36C26118Q0096-006.pdf

DEPARTMENT of VETERANS AFFAIRS MEDICAL CENTER

San Francisco, California

San Francisco VA Medical Center Downtown Clinic/Annex Procedures No. 719

April 21, 2017

SUBJECT: HUD-VASH Clinical Documentation

PURPOSE: To formalize and outline the expectations around clinical and case management documentation, as well as data tracking duties, for providers in the HUD-

VASH program.

POLICY: This policy addresses compliance, guidelines, and expectations for clinical documentation in the HUD-VASH program.

RESPONSIBILITIES:

1. Case managers are required to document clinical and case management interventions into CPRS within 72 hours of service provision.

2. Case managers are responsible for communicating the course of treatment, strengths, and needs of the Veteran in the clinical notes as well as presenting challenges and barriers to goals as outlined in the Care Plan.

3. Case managers are responsible for maintaining accurate records in HOMES and

CPRS. They will be charged with regular reporting to program supervisors who, in turn, are required to provide data to local, regional, and national HUD-VASH program representatives.

4. HUD-VASH Supervisors are responsible for ensuring that staff is trained in documentation procedures and protocols. The Supervisor will conduct regular and structured chart audits to track staff compliance with this policy.

5. Case managers must utilize the SOAP (Subjective, Objective, Assessment, and

Plan) format of documentation and will reference the goals in the Veteran’s Care

Plan as they relate to services provided in each note.

6. The Director of Comprehensive Homeless Services and the Chief of Social Work will provide regular oversight to ensure documentation compliance with San

Francisco Medical Center and VA national protocols.

PROCEDURES:

1. Referrals and screening interviews of Veterans to the HUD-VASH program will be documented in CPRS and in HOMES (Homeless Operations Management and

Evaluation System) according to standards established by NEPEC (North East

Program Evaluation Center).

2. HUD-VASH case managers will enter information into HOMES during the screening and intake processes as well as in the event of any updates or changes in housing status.

a. HOMES Assessment: Veterans who have been screened for HUD-VASH will complete an assessment in HOMES within 24 hours of the screening.

This is required for program referral and admission.

b. HOMES Program Referral: If a Veteran is determined to be eligible for program entry, the program referral will be documented in HOMES within

30 days of the completion of the HOMES Assessment or NEPEC assistance will be required.

c. HOMES Entry Form: This task will be completed by the case manager within 30 days of a program referral or NEPEC assistance will be required.

d. Housing Progress Forms (HPFs): The Housing Progress Form in HOMES should be completed as soon as a Veteran has entered the program, throughout the vouchering process and immediately after any housing developments, including vouchered date, move-in date, lease-up date, changes in status, etc.

e. HOMES Exit Form: The HUD-VASH Exit Form is used to document a

Veteran’s exit from the HUD-VASH program and should be completed whenever a Veteran exits the program, regardless of length of time in the program or the circumstances surrounding the exit.

3. Admission Note: A brief admission note is completed in CPRS on the day of admission to document that the Veteran has been accepted into the HUD-VASH program. The “HUD-VASH Admission Note” progress note title is utilized and will contain a brief admission note with assessment, Mental Status Exam (MSE) and mini-treatment plan goals.

4. Psychosocial Assessment: The case manager is responsible for utilizing the

“Social Work Psychosocial Assessment” template in CPRS. This assessment should be completed within 30 days of admission to the program. The psychosocial assessment is updated when there are significant changes in the

Veteran’s status or condition, but at a minimum of once every year.

5. Individual Treatment Plan: The case manager is responsible for utilizing the

“HUD-VASH SW Treatment Plan” note template and progress note title in CPRS.

The Individual Treatment Plan should be completed within 30 days of the

Psychosocial Assessment. In addition, the case manager will use a collaborative approach in completing the plan with the Veteran. The Individual Treatment Plan should be updated annually or when there are significant changes in the Veteran’s status or treatment needs. Care should be taken to develop measurable goals, which are revisited during regular meetings between the case manager and the

Veteran.

6. Progress Notes: Ongoing progress notes to monitor HUD-VASH program participants’ progress towards individual goals will be documented in CPRS at least monthly, though more frequent contact may be indicated depending on the complexity of the Veteran’s circumstances and needs. The case manager should address the following issues in the progress note:

a. Mental status

b. Physical status

c. Suicidal/homicidal ideation

d. Coping skills

e. Physical status of the home

f. Skills of daily living

g. Daily activities

7. Group notes: If Veterans participate in HUD-VASH groups, this should be documented using the “HUD-VASH Group Note” progress note title.

8. Telephone contacts: Relevant telephone contacts should be documented using the

“HUD-VASH Telephone Note” progress note title.

9. Discharge Note: A “Discharge Note” should be completed in CPRS whenever a

Veteran exits the program, regardless of the length of time that he or she has been in the program or the circumstances surrounding his or her exit. (Please see HUD-

VASH Discharge Policy and Procedure for additional details.)

10. North East Program Evaluation Center (NEPEC) data forms will be completed and submitted according to the standards set forth in the various programs.

11. Case managers will identify the components of the service at the beginning of each note according to time, e.g., travel time, face-to-face contact, time to enter note, etc.

REFERENCES: VA HUD/VASH Handbook, 1162-05

Joint Commission for Behavioral Health Care Manual, latest edition

RECISSIONS: Housing and Urban Development – VA Supported Housing (HUD-

VASH) Clinical Documentation, November 22, 2016

REVIEW: April 21, 2018

Joanne Peters, LCSW

Chief, Social Work Services