Care Planning
What are the two sections of the Plan of Care?
Non-Waiver/Agency Supported Services
What form needs to be completed when a client wants to receive meals for the first time?
Home-Delivered Meals Assessment
Bonus: Freedom of Choice
What is the smallest unit of time that can be billed for (in minutes)?
15 minutes
How often are Redeterminations completed?
Annually
If a client is admitted to the hospital, what two items in FamCare does the CM need to complete (in addition to documenting in the narrative?)
Transition Tracker and Service Hold
What are the two options that clients can choose between in order to receive services? (hint: one of them allows the client/caregiver to choose their worker)
Personal Choices and a DSP
How often does the Home Delivered Meals Assessment need to be completed?
Only once, unless a new service is added
What is an SVR?
Who completes it and how often?
Supervisory Visit Report
Completed by the DSP RN at least every 60 days while the client is active and does not have a service hold in place
What are the two parts of the redetermination that the CM will need to complete and submit to their Team Lead?
HCBS Assessment and HCBS Medical
Critical Incident Report
How old does a client have to be in order to receive GA Foods Home Delivered Meals?
21+
DAILY DOUBLE!!!!
What form needs to be completed and signed when services are terminated or decreased?
Notice of Action (NOA)
What does a client need in order to qualify for respite services (skilled or unskilled)?
A Primary Caregiver
What forms need to be completed with the client before the redetermination? After the redetermination is approved?
Before: Home Folder Forms, Signature Cards, Have Medical Signed
After approval: Expanded Assessments, PCCP, Have AIMS POC signed
Who is never allowed to sign for the client?
DSP aid
Bonus: Case Manager
Who determines the amount of hours clients receive?
The Case Manager
What form needs to be updated if a client changes providers?
Choice of Provider
Bonus: Care Plans
How often does an SPA need to be updated?
Bonus: When is an SPA not required to be completed?
Annually and when there is a change in DSP or service hours
Bonus: When the client has Personal Choices
True or False: A redetermination can be submitted and approved without receiving the original medical back from the MD office?
FALSE (since the PHE has officially ended)
What will you need to do to update this?
What will Dr. Brown's start date be?
1. Add Dr. Brown to the Care Plan (AIMS & FamCare)
2. End date Dr. Adams on the Care Plan
3. Draft an end-dated AIMS Care Plan (Uploads --> PDF) and upload
4. Complete an updated PCCP
Start date: Today
What are the services that can be added to the Agency Provided Services/Waiver services for E&D Waiver?
- Homemaker
- Personal Care
- Unskilled Respite
- Skilled Respite
- Companion
- Home Delivered Meals
- Case Management
- Monthly Supplies (NEW)
- PERS (NEW)
- Home Modifications (NEW)
What will the CM need to complete in FamCare if the client has complaints about their services?
Complaint/Grievance Report
DAILY DOUBLE!!!
In what situation can a client receive services from both Personal Choices and a DSP at the same time?
When the client requires Skilled Respite in addition to another service.
After a redetermination approval, the CM must update the start dates for HM, PC, UR, SR, and Companion Services IF what is true?
The client has a DSP
In the PCPOC, what is the difference between a Consumer Goal and a Consumer Self-Management Plan?
A goal states what the client WANTS to do and lists at least one barrier
A plan states what the client PLANS TO or WILL do to maintain health; does not require a barrier