(Revised 9/1/18 ML #3543)
Purpose:
The Medicaid Waiver 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.
This form is only completed for clients receiving Medicaid Waiver service(s).
When Prepared:
The Medicaid Waiver 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 and 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 the web-based data collection system.
The Medicaid Waiver 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 client identification number (ND number), physical address, county of residence, and level of care (LOC) screening effective date.
Section II Services:
If receiving Rural Differential (RD) 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 adding or removing RD, a SFN 212 is required to be sent to Aging Services/HCBS.
Mark “yes” or “no” if this plan overlaps the current plan filed at Aging Services/HCBS.
Column Headings:
Case Management has been pre-entered on the form. The Provider and Provider Number must be entered by the Case Manager.
Total Cost: The total per month costs of services is the total to be reimbursed under the Medicaid Waiver. 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.
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. A Contingency Plan is required if the provider is not an agency. If a contingency plan is not required, N/As need to be entered in this section.
Section III: ADL’s & IADL’s
ADL & IADL Scores: must be added from the Functional Assessment scoring.
Section IV: 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.
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.
Six-Month Review: If there is NO change to be made in Section I to the Medicaid Waiver Person Centered Plan of Care as a result of the six-month review, the client/legal representative can sign the original Medicaid Waiver Person Centered Plan of Care, SFN 404, in the area provided. The signature of the HCBS Case Manager completes the six-month review requirements for the care plan.
Section V: Restrictions
Purpose:
Any restriction on the client's living experience needs to be documented in the Medicaid Waiver 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.
Example: client living in AFC 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 V:
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.
Current 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.
Plans Tried in the Past: what plan(s) has/have been tried in the past?
What has been tried to before getting to this restriction?
Client/Legal Representative 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.
Six- month review:
If the plan is working and there are no negative impacts to the client for the restrictions mark the box "yes " and client/legal representative and case manager sign.
If the plan is not working mark the box "no", note what is not working in the plan and develop new restriction plan, date and sign.
Restriction plan may be revised any time a restriction is not working – CM does not have to wait until annual or six month review to make changes.
Section VI: Waiver Risk Assessment
List client’s strengths, needs,/ goals and tasks within each identified category. Plan must have minimum of two goals.
Every category under the risk assessment must include at least one strength. If there is not a need, indicate “n/a”. If there is a need identified, the risk assessment must list a goal and tasks to meet the stated goal.
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 the service may be Personal Cares.
Six-month review:
Indicate the date of the six-month assessment.
Note any changes/additions to each category under the risk assessment. If there are not any changes, note “n/a”.
Three- and Nine-month contacts:
A new Medicaid Waiver Person Centered Plan is not required unless changes are indicated. A note in the narrative section of the web-based data collection system may be completed at 3 month and 6 month contacts.
Number of Copies and Distribution:
The original is filed in the client's case file. One copy is provided to the client/legal representative when completed. One copy is emailed or faxed within three working days to Aging Services/HCBS. This includes plans completed annually continued, updated at the six-month contact and a care plan that identifies a change.
An electronic copy is available through the state e-forms (SFN 404).