Start of Care (SOC) Checklist

Purpose: 

To ensure comprehensive assessment and compliance with MN Home Care Statutes and ensure the highest quality of care of all Recover Care Clients. 

Regulation: 144A.4791.8
Policy: 

Measurement:

  1. 100% of clients receive a complete comprehensive assessment, as documented in ClearCare. And 100% of clients have a completed checklist below, ensuring all items have been completed on behalf of the client. 

Process:

SOC Checklist

Initial Comprehensive Checklist

Complete
Task

Schedule Initial Assessment in Client Shift Calendar

Complete Service Plan including IMMP and ITP and obtain client / responsible party signature

Review "Client Handbook" with client and leave a copy with client / responsible party (Admission Packet)

If Client has given photo consent, take photo and upload to ClearCare

Complete ClearCare Client Profile and Demographics
  • Name
  • Address
  • Date of Birth
  • Phone Number
  • Email Address
  • Location Tag
  • Hospice Tag, if applicable
  • DNR Status Tag
  • Include in Note Section:
    • Admission Date
    • Date of Birth
    • Essential vs. Non-Essential Services
    • Staffing Contact
    • Specific Instructions Including Lock Box Code, door / garage code needed for home entry instructions, etc. 

Confirm and Document Client's Contacts
  • Physician
  • Emergency Contacts: Including Email
  • Preferred Hospital
  • Pharmacy
  • Any Home Health, Hospice, or DME Providers
  • Indicate Family / Friend Contacts
  • Identify Payer

Complete SOC Assessment - Human Systems Review Form
  • This must be completed and scanned into client record

Document Assessment Results in ClearCare
  • Match Criteria: include if services are essential or non-essential: If transportation is needed or errands only
  • Care needs
  • Advanced Directives   
  • ADLs includes Vulnerabilities and Medication Assessment: Competency Instruction Sheets:  cut and pasted into the notes section of the assessment. 
  • IDLs
  • Allergies
  • ICD 10 code for primary diagnoses
  • Any other applicable sections

Complete Medication Assessment and Document in ClearCare
  • A RN must conduct a face-to-face client assessment to determine what medication management services will be provided and how those services will be provided. This is typically a part of the Comprehensive Assessment. 
  • The home care provider must prepare and include in the Service Plan a written statement of the medication management services that will be provided to the client. This will be documented on the "Individualized Medication Management Plan" (IMMP) on the client Service Plan.
  • If Recover Care is setting up medications, follow Medication Setup Process
  • RN to document the results of the medication assessment in ClearCare

Complete Home / Safety Assessment and Document in Clear Care
  • If side rail / transfer pole is present in bedroom (or anywhere else) ensure to follow side rail / transfer pole policy and procedure

Once ClearCare Documentation is complete, save final version (bottom of Assessment) as Initial Comprehensive Assessment

Obtain Service Deposit and Submit to Office Specialist

Discuss Recurring Payment Authorization / Credit Card and complete paperwork, as necessary. 

Enter Clinical Note in Client Chart with the following information:
  •  Who was present at the assessment?
  • Where was the client referred from (or discharged)?
  • What is the client’s primary diagnoses / reason for services?
  • Indicate you have reviewed the health assessment
  • Indicate you reviewed the IMMP / ITP as part of the service plan
  • Describe the various support resources internal and external (family, neighbors, organizations, etc.)
  • Indicate if client is utilizing bedrails
  • Indicate client / representative had the opportunity to participate in the creation of the Service Plan
  • Summarize the plan for service offerings

HHA Competencies
  • Ensure any client competencies, outside the scope of general HHA orientation are reviewed with HHA staff and put in physical chart in the home
  • Copy and paste instructions into tasks in Care Plan

N marks the assessment as complete and converts “Prospect” to “Client” in EMR

Add Client to MDH Roster in Shared Files Drive

Schedule 14-Day Monitoring Visit Task in ClearCare with due date of 10 days after SOC

Schedule 190-Day Monitoring Visit Task in ClearCare with due date of 10 weeks after 14-day visit

Communicate to Internal Team the Regular Schedule and Any Client Details:
  • Email sent to Administrator, Scheduling Coordinator, Office Specialist and COO: 
    • Subject Line: “SOC Assessment – New Client Details: CLIENT NAME” 
    • Email must include:
      • Service Plan Attachment
      • SOC Date
      • Service Type (HHA, Homemaker, HHA Visit, etc.)
      • Schedule and Frequency of Care
      • Care specifics (male or female caregiver, Smoker, pets, care level, if vaccinated caregiver is needed, if caregiver needs to transport client)