Assurance 2 - Service Planning
A person's needs and preferences are assessed and reflected in a person-centered service plan.
Service planning is one of the most critical aspects of the HCBS waiver program. It is through this process that the needs, goals, and preferences of participants are expressed. Risks are also identified and addressed.
As a case manager you play a key role in assuring that participants actively engage in the planning process, have the information they need to make decisions, and understand the choices available to them.
What are the requirements of this HCBS waiver assurance?
A state must establish policies and procedures for how service plans are developed, who coordinates and monitors service delivery, and how plans and services are updated when necessary. The following are key components of this assurance.
Every HCBS waiver participant must have an assessment of his/her needs, goals, preferences and health and safety risk factors. (click here for more information about assessments)Many states use a standard assessment form to document a person’s need for assistance, supervision or supports. This typically includes an assessment of a person’s general health, emotional and behavioral health, cognitive ability, ability to understand and communicate with others, and ability to perform activities of daily living (e.g., ability to bathe, walk, eat). The use of standard forms improves the reliability, consistency and accuracy of the data that is collected. For older adults and adults with disabilities, many states use a form called the MDS-HC to assess a person’s health, personal care, or other needs. For people with intellectual or developmental disabilities, a number of states use the ICAP (Inventory for Participants and Agency Planning) or the Support Intensity Scale (SIS). In some states, the forms are automated as part of a computerized database or other electronic data system.
Every HCBS waiver participant must have a written service plan. The service plan must address all of the participant’s assessed needs and personal goals, including health and safety risk factors. (click here for more information about risk factors)Health and Safety Risk Factors - Risks are often categorized into
- 1) health risks (e.g. malnutrition, seizures, cardiac or respiratory diseases, chronic conditions such as diabetes),
- 2) behavioral risks (e.g. poor decision-making about safety and health issues as a result of a brain injury or cognitive limitation; violent or criminal behavior; substance abuse; and suicide), or
- 3) risks to personal safety (e.g. abuse or exploitation).
The service plan must reflect the full range of a participant’s needs and include both Medicaid and non-Medicaid services as well as informal supports.
Arrangements for back-up when workers do not show up or when emergencies occur must be discussed as part of service planning
The service plan must include the type, scope, amount, duration, and frequency of services authorized. (click here for more information about service plans)
The service plan must be updated at least annually, or when the needs of the participant change.
Services must be delivered in accordance with the service plan. The state Medicaid Agency will only pay for services that are first authorized through the service plan.
Participants must be able to choose between getting services at home/in the community versus getting services in an institution. Each participant must sign a statement indicating he or she has chosen to be served under the HCBS waiver.
Participants must be able to choose between/among HCBS waiver services and providers.