Assistive Care Services and Assisted Living for the Elderly Waiver

Assistive Care Service and Assisted Living for the Elderly Wavier Services
Coverage and Limitations Handbook
Service Plans for ALF and AFCH Residents, continued
Service Plans,
continued
Service plan development involves six principles:
• Individuality—addresses individual needs and preferences;
• Accountability—specifies who is responsible for providing service;
• Outcome orientation—identifies outcome of service;
• Completeness—addresses all needs in the health assessment;
• Input—resident must be consulted and agree with the plan; and
• Staffing—guides staffing and facilities.
Required
Components
The service plan must be completed within 15 days after the initial health
assessment or reassessment, be in writing, and based on information
contained in the health assessment. The service plan must include:
• Ιdentifying information (facility name, resident’s name, Medicaid
identification number, and date);
• Services that address all needs identified in the health assessment;
• Level of functioning and assistance needed;
• Service provider;
• Expected outcome of service;
• Signed and dated by facility representative and resident, guardian or
designated representative; and
• Updates when conditions change.
All needed ACS components must be specified in the recipient’s service plan.
July 2001 2-8