Documentation of Prescription for Services: Covered ADDT services require a written prescription signed and dated by the client’s PCP or attending licensed physician. (Section 212.200). Prescriptions for covered services are valid for 1 year unless a shorter time period is specified. Prescriptions must be renewed at least yearly.
Documentation of Qualifying Diagnosis: Clients must have a documented qualifying intellectual or developmental disability diagnosis that originated before the age of 22. Please refer to Section 212.300(B) for a list of qualifying diagnoses.
Documentation of Individual Treatment Plan (ITP):
215.000 Individual Treatment Plan (ITP)
A. Each client receiving covered ADDT services must have an individual treatment plan (ITP).
1. An ITP is a written, individualized plan to improve or maintain the client’s condition based upon evaluation of the client.
2. An ITP must be reevaluated and updated at least annually.
B. Each ITP must at a minimum contain:
1. A written description of the goals and objectives for each covered EIDT service. Each client goal and objective must be:
a. Written in the form of a regular function, task, or activity the client is working toward successfully performing;
b. Measurable; and
c. Specific to each individual client.
2. The specific medical and remedial services, therapies, and activities that will be provided and how those services, therapies, and activities are designed to achieve the client’s goals and objectives;
3. Any evaluations or other documentation that supports the medical necessity of the covered ADDT services specified in the ITP;
4. A schedule of service delivery that includes the frequency and duration of each type of covered ADDT service;
5. The job title(s) or credential(s) of the personnel that will furnish each covered ADDT service;
6. The schedule for completing re-evaluations of the client’s condition and updating the ITP.
A. ADDT providers must maintain in each client’s service record sufficient, contemporaneous written documentation demonstrating the medical necessity of all covered ADDT services included on a client’s individual treatment plan (ITP).
B. ADDT providers must maintain in each client’s service record the following documentation for all day habilitative and nursing services performed pursuant to Sections 214.120 and 214.220 of this manual:
1. The specific services furnished each day;
2. The date and beginning and ending time for each of the services performed each day;
3. Name(s) and credential(s) of the person(s) providing each service each day;
4. Which client ITP goal(s) and objective(s) the day’s services are intended to address; and
5. Weekly or more frequent progress notes signed or initialed by the person(s) providing the service(s) describing the client’s status with respect to ITP goals and objectives for that service.