegated by Brittney Hyland, Delegating Nurse. Health Advocate, RN cannot delegate staff.
  • Giving a PRN medication to treat a condition that it is not prescribed to treat. Example-Giving Benadryl to aid a client’s sleep when it is prescribed for colds and allergies.

Prepare the Medication Administration Record (MAR) for the Upcoming Month:

On approximately the 20th of each month, the pharmacy delivers the clients’ Medication Administration Records (MAR) for the following month. Reconcile the client’s MAR for the upcoming month by comparing the new month’s MAR to the current month’s MAR that you have been using. Update the new MAR with any changes that occurred since the new MAR was printed. When you notice something is off, such as a medication is not present that you think should be, a dosage is different, and you have no documentation to explain why etc. let the Health Coordinator and the assigned Client Services Coordinator know and we will help you look into this further. This task must be done before the last day of the month. If changes occur before the first of the new month after you reconcile the MAR, you must go back and reconcile them again. If you need assistance, please contact the Health Office before the last day of the month to allow sufficient time for support.

Medication Check in Procedure: See the Medication Check-in Procedure in DSP section for instructions to complete the task. As a Team Leader, you check-in medications when needed and time allows. As part of your oversight role, review the medication check-in sheets once a week for the following:

  • Medications Deliveries are documented.
  • The staff is completing the form correctly.
  • Always have the client’s name with the year on the form.

When you notice a delivery is not documented, check the medication delivery slip for the staff signature. Talk with the individual to determine if they checked in the medication if so, have a mentoring conversation about the process of medication check-in. If the staff who signed for the delivery is not the person responsible for checking in the medication, talk with other team members. Once the appropriate person is identified, have a mentoring conversation about the medication check-in process. The check-in forms are removed at the end of the calendar year to the archiving binder.

Medication Profiles or Master Medication Lists: The medication profile sheets from the client’s pharmacy must be current and available at the worksite. This is important because the profile is used by medical professionals and when a client goes to the hospital. When the client uses a different pharmacy, request a profile of all their medications. The profiles are only as accurate as we make them, which means you have the responsibility to have all medication changes including discontinued medications, new medications, and order changes reflected on the master list or profile. The Health Office prints a medication profile for each client from Lincoln Pharmacy that is ready on the 25th of each month. You will need to handwrite any changes to the Medication Profile as they occur. When there are new orders, contact the Health Office to request a copy of the Medication Profile. A print out is available within 1-2 business days. When you receive the new copy always archive the outdated profiles to ensure the most current list is available at all times. See Example Profile.

Medication Disposals: See the Medication Disposal section in DSP section. Team Leaders dispose of medications when needed following the proper procedure. You have the additional responsibility to verify that the medication disposal sheets are accurate. Check the disposal forms weekly for complete entries made for each medication on the form. When a medication in the lockbox does not have an entry, talk with the staff who disposed of the medication to have a mentoring conversation about the disposal procedure. When all medication is accounted for accurately on the sheet, then they are ready for removal. The assigned Client Service Coordinator checks the locked disposal box weekly. When the box is full and cannot properly lock, contact the assigned Client Service Coordinator to remove the contents. When a controlled medication is disposed of, contact the Client Service Coordinator, or The Kokua On-call system, after hours to have it removed from the worksite promptly. See Medication Disposal forms-Controlled and Non-Controlled.

Medication Availability and Ordering Refills: See the Medication and Supply Ordering section in DSP Section. Prescribed medications must be available to the clients at all times. You have the responsibility to ensure all medications are at the worksite and refills are ordered promptly to avoid a client missing medication. The level of support a client needs with medication orders will be identified in their Person-Centered Service Plan. The staff assigned as the worksite Safety AOR checks the medication supplies once a month to see that all are present, and none have expired. This task is done by cross-referencing with the Medication Administration Record. As the Team Leader, you need to follow up with the staff and ask if the check has been done, and done correctly. Direct staff to write down any medications that were on the Medication Administration Record, but not in the medication lockbox, those expiring this month, and any medications with 7 days or less remaining. 7 days remaining is a good guideline, as this allows time for a provider to respond to a refill request from the pharmacy if the prescription is expired. The refill process turns- around time can take up to 72 hours. Based on information collected the Team Leader or staff you delegate the task to calls in a refill request to the pharmacy and documents on the Medication Order Log. The staff needs to record the call to the pharmacy in a T-log. Document the phone call, who you spoke with, and what information was given to you about the refill. Be mindful when refills have not yet arrived and only 1-2 doses remain. This is your cue to call the pharmacy again to check the status of the refill request. Document the follow-up call in the T-log.

Inventorying and Ordering Supplies: See Medication and Supply Ordering in DSP section. As a Team Leader you have the additional responsibility of ensuring that all medical supplies the client may need are in stock and ordered promptly when supplies are running low. The best way to prevent running out of supplies is to do a weekly inventory for each client. This would include gloves, any supplies needed to test blood sugar, tubing and filters for CPAP, supplies for nebulizers, feeding supplies, care for ostomy and g and j tubes and any other supplies clients need for medical treatments. You can delegate this to a staff who has more down time on shift like swing or grave. Direct them to document the inventory on the Medical and Medication Supply form (See Appendix). In the note’s column document, the date of inventory and the supplies remaining. Reorder when a 7-day supply is remaining or as needed, see form for specific to allow time to process through insurance and delivery time. A staff can re-order but you are responsible for following up with the identified staff to verify the order was placed. An individual may use more than one vendor for their supplies, so you will need to learn this information, and how refills are addressed with each supplier. See Supply Inventory, See Inventory for client with tube.

Medication Changes-What should you do?

When an order changes for a client including a new prescription, discontinuing or changing the dose or other instructions follow the steps below.

  1. Ask the provider for a hard copy of signed prescriptions or a signed discharge medication list for new medications and/or changes (dose change, d/c, new med, etc.)

Examples of Prescriptions (see below): Pay attention to the important features of a prescription as documented in the images below- client name, medication, strength, frequency, route, and the physician’s signature

http://www.medicalschoolhq.net/wp-content/uploads/2012/03/script_errors_Example3.jpg http://www.medicalschoolhq.net/wp-content/uploads/2012/03/script_errors_Example2.jpg https://img.apmcdn.org/80c5702ac82e9ac239f6b2f259441d32abcce000/uncropped/045f54-20061128-newprescrip.jpg

Note: Instead of a handwritten signature, you may also see the prescriber name typed and “Electronically signed by”

    • Note: We can’t use range orders (example of range directions: 1-2 tabs.) Please inform the prescribing physician of this and ask them to clarify this by writing the prescription with exact directions.-For Nurse Delegation.
    • Aside from prescriptions, the only other orders used to change a Medication Administration Record (MAR) is a discharge medication list if a client has been admitted to a hospital and is being discharged. Do not change the MAR based on after visit summaries for routine medical visits, ER, or Urgent Care visits without a signed prescription.
  1. Contact the assigned Client Service Coordinator during business hours and the Kokua On-Call System after regular business hours and on weekends to report all medication change orders.
  2. Team Leaders should scan a copy of the prescription, after visit summary, and any relevant medical paperwork from the appointment.
  • On the Scanner select the name of the assigned client service coordinator and the name of the Health Coordinator. The records will be e-mailed directly to them.
  • If for any reason you cannot scan the documents the same day as the appointment, inform your Client Service Coordinator when you contact them about the medication change. If this occurs afterhours, or on a weekend the documents need to be scanned the next business day.
  1. Fax a copy of the change to the pharmacy. The assigned CSC will assist as needed but please communicate any support needed with getting the prescription to the dispensing pharmacy.
    • Note for clients that use Lincoln Pharmacy: If the medication change is not being filled by Lincoln, you still need to send it in to them with a note that states “DO NOT FILL” so they have the prescription for their records.
  2. Call the pharmacy to ensure they received the prescription and find out when it will be delivered
    • Note for clients that use Lincoln Pharmacy: If this change is from an afterhours Urgent Care or ER visit and the medication is an immediate need (severe pain medication or an antibiotic) for that night and Lincoln cannot get it out to us, please utilize either the clinic/hospital pharmacy or a nearby pharmacy (Walmart, CVS, Rite Aid, etc.) If you need further guidance or support, call Kokua On Call.
  3. Contact the delegating nurse if your client is delegated to ensure she is aware of all medication changes. Do not give the medication until you have been delegated if it is a new task. For example, a client is prescribed eye drops or ear drops and has never used these before.
  4. Create a Med Alert letting staff know about new prescriptions so staff knows to expect that new meds are arriving. Please note on the med alert that staff should follow up within 24 hours if the expected prescription has not arrived
  5. Transcribe the medication change to the MAR All changes to medication must be transcribed on its own new line; we cannot just cross something out on a pre-existing order.
    • Note: Don’t forget to write Start, Stop, or Order Change, the date, the provider, and your initials, in addition to drawing in the appropriate lines to indicate the exact date and time when medications start.
      • Example: Start 4/24/17 per Dr. Feelgood PV confirmed by LR
      • Example: Stop 4/24/17 per Dr. Feelgood PV confirmed by SB
      • Example: Order change per Mary Mack, ARNP JM confirmed by PV
    • Note: Don’t forget to check the labels on prescription meds from the pharmacy to ensure they match the written prescription directions.

Use the Reference Tool Medication Administration Record (MAR) located in the staff Log for examples of how to transcribe orders.

  1. Use Med Alert pages to flag changes to medications in stock. Call Lincoln to request new labels for these medications, if they were filled by Lincoln Pharmacy.
  2. Document all appointment details in the Appointments on Therap. Please make sure you create new Therap Appointments for follow-up appointments or reminders to schedule follow-up appointments. Follow the Documenting Appointment Training, update 8.2021.

 

  1. If a second staff is on with you, have that staff review your changes and confirm they are accurate. Once accuracy is confirmed, have them write “Confirmed by” and their initials. If you are single staffed, have the staff coming in to relieve you confirm the accuracy of your transcription during shift change.
  2. Place the prescription in the Medical and Medication Details book under the “Prescriptions” tab

Narcotic Books: See Narcotic Book in DSP section of the manual.

Each staff member is responsible for following the Narcotic Book Instructions. See Instructions at the end of Narcotic Book Section.

  • Checking in
  • Administration
  • Counting at Shift Change
  • Discontinuation of a Narcotic
  • Dose Change
  • Medication Administration by a 3rd Party

Team Leaders have the additional level of responsibility of ensuring staff follows documentation standards for the Individual Narcotic Record Sheets and Change of Shift Verification Signatures sheets. After you know a new narcotic or a refill has arrived, check the Individual Narcotic Record to verify the information was completed correctly. If you see any discrepancies, inaccurate information, or errors you need to check the client’s MAR, T-logs, General Event Reports (GER), and talk with staff to determine what occurred. Depending on the issue, have a mentoring conversation with the responsible staff, and inform the assigned Client Service Coordinator, if support is needed. The Narcotic Books are reviewed at each shift change as well. Team Leaders contact the Health Office when you have approximately 3 days remaining in the book in the Individual Narcotic Record Sheets or Change of Shift Verifications. You will be provided a new book. Bring the full book into the Kokua Health Office to be filed in the client’s record.

Healthcare

Nursing Hours and the Health Care Advocates: Some individuals have been assessed by DDA as needing additional oversight and support for complex medical needs that is provided by a Healthcare Advocate, who is a registered nurse. When you start at your worksite you will be informed if any of your clients are on the caseload of the Health Care Advocate. This individual provides additional support to you and the other staff to ensure the client’s needs are being met and advocates with the client’s medical team. For example, coordinating appointments, clarifying doctor’s orders, requesting new orders, and helping with hospital discharges. The Health Advocate will work with the Team Leader, Client Services Coordinator and Health Office to determine the individualized support that is needed for your clients and on how they would like to be kept informed of the client’s status. A general guideline is to communicate any information regarding the client’s health, mental health, and general welfare to the Health Advocate, who has access to all of the client’s records.

Monitoring Client Health Status: All staff needs to be observant to notice any changes in a client’s behavior or health conditions. All changes need to be documented in a Health T-Log and depending on the severity, like an illness or injury also in a General Event Report. Talk with your clients regularly about how they are feeling and ask if anything is concerning or bothering them. If a client communicates in ways besides, verbally look for their known communication signs that they may be experiencing pain. Some clients may not want to tell you or don’t know how to tell you about pain or other symptoms they are experiencing.

Team Leaders have the responsibility of overseeing that staff are following all doctor’s orders, protocols, and treatments. If this is not occurring you will begin the steps in the retraining process and talk with your supervisors. Communicate promptly with your assigned Client Service Coordinator and the Healthcare Advocate RN, if the individual is part of their caseload about any concerns or changes you have noticed in the client. They need to be aware of all issues in order to ensure the client is receiving the needed care and supports. These staff will also help communicate with the Health Coordinator. See Pain Job Aid, See WAC 388-101D-0190 Changes in client service needs—Nonemergent; WAC 388-101D-0195 Changes in client service needs—Emergent

Appointments: WAC requires 388-101D-0150 Client Health Services Support requires the service provider (Kokua) must provide instruction and/or support as identified in the PCSP and as requested in this chapter to assist with

  • Accessing health, mental health, and dental services
  • Medication management, administration, and assistance
  • Maintaining health records
  • Arranging Appointments with health professionals
  • Monitoring medical treatment prescribed by health professionals
  • Communicating directly with health professionals when needed; and
  • Receiving an annual physical and dental examination unless the appropriate medical professional gives a written exception.

Any time a client would like to schedule a health appointment, support them with this process to the degree needed. The client’s IISP and PCSP will identify what supports the individual needs.

As the Team Leader, you are responsible for supporting a client to schedule medical appointments as recommended by their medical care team, including all follow-up appointments and lab work. These need to be scheduled and completed following the advised schedule by the provider. For example, if a podiatrist tells a client to come back in 3 months, support the individual to look at the calendar, and schedule the appointment within that timeframe.

Team Leaders will attend the majority of appointments with a client to support and advocate. Follow the steps in the Procedure for Appointments below to ensure a successful visit. Also, see the Direct Support Professional (DSP) section of the manual for details of the DSP’s role with Appointments. You may delegate out a routine appointment to another staff when they are completely trained with the client, are familiar with the individual’s medical issues, and are trained on the appointment process. A client needs to be accompanied by the Team Leader to any urgent or critical appointments. When you need support arranging staffing for appointments or additional assistance at the appointment, contact the Client Services Coordinator as soon as reasonably possible.

Annual Exams: The Team Leader tracks when the client is due for annual wellness, dental, and every 2-year or more frequently as ordered eye exams. When a client’s annual exam is due within the next 6o days, call the provider to schedule, as it may take a few months to get in. Ensuring every appointment is scheduled in Therap will help you remain organized with medical appointments. You can use the search function to look for an upcoming appointment if this is helpful. Scan all the appointment information to the Health Coordinator and the assigned Client Services Coordinator for annual appointments. The original paperwork is filed in the client’s Medical and Medications Details book in the appointment section.

Appointment Schedule Forms: To assist with tracking the medical appointments the Client Service Coordinator or the Healthcare Advocate maintains the Appointment Schedule form for the client. This document has the dates of when medical appointments have been completed and the next due date. This information is gathered from Therap Appointment entries and After Visit Summary information. Team Leaders have a responsibility to add any changes to the form and submit monthly at the Team Leader Meeting or give the form to the assigned CSC. An updated Appointment Schedule is sent out on or near the first business day of the month. Always keep the most current copy in the client’s book. All other versions of the form are archived. See Appointment Schedule form.

What if A Scheduled Appointment is Not Completed? When a client does not complete a scheduled appointment write the reason in the comments. For example, “client name refused to attend”; “provider rescheduled due to being sick”, or “the appointment was rescheduled to a date”. Leaving the Comments section blank makes it appear as if a client did not complete an appointment, even if they did.

Procedures for Medical, Dental and Mental Health Appointments

Preparing for the Appointment

  • Discuss what will happen at the appointment with the individual
  • Follow any instructions to prepare such as fasting, taking pre-procedure medications, wearing appropriate clothing, etc.
  • Ensure you have all the arrangements made for staffing and transportation, including staff to transfer client when in a wheelchair and a wheelchair accessible vehicle, or Dial a Lift scheduled.
  • Talk with the Assigned Client Services Coordinator, Health Office, or the Healthcare Advocate at least 2 business days in advance if there are any supporting documents you need printed, such as a current medication profile, blood pressure, blood sugar, or behavior tracking logs.
  • Prepare any paperwork as much as you can in advanced to increase the likelihood the provider will sign the requested documents. For example, if a psychotropic annual review form is due for the client, complete all the information, so the prescribing professional only needs to review and sign.

What to Take to the Appointment

  • Medical & Medication Details Book. This includes the current medication profile, prior appointment information and insurance cards
  • Current MAR
  • Ask the client to take their wallet or purse if it contains ID and insurance cards
  • Any notes regarding questions and the agenda for the appointment
  • Any documents the medical office has requested the individual bring to the appointment
  • Any forms you need reviewed and signed. For example, if this appointment is for medication monitoring bring the psychotropic medication forms that require the provider’s signature.
  • Any medication or supplies that may be needed during the time period you will be out.
  • Paper and a pen to take notes. This information will be transferred to Therap after the Appointment.

What to Do When You Arrive at the Appointment

  • When needed support the individual to check in the receptionist desk and provide the requested information
  • Ask the individual where they want to sit and wait. If they do not indicate select an area you think they would be comfortable.
  • For some appointments the clinic staff may ask you to wait in the waiting area. For example, if the client is having an x-ray, other diagnostic testing or counseling sessions. This is okay. Remain in the waiting area should the medical staff or client need your assistance.

What to Do During the Appointment

  • Support the client during the appointment to the degree needs. Some individuals are more comfortable than others talking with their medical team. Encourage the client to answer questions themselves, when possible.
  • Provide the requested information to the provider. Ensure the information provided is concise and factual. Refer to the notes and agenda you prepared before the visit. Also utilize any of the supporting documents you brought to the appointment.
  • When asked a question you do not know the answer to, write it down and let the provider know that someone at Kokua will look into this and contact them.
  • Take notes on the information related to you, as not all clinics provide an After-Visit Summary at the end of the visit.
  • For any medication changes ask for a written order and that the change is sent to the pharmacy. Tell the clinic the pharmacy will not make any changes or fill a prescription without a written order. Most providers electronically send orders to the pharmacy. Ask the doctor to sign the After-Visit Summary or any document that has the medication changes.
  • Ask any clarifying questions to the provider before you leave.
  • Assist the client to schedule another appointment, when needed

What to Do After the Appointment

  • Check in with the client to see if they have any questions or concerns about the appointment.
  • When a client has a paper prescription and is not using Lincoln pharmacy go to the client’s preferred pharmacy to fill the prescription. For example, a client may need antibiotics and will decide to go to a local Safeway or Walgreens to fill. This is okay as the client has the right to use a pharmacy of their choosing.
  • For clients that use Lincoln Pharmacy: If this change is from an afterhours Urgent Care or ER visit and the medication is an immediate need (severe pain medication or an antibiotic) for that night and Lincoln cannot get it out to us, please utilize either the clinic/hospital pharmacy or a nearby pharmacy (Walmart, CVS, Rite Aid, etc.) If you need further guidance or support, call Kokua On Call.
  • Contact the Client Service Coordinator during business hours and the Kokua On-Call System after hours, if any medication order changes are prescribed to the client.
  • Team Leaders should scan a copy of the prescription, After Visit Summary, and any relevant medical paperwork from the appointment.
  • On the Scanner select the name of the assigned client service coordinator and the name of the Health Coordinator. The records will be e-mailed directly to them.
  • If for any reason you cannot scan the documents the same day as the appointment, inform your Client Service Coordinator when you contact them about the medication change. If they are unavailable contact the Healthcare Advocate or Health office to communicate the need for assistance and to come up with an alternate plan for scanning the documents. If this occurs afterhours, or on a weekend contact the Kokua On-call as the documents may need more urgent attention or may be able to wait until the next business day.
  • Fax a copy of the change to the pharmacy
      • Note for clients that use Lincoln Pharmacy: If the medication change is not being filled by Lincoln, you still need to send it in to them with a note that states “DO NOT FILL” so they have the prescription for their records.
      • Call the pharmacy to ensure they received the prescription and find out when it will be delivered

Note Contact the Delegating Nurse if your client is delegated to ensure she is aware of all medication changes. Do not give the medication until you have been delegated if it is a new task. For example, a client is prescribed eye drops or ear drops and has never used these before.

  • Create a Med Alert letting staff know about new prescriptions so staff knows to expect that new meds are arriving. Please note on the med alert that staff should follow up within 24 hours if the expected prescription has not arrived
  • Transcribe the medication change to the MAR All changes to medication must be transcribed on its own new line; we cannot just cross something out on a pre-existing order.
    • Note: Don’t forget to write Start, Stop, or Order Change, the date, the provider, and your initials, in addition to drawing in the appropriate lines to indicate the exact date and time when medications start.
      • Example: Start 4/24/17 per Dr. Feelgood PV confirmed by LR
      • Example: Stop 4/24/17 per Dr. Feelgood PV confirmed by SB
      • Example: Order change per Mary Mack, ARNP JM confirmed by PV
    • Note: Don’t forget to check the labels on prescription meds from the pharmacy to ensure they match the written prescription directions.

Use the Reference Tool Medication Administration Record (MAR) located in the staff Log for examples of how to transcribe orders.

  • Use Med Alert pages to flag changes to medications in stock. Call Lincoln to request new labels for these medications, if they were filled by Lincoln Pharmacy.
  • Document all appointment details in the Appointments on Therap. Please make sure you create new Therap Appointments for follow-up appointments or reminders to schedule follow-up appointments.
  • If a second staff is on with you, have that staff review your changes and confirm they are accurate. Once accuracy is confirmed, have them write “Confirmed by” and their initials. If you are single staffed, have the staff coming in to relieve you confirm the accuracy of your transcription during shift change.
  • Place the prescription in the Appointment book under the “Prescriptions” tab

Documenting the Appointment Documenting Appointments in Therap is vital to ensuring a client receives appropriate care and that all team members are well informed about how to support the client’s medical and mental health needs. If a DSP takes the client to their appointment you as the Team Leader have the responsibility of ensuring the appointment information is appropriately documented in Therap.

Scheduling a Medical Appointment: The Appointment in Therap’s Health Tracking Module under appointment. Complete as much information as is available. Refer to the Reference Tool Documenting Appointments for specific instructions.

After an Appointment is Completed document the outcome of the appointment. Do not leave the Comments section blank. Follow the Documenting Appointment Training updated 8.2021.

Updating Therap Information

Part of a Team Leader’s responsibility is to work with the Client Services Coordinator to ensure the client has up-to-date information on Therap. This matters as staff look to this information as another tool explaining how to support the client. Refer to step-by-step instructions for using Therap modules available on the Therap’s Help & Support. You may also access training courses and webinars to increase your skills.

Individual Details: As a guideline, check each client’s Individual Details section of Therap weekly, or more often when the client is having frequent changes in health or behaviors. Also check other sections of Therap for any needed updates. See Screenshot below of the Go to drop down menu accessible on the left panel of each’s clients Dashboard for details. To review the information read through each section, if you notice information is not accurate, out of date documents are provided, or you have questions contact your Client Services Coordinator as soon as reasonably possible with what needs to be updated. This should be done before you leave your shift. If you notice a discrepancy that impacts a client’s health and safety, such as the wrong diet, swallowing protocol or supervisor level information contact the Kokua On-Call System after hours and the assigned Client Services Coordinator immediately during business hours.

Shared Contacts: Each provider a client works with will be listed in the Shared Contacts section accessible through the Go To menu on their home screen. When a client has a new provider, you will add to the Shared Contacts using the following steps. You may also remove providers when client’s are discharged for their services or change providers.

To Add an Existing Shared Contact

  1. From the client’s home open Shared Contact List on the Go to Menu
  2. Click on the bottom left of the screen
  3. When you click on the contact Therap adds to the client’s Shared Contact List.
  4. If cannot locate the needed contact or the information is inaccurate (need to edit contact) then contact the assigned Client Services Coordinator who will need to create the Contact in Therap, as Team Leaders to do have access to this feature of the program.

To Remove an Existing Shared Contact from the Client’s Individual Data

  1. From the client’s home open Shared Contact List on the Go to Menu
  2. Click remove on the far-right column of the applicable contact.

Releases of Information

There needs to be a current Authorizations to Release & Receive Information for every medical provider. When a client has a new provider, fill out the release form, explain to the client, ask if they are agreeable to the doctor and Kokua sharing the information indicated, if yes have the client sign the form. When the client is able ask them to date, otherwise you can date. When the client has a guardian, they must sign the form verifying agreement with the exchange of information.

  • Scan and copy at the office to the assigned Client Services Coordinator and file the original in the Authorization section of the client’s Protocols & Plans book. When you need assistance obtaining guardian signature contact the Assigned Client Services Coordinator within 1 business day for assistance.
  • Check through the Release of Information forms at least monthly to see that there is a signed current release for each provider and other entity the client works with. Below is a list of the release of information a client typically needs to have on file. The Assigned Client Services Coordinator will also review releases annually and update. It is your responsibility to notify the Coordinator when the client has anyone new information needs to be shared with.

A Guideline for the Authorizations to Release and Receive Information Kokua needs on file:

  • Landlord/property management
  • Utility companies applicable to client such as LeMay Pacific Disposal, City of Olympia, PSE, etc.
  • Xfinity/Comcast
  • All medical and mental health providers, can use Shared Contacts on Therap as a reference
    •  Specialty Supply/service companies such as NuMotion, Bellevue Healthcare,
  • Intercity Transit (if using services, especially Dial a Lift)
  • Any family members and/or friends of clients that information would need to be exchanged with
  • Thurston County Food Bank
  • Thurston County Parks & Rec
  • Power of Attorney
  • Rep Payee-if not Kokua
  • Specialty Pharmacies
  • South Sound Radiology for Diagnostics
  • Insurance Providers-such as Molina, Tricare, etc.
  • Guardians
  • Guardian Ad Litem
  • Stand by Guardians
  • Emergency Contacts
  • Necessary Supplemental Accomodation (NSA) Representative-identified in the PCSP-in case they need to be contacted re: the PCSP/annual meeting.
  • The Arc of Washington-if the Arc administers a Trust-check with the financial office.
  • Include Heritage bank if Kokua is the identified Rep Payee.
  • DispatchHealth
  • Providence Network-All clinics, hospitals or urgent cares for healthcare services
  • Capital Medical Center for emergency or routine care and treatment

Washington POLST (Portable Orders for Life Sustaining Treatment)

POLST forms and CPR:  POLST stands for Portable Orders for Life-Sustaining Treatment. In 2017 the National POLST started defining the term POLST as Portable Orders for Life-Sustaining Treatment. In April 2021, Washington state’s POLST form was revised, and the term POLST was known as Physician Orders for Life-Sustaining Treatment. The clients you support may have a version of the POLST dated prior to April 2021. Completing a POLST form is voluntary.

Washington State Medical Association describes a POLST as, “If you are seriously ill or in very poor health, your health care provider can use the Portable Orders for Life-Sustaining Treatment (POLST) to represent your wishes for future care as clear and specific medical orders, indicating what types of life-sustaining treatment you want or do not want in the case of a medical emergency. The POLST form is a summary of wishes and interventions for care that documents the following decisions:

  • Attempt cardiopulmonary resuscitation (CPR).
  • Administer antibiotics and IV fluids.
  • Use a ventilator to help with breathing.
  • Provide artificial nutrition by tube.

Source: https://wsma.org/POLST

For the POLST to Be Valid– the field will be indicated with a mandatory

  • Needs to contain the individual’s name (client) and Date of Birth.
  • Section C Signatures, Page 1:
    • A medical provider’s printed name, signature, and the date. The form may be completed with a physician-MD/OD; Advanced Registered Nurse Practitioner-ARNP; or a Physician Assistant-certified PA-C.
    • The individual’s or a legal medical decision maker’s signature and the date.
  • A medical provider may document verbal consent for the individual or medical decision maker’s signature. The clinician’s signature is sufficient for witness to verbal consent.

See POLST form to review in more detail.

Information from POLST Physician Orders for Life Sustaining Treatment (wa.gov), Washington State Training Curriculum for EMS Providers.

How to Use: If the form is Valid as described above staff must honor the individual’s wishes. Staff need to pay special attention to

Section AUse of Cardiopulmonary Resuscitation (CPR): The individual has no pulse and is not breathing.

1. If the client wants CPR, the YES-Attempt Resuscitation/CPR box is checked.

2. If the client does not want CPR, the NO Do Not Attempt Resuscitation (DNAR)/allow natural death box is checked. Resuscitation should not be attempted, if DO NOT ATTEMPT Resuscitation box is checked.

Team Leader and Client Service Coordinators’ Responsibilities You will be responsible for ensuring staff are trained on the existence of the POLST form, what the client’s preference is for CPR, and where to locate and keep the form. In the absence of a TL, this responsibility will fall to the CSC.

Filing the POLST: File the original document in the client’s Medical and Medication Details Book, Section 1. When doing client record reviews, ensure the form is present and filed correctly. A copy is also in the client’s Legal File at the Kokua office, and a PDF of the POLST will be available in Therap for viewing. A client may also choose to have a copy posted in a prominent location, for example, on their refrigerator in a protective sleeve, allowing for quick access for staff and EMS. Follow DDA Policy 6.09 Supporting End-of-Life Decisions for Client Receiving Community Residential Services. 

When a Client’s Preferences Changes or When a POLST is Initially Completed: When you learn a valid POLST is changed or when a valid POLST is initially completed, alert the Kokua On-Call System on the same day and as soon as reasonably possible.

Action Steps to Complete

  • Coordinate bringing the POLST to the office for scanning and to make a copy for the client’s office record. Contact the assigned Client Service Coordinator (CSC) and the Health Office with the updated POLST information.
  • Remove the old/inactive POLST from the Medical and Medication Details book and from any other location it may be in the client’s home. Archive the inactive form immediately to avoid confusion.
  • File the current POLST in the client’s Medical and Medication Details book and any other prominent location the client would like it posted in their home. Consider the client’s confidentiality when they are living in a shared household.
  • SCOMM all staff and communicate at shift change the existence of a new POLST.
  • The assigned CSC provides a copy of the POLST to the client’s DDA Case Manager and the Registered Nurse Delegators: Brittney Hyland, RN & David Hyland, RN, when under nurse delegation. In the absence of the CSC this will fall to the Health Coordinator.
  • The assigned CSC will update the client’s IISPs with the needed changes. In the absence of the CSC this will fall to the IS Program Manager.
  • The assigned CSC will update the emergency directives and Emergency Orders in the Individual Details sections of Therap, with current POLST information. Attach the POLST into the Attached Files and Advanced Directives Section of Therap. In the absence of the CSC this will fall to the Health Coordinator.

CPR and POLST Directives in the IISP Each staff must follow the orders indicated in Section A of the POLST for the use of CPR. The general steps staff need to take during an emergency where a client is not breathing, has no pulse, and is unresponsive will be in the Risk Summary section of the IISP. Regardless of the individual’s decision to have CPR or not, staff still need to perform the Heimlich maneuver as an intervention for choking.

See DDA Policy 6.09 Supporting End-of-Life Decisions for Clients receiving Community Residential Services.

Medical Equipment

Medical Devices: When you are trained for your role as a Team Leader you will be trained on the proper use of all medical equipment. You will be responsible for training staff and providing any mentoring or retraining on the use of medical devices when the needs arises. When you see a client may benefit from a different medical device, their equipment is getting worn, or needs replacement contact the assigned Client Services Coordinator. Depending on the device the client may need to schedule a medical visit to obtain a new prescription. It is important to know where the client gets medical equipment, so when service or repairs are needed you can contact the appropriate vendor.

Medical Device Orders: See Medical and Adaptive Equipment and Devices in DSP section. Per WAC 388-101D-0155 Medical devices. for medical devices the services provider needs to Obtain a current physician’s order that describes the medical necessity for use of the device and the anticipated duration of use. When a client attends a medial appointment and a new device is prescribed ask the physician to sign the form below as this will serve as the medical order for Kokua’s records. You can fill out the form with the device information and ask the provider to sign. After receiving a prescription for t new device, scan the orders to the assigned Client Services Coordinator and the Health Coordinator. These individuals will collaborate with you on how to obtain the needed device. The Health Coordinator is responsible for writing a medical device protocol. File the original prescription in the Protocol section of The Protocols & Plans book. See Prescription form for Medical Device.

Medical Device Protocols: As a Team Leader, you need to be familiar and competent using each medical device. You will observe the staff using the devices to ensure they are doing so correctly. When this does not happen, begin with a mentoring conversation, followed by the next step in the re-training process, as needed. Each prescribed medical device with a known safety risk needs to have an available protocol either electronically or on paper. As a guideline check through the client’s protocols in the Protocols and Plans book once a month for the device orders and protocols. When you do not see device orders or the protocol, contact the Health Coordinator within 1 business day to verify and request copies.

Below is the General Process for what to do when a client receives a new or updated Medical Device Protocol. Please direct questions to the Health Coordinator and follow all of the most current instructions from the Health Office

 

The new protocol you receive will include the following:

 

A device order chart signed by the client’s medical provider and the Medical Device Protocol, with a staff signature page attached. Every staff member needs to read the protocol and the instructions on the signature page before signing off. New staff will need to read and sign protocols as they are trained at houses. Please let your CSC or the Health Office know if you need more signature pages.

 

When the individuals you support have a guardian, the legal representative receives a copy of the protocols and a protocol signature page that signing verifies they agree with the protocols. When the health office receives back the signed letter, a copy is sent to the house for filing with the protocols.

 

When the individual does not have a guardian, there will be a second copy of the protocols for them to read and keep. Please ensure the client receives support reviewing their protocols if needed or requested. After reading the protocols and the client agrees, ask them to sign the protocol letter and return the original document to the health office after you make a copy to keep with the protocols in the clients’ Protocols & Plans book.

 

Remove and archive all older versions of the medical device protocols to avoid any confusion and duplicate copies with the now current protocols. The latest protocols will also be available in Therap.

 

Psychotropic Medications

See Kokua Policy 2.45 Psychoactive Medications Any number of the clients you support may be prescribed a medication to treat a wide array of conditions. Often, our clients are living with a mental illness or a behavior challenge that a provider has deemed a psychotropic medication will be useful. DDA Policy 5.16 Psychotropic Medications defines psychotropic as “possessing the ability to alter mood, anxiety level, behavior, cognitive processes, or mental tension, usually applied to pharmacological agents”. Psychotropic medications are defined as “medications prescribed to treat a mental illness. Psychotropic medications include antipsychotics, neuroleptics, atypical antipsychotics, antidepressants, anticonvulsants, anti-mania drugs, medications to treat symptoms of dementia, as well as psychotropic medications such as stimulants, sedatives, hypnotics, and anti-anxiety drugs. Regardless of classification, any drug used to alter mood or behavior is considered a psychotropic medication for the purposes of this policy.” The prescribing of psychotropic medications requires Kokua have certain documentation to track their effectiveness. The following are required documents you are responsible for preparing for the client. When you need assistance contact the client’s assigned Client Services Coordinator in their absence contact the assigned Health Coordinator. When signatures are need from guardians who do not live locally or see the client regularly, the Client Services Coordinator will assist with sending the documents and requesting signatures.

Behavior Health Assessment: The service provider needs to support a client request a referral for a behavioral health assessment when they display symptoms persistently or significantly different from what is typical for the individual. Also, when a client shows signs of mental illness and, or ongoing challenging behavior, a referral needs to be requested, per DDA policy and WAC. Work with the assigned Client Services Coordinator and Health Coordinator to gather all behavioral health documentation to prepare for the appointment and complete the referral information. Information from Therap will need printing.

Psychotropic Medication Plan

  • Must have a form for each Psychotropic medication.
  • Have the drug information sheet available for each psychotropic medication that is being used by each client. This can be from the dispensing pharmacy or the prescriber.
  • Per DDA policy 5.16 Service provider staff must review with the client and the client’s legal representative the name, purpose, potential side effects and any known potential drug interactions of the medication. This information is on the Psychotropic Medication Plan. Also attach the drug information sheet from the pharmacy to the psychotropic medication plan sent to the client or legal representative for review.
  • The form must be filled out in its entirety. Do not leave blanks
    • While at the appointment you can fill in as much information as the prescriber provides, ask questions to obtain the rest of the information and ask the prescriber to sign and date, if they are in agreement.
    • Do not put different medications on the same form.
    • Per DDA policy Kokua is required to note the date you sent or gave the information to the legal representative.

See the following policies and WAC for more details regarding psychotropic medications and documentation requirements. DDA Policy 5.16 Psychotropic Medications; DDA policy 6.19 Residential Medication Management; See WAC 388-101D-0350 Psychoactive Medication Assessment.

Psychotropic Medication Monitoring Visits: The frequency of monitoring appointment is determined by the prescriber of the medication. Refer to the Return for Medication Monitoring section of the Psychotropic Medication Plan for frequency, but know this may change based on the client’s needs. The Annual Review form also advises how often the client should be seen for monitoring in the recommended frequency of follow up appointments section. Please schedule a face to face appointment for medication monitoring to discuss the effectiveness of medication and any questions/concerns. DDA Policy 5.16 Psychotropic Medications states the service provider should request the prescribing professional sees the client at least every 3 months unless the prescribing professional recommends a different schedule. WAC 388-101D-0350 Psychoactive medication assessment requires the prescribing professional assess client at least annually to review the continued need for the medication(s) and possible dosage reduction.

Psychotropic Medication Prescriber Visits

  • Fill out the form for any and all medication monitoring appointments
    • Include who was present at the appointment and if the client attended independently. For example, Jane Doe, guardian; Sally Jones, Kokua
  • Always complete form during an annual review visit
  • Come prepared to the appointment with all data about the frequency and severity of symptoms. Explain the information shared with the prescriber about the client’s medical or behavioral health provide the prescriber with behavior data from Therap in addition to any observations, concerns, and any other supporting documentation. Report any changes in behavior that might be adverse side effects, report when medication does not appear to have the intended affect.
  • Explain the prescriber’s instructions to the client and, or Kokua: Specify any directions, recommendations, labwork orders, follow up appointments and, or prescription
  • Explain medication changes including drug name, dose, frequency or write N/A. Attach the drug information sheet
  • Explain the Purpose of the medication as stated by the prescriber.
  • Fill out the form if you talk about any Psychotropic medications during a medical visit. Examples, PCP, psychiatrist, mental health professional, or any prescriber of the psychotropic medications.
  • After scan the form to the assigned Client Services Coordinator and Health Coordinator. File the original in the client’s Medication & Medical Details book, Psychotropic Medication section.

Psychotropic Medication Plan Annual Review

  • Per WAC continued need for the medication and possible reduction should be assessed annually by the prescribing professional. Please make sure you complete the form as much as possible before the appointment.
  • Schedule a face to face appointment for the annual review whenever possible
  • Ask the prescriber to review the form and sign if agreeable.
  • Review the form with the client and ask them to sign if they are agreeable to continuing to consent to the prescribed psychotropic medications. The prescriber has the responsibility of obtaining consent for prescribed medications from the client and or legal representative as Kokua does not have legal decision making power for the client.
  • When a client has a guardian and they did not attend the appointment notify your Client Services Coordinator for assistance getting the form to the guardian for review and signatures.
  • Scan the form to the assigned Client Services Coordinator and The Health Coordinator. Make a copy for the client’s Health Office file.
  • File the original in the Client’s Medication & Medical Details book, Psychotropic Medication section.

See the commonly prescribed psychotropic medications. See Psychotropic Medication Plans, Psychotropic Medication Prescriber visit forms and Annual Review forms. WAC 388-101D-0355 What must a client record contain if the client is prescribed a psychotropic medication? WAC 388-101D-0350 Psychoactive medication assessment

Nurse Delegation

See Required Training Section in Overview; See Nurse Delegation in DSP section of manual; See DDA Policies 6.15 Nurse Delegation; 6.19 Residential Medication Management

As a Team Leader you have the additional level of responsibility consisting of the following:

  • Staff are trained appropriately on a client’s delegated tasks
    • Client who receive medications through tubes and have ileostomy require additional observation and training by you. Refer to the Preparing Staff for Delegation forms at the end of this section.
  • Staff do not perform delegated tasks until delegated by Brittney Hyland or David Hyland, RN Nurse Delegator.
    • The list of all current delegated tasks is on the 90-day Visit form
  • The Delegating Nurse, Health Coordinator, Service Coordinator and Health Advocate, RN are notified of any changes in the client’s need for delegation or new delegation orders.
    • Ensure new orders and/or prescriptions and After Visit Summaries are sent to the Delegating Nurses promptly for their review. This allows for the nurse to provide accurate medication lists, task instructions and support/recommendations for treatment and care. Communicate with the client’s assigned CSC when assistance is needed getting information to the Nurse Delegators.
    • Nurse Delegation rules require the following:
      • All orders must be clear, specific and current
      • No range orders are accepted for example, 1-2 tabs every 4 to 6 hours.
      • All PRN (as needed) medications must have a purpose/indication of when to use. For example, PRN for pain relief.
  • Check the Nurse Delegation book weekly to verify contents are up to date and organized.
  • Delegate one staff to ensure paperwork is filed in a timely manner and organized to the Table of Contents.
  • When you do not see up to date paperwork (more than 90 days have passed since last visit, medication record is missing medications, missing task instructions, missing seizure protocol, or staff signature pages) ensure you contact the Health Office within 1 business day. if you cannot locate the necessary documents.
  • The Health Coordinator is responsible for disbursing the nurse delegation documents that the Delegating Nurse sends. This includes Consents, 90-day visits, Instructions, medications charts, signature pages, protocol instructions, etc.
  • Contact the assigned Client Services Coordinator if you are not able to check the house box at the office after being alerted Nurse Delegation paperwork is ready. This paperwork needs to be in the home and available to the staff per WAC and DDA policy.
  • Asking the Delegating Nurse any questions needed to perform the delegated task safely and correctly.
  • Competing mentoring and retraining as need when delegation errors occur. These will be documented and sent to Brittney.
  • Do not perform a new delegated task without delegation. For example, a client is prescribed ear drops that has never had the need for this medication before.

The goal is for Team Leaders to be able to perform delegated tasks with every client. This provides for urgent and emergency staff coverage.

The priority is to be delegated with clients who have rescue medications or tasks that need to be administered within minutes of a presented need. Examples include medications for seizures or chest pain, and suctioning to prevent aspiration. Check with the Health Office to verify the most current list of individuals with this need.

Delegation Process for On-Call: To become delegated with clients outside of your worksite or for a refresher on tasks please do the following *After you have been alerted by the Training Department that you are eligible for delegation*

  1. Work with your team members and CSCs on coverage to allow you time to go to other worksites
  2. Contact the Team Leader or CSC at the worksite to arrange time to come over to observe delegated tasks.
  3. Read all the Nurse Delegation Task Instructions. The most current instructions will be in the Nurse Delegation binders
  4. Once you understand the task and have observed it, then contact Brittney for delegation-Depending on the task and your comfort level she may delegate over the phone, at a skills lab, or after an onsite skills demonstration.
    1. EXCEPTION: delegation for tube medications and Ilestomy requires additional training
      1. See the Preparing Staff for Delegation: Ilestomy and Tube medications sheets for specific steps. These will be in the Nurse Delegation Binders for the applicable clients.
  5. Notify the assigned CSC of what houses you have been delegated at.
    1. The Delegating Nurses will add you to the Delegation worksite lists
  6. As always you may ask any questions regarding delegated task to the Delegating Nurses. Do not perform a task until you feel comfortable and all questions answered.

If you have any questions or concerns about the above process please talk with the assigned Client Service Coordinator.

Hygiene: The level of support a client needs with hygiene will be detailed in the client’s IISP and PCSP. You will support the client as outlined in the IISP and any other protocols and will direct staff to as well. If this is not occurring you will have a mentoring conversation with the staff, followed by the next steps in the retraining process, when needed. Part of your responsibility is to monitor clients closely to ensure routine hygiene and grooming needs are met. This is achieved by talking with the client about their care, a visual check of the client. Most clients will need a skin check each day due to risk of skin breakdown. During shift changes the Hygiene Trackers are checked to see which hygiene tasks the client has been assisted with or completed independently on any given day. When any changes in the client’s ability to care for hygiene or their behaviors changes around hygiene document the information in a Health T-Log and communicate your observations to the Client Services Coordinator within 1 business day or sooner if a threat to Health & Safety. A change may be a sign or symptom of another issue developing with a client that staff will need to be attentive to. All hygiene/grooming refusals need to be documented in a GER and

General Event Reports (Incident Reporting)

See DSP Section of Manual Reporting of Critical Incidents or Events. All completed General Event Reports (GER) require a follow up by the Team Leader and the Client Services Coordinator at a minimum, other staff may also complete additional follow up.

See Kokua Policies 2.1. Report of Abuse, Neglect or Mistreatment; 2.15 Incident Reporting to the Developmental Disabilities Administration. See DDA policy 5.13 Protection from Abuse: Mandatory Reporting; 6.12 Incident Management and Reporting Requirements for Residential Service Providers; WAC 388-101-4150 Mandated reporting to the department; WAC 388-101-4160 Mandated reporting to law enforcement;

Responding To a GER: During shift change when you see a GER has been completed or learn of an incident you need to read through the entire GER as promptly as you are able during your shift. Read the GER to determine if the client is safe, what the incident was, and how the incident has been addressed to this point. When reading the GER if you are unclear as to what occurred return it to the writer and explain what additional information is needed. Staff can edit and resubmit the GER. As a Team Leader you will write GERS as needed when an applicable incident occurs.

Verify GERS are Completed When reading through documentation you notice an event took place that warrants a GER you must follow up to see that a GER has been written. When you do not see one, you need to identify the appropriate staff and contact them to complete.

General Event Report (Follow Up): You need to review and start follow up before the end of your shift. Some events will not be resolved the same day, but do require you to start the follow up process. When reviewing the GER you are looking to see if there are client health and safety issues, was the incident handled appropriately, and what can be done to prevent a similar incident from occurring again.

When the incident was handled appropriately by staff you do not need to address any retraining. When there are violations of policy, procedures, protocols, care plans, WACs, or a report of witnessed abuse or neglect, abandonment, or improper use of a restraint and quality of care issues you need to respond promptly and appropriately. Follow up Examples: This may consist of contacting a client’s doctor, mandatory reporting, contacting HR, contacting the Delegating Nurse, talking with the client about an issue, or starting the retraining process. The type and details of the incident will determine how you respond. Your assigned Client Services Coordinator is also viewing the GER. When you have questions or need additional guidance on how to respond communicate with the assigned Client Services Coordinator during regular business hours and the Kokua On-Call System after hours. What’s most important is that prompt action is taken to ensure a client’s safety and wellbeing. In the absence of the assigned Client Services Coordinator, contact the Kokua Program Manager.

Documenting the Follow Up: All action you take in responding to an incident needs to be clearly written in the follow up. Write down what steps you took. For Example,

  • The name of anyone you contacted, when and what was related to you.
  • Any documents you read through to clarify what happened
  • Any conversations you had with the client about the incident
  • What the plan is. For example, client has a doctor’s appointment, a retraining is scheduled, or you ordered more medications or supplies, etc.
  • When a retraining is completed
  • Any Mandatory Reporting

See Screenshots below for sections of GER you need to complete. The Client Services Coordinator will also add applicable information when they complete a review.

Person Centered Services Plans (PCSP)

Person Centered Service Plan meetings happen at least annually and more often if a client has a significant change in the level of supports needed. The DDA Case Manager sends a written notice to the client when their annual due date is coming up. They also send documents for the client to work on regarding their goals and skills. It is your responsible to ensure the client is supported by staff, when they choose to fill out the forms. When the case manager calls support the staff is setting up an appointment time that they prefer. Before the meeting you will attend a pre-planning meeting with the assigned Client Services Coordinator, Program Manager, Financial Coordinator, and Health Coordinator. The purpose is to review the previous year’s PCSP, Authorizations, Consents, Medications, Financial Plan and Medical Providers to ensure all information is current.

Team Leader Role: The views and knowledge the Team Leader has regarding the client’s support needs, preferences, and goals is vitally important as you spend time with the client on a regular basis and have built a relationship. This is a good time to advocate for any supports, resources or changes in the care plans you think would benefit the client. Talk with the Client Services Coordinator prior to the meeting when you need assistance with scheduling additional staffing to allow you to participate in the meeting.

You are responsible for gathering the following data and having ready prior to the annual plan visit.

  • Last Known Height
  • Last Known Weight
  • Date of Last Physical (Annual Wellness)
  • Date, provider name and reason for Last Medical Visit, not dental
  • Any ER Visits or hospital overnight stays in the last 6 months. If yes, how many
  • Any new Treatments
  • Any preventative Treatments
  • Pain reported over the last 7 days
  • Any Skin Issues
  • Any Foot care issues
  • Quality of sleep at night
  • Flu shot date or documentation of refusal

To prepare the above information review the client’s Therap Appointment Entries and any After Visit Summaries. Record all the answers on the Pre-PCSP checklist provided to you by the Client Services Coordinator. See form at end of section.

During the Meeting Participate in the meeting by providing answers to questions, and requested documentation when needed, and supporting your client to answers questions for themselves as much as possible.

When you Receive the PCSP: The Case Manager will sign the Service Summary signature page before mailing the PCSP in its entirety to the client’s home for their records and signature. The PCSP service summary signature page must be returned to the case manager by the date written in the sign and return section.

The Service Summary page must be signed by the client if they do not have a Legal Representative. Ask the client to review the assessment and review with them, when support is needed. If they agree, have the client sign the Service Summary page. The Client Services Coordinator will arrange for the program administrator to sign and mail back to the case manager. If the individual wants changes made to the plan, inform the Client Services Coordinator who can speak with the client about their requests and how to communicate with their case manager. The client has a right to call their case manager at any time and staff need to support the client to call when needed or requested.

Contact the assigned Client Services Coordinator when the PCSP has arrived at the home. You two can arrange for how to get a copy to the office for the client’s record. The Client Services Coordinator will prepare a staff signature page to attach to the PCSP to be filed at the client’s home in the Protocols and Plans book. You will read the PCSP and direct/remind the staff to also read. Answer any questions the staff have about the plan. If you do not know the answer contact the assigned Client Services Coordinator for clarification.

Oversight for Area of Responsibility (AOR):

See Area of Responsibility (AOR) in DSP section. The Team Leader is always the designated Medical AOR for each client. You have the following responsibilities:

  • Staff work on their AOR duties throughout the month through monitoring work performance
  • Staff are completing their applicable section of the AOR reports. You are responsible for completing the report for Areas where there is not a current AOR and you must review and sign the report.
  • Assign AOR or redistribute AORS when staff changes occur. You can ask staff to pick areas that interest them or you can assign based on need or an area you see a staff has a skill set in.
  • Review AOR manual will staff during Peer Coaching
  • When staff are assigned a new AOR direct them to read the manual. Ask the staff if they have any questions about their duties
  • Submit the AOR reports on the 1st business day of each month. The reports are reviewed by the Assigned Client Services Coordinator and filed with the client’s records at the Kokua Office.

Timesheets

See Pay Periods, Timesheets and Tracking Work Time in DSP section of the manual. Team Leaders have the responsibility of verifying DSP timesheets and submitting according to the due date calendar. On timesheets due date days, be prepared to dedicate time to reviewing the sheets and completing the Timesheet Accuracy form required to be submitted with the worksite timesheets each week. Direct timesheet questions to the Business Operations Coordinator during regular business hours. See Timesheet Accuracy form.

Remind staff when they are done with their timesheet for the weeks’ period to place it in the Going to the Office folder or the designated location may vary by the worksite. This will make it easier for you to locate and account for all timesheets. Staff are responsible for knowing timesheet guidelines. When reviewing timesheets look for accuracy and completion.

  • A timesheet will not be submitted for approval without a signature
  • Compare the timesheets to the Sign in Sheets.
  • Check that staff has calculated their time correctly with the conversion chart
  • When there are discrepancies between the staff log and the timesheets, use the staff log. Write the entry next to the original entry on the timesheet with your initials
  • Check SCOMM for any communication from administrative staff regarding staff’s use of PTO. If you are notified staff need to use PTO make sure the information provided is on the timesheet. Ask the staff to write their PTO on the sheet when directed by an administrative staff. When the staff will not be back on shift to complete the timesheet, you can make the entry, but need to initial next to it.
  • If you have any suspicions of falsifications of timesheets. Do not sign the timesheets and contact your Client Services Coordinator as soon as reasonably possible explaining your concern. This is considered a serious policy violation. When the CSC is not available or absent contact the Program Manager.
  • When a staff has an entry on the timesheet but no entry on the staff sign in sheet check the staff schedule and contact the employee for verification. This is considered a time for a mentoring conversation to remind staff of standard timesheet expectations. If you are unable to determine accurate times the staff works or if they were on shift, contact the Client Services Coordinator with your concerns
  • When you are unable to deliver timesheets to the office on the due date contact the Assigned Client Services Coordinator with as much advanced notice as possible, so arrangement can be made for a pick up.

Mileage

See Mileage Reimbursement in DSP section. Team Leaders have the responsibility of reviewing Mileage Logs for accuracy and completion when they are submitted. Read through the sheet, when all entries are completed and travel was client-related, sign, and submit to the Business Operations Coordinator. When you have questions about an entry first talk with staff for clarification, and when you have any suspicion information is falsification contact the assigned Client Services Coordinator as soon as reasonably possible reporting your concerns. When the staff does not complete the form correctly, have a mentoring conversation to review the correct procedure.

Community Integration (CI)

See Community Activities in the DSP section. Clients may need assistance to go out in the community to participate in chosen activities. Many individuals have goals related to community activities or events. The level of support a client needs for community engagement will be explained in the PCSP and IISP. As a Team Leader, you oversee the work of the team to ensure a client is accessing the community. To do this take the following actions:

  • Work with the client to place calendars where they can easily view and write on when scheduling.
  • Support the clients and direct staff, when needed to schedule outings
  • Monitor transportation and staffing arrangements
  • Be familiar with the client’s Habilitative goals in their IISP
  • Check Individual Support Program (ISP) used for goal tracking to ensure it is being completed when needed.
  • Communicate with the assigned Client Services Coordinator when revisions are needed to goals, such as client expressed lack of interest, wants to do something else, or has achieved the goal.
  • Support the client to request checks from the Financial office.
  • Ensure transportation and staffing is arranged for picking up checks and banking. The individual must be present with valid ID to cash their check at any Heritage bank location. Requirements may vary if a client has a different bank they use.

Client Finances

See Client Finances in DSP section for details. Team Leaders have the additional responsibility to ensure staff are following the guidelines of support in the IISP, policies, and procedures regarding managing client funds. Your duties include:

  • Ensure you, the assigned Financial and Nutrition AORs are trained on client grocery shopping procedures. Direct questions to the financial office regarding financial procedures and training.
  • Work with the client about their budget when planning activities and purchases.
  • When applicable, support the client to grocery shop online and place their order using their EBT card, if they have one. Follow instructions from Client Financial Office for the ordering process.
  • Support the staff to communicate promptly with the Financial office and the assigned Client Services Coordinator when they have questions or concerns about their budget and available funds.
  • Separate from the money counts during a shift change, check the client’s required financial ledgers weekly for accuracy and completion.
  • Submit the Financial Leaders and receipts to the Financial Office on the first business day of each month.
  • When you notice any policies, procedures, etc. are not followed regarding supporting the client with their finances, identify the staff and begin a mentoring conversation and follow up with additional retraining steps, when needed.
  • When there are any reports of missing client funds ensure the policy is followed for reporting. Refer to Client Financial Office Training
  • Advocate for the client with the Financial Office and Client Services Coordinator, when you notice or staff reports to you any items a client needs or would like to purchase that they do not have sufficient funds for at their home.

Personal Possessions Lists (PPL): See the Personal Possessions List in DSP section. Team Leaders are responsible for overseeing the accurate and timely completion of the 6-month Personal Possession List (PPL) reviews. The Financial Office provides the review forms, makes any changes to the PPL that are on the review, and sends out a new copy to the worksite for the Financial binder when needed. Team Leaders need to also ensure the Household Item Disposal request sheet is completed when an item belonging to a client needs to be removed. Submit the forms to the Maintenance Specialist. When delegating the 6-month review and item disposal sheets to another staff, first review the procedure with them and ask if they have any questions. When the task is completed, Team Leaders verify the procedure was followed. See Household Item Disposal Request form; See WAC 388-101D-0390 Client’s property records.

Vehicles

See Transportation in DSP section, see AOR manual. See WAC 388-101D-0165 Client transportation for more details. When your worksite has a vehicle the Team Leader has a responsibility to ensure the assigned AOR is fulling their duties. In general, your duties include:

  • Orientating staff at your worksite and other Kokua employees on the vehicle using the Vehicle Orientation Checklist. A Team Leader or higher position needs to orient a staff, this is not a duty of a DSP. When you are on shift and a staff comes to pick up a vehicle ask the individual, “Have you been orientated?” If yes, they may take. If no, complete an orientation.
  • Report any routine vehicle maintenance needs to the Business Operations Coordinator, such as tire rotation or oil changes. This position will coordinate with you to schedule a time for services.
  • Report any urgent or emergency maintenance issues to the Business Operations Coordinator as soon as you reasonably can or the Kokua On-Call System after hours.
  • As a Team Leader you need to monitor along with the Vehicle AOR the cleanliness of the vehicle. It should be in safe and comfortable condition for the clients and staff. When the vehicle needs anything beyond a light cleaning, contact the Business Operations Coordinator for assistance.
  • Turn in completed Vehicle Orientation forms to the Training Department for tracking.

Worksite Supplies

A Team Leader has a responsibility to ensure the worksite is stocked with supplies for the staff. You may delegate out the tasks of checking supplies and the AOR position will be checking supplies and reporting needed items to you. Your duties include:

  • Check the Blank Forms binder and office supplies routinely. When low, pick up supplies or contact your Client Services Coordinator for assistance, if you are unable to come to the office before running out.
  • Office Supplies are available in the Business Operations Coordinator’s office or in the cabinet in the B-2 office suite during regular business hours. When you do not see an item, you need make a request to the Business Operation Coordinator via phone or SCOMM.
  • Work with the Safety AOR if there is currently one at the house or you may delegate out to a staff to routinely check Personal Protective Equipment (PPE) at least every 2 weeks to ensure there are enough supplies for all staff. Contact the Training Department within 1 business day when you see a refill of PPE is needed. Also you or a staff may pick up needed PPE supplies in the C-2 office suite. These do not require check out or approval.
  • Routinely check the supply of staff emergency food. When you see there is approximately a 3-day supply for all staff contact the Training Department. When staff make any special requests for emergency supplies, contact the Training Department to determine if the request is possible. There is also staff food supplies available in the C-2 office suite. You or staff may pick up the supplies you feel are necessary for the worksite. No check out or approval is required.

Checking the Worksite Mailbox: Each worksite has a mailbox located at the Kokua Office. It is the Team Leader’s responsibility to ensure the box is checked regularly, at least once a week. Client mail, care plans, instructions, office memos, etc., are delivered to boxes that need prompt attention. This task can be delegated to staff. Ask the assigned Client Services Coordinator for assistance checking the box, when the house schedule does not allow.

Safety Checks and Drills

See Safety and Safety Hazards in DSP section. See WAC 388-101D-0170 Physical and safety requirements for more details. The Team Leader has the additional responsibility to oversee that the Safety Drills and Monthly Safety Reviews are completely appropriately each month by the 10th. The assigned Client Services Coordinator will also monitor that Drills and checks are completed. See WAC

  • Visually check each category on the form to ensure staff have initialed for completion.
  • When a category does not apply to a client and or worksite, write N/A. This is only for the door alarm/window alarm, Hoyer and feeding supply/equipment fields. The same forms are used at each worksite, where client supply needs vary.
  • Check that all staff who have worked on the form initial and sign.

Exposure Control and Disaster Preparedness Plans: See the Safety in DSP section of Manual. Team Leaders also have oversight responsibility to either delegate the assigned Safety AOR, or other staff to check the Disaster Preparedness Plan and Exposure control plan each month for accuracy and completing any changes. You will follow up with the assigned staff to ask if the duty is complete and then check the plans. When you or another staff need to make any updates, handwrite the changes next to the original text and submit to the Training Coordinator, who is responsible for updating the plans. When your new plan is received, place the old plan in one of the client’s Archiving books. See example Exposure Control Plan and Disaster Preparedness Plan. See Exposure Control Plan and Disaster Preparedness Review sign off sheet.

Team Meetings

See Communication in DSP section. Kokua work teams have a designated team meeting every month or every other month held at the Kokua office. Each team is assigned a set day and time. A scheduled is sent out by an administrative team member 2-3 weeks in advance to allow time to prepare.

Preparing for the Meeting: Team Leaders have the responsibility to notify their teams of the scheduled day, date, and time of the meeting, as well as communicating attendance is mandatory. Ask staff to come prepared with any questions, concerns, or thoughts regarding the care of the individuals you support or the work team. This is not the time for staff to bring up any gossip or air grievances about one another. The meeting is an opportunity for all staff to come together for additional support and training. As a Team Leader you will come prepared with any topics you want to discuss or a training you would like to hold during the meeting. Work with the assigned Client Services Coordinator and or the Training Department with support getting materials and information ready.

During the Meeting: The Team Leader and Client Services Coordinator will facilitate. Ask for staff volunteers to record meeting notes (on the supplied) meeting minute sheet. You also need a timekeeper to ensure the meeting stays on track to allow time for all agenda items. There will be a white board available for you to write the agenda items you have. Ask your teammates what agenda items they have and allow time at the end for any additional topics. Discuss all items on agenda and note any topic you need to follow up on or research. The minute sheets are stored at the Kokua office for reference at future meetings.

Archiving

At the beginning of every calendar year, Kokua undergoes a process to review records called Archiving. The client and worksite records for the previous year are sorted through to make room for the upcoming years’ documents. The role of the Team Leaders and Direct Support Professionals is to gather, organize, and file the required documents before bringing them to the office. As a Team Leader, you can delegate the task of preparing the documents following the archiving instructions. Communicate with the assigned Client Services Coordinator when you need assistance. Once the documents are submitted to the office, they are organized and complied with records from the client’s office file into boxes and stored on-site for about 2 years before they are transferred to the Washington State Archives storage facility. An Administrative staff will send out a reminder and instructions for archiving when the calendar year end is approaching. See Example Archiving Instructions.