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NPS Report
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NPS Report
NPS Report
Non-Provision of Services (NPS or Gap) Report (Please answer ALL Questions)
Funding Source
DDD
Yes
UHC
Yes
Bridgeway
Yes
NARBHA
Yes
PD
Yes
Client's Name
*
County Code
*
01-Apache
03-Cochise
05-Coconino
07-Gila
09-Graham
11-Greenlee
13-Maricopa
15-Mohave
17-Navajo
19-Pima
21-Pinal
23-Santa Cruz
25-Yavapai
27-Yuma
29-La Paz
AHCCCS ID#
*
Zip Code
*
Date Gap was reported
*
Date Format: MM slash DD slash YYYY
Time gap was reported
*
Round to the nearest quarter hour
:
HH
MM
Person gap was reported to
*
Who reported the gap?
*
DSP's Name
*
Scheduled time of service
Scheduled Date of Service
*
Date Format: MM slash DD slash YYYY
Time: From
*
Round to the nearest quarter hour
:
HH
MM
Time: To
*
Round to the nearest quarter hour
:
HH
MM
Type of service scheduled to provide
RSP
Yes
Attendant Care
Yes
HSK
Yes
HID/HAI
Yes
RSP Time: From
*
Round to the nearest quarter hour
:
HH
MM
RSP Time: To
*
Round to the nearest quarter hour
:
HH
MM
Attendant Care Time: From
*
Round to the nearest quarter hour
:
HH
MM
Attendant Care Time: To
*
Round to the nearest quarter hour
:
HH
MM
HSK Time: From
*
Round to the nearest quarter hour
:
HH
MM
HSK Time: To
*
Round to the nearest quarter hour
:
HH
MM
HID/HAI Time: From
*
Round to the nearest quarter hour
:
HH
MM
HID/HAI Time: To
*
Round to the nearest quarter hour
:
HH
MM
If the shift included habilitation, what time was the habilitation to be served?
HAB Time: From
Round the nearest quarter hour
:
HH
MM
HAB Time: To
Round to the nearest quarter hour
:
HH
MM
(we do not report habilitation hourly (HAH) unless if its habilitation independent-service code HAI, or habilitaion daily-service code HID)
When the gap was reported, what timeline did the family/member specify as to when they needed the gap filled?
*
within 2 hours
services today
within 48 hours
next scheduled visit
According to the last ISP or Care Plan what was the specified timeline for filling a gap?
*
within 2 hours
services today
within 48 hours
next scheduled visit
What was the reason for the gap? (Give Details)
*
How many hours were scheduled for the shift?
*
When was the gap filled? (Give gap in hours)
*
Who filled the gap i.e. mom, dad, another family member, neighbor, we sent staff, or if nobody else was there did the client stay alone or not have services at all? (Be Specific)
*
If we did not fill the gap how many hours passed before we provided services for the client again?
*
round to the nearest quarter hour
Was the family offered a replacement provider?
*
Yes
No
What was their response?
*
Why were they not offered a replacement provider?
If the member/family requested coverage and you were unable to offer a replacement caregiver, did you contact the member’s case manager or after hours call number?
*
Yes
No
Date
Date Format: MM slash DD slash YYYY
Time
round the nearest quarter hour
:
HH
MM
Why did the case manager not get contacted?
*
Was the gap due to hospitalization?
*
Yes
No
Is SC aware?
*
Yes
No
Have they been discharged?
*
Yes
No
What date were they discharged?
*
Date Format: MM slash DD slash YYYY
Services restarted as of:
*
Date Format: MM slash DD slash YYYY
Additional Comments:
If this gap was reported after the service was due to start, please explain why the employee did not notify his/her supervisor of the gap prior to the start of service:
Has a corrective action plan been considered?
*
Yes
No
Why was no corrective action plan considered?
*
Form Completed By
*
First
Last
What is your name?
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