PLAN OF CARE (POC) - Department of Health



Program Choice (Check all that apply): FORMCHECKBOX ADHC Waiver FORMCHECKBOX LT-PCS FORMCHECKBOX CCW Plan Type: FORMCHECKBOX Initial FORMCHECKBOX Annual FORMCHECKBOX Provisional (Initials only) FORMCHECKBOX Comprehensive (Only after Provisional) FORMCHECKBOX Revision: FORMCHECKBOX Routine FORMCHECKBOX Emergency Individual Risk Agreement: FORMCHECKBOX Yes FORMCHECKBOX NoMy Place Louisiana Participant: FORMCHECKBOX Yes FORMCHECKBOX NoMy Choice Louisiana Participant: FORMCHECKBOX Yes FORMCHECKBOX NoSelf-Direction: FORMCHECKBOX Yes FORMCHECKBOX No Patient Liability (PLI): FORMCHECKBOX Yes FORMCHECKBOX NoMonthly Amount$ FORMTEXT ?????Justification for Revision (If applicable): FORMTEXT ?????ADVERSE ACTION: FORMCHECKBOX Partial Denial/Reduction FORMCHECKBOX NoneExpedited CCW: FORMCHECKBOX Yes FORMCHECKBOX NoHEALTHY LOUISIANA: FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Aetna Better Health FORMCHECKBOX AmeriHealth Caritas Louisiana FORMCHECKBOX Health Blue FORMCHECKBOX Louisiana Healthcare Connections FORMCHECKBOX United Healthcare Community PlanTHSCI: FORMCHECKBOX Yes FORMCHECKBOX NoName of Support Coordination Agency: FORMTEXT ?????Name of Support Coordinator: FORMTEXT ?????SECTION A: IDENTIFYING INFORMATIONFirst Name: ? FORMTEXT ?????Middle Name FORMTEXT ?????Last Name: FORMTEXT ?????Suffix: FORMTEXT ?????Birthdate: FORMTEXT ?????Age: FORMTEXT ???Gender: FORMCHECKBOX Male FORMCHECKBOX FemaleSSN: XXX-XX- FORMTEXT ????Marital Status: FORMCHECKBOX Never Married FORMCHECKBOX Married FORMCHECKBOX Widowed FORMCHECKBOX Separated FORMCHECKBOX Divorced FORMCHECKBOX OtherMedicaid #: FORMTEXT ?????Medicare : FORMCHECKBOX YES FORMCHECKBOX NOPrimary Physician: FORMTEXT ?????Primary Physician Phone Number: FORMTEXT ?????Medication Administration: FORMCHECKBOX Yes FORMCHECKBOX No Private Insurance Name: FORMTEXT ?????VA Benefits: FORMCHECKBOX Yes FORMCHECKBOX NoHome Health: Contact Name: FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX No Contact Phone Number : FORMTEXT ?????Hospice: FORMCHECKBOX Yes FORMCHECKBOX NoHome Phone Number: FORMTEXT ?????Alternate Phone Number/Cell: FORMTEXT ?????Street Address: FORMTEXT ?????City: FORMTEXT ?????State: FORMTEXT ??Zip Code: FORMTEXT ?????Mailing Address: FORMTEXT ?????City: FORMTEXT ?????State FORMTEXT ??Zip Code: FORMTEXT ?????SECTION B: RESPONSIBLE REPRESENTATIVE INFORMATIONFirst Name: FORMTEXT ?????Middle Name: FORMTEXT ?????Last Name: FORMTEXT ?????Suffix: FORMTEXT ?????Age: FORMTEXT ???Relationship: FORMTEXT ?????Lives with Participant: FORMCHECKBOX Yes FORMCHECKBOX NoEmergency Contact: FORMCHECKBOX Yes FORMCHECKBOX NoResponsible for Evacuation: FORMCHECKBOX Yes FORMCHECKBOX NoHome Phone Number: FORMTEXT ?????Alternate Phone Number/Cell: FORMTEXT ?????Street Address: FORMTEXT ?????City: FORMTEXT ?????State: FORMTEXT ??Zip Code: FORMTEXT ?????SECTION C: LEGAL STATUS FORMCHECKBOX Full Interdiction FORMCHECKBOX Limited Interdiction FORMCHECKBOX Tutorship FORMCHECKBOX Competent Major SECTION D: POWER OF ATTORNEYFirst Name: FORMTEXT ?????Middle Name: FORMTEXT ?????Last Name: FORMTEXT ?????Suffix: FORMTEXT ?????Age: FORMTEXT ???Relationship: FORMTEXT ?????Lives with Participant: FORMCHECKBOX Yes FORMCHECKBOX NoEmergency Contact : FORMCHECKBOX Yes FORMCHECKBOX NoResponsible for Evacuation: FORMCHECKBOX Yes FORMCHECKBOX NoHome Phone Number: FORMTEXT ?????Alternate Phone Number/Cell: FORMTEXT ?????Type of Power of Attorney: FORMTEXT ?????Street Address: FORMTEXT ?????City: FORMTEXT ?????State: FORMTEXT ??Zip Code: FORMTEXT ?????SECTION E: PARTICIPANT PROFILESummary – (“Paint the Picture.” By writing ONLY 2-3 sentences per category, summarize the participant’s status in each of the following four (4) categories.) Social Life: FORMTEXT ?????Cognitive/Mental Health: FORMTEXT ?????Physical/Functional: FORMTEXT ?????Clinical: FORMTEXT ?????Participant’s Individual Goals (Short and/or Long Term Goals) – Identify and describe the participant’s goals. FORMTEXT Primary Concerns of the Participant – Identify and describe the concerns of the participant. FORMTEXT ????? Primary Concerns of the Assessor – Identify and describe the concerns of the assessor. FORMTEXT Primary Concerns of the Family/Caregiver – Identify and describe the concerns of the family/caregiver. FORMTEXT SECTION F: CLINCAL ASSESSMENT PROTOCOLS (CAPs) SUMMARY- AttachedSECTION G: FLEXIBLE SCHEDULE - ADHC WAIVER OR CCW- Attached SECTION H: EXCEL BUDGET WORKSHEET- ADHC WAIVER OR CCW- AttachedSECTION I: PLAN OF CARE (POC) PARTICIPANTSAll participants in the Plan of Care (POC) development meeting must sign below indicating that he/she participated in the planning process.Signatures of POC Attendees:Relationship to Participant:Date:Participant FORMTEXT ??? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Support Coordinator/Assessor FORMTEXT ?????Signature of Reviewing Support Coordinator/Assessor Supervisor: Date of Review: FORMTEXT ?????SECTION J: APPLICANT/PARTICIPANT ACKNOWLEDGMENT AND SIGNATUREBy signing below, I agree to the following statements:All information on the OAAS Rights and Responsibilities for Applicants/Recipients/Participants of Home and Community-Based Services (HCBS) including information about how to report abuse, neglect, and critical incidents has been reviewed/re-reviewed with me, and I have received a copy.I have been offered/reoffered freedom of choice of all providers of services contained in this plan and have exercised my right to freely choose these providers.I understand that I have the right to choose between institutionalization and home and community-based services and have opted to receive home and community-based services.My support coordinator has explained the services available in this waiver and allowed me the opportunity to choose the services which best meet my needs and has reviewed the contents of this plan with me. I understand I have the right to accept or to refuse all or part of the services identified in this plan.I understand that I have the responsibility to notify my support coordinator/assessor of changes in my status and/or my income which might affect my eligibility for and/or the effectiveness of these services. I also understand the reasons that may cause me to lose these supports and services. I have been informed of the option to Self-Direct my services. X______________________________________________ FORMTEXT ????? FORMCHECKBOX Participant’s Signature or FORMCHECKBOX Responsible Representative’s Signature Date:SECTION K: OAAS OR DESIGNEE PLAN OF CARE (POC) ACTIONDate POC Approved: FORMTEXT ?????Currently in NF: FORMCHECKBOX Yes FORMCHECKBOX NoDate Transitioned from NF to Community: FORMTEXT ?????(if applicable)MDS-HC Assessment Date: FORMTEXT ?????POC Begin Date: FORMTEXT ?????POC End Date: FORMTEXT ?????POC Revision Begin Date: FORMTEXT ?????POC Revision End Date: FORMTEXT ?????Date POC Packet Mailed/Faxed to Individual/DSP: FORMTEXT ????? FORMCHECKBOX POC Denied FORMCHECKBOX Yes FORMCHECKBOX NoDenial Reason: FORMTEXT ????? FORMCHECKBOX POC Referred to Service Review Panel FORMCHECKBOX Yes FORMCHECKBOX NoDate: FORMTEXT ?????Findings: FORMTEXT ?????___________________________________________________________________ OAAS or Designee Authorized Representative’s Signature FORMTEXT ?????DateFOR ADULT DAY HEALTH CARE (ADHC) WAIVER: FORMCHECKBOX You have been approved to receive/continue to receive Adult Day Health Care (ADHC) Waiver services with or without Long Term-ctoberer 21,Personal Care Services (LT-PCS). You were assessed for these services on FORMTEXT ?????. The results of your assessment are in the following table. MET LT-PCS PROGRAM REQUIREMENTS:YOUR ADL INDEXYOUR WEEKLY # OF LT-PCS HOURSYOUR ANNUAL APPROVED BUDGET AMOUNTBEGIN DATE FORMCHECKBOX YES FORMCHECKBOX NO FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? NOTE: The maximum # of weekly LT-PCS hours is 32.FOR COMMUNITY CHOICES WAIVER (CCW): FORMCHECKBOX You have been approved to receive/continue to receive CCW services. You were assessed for these services on FORMTEXT ?????. The results of your assessment are in the following table. YOUR RUG SCOREYOUR ANNUAL APPROVED BUDGET AMOUNTBEGIN DATE FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? NOTE: The maximum annual budget amount for all services is $46,090. ................
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