Assistive Care Services and Assisted Living for the Elderly Waiver

Assistive Care Services and Assisted Living for the Elderly Wavier Services
Coverage and Limitations Handbook
Case Management Documentation, continued
Permanent Record
Documentation
All case record documentation (including the case narrative), must be in ink
and must be legible. No erasures or white out are permitted. Case narrative
entries must be signed and dated by the case manager. In case of an error,
the case manager lines through the error and initials and dates it, then makes
the correct entry.
Computer records
Case narratives may be written on a computer. A printout of the narrative
must be kept in the recipient’s case record. Each computer entry must be
signed and dated by the case manager.
Plan Of Care
Description
A plan of care is a written document that describes the service needs of a
recipient, and specifically identifies the services and service components to
be provided, the provider of services and service components, their
frequency, duration, and estimated cost.
The plan of care is based on a review of assessments by the facility
administration and nursing staff, the DOEA Comprehensive Client
Assessment and the CARES HRS-Med Form 3008, Health Assessment.
The information gathered through these assessments is used by the case
manager to establish the recipient’s plan of care and identifies both waiver
and non-waiver services required to maintain the recipient in the ALF and
reduce functional limitations in order to avoid nursing facility placement.
In order for the ALE provider to bill for ACS, the plan of care must show a
need for ALE waiver services, including an average of more than one hour of
direct services per day. Services must be coordinated and monitored by the
ALE case manager.
July 2001 5-6