Home and Community Based Services Waiver
Guidance Document
Division of Children and Families

Policy

Progress note documentation is a very important function of the ICC’s and subcontract workers. Progress Notes are completed when workers provide services to the child or when any significant event occurs during the child’s enrollment in the HCBS Waiver. These notes provide an opportunity for objective observations during home visits, contacts on phone and during other service provision occasions.  Progress notes present a picture of the unique child and family as well as of how the ICC Agency has implemented the HCBS Waiver. The Waiver’s philosophy, values and successes are reflected in these notes. Progress Notes often are the reviewed documentation in audits for comparison against Medicaid billing claims, flex dollar usage and relationship to goals and objectives. A billable ICC contact is a face-to-face interaction for a minimum of 15 minutes.  Six face-to-face contacts are required each month, three of which must be with the child. All Progress Notes must indicate both whether the contact was with the child or was collateral and whether it was face-to-face or telephone. Additionally, Progress Notes must specify which of the six services is being provided.  Each Progress Note must be complete, timely, and must accurately relate to, and identify, the child’s service plan goal and objective(s). Notes must identify areas of need and be written in a strengths-based manner. 

Each ICC Agency must develop and implement quality assurance standards to ensure that all individual worker’s notes, as well as other documentation, are reviewed periodically by a supervisor. Supervisors must document corrective actions needed, how they will be accomplished and a time frame for completion.

Purpose of the Progress Note

Progress Notes provide a narrative history of the child’s progress.  A Progress Note:

• identifies services, activities, interventions and providing staff;
• identifies relevant goals, objectives which can be measured for progress and specific methods of implementation;
• describes significant events or unusual circumstances that relate to the child’s progress toward meeting the goals and objectives of the Service Plan;
• recommends/justifies changes or additions to current goals, objectives and methods/services of the Service Plan;
• describes newly identified strengths, needs, and barriers;
• describes the type of contact, time, duration and service provided and
• documents use of flex funds, both amount spent and how its use relates to a specific goal and objective(s).

Progress Note Content

Progress Notes must specify:

• the date the note is being recorded;
• what service was provided (using service abbreviations);
• to whom the service was provided;
• type of contact
• contact date for the unit of service;
• the duration of the service that was provided (including the time of day as well as hours/minutes);
• amount of flexible service dollars spent and the goal to which expenditure is related;
• progress toward the service plan goals and objectives  (citing which specific goal or objective the service provision is related to);
• level of participation of child/family;
• revisions to the service plan, and barriers to timely service plan completion, if any;
• name of person/agency providing the service; and
• name(s) of person(s)/agency with whom services were  coordinated.

Group Progress Notes

Note that for group progress notes, in addition to the above, the type of group (Respite, Skill Building or Family Support Services) and the worker to child ratio must be indicated. The Group Progress Note form should be used and filed in a separate section of the case record.

When Skill Building groups include the Waiver sibling(s) and/or caregiver(s), the sibling and caregiver must be noted in the service plan to be billableand their purpose in the group must be directly related to the Waiver child’s goals and objectives. One Group Progress Note must be written for each group. If the group includes Waiver child’s siblings or caregivers, this must be indicated in the heading with their name(s). When writing the note, a description must be given of what occurred as it pertains to each participant for whom there will be billing. Included must be how the inclusion of siblings/caregivers relates to the specific identified goals and objectives of the Waiver child. It is essential that the Progress Note be fully completed.

Subcontract Worker Progress Notes

For every HCBS Waiver service delivered to an enrolled child or family member, progress notes must be completed by the worker and must comply with all of the above criteria.  The subcontractor must submit original progress notes to the ICC Agency immediately following  service delivery except in cases where respite care is provided under the Waiver in an OMH certified Community or Crisis Residence (copies are then sent to the ICC Agency by the subcontractor).  The ICC monitors service delivery and coordinates any needed services that arise from other worker contact with the child and family.

Comments or questions about the information on this page can be directed to the Home and Community Based Waiver Program.