Fallon Kornegay

• Assessment and Planning:

1. Completion of comprehensive assessment.

2. Utilizes person centered planning methods/strategies to gather information and to get to know the members supported. 3. Provides education and support to members in learning about and exercising rights and responsibilities.

4. Consistently completes discovery activities (information gathering and assessment) in advance of the planning meeting 5. Completes annual re-assessment of level of care for Innovations Waiver participants.

6. Completes the NC Innovations Risk/Support Needs Assessment for Innovations Waiver participants at least annually prior to the development of the ISP, and updated as significant changes occur.

7. Ensures that members/legally responsible persons are informed of services available, service options available (e.g. Individual/Family Direction for Innovations participants), processes (e.g. requirements for specific service), etc.

8. When discussing a proposed ISP with an Innovations Waiver participant, the care coordinator discusses the duration of the service requested by the participant, and assures that the proposed ISP requests authorization for that service at the duration requested by the participant during that plan year.

9. Assists members/legally responsible persons in choosing service providers, ensuring objectivity in the process.

10. Assists the member supported to direct the planning process/plan development, to the extent desired by the member. 11. Facilitates timely development of the Individual Support Plan and crisis plan (as applicable).

12. Actively collaborates with members supported and members of the treatment team to ensure development of a comprehensive plan that accurately reflects the individual’s needs and desired life goals.

13. Promotes use of natural/community resources through the assessment/planning process.

14. Ensures that assessments and plans are updated, as needed, whenever the individual’s life circumstances change. Submission of the Individual Support Plan and/or Revisions to the Individual Support Plan and required supporting documentation for Innovations Participants to Utilization Management at least annually, or as needed.

15. Ensures needed community-based resources and social support needs are addressed in participant’s ISP.

• Support Monitoring/Coordination:

1. Monitors to ensure quality care, health/safety of the member, as well as the continued appropriateness of services.

2. Monitors services on site, in all settings and on a schedule outlined in the participant’s ISP.

3. Closely coordinates care with the member’s IDD/TBI providers, physical health provider(s) and, when appropriate, behavioral health providers.

4. Supports psychotropic medication management as prescribed by medical providers, focusing on treatment adherence monitoring, side effects, and effectiveness of treatment, ensures that services are monitored (including direct observation of service delivery) in all settings.

5. Verifies that participants are satisfied with the services and supports they are receiving.

6. Makes announced/unannounced monitoring visits, including nights/weekends as applicable.

7. Monitors services and provider documentation for compliance with state standards, waiver requirements, and Medicaid regulations, as applicable.

8. Promotes problem-solving and goal-oriented partnership with individuals/legally responsible persons, providers.

9. Recognizes and reports critical incidents.

10. Promotes member satisfaction through ongoing communication and timely follow-up on any concerns/issues.

11. Coordinates with the member, the legally responsible person/parent/guardian, and members of the person centered planning team to ensure that needed changes are effectuated in a timely manner.

12. Coordinates and links all Medicaid funded services for the member, as appropriate.

13. Follows up on quality of care issues regarding health and safety and complexity of care for specific members.

14. Participates in Case Reviews/staffing with supervisor, I/DD Clinical Director, and/or Medical Directors as needed.

• Comprehensive Transitional Care and Follow-up:

1. Management of transitions of care for members moving from one clinical setting to another to prevent unplanned or unnecessary readmissions, ED visits, or adverse outcomes.

2. Ensures comprehensive transition planning to ensure that members will maintain, or access needed services and supports, transition to the new care setting, and integrate into their community.

3. Management of care transitions (e.g. provider changes, implementation of new service, critical staffing changes, etc) to prevent adverse outcomes.

4. Facilitates member engagement and follow-up care.

5. Ensures accurate, timely and effective communication is both obtained and provided to all parties involved in care transitions.

• Individual and Family Support:

1. Training the member in self-management.

2. Providing education and guidance on self-advocacy to the member, family members and support members.

3. Connecting the member and caregivers to education and training to help the member improve function, develop socialization and adaptive skills, and navigate the service system. 4. Providing information and connections to needed services and supports including but not limited to self-help services, peer support services and respite services.

5. Providing information to the member, family members and support members about the member’s rights, protections, and responsibilities, including the right to change providers, the Grievance and complaint resolution process, and fair hearing processes.

6. Health promotion, including promoting wellness and prevention programs.

7. Providing information on establishing Advance Directives, including advance instructions for mental health treatment, as appropriate, and guardianship options/alternatives, as appropriate.

8. Connecting members and family members to resources that support maintaining employment, community integration and success in school, as appropriate.

• Documentation and Fiscal Accountability:

1. Educates members/families on methodology for budget development, total dollar value of the budget and mechanisms available to modify the individual budget. Educates the member/families on waiver requirements/limits however, ensures services, as requested are outlined in the budget.

2. Verifies that services are delivered as outlined in person centered plan and addresses any deviations in service.

3. Ensures that service orders/doctor’s orders are obtained, as applicable.

4. Verifies member’s continuing eligibility for Medicaid and promptly follows-up on identified issues, as indicated.

5. Ensures that service orders/doctor’s orders are obtained, as applicable.

6. Proactively responds to an member’s planned movement outside the LME/ MCO geographic area to ensure changes in their Medicaid County of eligibility are addressed prior to any loss of service.

7. Coordinates Medicaid deductibles, as applicable, with the member/legally responsible person and provider(s).

8. Proactively monitors own documentation to ensure that issues/errors are resolved as quickly as possible.

9. Ensures all clinical documentation (e.g. goals, plans, progress notes, etc.) meet state, agency and Medicaid requirements.

10. Maintains medical record compliance/quality, as demonstrated by ≥95% compliance on Qualitative Record Reviews.

• Managed 4 IDD group homes, serving individuals with IDD and Autism who receive Residential Supports, Day Supports, and Community Networking services.
• Participated in the weekly Clinical Team Meetings.
• Attended annual ISP meetings and tri-annual SIS evaluations.
• Frequently Communicated with Guardians to ensure service quality.
• Directly Supervised Group Home Leaders and Group Home Paraprofessionals.
• Clinically Supervised of Paraprofessional Staff members, from person-specific Training to Quarterly Clinical Supervision Evaluations.
• Monitored Electronic Health Record system daily to verify completion of services.
• Participated in On-Call Schedule to meet needs of individuals in a Crisis situation after hours.
• Participated in Quarterly QA/QI Meetings, Safety Meetings, and Human Rights Committee.
• Marketed Ambleside, Inc in a positive way to secure additional members for your Caseload.
• Performed House inspections.
• Reported incidents.
• Reviewed incident reports.

• Communicated with clients about servicing needs.
• Asked questions to determine customer needs.
• When applicable, advised caller of steps necessary to resolve issues.
• Accountable for each call from beginning to end; including following up with customers to assure their issue was resolved.
• Maintained accurate documentation of interactions with customers

• Shopped for customer using hand held device.
• Made substitutions when items not available.
• Communicated with customers via cellphone when appropriate.
• Dispensed items upon customers arrival.
• Kept back room area neat and organized.
• Uploaded metrics from computer.

• Skilled at working independently and collaboratively in a team environment.
• Self-motivated, with a strong sense of personal responsibility.
• Proven ability to learn quickly and adapt to new situations.
• Worked well in a team setting, providing support and guidance.
• Coordinated, conducted, and documented meetings with parents/guardians and team members.
• Provided ongoing communication between facility and guardian.
• Monitored implementation of PCP for 16-24 individuals with developmental disabilities.
• Monitored overall progress on objectives to maximize the physical, intellectual, social, and vocational potential of the individual.
• Conducted pre-admission team meetings.
• Prepared for and conducted initial and annual team meetings.
• Wrote Person Centered Plans.
• Conducted quarterly program reviews and developed plan of action for deficit areas.
• Conducted and documented core team meetings, Psychiatric Clinic; and Level III program reviews.
• Ensured ICF regulations are followed.
• Maintained all required documentation in individuals' records.
• Identified needs of individuals and coordinated services to meet those needs.

• Enhanced member satisfaction by providing exceptional customer service and promptly addressing inquiries.
• Assisted in the retention of members through timely problem resolution and personalized support.
• Managed member accounts, ensuring accurate record-keeping and prompt assistance with any issues.
• Collaborated with team members to develop strategies for improving overall member experience.
• Presented membership information to potential members.
• Asked questions to assess which membership fits the individual's needs.
• Adjusted presentation to increase member sign-ups and renewals.
• Implementation of policies and procedures.
• Organized work area to make work more effective and maximize time.
• Collaborated with other associates to prioritize and complete projects in a timely fashion.
• Served as liaison between contractors/ delivery person and other associates, supervisors, and managers.

• Enhanced client independence by developing and implementing individualized habilitation plans.
• Provided personalized support for clients with disabilities, promoting self-advocacy and community integration.
• Collaborated with interdisciplinary teams to assess client needs and develop comprehensive care plans.
• Assisted clients in achieving personal goals by providing guidance, encouragement, and skill-building opportunities.
• Evaluated and assessed each client’s current level of adaptive behavior, areas of self-help, daily living, personal safety, community living, academics, pre-vocational and vocational skills upon admission and updates annually.
• Developed personal outcome programs based on priority objectives identified by the interdisciplinary team.
• Specified behavioral objectives, training methods, reinforcers, criteria, data collection method, and task analysis or training steps for each program; writing program and implemented within required timelines.
• Observed and provided feedback while working closely with home care staff as they carry out personal outcome program procedures; providing encouragement and offering suggestions for fine-tuning the intent of programs and overall support plan.
• Reviewed and documented formal programs on 30-day cycles to modify as appropriate and conducted in-service training.
• Conducted Personal Outcome Interviews along with other staff members to assist in identifying outcomes and supports.

• Improved customer satisfaction by providing timely and efficient technical support to clients.
• Resolved complex technical issues for better client experience and smoother operations.
• Assisted colleagues in troubleshooting software and hardware problems, enhancing team productivity.
• Diagnosed system errors with meticulous attention to detail, ensuring accurate solutions were provided.
• Communicated with clients about servicing needs.
• Asked questions to determine customer needs.
• Advised customer of steps necessary to resolve issues.
• Developed creative ways to resolve customer issues to decrease handle time and increase productivity.
• Accountable for each call from beginning to end; including following up with customers to assure their issue was resolved.
• Discussed solutions to common technical issues to resolve member issues quickly.
• Actively participated in staff trainings and meetings.
• Maintained accurate documentation of interactions with customers.

• Enhanced patient well-being by providing compassionate and attentive care in daily routines.
• Assisted with personal hygiene tasks for improved health and dignity of patients.
• Safeguarded patients by closely monitoring their behavior and intervening during crises when necessary.
• Collaborated with interdisciplinary teams to develop and implement individualized care plans for optimal patient outcomes.
• Provided medication management, ensuring accurate administration and adherence to prescribed schedules.
• Supported patients with mobility challenges, utilizing proper techniques to prevent injury and promote independence.
• Established strong rapport with patients, fostering trust and open communication for better understanding of individual needs.
• Documented patient progress through detailed record-keeping, contributing to ongoing evaluation of care plans effectiveness.
• Maintained cleanliness and organization of living spaces for a safe and comfortable atmosphere conducive to healing.
• Actively participated in staff meetings, sharing insights on patient experiences to inform team-wide decision-making processes.
• Developed essential life skills in patients through hands-on training in areas such as budgeting, cooking, and self-care practices.
• Guided patients toward achieving personal goals by offering emotional support, encouragement, and practical advice.
• Stayed current on best practices within the direct care field through ongoing professional development opportunities and trainings.
• Utilized crisis intervention techniques effectively during emergencies, ensuring safety of both patients and staff members involved.
• Advocated for patient rights, ensuring that their voices were heard and respected within the care environment.
• Documented client progress and services performed, reporting changes in client condition to manager or supervisor.
• Remained alert to problems or health issues of clients and competently responded.
• Assisted clients with daily living needs to maintain self-esteem and general wellness.
• Recognized and reported abnormalities or changes in patients' health status to case manager.
• Monitored and assisted residents through individual service plans.
• Determined specific needs and provided most appropriate level of services for patient well-being.
• Recorded temperature, blood pressure, pulse, or respiration rate as directed by medical or nursing staff.