Assistive Care Services and Assisted Living for the Elderly Waiver
Assistive Care Services and Assisted Living for the Elderly Waiver
Assistive Care Services and Assisted Living for the Elderly Waiver
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<strong>Assistive</strong> <strong>Care</strong> <strong>Services</strong> <strong>and</strong> <strong>Assisted</strong> <strong>Living</strong> <strong>for</strong> <strong>the</strong> <strong>Elderly</strong> Wavier <strong>Services</strong><br />
Coverage <strong>and</strong> Limitations H<strong>and</strong>book<br />
Plan Of <strong>Care</strong>, continued<br />
Purpose<br />
The purpose of <strong>the</strong> plan of care is to:<br />
• Enable <strong>the</strong> case manager <strong>and</strong> <strong>the</strong> recipient to summarize <strong>the</strong> findings of<br />
<strong>the</strong> Comprehensive Client Assessment (Form 701B);<br />
• Identify realistic goals <strong>for</strong> <strong>the</strong> recipient;<br />
• Identify problems that present barriers to attaining <strong>the</strong> goals; <strong>and</strong> <strong>the</strong>n,<br />
• Develop outcomes <strong>and</strong> patterns of service delivery that will help resolve<br />
identified problems so that stated goals can be achieved.<br />
Comprehensive<br />
Client Assessment<br />
The case manager must conduct a comprehensive client assessment, DOEA<br />
Form 701B, by evaluating <strong>the</strong> recipient's health status, functional status,<br />
support system, <strong>and</strong> living environment. The case manager must make a<br />
face-to-face visit with <strong>the</strong> recipient to complete <strong>the</strong> assessment <strong>and</strong> may<br />
speak with <strong>the</strong> recipient’s <strong>for</strong>mal <strong>and</strong> in<strong>for</strong>mal caregivers. The recipient must<br />
give permission <strong>for</strong> <strong>the</strong> case manager to contact <strong>the</strong> caregivers.<br />
The comprehensive client assessment must be placed in <strong>the</strong> recipient’s case<br />
record as a separately identifiable document. All contacts <strong>and</strong> visits made in<br />
completing <strong>the</strong> assessment must be noted in <strong>the</strong> case narrative.<br />
Plan of <strong>Care</strong><br />
Contents<br />
The plan of care must be in writing, based on in<strong>for</strong>mation obtained during <strong>the</strong><br />
comprehensive assessment process <strong>and</strong> include:<br />
• Specific services <strong>and</strong> service components to be provided, with a<br />
beginning date <strong>for</strong> each;<br />
• Who will provide each service <strong>and</strong> component;<br />
• The amount, frequency, <strong>and</strong> duration of services <strong>and</strong> components;<br />
• Documentation of <strong>the</strong> dates that services <strong>and</strong> components are revised or<br />
terminated;<br />
• Projected service costs; <strong>and</strong><br />
• The plan of care review date.<br />
July 2001 5-7