(NEW 8/1/22 ML #3692)
Purpose
The Person-Centered Plan of Care - HCBS web-based version is a summary of the needs and service options identified in the assessment process and is an outline of the plan developed by the individual, case manager and the person-centered planning team.
When Prepared:
The Person-Centered Plan of Care is completed for all individuals served under home and community-based services including, Medicaid Waiver (MW), Medicaid State Plan – Personal Care Services, (MSP-PC), Service Payments for the Elderly and Disabled (SPED), Expanded Services Payments for the Elderly and Disabled (EX-SPED).
The Person-Centered Plan of Care is to be revised or updated as client's needs warrant. It is to be reviewed and updated with the individual at the annual and six-month review. A new Person-Centered Plan of Care is to be completed when there are necessary changes in the individual’s needs, or service(s) authorized.
The Person-Centered Plan of Care must be revised when a change occurs (unless it is a result of legislative action).
Instructions for Completing the HCBS Person-Centered Plan of Care
About Me
The following three questions encompass the person-as-a-whole. Discuss and document the individual’s responses to the questions.
What People Admire about Me (? Help What are my strengths?)
Example: (Individual’s) strengths include that she is able to make her own decisions in all aspects of her life. She is proud of her independence and motivated to work with her care team to meet her needs. (Individual) has a positive outlook on life and is also willing to accept assistance were needed.
What is Important to Me (?) List the Individuals goal statement in this section. What is important to me to live the life I choose?
Important to a person includes things that make the person satisfied, content, comforted and happy. It includes relationships, things to do, places to go, rituals or routines, pace of life, status and control, things to have.
Example: It is important for (Individual) to have support for his ADL’s and IADL’s as noted in the assessment. (Individual needs and has a living environment that is handicap accessible. (Individual) is able to access the home and community with the equipment and modifications that have been made to the home. (Individual’s) goal is to have the support to meet his daily needs which is met through the authorized services under HCBS.
(Individual’s) goal is to remain as independent as possible. It is important to (individual) to make their own decisions. (Individual) values her families input and advice for support, yet wants to make the final decision. It is important to (individual) to be as independent as possible.
How to Support Me Best (?) What supports would help me the most to live the life I choose?
Consider issues of health [prevention and treatment of illness, promotion of wellness, services needed] and issues of safety [environment, physical and emotional wellbeing].) Supports include someone to stay with me for certain portions of the day; toileting, bathing, or transfer assistance; help with medications, housework, or transportation; grab bars in bathrooms; ramps or lifts to avoid stairs.
Example: (Individual) is receiving assistance with personal cares and homemaker services as outline in the comprehensive assessment. (Individual) states she can be best supported by providing having assistance with her care at home by having HCBS and home health care. At this time, she feels the support allows her to interact with her family and friends and continue to do many of the activities she enjoys.
Services and Supports
This section is for Home and Community Based Services authorized.
(This section will not be utilized in the Person-Centered Planning of Individuals receiving Long- Term Services and Supports Options Counseling.)
Select “Add Service Support”
Column Headings:
Funding Source
HCBS- Home and Community Based Waiver
IID/DD HCBS – Traditional Developmental Disabilities Waiver – (HCBS will not use)
MSP-PC- Medicaid State Plan Personal Care
SPED – Service Payments for the Aged and Disabled
TCM - Targeted Case Management (HCBS will not use)
TECH – Technology Dependent Medicaid Waiver
XSPED – Expanded Service Payments to the Elderly and Disabled
Services(s): Enter the service that has been identified for which the client is eligible, and the client has accepted.
Service Provider: Identify the qualified service provider (agency or individual) who will provide the service. (Note: this can be left blank if a provider has not been selected. A “Change Form” can be completed to update the PCP appropriate once a provider is selected.)
Service Provider Other: Identify a provider they are an approved QSP but not showing up in Therap yet. You may also place a provider’s name in this place if the individual has chosen a provider and the provider is pending approval, such as with Family Home Care or Family Personal Care. The pending providers name with pending after would be placed in this box.
Example: Sally QSP- Pending
Service Date From: Enter the start date for service of the QSP.
Service Date To: Enter the end date for service of the QSP.
Total Units: Enter the total units per month for the QSP
RATE: Refer to the Qualified Service Provider (QSP) listing for rate. Enter the QSP unit rate.
If Rural Differential (RD) the rate should match rates determined within Rural Differential policy. (Total rate cost may be over cap however units should match cap. For example: Homemaker service cap is 70 units per month.)
UNITS PER MONTH: Enter the total number of units of service to be provided per month.
COST/MONTH: The cost per month is calculated based on the amounts in the columns headed "Unit Rate," and "Units per Month" (based on a 31-day month).
Cost: Select the “Calculate” and the cost will auto populate according to the units and rate.
Notes: note that you may put units shared in this box or some other directions. If the total units are shared between two or more providers, DO NOT calculate the second and proceeding providers cost and it will populate the total for the funding source authorized.
Cost by Funding Source
Total Cost: The total per month costs of services is the total to be reimbursed under the service program (SPED, XSPED, Medicaid Waiver and MSP-PC). 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.
Questionnaire
Initial Service Plan
Is this an initial care plan?
Hints ×
Is this the first- time services are being authorized? (Complete even if services were previously authorized and formally closed, but now open again.)
Yes
No
Please check below if any of the following funding sources are being authorized for the first time.
Hints ×
Complete even if the funding source was previously authorized and formally closed but is now open again.
SPED
Ex-SPED
HCBS MW
MSP Level A
MSP Level B
MSP Level C
If this is the first-time funding source(s) are being authorized, indicate the effective date.
SPED
Hints: Indicate the date SPED was approved
Ex-SPED
Hints: Indicate the date Ex-SPED was approved
HCBS MW
Hints: Indicate start date of care plan
MSP Level A
Hints: Indicate start date of care plan
MSP Level B
Hints: Indicate start date of care plan
MSP Level C
Hints: Indicate start date of care plan
Home and Community Based Services
Does plan overlap previous plan?
Yes
No
Mark the correct tier for rate
Hints: When adding or removing a Rural Differential (RD), SFN 212 is req
RD1
RD2
RD3
RD Removed
SPED Fee Percentage
Hints: Percentage or N/A
Check any services below that have pending final service amounts.
Transition Coordination
One-Time Transition Cost
Specialized Equipment
Environmental Modification
Demographics
NF LoC Effective Date (This is a free text box and allows you to specify the effective dates of the NF LoC for both MSP-PC and HCBS Waiver. For LTSS-OC indicate the LOC screening date last completed on the SNF resident)
Integrated Settings
Integrated settings are settings where individuals live in a private home alone, with family, significant other, or roommates of their choosing. Non-integrated settings include skilled Nursing Facility, Assisted Living, Basic Care.
In the first section document from the case managers perspective what you believe to be the individuals most integrated setting. Integrated settings must meet the HCBS Settings rule. Adult Residential Service meets the HCBS Settings rule and is classified as an integrated setting.
Identify the Individual's Most Integrated Setting
A private home in the community, rented or owned, where the individual lives alone or with others
Other Integrated Settings
Non-Integrated Settings
Provide answer if "Other Integrated Settings" is selected in "Identify the Individual's Most Integrated Setting"
Adult Foster Care
Provide answer if "Adult Foster Care" is selected in "Other Integrated Settings"
Family
Agency
Or if you believe the individual would be best served in a non-integrated setting mark one of the following non-integrated settings.
Skilled Nursing Facility
Assisted Living
Basic Care
Integrated Setting Comments (Comment on the rationale for the selection of the setting chosen based on the HCBS Comprehensive Assessment.)
In the second section document from the individuals preferred setting. (Answer the following three questions according to the wishes of the individual.)
Identify the Individual's Preferred Setting (select one of the following)
A private home in the community, rented or owned, where the individual lives alone or with others
Other Integrated Settings
Non-Integrated Settings
Provide answer if "Other Integrated Settings" is selected in "Identify the Individual's Preferred Setting" (Select if Applicable)
Adult Foster Care
Provide answer if "Adult Foster Care" is selected in "Other Integrated Settings" (Select if Applicable)
Family
Agency
Provide answer if "Non-Integrated Settings" is selected in "Identify the Individual's Preferred Setting" (Select if Applicable)
Basic Care
Assisted Living
Skilled Nursing Facility
Answer the following questions relating to where the individual prefers to live.
Name of Person Individual Would Like to Live With
Address Where the Individual Would Like to Live
Preferred Setting Comments
Hospital/Nursing Home Stay
Answer the following questions relevant to any Hospital/Nursing Facility admission or discharge.
Hint: Is this individual currently residing in a nursing home or are they in a hospital for a long stay? If yes, complete the following. HCBS Case Manager: Once the individual is discharged back home and on services, please complete the section: Date Home and Community Based Services (HCBS) resumed.
Facility Name
Date of Admission (MM/DD/YYYY)
Expected Length of the Nursing Home or Hospital Stay
List reasons for the expected duration of the stay
Date Home and Community Based Services (HCBS) Resumed (MM/DD/YYYY)
Hospital/Nursing Home Comments
Please write N/A at the top of this section if not applicable as some individuals have not had a hospital or nursing facility stay.
Housing Supports
Identify Housing Services, if any, necessary for the individual to successfully live in the most integrated setting (check all that apply)
Assistance with housing search
Assistance with the completion of applications for housing assistance. (Housing Assistance/Rental Assistance Vouchers of any kind)
Assistance with locating needed documents for apartment and rental assistance applications
Assistance with securing housing modifications
Education about the rights and responsibilities of being a good tenant
Assistance securing any rental modifications and/or accommodations needed.
Rental Assistance
Other (specify):
Date of Housing Facilitator Assignment (MM/DD/YYYY)
Reduction Notice
Complete the following pertaining to a reduction notice:
Are services being reduced from the previous care plan?
Yes
No
N/A
Please complete for reduction of MSP-PC services only:
Services are reduced in accordance with 42 CFR 440.230 and NDAC 75-02-02-09.5 for the following reason(s).
Enter reason in comment box.
Reduction Acknowledgement
I am aware of the reduction in service, that the Reduction will be effective on date given below and I have been given a copy of my appeal rights (printed on the back of this form). The effective date of the reduction must be no sooner than 11 days after client signs the Person-Centered Plan of Care.
Signed Statement
If the individual requested the citation, a signed statement is saved on file.
Please complete for reduction of services for SPED, ExSPED or/or Medicaid Waiver only:
Select the services funding source for which the services are being reduced. (Multi-select)
SPED
ExSPED
HCBS-MW
Please complete for reduction of SPED, ExSPED and HCBS-MW services only
Services are reduced for the following reason(s): (request the closure code from HCBS Program Administrator) Enter reason for citation in the text box.
In Accordance With (write the citation from program administration in the box)
Reduction Acknowledgement
I am aware of the reduction in service, that the Reduction will be effective on date given below and I have been given a copy of my appeal rights (printed on the back of this form). The effective date of the reduction must be no sooner than 11 days after client signs the Person-Centered Plan of Care.
Reduction will be effective on (MM/DD/YY)
Signed Statement
Check box if the individual requested the citation, a signed statement is saved on file.
Long-Term Services and Supports
Answer the following questions.
(If the question is not applicable, please state why).
List other community-based services (other than HCBS) examples include MFP, hospice, public health services, or other services provided by partners in the community. If transition coordination is also involved indicate the goals and action plan for the transition are addressed in the transition plan.
List and describe services requested but not authorized: (include date of request and date of denial).
Example: “Not applicable, [NAME] has not requested other services that were not authorized.”
Describe why requested services were not authorized
Example: If Not Applicable explanation maybe “All requested services have been authorized.”
Services eligible for but not accepted.
Hint: It would be easier for non-clinicians to understand if the acronyms were spelled out, e.g., HDMs – Home Delivered Meals, ERS – emergency response system
Example: “[NAME] is receiving all eligible services.”
Reasons eligible services not accepted
Services needed but not available
Example “Not applicable. All services needed to achieve goals are available.”
Describe why services needed are not available
Contingency/Health and Safety Plan
The Contingency Plan must be completed. Name of person assisting, and their contact information must be listed in the contingency plan so the resource can be reached if needed.
Explain the alternative plan in the event that one/all of the providers listed are unable to provide care: (Describe in free text the contingency plan).
Barriers
List Barriers to Receiving Community-Based Services (select all that apply).
Lack of available Qualified Service Providers for the types of service needed
Services Needed
Lack of available Qualified Service Providers in the location where the individual will live
Location
Lack of available Qualified Service Providers for the types of service needed
Services Needed
Lack of housing that meets the individual's needs
Family not supportive of community living or return to community
Lack of Home Health/Hospice services
Lack of medical service to meet needs in the community of choice. (Example: No dialysis services)
Ineligibility for a necessary service
Individual does not want services to address identified need
Lack of transportation services in the location where the individual will live
Transportation Needed
Location
Other (specify): (enter free text in “If Other, specify”)
None
Identify strategies to address barriers checked above. (Describe what steps have been taken thus far, when, by whom, and what result):
Lack of available Qualified Service Providers for the types of service needed
Hints: If lack of available Qualified Service Providers is selected above, list services needed
Lack of available Qualified Service Providers in the location where the individual will live
Hints: If "Lack of available Qualified Service Providers in the location where the individual will live" is selected above, list location.
Lack of transportation services in the location where the individual will live
Hints: Provide answer for "Transportation Needed" and "Location" if "Lack of transportation services in the location where the individual will live" is selected in "List Barriers to Receiving Community-Based Services"
Transportation Needed (describe the transportation needed)
Location (state the location that the transportation is needed)
Identify strategies to address barriers.
Hints: Describe what steps have been taken thus far, when, by whom and what the result.
Restrictions
Answer the following questions. Enter NA if not applicable
Date
Reviewed - No restrictions required
Identified Restriction
Plans Tried in the Past
Current Restrictive Plan
Assurances
The client/legally responsible party must check all applicable boxes acknowledging agreement and or awareness of the specific information.
I wish to receive the services described in this person-centered plan of care rather than receiving care in a nursing home.
I am aware that I may have a recipient liability.
I am aware that the services and estimated cost is subject to change based on legislative action.
I have been made aware of services, funding caps, and limits.
I selected the services listed above.
I selected the providers listed above.
I am aware that if my Medicaid eligibility terminates, I will no longer be eligible for services funded by ExSPED, MSP-PC, or Medicaid waiver.
I am aware that Case Management, as well as personal care services, will be billed to Medicaid and may be subject to a recipient liability if Medicaid is active, even if it has been determined that I have a 0% SPED fee.
I am aware of my right to appeal by writing to:
Appeals Supervisor
600 E Boulevard Ave - Dept. 325
Bismarck, ND 58505-0250
Authorization Span and Signatures
The effective date of plan and the signature of the client/legal representative and HCBS Case Manager is required on all PCPs.
If the client or representative refuses to sign the ICP, the reason for the refusal should be noted in the case notes, and that the client was made aware of the right to appeal.
Family Home Care and Family Personal Care providers may sign the person-centered plan of care in leu of signing the preauth.
*Provider signature is included on the Service Authorization
The HCBS Signature Sheet may be used to obtain the signature for changes in the care plan that have been initiated by the individual. Additionally, the HCBS signature sheet may be used to sign for the electronic version of the Person-Centered Plan of Care (PCP) and/or the Risk Assessment and Health and Safety Plan and the Referral for Long-Term Services and Supports Option Counseling. Guidance for utilization of the HCBS Signature Sheet is provided in this policy.
Plan Addendum
Check all that apply
Caregiver Assessment (If Applicable)
Individual Program Plan (If Applicable)
Service Authorization (Required)
Transition Plan (If Applicable)
Risk Assessment/Health and Safety Plan (Required)
Vision Tool (Required)
Type of Case Management
Select one of the following types of case management
Targeted Case Management
Higher Level Case Management
Please complete if Targeted Case Management is selected.
T2023-TG Case Management Assessment
T2023-TG Case Management Assessment is billed (amount given below) when service is provided. May have cost share based on Medicaid recipient liability or SPED fee.
Bill amount for T2023-TG Case Management Assessment
Hints: $
T2023 Case Management
T2023 Case Management is billed (amount given below) when service is provided. May have cost share based on Medicaid recipient liability or SPED fee.
Bill amount for T2023 Case Management
Hints: $
Please complete if Higher Level Case Management is selected
T2024 Higher Level Case Management Assessment
T2024 Higher Level Case Management Assessment is billed (amount given below) when service is provided. May have cost share based on Medicaid recipient liability.
Bill amount for T2024 Higher Level Case Management Assessment
Hints: $
T2024 Higher Level Case Management
T2024 Higher Level Case Management is billed (amount given below) when service is provided. May have cost share based on Medicaid recipient liability.
Bill amount for T2024 Higher Level Case Management
Hints: $
Signature Sheet Utilization Policy
Introduction
This document provides guidance for utilization of a signature sheet when completing the Person-Centered Plan of Care (PCP) and/or the Risk Assessment and Health and Safety Plan and the Referral for Long-Term Services and Supports Option Counseling. These documents necessitate signatures from entities such as the individual receiving services, legal decision maker, and provider for the delivery of services. Obtaining necessary signatures is the responsibility of the Case Manager or LTSS Options Counselor originating the document. The signature sheet allows for a non-digital option for individuals to sign the plan. It is required that a signature is obtained for initial, 6-month and annual PCP and the Risk Assessment and Health and Safety Plans. Additionally, signatures are required by the service provider which is obtained when acknowledging the Preauth (for FHC and FPC the PCP must be signed by the FHC/FPC provider on the signature sheet or digitally it Therap).
The signature sheet may also be utilized when a change in the Person-Centered Plan of Care (PCP) and/or the Risk Assessment and Health and Safety Plan is initiated by the individual receiving care and a signature is not able to immediately be obtained by an individual or legal decision maker on the Person-Centered Plan of Care (PCP) and/or the Risk Assessment and Health and Safety Plan.
This policy cannot account for every situation; therefore, the case manager must use their professional judgment when applying this policy.
Guidelines
When completing the Person-Centered Plan of Care (PCP) and/or the Risk Assessment and Health and Safety Plan and the Referral for Long-Term Services and Supports Option Counseling the case manager or LTSS Options Counselor work with the individual and team to discuss and develop the plan. The plan is reviewed with the individual and the team and the individual and team members have the option to sign the signature sheet which is attached to the plan in Therap. The plan with the signature sheet is then mailed out to the individual and team members as documented on the plan within 30 days.
When an individual initiates a change in their PCP or the Risk Assessment and Health and Safety Plan, and a case manager is unable to acquire a necessary signature through direct contact with the individual or the legal representative (e.g., guardian attending meeting by phone), a minimum of 3 attempts must be made to obtain the signature of the individual and/or legal decision maker within 30 calendar days. Methods of contact can be made by mail, email, phone contact, or other communications that are available to the person. Services will continue to be provided as long as the person meets the eligibility requirements, and the service is appropriate.
If verbal consent is given, this can be noted on the document along with the signature of the case manager and date. Attempts to obtain the signed signature are still applicable.
Each attempt to acquire signatures should be documented in case notes and should vary from previous unsuccessful attempts. The attempts should inform the individual of the timeline to respond and that if the documents are not signed and returned, it will be assumed that they are in agreement and understand any rights afforded to them.
If the signature is not acquired within the 30 calendar days, it will be acknowledged on the document that the signature was attempted (e.g., unable to obtain signature). Services will continue to be provided as long as the person meets the eligibility requirements and the service is appropriate, or the individual/legal decision maker is given advance notice in writing of the intent to terminate the service(s) and includes the person’s right to appeal that determination.
If an individual and/or legal guardian refuses to sign the Person-Centered Plan of Care (PCP) and/or the Risk Assessment and Health and Safety Plan because they are not in agreement, the case manager should explain to the person and/or legal decision maker that failure to sign may lead to the discontinuance of services, and that signing the document does not affect their right to appeal. The case manager should then send out a letter documenting the conversation with the individual/legal decision maker and provide information on their right to appeal service level determinations.