Information to record in each applicable FACS tab of the Interview Notebook during an LTC application interview or annual review and prior to taking action on an application or review includes:

Case Information Tab:

• Describe the type of action being processed (Application, Annual Review, Change, etc.)
• Record the date the client entered nursing facility.
• Document interview date
• Document who was interviewed
• Record the address and relationship of the person who handles the client’s business. (Authorized representative).
• Document verification Requested: Document what verification has been requested. List items in enough detail that someone else would be able to process the case or answer any questions. Document if no further verification was needed.

Typical case info notes will include, but are not limited to:

1. LTC app/renewal/change submitted on 00/00/00. Phone interview conducted 00/00/00 with _____.

   ADM-92 issued on 00/00/00 requesting ______.

2. Annual Review received 00/00/00, screened for completion.
3. Interview completed on 00/00/00 with authorized representative (Client’s son ____, resides at 123 W Main, Indio, OK. PH 405-555-5555.

Intake / Household Tab:

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• Record the name of the facility where the nursing home or ADvantage assisted living client resides.

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• Record the date client entered nursing facility.

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• Explore and document all special circumstances* and program eligibility as applicable for each household member:
  • Citizenship/alien status
  • Categorical Relationship
  • Marital Status

Typical Intake / Household notes will include, but are not limited to:

1. 1 adult applicant, Carrie, is categorically related to age.
2. HH consists of 2 adults (William and Theresa, married couple) and 3 minor children. William is categorically related to disability and received medical services prior to application.
3. HH consists of 2 adults. Sharon and Seth, married couple, both are categorically related by age. Seth entered the nursing home on 00/00/00.

Income Tab:

• Document how income was verified and calculated
• Address and document unearned income SSI, RSDI showing on data exchange screens (SDX, BEN).
• Explore and document other unearned income sources for all household members such as:
  • Pension/ Retirement
  • Veteran’s Benefits
  • Worker’s Comp
  • Royalties and Dividends
• Show calculations for the monthly amount to be left in the Medicaid Income Pension Trust (MIPT). Verify and document that the correct monthly amounts have been deposited into the MIPT at each review.
• Show calculations for amount to be deemed to the community spouse.
• Always record the vendor payment calculations for nursing facility case or assisted living services.

Include documentation of special circumstances* as applicable such as:

• Recoupments
• Lump Sums
• General Income Exclusion ($20)
• Reduced Veteran’s Pension
• MIPT
• Spousal Impoverishment
• Income Producing Property

Typical income notes will include, but are not limited to:

1. Client receives $0000 RSDI verified by BEN screen; Client also receives a monthly pension of $000.00 verified by letter.
2. Client receives a retirement benefit (verified by benefit letter) of $0000.00 and RSDI (verified by BEN screen) in the amount of $0000.00. MIPT is established for $000.00 each month.
3. Client receives VA Aid and Attendance $0000.00 per month. Client resides in the home so $000 is used for an attendant in the home. Balance of $000 is used as income.

Resource Tab:

• Document client’s resources and how they were verified (AVS, bank statements etc.,
• Document client’s response regarding any resource they had within past 5 years and what has happened to the resource(s).
• Document the date and amount of all transfers of resources.
• Document any penalty period time frames (if applicable) regarding transfer of resources.
• Document if there is any property which is exempt and why. If the exemption ends, explain when and why.
• Record 90-day good faith effort follow-ups if there is property that is for sale.
• Record the date any home property lien is submitted to OHCA/TPL Unit.

Typical resource notes will include, but are not limited to:

1. Client provided bank statement from _________. Countable resources is $0000.00
2. Client provided receipts on how excess resources were spent down. $000.00 to pay medical bills.
3. Client provided the website address for ________ Realty which shows the home is currently on sale for market price $000000
4. Riley (Institutionalized spouse) and Ruth Jones (Community Spouse) has combined countable resources are $14,000. As combined resources total less than the Minimum resource standard – all resources are deemed to Ruth.
5. Client has a $0000 irrevocable burial policy and a $000 face value life insurance policy that is not part of the burial. The cash value of the policy is $000. The $0000 irrevocable burial policy is exempt. The $000 cash value is a countable resource.
6. Client is applying for ADvantage and has home property with an equity value of $000000, which is less than the Maximum Home Equity Standard. Home property is exempt as client resides in the home.
7. Client states on 00/00/00 that she does not plan to return to home from the NH. MA-10 and FSS-ML-1 forms signed and imaged. As client’s spouse lawfully remains in the home, a lien may not be filed on the home property.

TPL Tab:

• Document any insurance coverage (Long-Term Care insurance) the client has. Include policy number, start date, coverage type, and policy holder, etc. Notify OHCA by email.
• Explain how health insurance was verified.
• Document when any previous health insurance coverage was terminated.

Typical TPL notes will include, but are not limited to:

1. Client has major medical coverage through ________ insurance. Copy of card provided.

Expenses Tab:

• Document the cost of medical insurance premiums, Medicare Premium, Supplemental Health Insurance Premiums, etc.
• For nursing home and assisted living clients – document maintenance and vendor payment.

ELIGIBILITY – Medical General Tab:

• Record the reason for any LOCEU decisions and when the next decision will be needed.
• Document the client’s categorical relationship.
• Record the waiver code and date of waiver eligibility for individuals who are approved for either the DDS or Living Choice Home and Community-Based waivers.
• Document when the ELDERS uniform comprehensive assessment tool (ELDERS UCAT) is completed.

ELIGIBILITY – Auth LT Care Tab:

• Document LTC decision from Area Nurse and copy email into case notes.
• Record any changes or closures made to the nursing home authorization including vendor payments. Document the reason and effective date for the change.
• Document permission was granted by client or responsible person if there is a retroactive vendor payment increase.