Pending F2F Case Study

Housing Update: client NY NY I, II was approved. Client is waiting for DHS manifest to tour apartment. Another alternative housing is MRT once client SSI is approved. Client also mentioned she signed up with Brightpoint Health Home Health Services since 5/9/2015, Client report she will like to sign up with CAMBA/Home Health and she provided BrightPoint Home Health approval letter for CM to submit to CAMBA/Home Health Coordinator. Client is waiting for her coordinator at Brightpoint to return from vacation to close her case, so that she can sign up with CAMBA/Home Health

To whom it may concern , the patient listed above transferred to team 302 on 2/23/2017. The patient was currently on team 302 then the Delray IPU . On February23,2017 the patient went to Manor care of Boynton Beach from the Delray IPU Manor Care is requesting the patient 3008 would the responsible team please forward the 3008 to team 302.

The pt Poteat, Edward L is supposed to tx today at unit 1087. The unit 1087 is requesting the referral source to send a shortened and missed treatment report in order for the pt to be accepted. This report is not one of the requirements that is needed in order for a pt to transfer to a FKC unit. Also the referral source stated the she sent the report several times and received several conformations and clinic 1087 is stating that they never received it. The referral source and the unit 1087 have been in contact and I am just now finding out about this. Please let me know if the pt is accepted and to see what we can do regarding this patients

CCIB received a Corrective Plan of Action (CAP) detailing the visit to the home on 10/18/17 by Service Coordinator, Sally Cano. Ms. Cano arrived at the home, but no one was there. Ms. Cano proceeded to check Delta Home 3 (located next door) and found 2 of Delta Home Care IV residents along with residents from Delta Home Care 3 at the home. As Ms. Cano was leaving, she observed a bus arrive at the Delta Home Care 2. The bus driver reported that there was no staff at the home and that the residents were waiting outside. It was observed the Delta Home Care 2, 3, and IV to be lacking staff. On 10/19/17, RP and Quality Assurance specialist (QAS) Jesus Ozeda went to the facility to observe the staff to resident ratios and to collect the staff schedules

The worker met with Mrs. Marilyn Beaird on 8/18/15. She is bed and wheelchair bound and requires two assists when transported. Mrs. Beaird has diagnoses of Vascular Dementia and is unable to answer questions

The patient is in the process of being reassigned with a mental health therapist through CHR and it is currently pending. The patient is planning to follow up today about the outcome because she then reports, " I have to do the intake again."

There has been a delay in completing this wellness check. Ms. Bell has been out of the State of Michigan for the winter. Coordination of the visit was determined by her return to Michigan. This is a onetime visit that per attorney Mr. Goodwin needed to be coordinated with the prior nurse case manager Joyce Lucas from Wellspring Case Management. On 5/16/18 I met with Ms. Bell and her husband along with Ms. Lucas

Intervention: As per member's request days of PCA services changed as Monday, Tuesday, Wednesday and Friday 4D/8H, Thursday, Saturday and Sunday 3D/4H effective 03/12/2017. Spoke with Ms. Irina Simkhovich from HCS home health care, authorization and billing department, CM informed changes of schedule and sent an fax with updated authorization. Also, Ms. Irina Simkhovich reminded CM request of 8 hours for 03/03/2017 and 03/06/2017, CM kindly informed member is only approved 4D/8H, 3D/4H by ABH and by 02/28/2017 Americare( covered by Medicare) informed they would covered M,W,F 4 hours each day. on 03/07/2017 Morrine Fox , Americare, informed as per RN recommendation 2 additional hours each day was approved for M-F, case shown up as active by 03/08/2017. HCS provided from 03/02/2017- 03/06/2017 each day 8 hours for this reason are requesting coverage of 03/03/2017 & 03/06/2017.

SC completed monitoring telephone call with Pa on 1/20/2016. SC called Pa. Pa reported that ding “good”. Pa reported no new health problems, no medications, no falls, and no hospitalizations. Pa reported no outstanding doctor’s visits. Pa reported that’s he saw her PCP on 1/19/2016. SC reviewed Pa's ISP. Pa confirms that she is receiving services in the following type, scope, amount, frequency and duration of services specified in the ISP agency model aide via Total Home Health Care from 10-2PM, Monday through Sunday. Pa's aide provides assists her with the completion of ADLs, IALDs and supervision as needed. Pa has PERS system which gives her access to emergency medical service. Pa also, receives HMD from PCA weekly. She reported being satisfied

At today’s visit she is found in her room at Tiffany hall SNF. She is awake, alert and confuse. The facility staff reports that the patient often refused care. She is wheelchair dependent. She is assist with most ADLS. She has chronic edema in lower extremities and refuses to elevate legs. She also refused

Reporting party (RP) stated he arrived at the facility to meet with resident George Dixon (7/11/52) on 3/29/17. Resident was recently placed at the facility after being released from the hospital. Staff did not allow RP to enter the facility so that he could conduct his metal health assessment for the resident. RP presented his business card from his agency but was still denied entry. The resident has been enrolled in RP's program since 02/01/16 and has been visited previously by Social Worker Kathy Kleinman and by staff Denise Ramirez on 3/10/17. Staff told RP that he has to contact the administrator to make an appointment to visit with resident. RP's agency faxed over the consent for treatment to the facility and the DMH contract. Patient's

CM was unable to reach Lisa Marshall (caregiver) in regards to services and upcoming CFT meeting for Alexia (youth). CM left caregiver a detailed message informing her that at today’s, Wednesday 4/12/17 CFT meeting caregiver has to complete a full Medicaid package, 3560 OOH application. CM noted caregiver must bring the following: copies of private insurance card, youth’s birth certificate and youth’s social security card. CM requested to be contacted.

Mr. Flowers is a 41 year old male who presented to the ED via LEO under IVC from Daymark Recovery Services. TACT assisted ED staff with deescalating Mr. Flowers after being informed of Mr. Flowers was becoming agitated. Mr. Flowers was concern about when he was able to leave and was under the impression he could leave tonight. TACT spoke with Paige from MCBH who informed TACT that MCBH was still seeking placement for Mr. Flowers. Mr. Flowers was informed of the current status of his disposition. Mr. Flowers gave this clinician verbal permission to speak with his wife Vickie Flowers about the status of his disposition and explain the process to her. This clinician explain the process and informed her of status.

Counselor met with Pt. for his one hour mandatory individual session. In this session, Pt. processed his concerns for earning more take home privileges and institutionalize mentally that appear to be ongoing. Pt. reported that he learned the requirements of earning take home privileges while taking prescribed subutex. He also learned how a positive urine and/or missing monthly session can impact his health and this privilege. He mentioned that he would like to move to phase 2 because he is going to attend a weeding in New Jersey this coming Saturday, 4/29/17. Counselor helped Pt. to complete the Take Home Request form to be discussed during AMS Team meeting. Pt. stated that he takes his medication as prescribed, but he can remember the times

CM met with Thomas, Kevin/ Open Arms Case Manager and Amy/ ESP Staff to conduct Thomas's discharge, case management services and ID Waiver Intake. Thomas appeared tired as his eyes closed and head lowered for some of the Intake. He complained early during the meeting that he didn't want to answer a lot of questions, however with some verbal encouragement he went on with his responses. Thomas talked much about his medication and seemed at times to get his current medications confused with his old medications. Due to a history of overdosing and taking medications that weren't prescribed to him; his roommate makes sure Thomas is taking the correct medications. He has been living at current address for 2 months and Kevin feels the houses is in