CES-703 Waiver PCPS Forms - Home - Arkansas Department …



CES Waiver PERSON CENTERED SERVICE PLAN Demographics FORMTEXT ????? FORMTEXT ?????Individual’s NameMedicaid # FORMTEXT ????? FORMTEXT ?????Street AddressCity, State, Zip Code FORMTEXT ????? FORMTEXT ?????Mailing AddressCity, State, Zip Code( FORMTEXT ???) FORMTEXT ???- FORMTEXT ???? FORMTEXT ?????Home PhoneCounty FORMTEXT ?????School Name (if attending)PASSE: FORMTEXT ?????Date Attributed: FORMTEXT ?????GUARDIANSHIP/POWER OF ATTORNEYGuardianship: FORMCHECKBOX Self FORMCHECKBOX Power of Attorney (Explain Below) FORMCHECKBOX Other (Explain Below)(Power of Attorney which conveys same rights as guardianship) FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Guardian’s/Power of Attorney’s NameRelationshipGuardian’s/Power of Attorney’s County FORMTEXT ????? FORMTEXT ?????Guardian’s/Power of Attorney’s Street AddressCity, State, Zip Code FORMTEXT ????? FORMTEXT ?????Guardian’s/Power of Attorney’s Mailing AddressCity, State, Zip Code( FORMTEXT ???) FORMTEXT ???- FORMTEXT ????( FORMTEXT ???) FORMTEXT ???- FORMTEXT ???? FORMTEXT ????( FORMTEXT ???) FORMTEXT ???- FORMTEXT ????Guardian’s/Power of Attorney’s Home PhoneGuardian’s/Power of Attorney’s Work Phone and ExtensionGuardian’s/Power of Attorney’s Cell PhoneIndividuals Residing in Home of Recipient and Type of Residence: FORMTEXT ??Total number individuals in home with developmental disabilities FORMTEXT ??Total number individuals with developmental disabilities in home related to waiver person FORMCHECKBOX Residence owned, rented or managed by a DDS Provider FORMCHECKBOX Home owned or rented by individual or family that person lives with (Host Home or Foster Care) FORMCHECKBOX Home owned or rented by one or more individuals with developmental disabilities FORMCHECKBOX Home of related family memberCES WAIVER PLAN PROPOSED OUTCOMES, IMMEDIATE NEEDS & LONG TERM GOALS FORMTEXT ????? FORMTEXT ?????Individual’s NameMedicaid # FORMTEXT ?????Facilitator’s NameAbout Me: (Summary of strengths, preferences, talents and skills. Summary should reflect what is important to the person, and be written in plain language) FORMTEXT ?????Disclaimer: Waiver will not supplant other responsible authorities.Individual’s Goals(Must be specific, measurable, achievable, relevant and time-bound)Activities(How goals will be met)Target DateIdentify ServicesWaiver Medicaid State Plan & All Other Generic Services(Parents/Guardians, Regular Medicaid, Private Insurance, Name of School, etc.)Expected Outcomes(Specify any Service Barriers) FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????CES WAIVER PLAN SUPPORTED LIVING ARRAY WORKSHEET (WORD) FORMTEXT ????? FORMTEXT ?????Individual’s NameMedicaid #Total Number of Days in Plan of Care Year Service is Requested: FORMTEXT ???Total Days DDS Approved: FORMTEXT ???Supported Living Array includes supportive living and respite care. Salary and fringe are calculated as one rate. Fringe cannot exceed 32%. Any fringe 25% or more must be justified. Supported Living Array components cannot exceed the maximum rate for the level of care, i.e. pervasive, extensive or limited. Supportive Living includes direct salaries and fringe for supportive living staff, direct care supervisor, transportation and indirect costs. Note: If staff positions are vacant and filled with a higher or lower salary than submitted, a revision MUST be submitted.SERVICE COMPONENTTOTAL REQUESTEDDDS TOTAL APPROVEDDAYSANNUAL SALARY AND FRINGE AND/OR ANNUAL RATEBILLINGRATEDAYSANNUAL SALARY AND FRINGE AND/OR ANNUAL RATEBILLINGRATEH2016 Supportive Living FORMTEXT ???Days FORMTEXT ????? FORMTEXT ????? FORMTEXT ???Days FORMTEXT ????? FORMTEXT ?????S5151 Respite Care FORMTEXT ???Days FORMTEXT ????? FORMTEXT ????? FORMTEXT ???Days FORMTEXT ????? FORMTEXT ?????A. Total FORMTEXT ????? FORMTEXT ?????B. Supported Living Array Daily Rate(A ÷ Days in POC Year Requested) FORMTEXT ?????(A ÷ Days in POC Year Approved) FORMTEXT ?????TierTierDDS Use OnlyTier 2 FORMCHECKBOX FORMCHECKBOX Tier 3 FORMCHECKBOX FORMCHECKBOX FORMTEXT ????? FORMTEXT ?????Provider Designee/Agency SignatureDateDDS USE ONLY FORMTEXT ????? FORMTEXT ?????Reviewed byDate ReviewedCES WAIVER PLAN Service Provider Information FORMTEXT ????? FORMTEXT ?????Individual’s NameMedicaid # FORMTEXT ????? FORMTEXT ?????Service Coordinator NameService Coordination Provider FORMTEXT ????? FORMTEXT ?????Direct Care SupervisorDirect Service ProviderPlan Approval Type: FORMCHECKBOX Initial FORMCHECKBOX CSR FORMCHECKBOX RevisionType of Revision: FORMCHECKBOX Extension FORMCHECKBOX Update FORMCHECKBOX Provider Change FORMCHECKBOX ClosureReason for Closure: FORMCHECKBOX Deceased FORMCHECKBOX Moved Out of State FORMCHECKBOX Withdrew FORMCHECKBOX Unable to Locate FORMCHECKBOX Failure to Cooperate with Administrative Requirements FORMCHECKBOX Requested Closure FORMCHECKBOX Failure to Cooperate with Plan Implementation FORMCHECKBOX No Longer Meets ICF/ID Requirements FORMCHECKBOX No longer Meets Medicaid Income Eligibility Requirements FORMCHECKBOX Inability to Insure Health and Safety FORMCHECKBOX Entered Long Term Care Facility FORMCHECKBOX Other (specify): FORMTEXT ____________________________________________________________________________________ FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Plan of CareImplementation DateContinued Stay Review DateTransition Meeting Date (if applicable)Provider Change (if applicable): FORMDROPDOWN FORMDROPDOWN FORMDROPDOWN Service Coordination Approved UnitsUnits UsedBalance FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Supportive Living Array Approved DollarsDollars UsedBalance FORMTEXT ????? FORMTEXT ?????Individual’s NameMedicaid #ProviderName and NumberOHCDSCheck ifAppliesServices being RequestedProcedure Code/ Modifier/ServiceTotal RequestedBeginDateEndDateDDS Total ApprovedUnitsAmountUnitsAmount FORMTEXT ????? FORMCHECKBOX H2016 Supportive LivingN/A FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????N/A FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX S5151 Respite CareN/A FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????N/A FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX S5165 U1 Adaptive EquipmentN/A FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????N/A FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX S5160 Emergency Response System Installation and TestingN/A FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????N/A FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX S5161 Emergency Response System Service FeeN/A FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????N/A FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX S5162 Emergency Response System PurchaseN/A FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????N/A FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX K0108 Environmental ModificationsN/A FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????N/A FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX T2028 Specialized Medical SuppliesN/A FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????N/A FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX T2020 UA Supplemental SupportN/A FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????N/A FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX T2022 Care Coordination FORMDROPDOWN FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMDROPDOWN FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX H2023 Supported Employment FORMTEXT ???? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ???? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX H2023 U1 SE Discovery FORMTEXT ???? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ???? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX H2023 U2 SE Job Development FORMTEXT ???? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ???? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX H2023 U3 SE Employment Path FORMTEXT ???? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ???? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX H2023 U4 SE Extended Support FORMTEXT ???? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ???? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX T2025 Consultation FORMTEXT ???? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ???? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX T2034 U1 UA Crisis Intervention FORMTEXT ???? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ???? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX T2022 U2 Transitional Care Coordination/PCSP development FORMDROPDOWN FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMDROPDOWN FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX T2020 UA U1 Community Transition ServicesN/A FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????N/A FORMTEXT ?????Total FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Provider Designee/Agency SignatureDateDDS USE ONLY I have verified totals are within approved limits.?? I have compared this request to the prior year’s POC expenditures.?? If the request has a significant increase or decrease in the prior year’s POC expenditures, the provider has identified and justified in the PCSP Narrative why the amount increased/decreased from the prior year’s POC costs. FORMTEXT ????? FORMTEXT ?????Reviewed byDate ReviewedCES Waiver PLAN Cooperative Agreement FORMTEXT ????? FORMTEXT ?????Individual’s NameMedicaid # FORMTEXT ?????Plan Meeting DateThe people attending this meeting are people I invited. I have no objections to anyone who is/was present for the person centered service plan meeting.All providers identified in this plan of care were chosen by FORMCHECKBOX Me FORMCHECKBOX My Legal Representative FORMCHECKBOX Other (Specify) FORMTEXT ________________________________________________________________________________Signature of Waiver Individual/Legal Guardian/Legal Representative/Power of AttorneyAs members of an interagency service planning development team, we will review confidential information on children/adults and families referred to the team. In carrying out this network of services and case planning, the agencies and persons below commit to work cooperatively together and to keep confidential all information disclosed. We agree any changes must be requested in advance, as changes cannot be implemented without prior approval. We agree the waiver rules and regulations will be followedNameTitleDateSignature FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????CES WAIVER PERSON CENTERED SERVICE PLAN Physician LEVEL OF CARE CERTIFICATION/ Prescription FORMTEXT ????? FORMTEXT ?????Individual’s NameMedicaid #DIAGNOSIS: (Please check all that apply): FORMCHECKBOX Intellectual Disability FORMCHECKBOX Cerebral Palsy FORMCHECKBOX Epilepsy FORMCHECKBOX Autism FORMCHECKBOX Mental Illness (explain) FORMTEXT __________________________________________________________________________________ FORMCHECKBOX Other (explain) FORMTEXT _________________________________________________________________________________________MEDICAL DIAGNOSIS (if applicable): FORMTEXT ______________________________________________________________________MEDICATION (List all medications below) List all non-psychotropic medications: FORMTEXT ________________________________________________________________List all psychotropic medications: FORMTEXT ____________________________________________________________________Is any psychotropic medication used for behavior? FORMCHECKBOX Yes FORMCHECKBOX NoMEDICATION MANAGEMENT PLAN (for medication(s) listed in C): FORMTEXT ____________________________PROGNOSIS: FORMTEXT ___________________________________________________________________________________________SPECIAL ORDERS: FORMTEXT ______________________________________________________________________________________I have examined the patient within the past 30 days, and I have reviewed the Person Centered Service Plan (check one). FORMCHECKBOX I certify the waiver services and level of care listed in the plan. FORMCHECKBOX I disagree with the waiver services and level of care listed in the plan. FORMCHECKBOX I disagree with the following waiver service(s) listed in the plan: FORMTEXT _________________________________________________Physician’s Name (Printed): FORMTEXT ___________________________________________Telephone( FORMTEXT ???) FORMTEXT ???- FORMTEXT ????Ext FORMTEXT ????Address: FORMTEXT _________________________________________________________Physician's Signature:Date: FORMTEXT ????? ................
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