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