Forms 535-05-70

Instructions for Completing Personal Care Services Plan, SFN 662 535-05-70-01

(Revised 10/01/2024 ML #3871)

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A Basic Care Case Manager or Developmental Disabilities Program Manager will complete an SFN 662 for each initial assessment, annual assessment, or when changes in level of care occur.

Section I – Client Information

Case Manager will fill in the individual’s name, ND number, physical address, county of residence, city, state, zip code, and date the comprehensive assessment occurred.

Section 2 – Personal Care Services Eligibility

Activities of Daily Living (ADL) Scoring

Case manager will assess the individual’s activities of daily living (ADL) to determine if the applicant or individual’s meets the functional eligibility requirements. The individual must score a 2 in at least one area to meet impairment requirements to screen by ADL scoring.

1. Bathing

2. Eating

3. Inside Mobility

4. Transferring

5. Dressing

6. Toileting

7. Continence

Instrumental Activities of Daily Living (IADLs) Scoring

Only four IADLs are used when determining if an individual is eligible to receive personal care service. The individual must score at minimum a 1 on three out of four IADLS including meal preparation, laundry, medications, or housework. If an individual is eligible for personal care services, he/she may receive assistance with IADLs that are not considered when determining the eligibility for personal care services but have been scored a 1 or 2.

1. Meal Preparation

2. Housework

3. Laundry

4. Taking Medication

Instrumental Activities of Daily Living (IADLs) Not Considered in Determining Eligibility for Personal Care Services

1. Shopping

2. Mobility Outside

3. Management of Money

4. Communication

Obtain information regarding ADL or IADL impairments by observation, interview with family or friends, or by direct self-report of the individual. Narratives must be included in the electronic health record for each ADL or IADL identified as an impairment. Narratives must include:

• Reason for inability to complete the task.

• The kind of aids (grab bars, bath stool etc) the individual uses

• The kind of help the individual is receiving and frequency of assistance

• What services and the frequency the individual require to meet needs

• Outcome anticipated as a result of service provision

• Other relevant information

Section III – Approved Services

Case manager will enter:

1. Provider – Must be an approved provider listed on the “Basic Care Authorized Facilities” spreadsheet

2. Provider Number – Enter provider number listed on the “Basic Care Authorized Facilities” spreadsheet

3. Provider NPI Number– Enter provider’s NPI number listed on the “Basic Care Authorized Facilities” spreadsheet

4. Billable days – Enter “31”

Section IV – Assessment Type and Reductions

Case manager will:

1. Service Reduced: Check mark “Yes” or “No” if there is a service reduction

2. If the answer was “Yes”

   1. Reference Medicaid State Plan – Personal Care Services Policy, “Reductions, Denials, and Terminations 535-05-50"

   2. Obtain citation code from Medicaid State Plan Program Administrator

   3. Services are reduced in accordance with 42 CFR 440.230 and N.D. Admin. Code 75-02-02-09.5 for the following reason(s): Enter reason(s)

3. Review the reduction citation with the individual and/or legal decision maker

4. Enter date which service reduction will be effective (must be no sooner than 11 days after the individual signs the Personal Care Service Plan) Review the reduction citation with the individual and/or legal decision maker

5. Reason for Completing Plan or Change in Existing Care Plan – Mark whether the Personal Care Service Plan of Care was an initial assessment, annual assessment, other change – describe, or current care plan terminated – date.

6. Review assurances with individual including:

   1. I selected the services and providers listed above.

   2. I am aware that I may have a recipient liability.

   3. I am aware that if my Medicaid Eligibility terminates, I will no longer be eligible for services listed above.

   4. I am aware that the services and estimated cost is subject to change based on legislative action.

   5. I have been given a copy of my appeal rights (Right to Hearing).

   6. f. I am not in agreement with this plan.

Section V – Authorized Tasks

Case manager will check mark all applicable services the individual is eligible to receive.

Case manager will enter:

1. Effective Date of Plan:

   1. Initial assessments:

      1. “From” date will be the approval date received from Long-Term Care Medicaid Eligibility Unit

      2. “To” date will be no more than three-hundred and sixty-five (365) days from initial functional assessment.

   2. Annual assessment:

      1. “From” date will be the first day of the month preceding the assessment date, e.g., a functional assessment was completed on 8/16/2024, the effective date of the plan would be 9/1/2024.

      2. “To” date will be no more than 365 days following the annual assessment, e.g., From: 9/1/2024 – To: 8/31/2025.

2. Review Personal Care Services Plan of Care and Authorization in a Licensed Basic Care Setting with the individual and legal decision maker

3. If the individual and/or legal decision maker agree with the plan, ask the responsible person to sign and date the care plan.

4. Sign the care plan, check mark if the case manager is an HCBS or DDCM, and date the care plan.

5. Route signed copies of the care plan to the individual and/or legal decision maker preferred method of communication, email to DHHS Fax Line (dhshcbs@nd.gov), the basic care, and retain a copy in the individual e-file.