(Revised 5/1/16 ML #3471)
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Purpose:
The Person Centered Plan of Care (SFN 404) is a summary of the needs and service options identified in the assessment process and is an outline of the plan developed by the client, Case Manager and others to meet the client's needs.
When Prepared:
The Person Centered Plan of Care is required for all clients receiving HCBS Case Management/ Services under the Medicaid Waiver(s). It is to be revised or updated as client's needs warrant. It is to be reviewed with the client at the annual/six-month review, and complete a new form if necessary due to changes in service(s) and/or amounts. Quarterly visits to the client are required with a follow-up note within the narrative in SAM's.
Six month reviews: during client visit CM must complete a new front page listing services and new section VII to include new signatures. Cm may copy section X –Risk Assessment and Section VI – Restrictions from annual plan. CM adds date of 6 month visit to these sections and completed bottom portion of the Section VI. All pages are then sent to the department within 3 days of completed plan.
The Person Centered Plan of Care must be revised when a change occurs (unless it is a result of legislative action).
Section I Client Identification:
Enter the name, physical address, client identification number, county of residence, county code, and effective date of screening of level of care.
Section II Approved Services:
If receiving Rural Differential Rate (determined under Rural Differential policy 525-05-38) mark the correct tier (RD 1, 2, or 3) for rate.
HCBS/TD Waiver □ RD1 □ RD2 □ RD3 □ RD Removed
When marking RD Removal a SFN 212 is required to be sent to the department.
Column Headings:
Case Management has been pre-entered on the form. The Service Provider, Provider Number, and Unit Rate must be entered by the Case Manager.
Total Cost: The total per month costs of services is the total to be reimbursed under the Waivers. The Grand Total does NOT include the cost of HCBS Case Management. When authorizing services by unit and or daily rate the maximum amount must not exceed on the program and/or service cap.
Section III: ADL’s & IADL’s
ADL’s & IADL’s Scores: must be added from the Functional Assessment scoring.
Section IV: Contingency Plan
The Contingency Plan must be completed. Name of person assisting with meeting contingency plan must be listed along with phone number to be reached at.
Section V: Signatures
The client/legally responsible party must check all applicable boxes acknowledging agreement and or awareness of the specific information.
The signature of the client/legal representative and HCBS Case Manager is required. Any other person attending the Person Centered planning must sign here as an other.
If legal representative is not present in-person the plan is not complete and will not be able to have effective dates entered until signature has been received. Effective date of plan could either start on date of legal representative’s signature or a future date.
Section VI: Restriction
Purpose:
Any restriction on the client living experience needs to be documented in the Person Centered Plan of Care. A restriction is any control over a client that has been identified specifically towards one client and not required for all clients within that environment. Service where restrictions may occur are AFC/ ADC/ ARS.
Example: client living in AFFC not being allowed to have to food in bedroom for fear of choking, yet other individuals living there have this option.
SPECIFIC INSTRUCTIONS for Section VI:
Behavior: enter the behavior/ diagnosis that is requiring the restriction.
Identified Restriction: What is the restriction needed due to behavior?
Example: if client does not know when to stop eating. The restriction would be to not have food available at all times.
Restrictive Plan: What is the facility going to do to prevent the behavior?
Example: client would not be allowed to have a refrigerator in their personal space.
Plan tried in the past?
What has been tried to before getting to this restriction?
Signature:
Of client or legally responsible person and of the case manager is required.
The Team feels this plan will NOT cause harm to the client.
Mark this box if team is in agreement.
6 month review:
If the plan is working and there are no negative impacts to the client for the restrictions mark the box for yes and client and CM sign.
If the plan is not working mark the box for no, note what is not working in the plan and develop new plan, date this and sign.
Restriction plan may be revised any time a restriction is not working – CM does not have to wait until annual or 6 months to make changes.
Section VII: Authorization of Waiver Services
The HCBS Case Manager completes the "Authorization of Waiver Services" (Section VII) the HCBS Case Manager will determine the Qualified Service Provider (QSP) the client has selected is available and qualified to provide the service.
CM must ensure the chosen QSP has the ability to provide the requested service by checking the web-searchable database.
SPECIFIC INSTRUCTIONS for Section VII:
Section I: identifying information.
Enter the name, physical address, telephone number, and Medicaid provider number of the provider.
If QSP will be receiving the Rural Differential rate for traveling to clients within rural areas, mark the correct tier.
Do not combine services on the same authorizations, e.g. If you have a client that is receiving waiver homemaker services and waiver respite services from the same provider you will need to send two Section VII - one with homemaker and one with respite.
Enter the client’s name, Medicaid number, physical address, and telephone number.
"Authorization Period" - Identify the period of time the authorization is in effect. The authorization period MAY NOT exceed six (6) months except the initial. Renewal of the authorization would coincide with the 6-month Review or Annual Reassessment.
"Authorized Not to Exceed" - (Intermittent Unit Rate) is completed by recording the total dollar amount for all services based on a 31-day month.
“Authorized Not to Exceed" - (Daily Rate) is completed by recording the total dollar amount for services based on the daily rate times the number of days up to the maximum allowed for the funding source.
Section VIII is the authorizing of the service(s).
Column Headings
If Rural Differential was marked in Section I put in determined RD rate for service.
Section IX is the authorizing of the service(s) Tasks Authorized:
Check tasks authorized to be completed by this Qualified Service Provider. The explanation of tasks found on the back of the HCBS Authorization to Provide Services should be referenced in defining the parameters of the service tasks.
A written, signed recommendation for the task of vital signs provided by a nurse or higher credentialed medical provider must be on file which outlines the requirements for monitoring, the reason vital signs should be monitored, and the frequency. When the tasks of Temp/Pulse/Respiration/Blood Pressure are authorized, the individual to be contacted for readings must be listed on the SFN 404.
For the task/activity of exercise a written recommendation and outlined plan by a therapist for exercise must be on file and is limited to maintaining or improving physical functioning that was lost or decreased due to an injury or a chronic disabling condition (i.e., multiple sclerosis, Parkinson’s, stroke etc.). Exercise does not include physical activity that generally should be an aspect of a wellness program for any individual (i.e., walking for weight control, general wellness, etc.).
“Global Endorsements” These activities and tasks may be provided only by a service provider who has demonstrated competency and carries a global endorsement. Review the QSP list to determine which global endorsements the provider is approved to provide. If Temp /Pulse Respiration/Blood Pressure are checked, enter who is to be contacted for the readings.
“Client Specific Endorsements” These activities and tasks may be provided by a service provider who has demonstrated competency and carries a client specific endorsement to provide the required care within the identified limitations. The case manager must maintain documentation that a health care professional has verified the provider’s training and competency specific to the individual’s need in the client's file.
Section VII: must be sent to the identified provider for a returned signature – agreeing to provide the waiver service. Plan is not completed unless this signature is obtained.
Note: No signature from provider is required for ERS service– the signature on their provider agreement will be utilized.
IF a HDM provider is delivering the meals to the client – they need a signature on the Section VII. IF there is no contact (Mom’s Meals) there is no need for a signature – the signature on their provider agreement will be utilized.
The case manager must sign and date the form to officially authorize, or cancel the services authorized.
Section VII must be canceled when a QSP is no longer providing services or when a client is no longer eligible.
If client is no longer eligible for RD, mark RD removed box at end of Tier selection, enter end date. Send copy to QSP and to HCBS State office. Send completed SFN 212. If QSP is no longer providing services to identified client, then cancel entire Section VII.
Section VI: Risk Assessment
List client’s person strengths/ needs/ goals and responsible person within each identified category. Plan must have minimum of two goals.
Services listed on page one should be reflective in reaching client’s goals on the risk assessment.
Example: if goal is “I will have assistance within my home to meet my personal needs.” Then you service may be Personal Cares.
If there are no needs within a category then enter “N/A”.
A new Person Centered Plan must be completed at annual and six month, a note in the narrative section of SAM’s may be completed at 3 month and 6 month contacts.
Number of Copies and Distribution:
The original is filed in the applicant's/client's case record. One copy is provided to the applicant/client when completed. One copy is mailed within three working days to Medical Services Division - HCBS/DHS. This includes plans completed annually continued, updated at the six-month contact and a care plan that identifies a change.
This form is available from Office Services and an electronic copy is available through the state e-forms.