ORC Safety Risk Assessment - Maine.gov€¦ · Web viewWithin 30 days of initial face to face contact, the care coordinator will support the member in creating measurable goals to

OTHER RELATED CONDITIONS (MaineCare Benefits Manual Section 20) Care Plan

SECTION 1. Participant Information

Name:Effective Plan Date:Plan End Date:

DOB:Medical Eligibility Date:

EIS ID # Phone Number:Gender: ☐ Male ☐ Female MaineCare #:Address: Town: Zip Code:

Legal Guardian/ Power of Attorney :(Circle Applicable)

Representative Payee:(If Applicable)

Contact Information:

Name:

Address:

Town: State

Zip Code: Phone:


Name:

Address:

Town: State

Zip Code: Phone:

ORC Care Coordinator : MFP/Homeward Bound Transition Coordinator :(If Applicable)


Name:

Agency:

Address:

Town: State

Zip Code: Phone:


Name:

Agency:

Address:

Town: State

Zip Code: Phone:

Required Signatures:

☐ I approve the plan dated Enter a date.. I understand that I may revoke my approval of any or all parts of the plan at any time.

☐ I do NOT approve the plan and will get in touch with the care coordinator to discuss it.

By signing, I agree that I have been informed of any feasible alternatives under the waiver. I have been given the choice of either institutional or home and community-based services. This plan accurately reflects the planning process and my needs and desires. The recommended MaineCare services are medically necessary and in compliance with MaineCare rules.

Member Signature: Date:Guardian Signature: (if applicable) Date:Care Coordinator Signature: Date:

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Back-Up Support Contact Sheet:

Home Support Services Backup ContactsPrimary Support Back-up Support #1 Back-up Support #2Name and Phone # Name and Phone # Name and Phone #

Care Coordination Services Backup ContactsPrimary Support Back-up Support #1 Back-up Support #2Name and Phone # Name and Phone # Name and Phone #

Community Support Services Backup ContactsPrimary Support Back-up Support #1 Back-up Support #2Name and Phone # Name and Phone # Name and Phone #

Personal Care Services Backup ContactsPrimary Support Back-up Support #1 Back-up Support #2Name and Phone # Name and Phone # Name and Phone #

Work Support Services Backup ContactsPrimary Support Back-up Support #1 Back-up Support #2Name and Phone # Name and Phone # Name and Phone #

Employment Specialist Services Backup ContactsPrimary Support Back-up Support #1 Back-up Support #2Name and Phone # Name and Phone # Name and Phone #

Non-Traditional Communication Services Backup ContactsPrimary Support Back-up Support #1 Back-up Support #2Name and Phone # Name and Phone # Name and Phone #

Assistive Technology Services Backup ContactsPrimary Support Back-up Support #1 Back-up Support #2Name and Phone # Name and Phone # Name and Phone #

Specialized Medical Equipment Services Backup ContactsPrimary Support Back-up Support #1 Back-up Support #2Name and Phone # Name and Phone # Name and Phone #

Home Accessibility Adaptation Services Backup ContactsPrimary Support Back-up Support #1 Back-up Support #2Name and Phone # Name and Phone # Name and Phone #

Consultation and Maintenance Therapy Services Backup ContactsPhysical Therapy

Primary Support Back-up Support #1 Back-up Support #2Name and Phone # Name and Phone # Name and Phone #

Occupational Therapy


Speech Therapy


Behavioral Primary Support Back-up Support #1 Back-up Support #2

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Therapy Name and Phone # Name and Phone # Name and Phone #PsychologicalTherapy


Description of Person:(Write a summary about the person being served, their personal goals and other relevant

information.)

Description of Care Planning Process:(1) Includes people chosen by the individual.(2) Provides necessary information and support to ensure that the individual directs the process to the maximum extent possible, and is enabled to make informed choices and decisions.(3) Is timely and occurs at times and locations of convenience to the individual.(4) Reflects cultural considerations of the individual and is conducted by providing information in plain language and in a manner that is accessible to individuals with disabilities and persons who are limited English proficient, consistent with § 435.905(b) of this chapter.(5) Includes strategies for solving conflict or disagreement within the process, including clear conflict of interest guidelines for all planning participants.(6) Offers choices to the individual regarding the services and supports the individual receives and from whom.(7) Includes a method for the individual to request updates to the plan, as needed.(8) Records the alternative home and community-based settings that were considered by the individual.(Write a summary about the care planning process)

Routine Health:

Examination Date of most recent Name of ProviderAnnual Medical ExamDental/Oral (by dentist)IV Sedation for dental/oral procedure?☐ Yes ☐ No

Vision (if recommended by doctor)Hearing (if recommended by doctor)Psychiatric meds ☐ Yes ☐ NoReview

1. By psychiatrist? ☐ Yes ☐ No

Other Medical Providers:

Name of Provider Specialty

MaineCare Services: New Continued ChangeHome Support Services ☐ ☐ ☐Care Coordination (Case Management) ☐ ☐ ☐Community Support Services ☐ ☐ ☐

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Personal Care Services ☐ ☐ ☐Work Support Services ☐ ☐ ☐Employment Specialist Services ☐ ☐ ☐Non-Traditional Communication Services ☐ ☐ ☐Assistive Technology Services ☐ ☐ ☐Specialized Medical Equipment ☐ ☐ ☐Home Accessibility Adaptations (Home Modifications) ☐ ☐ ☐Consultation Services (PT, OT, SP, Psychological, & Behavioral) ☐ ☐ ☐Maintenance Therapy Services (PT, OT, & SP) ☐ ☐ ☐

Functional Assessment and Support NeedsThe care plan must address all assessed needs as reflected in the assessment process. (BMS99, Safety Risk Assessment, and MEDXX)

Description of Functional Assessment and Support Needs

Support Needed(Code A-E)

Purpose of Support(Code 1-3)

Self-Care/ADLs Choose an item. Choose an item.Mobility (locomotion, transfers, repositioning) Choose an item. Choose an item.Nutrition (meal Planning & preparation) Choose an item. Choose an item.Independent Living Skills Choose an item. Choose an item.Medication Management & Administration Choose an item. Choose an item.Interpersonal Skills Choose an item. Choose an item.Mood and Emotional Well Being Choose an item. Choose an item.Safety Maintenance and Skills Choose an item. Choose an item.Health Maintenance Choose an item. Choose an item.Communication Choose an item. Choose an item.Spiritual / Religious Activities Choose an item. Choose an item.Personal Development & Learning Choose an item. Choose an item.Accessing Community Events & Activities Choose an item. Choose an item.Accessing Community Resources Choose an item. Choose an item.Transportation Choose an item. Choose an item.Vision Choose an item. Choose an item.Hearing Choose an item. Choose an item.

Other Related Condition Waiver Services

Home Support Services

Home Support Needs:

Choose a need. Please describe how the home support staff will meet the needs identified while supporting the member’s independence and skill development.





Choose a need. Please describe how the home support staff will meet the needs identified while Page 4 of 20

supporting the member’s independence and skill development.Choose a need. Please describe how the home support staff will meet the needs identified while











supporting the member’s independence and skill development.

Service Planning Narrative:

Summary of the service planning process that includes the type of Home Support accessed (Home Support – per diem, Home Support quarter hour, and/or Home Support-remote support), and how these supports assist the member in the acquisition, retention, or improvement in skills related to living in the community. Include back up protocols and back-up contact information for Home Support and Remote Support Services. If the member uses assistive technology, please describe how the home support staff will assist the member in use of each device.

Direct 1:1 Support Hours (daily) Enter Hours. Total HS units/week From time estimator tool.

Home Support Goals:

Within 30 days of initial face to face contact, the care coordinator will support the member in creating measurable goals to strengthen relationships in personal, community, family, professional or other areas.

Goal 1: Description and Strategies to Meet this Goal:




Care Coordination Services

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Care Coordination Needs: Choose an item. Choose an item.Please describe how the Care Coordinator will meet the needs

identified while supporting the member’s independence and skill development.Choose an item. Choose an item.Please describe how the Care Coordinator will meet the needs









identified while supporting the member’s independence and skill development.


Care Coordination Services include the responsibility for assisting members in gaining access to needed waiver and other State Plan services, as well as medical, social, educational and other services, regardless of the funding source for the service to which access is sought. Care Coordinators are responsible for assisting the member to access and coordinate natural supports and for the monitoring and assurance of the implementation of the care plan. This includes monitoring of the health, welfare and safety of the member.

Care Coordination Goals:






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Community Support Services

Community Support Needs:

Choose a need. Please describe how Community Support staff will meet the needs identified while supporting the member’s independence and skill development.

















Write Summary of service planning that includes when service planning occurred, who talked with the focus person and guardian (if applicable) to review previous plan and learn person’s goals for upcoming year, and how staff will support the person. Include back up protocols and back-up contact information for Community Support Services. If the member uses assistive technology, please describe how the community support staff will assist the member in use of each device.

Direct 1:1 Support Hours (daily) Enter Hours. Total CS units/week From time estimator tool.

Community Support Goals: Page 7 of 20






Personal Care Services

Personal Care Needs:

Choose a need. Please describe how the personal care staff will meet the needs identified while supporting the member’s independence and skill development.











Write Summary of service planning that includes when service planning occurred, who talked with the focus person and guardian (if applicable) to review previous plan and learn person’s goals for upcoming year, and how staff will support the person. Include back up protocols and back-up contact information for Personal Care Services. If the member uses assistive technology, please describe how the personal care support staff will assist the member in use of each device.

Direct 1:1 Support Hours (daily) Enter Hours. Total PS units/week From time estimator tool.

Personal Care Goals:

Within 30 days of initial face to face contact, the care coordinator will support the member in creating measurable goals to

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strengthen relationships in personal, community, family, professional or other areas.





Work Support Services

Work Support Needs: Choose a need. Choose an item.Please describe how the Work Support staff will meet the needs

identified while supporting the member’s independence and skill development.Choose a need. Choose an item.Please describe how the Work Support staff will meet the needs









Write Summary of service planning that includes when service planning occurred, who talked with the focus person and guardian (if applicable) to review previous plan and learn person’s goals for upcoming year, and how staff will support the person. Include back up protocols and back-up contact information for Work Support Services. If the member uses assistive technology, please describe how the work support staff will assist the member in use of each device.

Direct 1:1 Support Hours (daily) Enter Hours. Total WS units/week From time estimator tool.

Work Support Goals:




Page 9 of 20



Employment Specialist Services

Employment Specialist Needs: Choose a need. Choose an item.Please describe how the Work Support staff will meet the needs










Write Summary of service planning that includes when service planning occurred, who talked with the focus person and guardian (if applicable) to review previous plan and learn person’s goals for upcoming year, and how staff will support the person. Include back up protocols and back-up contact information for Employment Specialist Services. If the member uses assistive technology, please describe how the employment specialist support staff will assist the member in use of each device.

Total ESS units/week Enter Hours.

Employment Specialist Goals:






Non-Traditional Communication Services

Non-Traditional Communication Needs: Page 10 of 20

Choose a need. Please describe how the Non-Traditional Communication services will meet the needs identified while supporting the member’s independence and skill development.







Write Summary of service planning that includes when service planning occurred, who talked with the focus person and guardian (if applicable) to review previous plan and learn person’s goals for upcoming year, and how staff will support the person. Include back up protocols and back-up contact information for Non-Traditional Communication Services.

Non-Traditional Communication Goals:






Assistive Technology Services

Assistive Technology Needs: Choose an item. Choose an item.Please describe how Assistive Technology will meet the needs

identified while supporting the member’s independence and skill development.Choose an item. Choose an item.Please describe how Assistive Technology will meet the needs


Page 11 of 20

















Write Summary of service planning that includes when service planning occurred, who talked with the focus person and guardian (if applicable) to review previous plan and learn person’s goals for upcoming year, and how staff will support the person. Include back up protocols and back-up contact information for Assistive Technology Services.

Device 1st Backup 2nd Backup

Assistive Technology Goals:

Within 30 days of initial face to face contact, the care coordinator will support the member in creating measurable goals to

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strengthen relationships in personal, community, family, professional or other areas.





Specialized Medical Equipment

Specialized Medical Equipment Needs: Choose a need. Choose an item.Please describe how specialized medical equipment will meet the

needs identified while supporting the member’s independence and skill development.

Choose a need. Choose an item.Please describe how specialized medical equipment will meet the needs identified while supporting the member’s independence and skill development.






Write Summary of service planning that includes when service planning occurred, who talked with the focus person and guardian (if applicable) to review previous plan and learn person’s goals for upcoming year, and how staff will support the person. Include back up protocols and back-up contact information for specialized medical equipment.

Device 1st Backup 2nd Backup

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Specialized Medical Equipment Goals:






Home Accessibilities Adaptations and Repairs

Home Accessibilities Adaptations and Repairs Needs: Choose an item. Choose an item.Please describe how specialized medical equipment will meet the

needs identified while supporting the member’s independence and skill development.

Choose an item. Choose an item.Please describe how specialized medical equipment will meet the needs identified while supporting the member’s independence and skill development.

Choose an item. Choose an item.Please describe how specialized medical equipment will meet the needs identified while supporting the member’s independence and skill development.


Write Summary of service planning that includes when service planning occurred, who talked with the focus person and guardian (if applicable) to review previous plan and learn person’s goals for upcoming year, and how staff will support the person. Include back up protocols and back-up contact information for Home Accessibilities Adaptations and Repairs.

Home Accessibilities Adaptations and Repairs Goals:






Consultation and Maintenance Services

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Consultation and Maintenance Needs: Choose an item. Choose an item.Please describe how consultation and/or maintenance will meet

the needs identified while supporting the member’s independence and skill development.

Choose an item. Choose an item.Please describe how consultation and/or maintenance will meet the needs identified while supporting the member’s independence and skill development.








Write Summary of service planning that includes when service planning occurred, who talked with the focus person and guardian (if applicable) to review previous plan and learn person’s goals for upcoming year, and how staff will support the person. Include back up protocols and back-up contact information for consultation and/or maintenance. If the member uses assistive technology, please describe how the provider will assist the member in use of each device.

Consultation and Maintenance Service Goals:






SECTION 11: SIGNATURES

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Member Signature Date

Guardian Signature/Power of Attorney (If Applicable) Date

ORC Care Monitor Date

ORC Care Coordinator Signature Date

Home Support Provider Signature Date

Community Support Provider Signature Date

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Description Unit Maximum Allowance

Units Selected Cost

Provider

Care Coordination (Case Management) ¼ hour 17.00Community Support (Day Habilitation) ¼ hour 5.28

Home Support (Residential Habilitation) Per Diem 285.19

Home Support (Residential Habilitation) ¼ hour 6.33 Home Support (Residential Habilitation)-Remote Support ¼ hour 1.62 Personal Care ¼ hour 3.75 Work Support (Supported Employment) ¼ hour 6.91 Employment Specialist Services (Habilitation-Supported Employment) ¼ hour 7.42

Assistive Technology-Assessment ¼ hour 16.04 Assistive Technology-Transmission (Utility Services) Month Per invoice

Assistive Technology-(Monitoring feature/device, stand alone or integrated, any type, includes all accessories, components and electronics, not otherwise classified)

Per Device $6000/year

Communication Aids Per invoice Consultation -Speech ¼ hour 5.40 Consultation -Occupational Therapy ¼ hour 5.40 Consultation -Physical Therapy ¼ hour 5.40 Consultation -Psychological (Psychologist, Psychological Examiner) ¼ hour 19.80

Consultation –Behavioral (LCSW,LCPC) ¼ hour 13.50

Home Accessibility Adaptations (Home Modifications)

Per invoice Per invoice

Home Accessibility Adaptations (Home Modifications)-Repairs

Per Invoice Per Invoice

Specialized Medical Equipment Per invoice Per invoice

Maintenance-Occupational Therapy ¼ hour 9.54 Maintenance-Speech Therapy ¼ hour 12.48 Maintenance-Physical Therapy ¼ hour 9.72 Non-Traditional Communication-Assessment ¼ hour 9.00 Non-Traditional Communication-Consultation ¼ hour 9.00

Total Cost:

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Remote Support Staffing In-Person Support Staffing Home Support Schedule Sunday Monday Tuesday Wednesday Thursday Friday Saturday12PM 12:00 to 12:15 12:00 to 12:15 12:00 to 12:15 12:00 to 12:15 12:00 to 12:15 12:00 to 12:15 12:00 to 12:15

12:15 to 12:30 12:15 to 12:30 12:15 to 12:30 12:15 to 12:30 12:15 to 12:30 12:15 to 12:30 12:15 to 12:30 12:30 to 12:45 12:30 to 12:45 12:30 to 12:45 12:30 to 12:45 12:30 to 12:45 12:30 to 12:45 12:30 to 12:45 12:45 to 1:00 12:45 to 1:00 12:45 to 1:00 12:45 to 1:00 12:45 to 1:00 12:45 to 1:00 12:45 to 1:00

1AM 1:00 to 1:15 1:00 to 1:15 1:00 to 1:15 1:00 to 1:15 1:00 to 1:15 1:00 to 1:15 1:00 to 1:15 1:15 to 1:30 1:15 to 1:30 1:15 to 1:30 1:15 to 1:30 1:15 to 1:30 1:15 to 1:30 1:15 to 1:30 1:30 to 1:45 1:30 to 1:45 1:30 to 1:45 1:30 to 1:45 1:30 to 1:45 1:30 to 1:45 1:30 to 1:45 1:45 to 2:00 1:45 to 2:00 1:45 to 2:00 1:45 to 2:00 1:45 to 2:00 1:45 to 2:00 1:45 to 2:00









10AM 10:00 to 10:15 10:00 to 10:15 10:00 to

10:15 10:00 to 10:15 10:00 to 10:15 10:00 to

10:15 10:00 to 10:15

10:15 to 10:30 10:15 to 10:15 to 10:15 to 10:30 10:15 to 10:15 to 10:15 to

Name: Page 18 of 20

10:30 10:30 10:30 10:30 10:30

10:30 to 10:45 10:30 to 10:45 10:30 to

10:45 10:30 to 10:45 10:30 to 10:45 10:30 to

10:45 10:30 to 10:45

10:45 to 11:00 10:45 to 11:00 10:45 to

11:00 10:45 to 11:00 10:45 to 11:00 10:45 to

11:00 10:45 to 11:00

11AM 11:00 to 11:15 11:00 to 11:15 11:00 to

11:15 11:00 to 11:15 11:00 to 11:15 11:00 to

11:15 11:00 to 11:15

11:15 to 11:30 11:15 to 11:30 11:15 to

11:30 11:15 to 11:30 11:15 to 11:30 11:15 to

11:30 11:15 to 11:30

11:30 to 11:45 11:30 to 11:45 11:30 to

11:45 11:30 to 11:45 11:30 to 11:45 11:30 to

11:45 11:30 to 11:45

11:45 to 12:00 11:45 to 12:00 11:45 to

12:00 11:45 to 12:00 11:45 to 12:00 11:45 to

12:00 11:45 to 12:00

Remote Support Staffing In-Person Support Staffing Home Support Schedule

Sunday Monday Tuesday Wednesday Thursday Friday Saturday12AM 12:00 to 12:15 12:00 to 12:15 12:00 to 12:15 12:00 to 12:15 12:00 to 12:15 12:00 to 12:15 12:00 to 12:15

12:15 to 12:30 12:15 to 12:30 12:15 to 12:30 12:15 to 12:30 12:15 to 12:30 12:15 to 12:30 12:15 to 12:30 12:30 to 12:45 12:30 to 12:45 12:30 to 12:45 12:30 to 12:45 12:30 to 12:45 12:30 to 12:45 12:30 to 12:45 12:45 to 1:00 12:45 to 1:00 12:45 to 1:00 12:45 to 1:00 12:45 to 1:00 12:45 to 1:00 12:45 to 1:00

1PM 1:00 to 1:15 1:00 to 1:15 1:00 to 1:15 1:00 to 1:15 1:00 to 1:15 1:00 to 1:15 1:00 to 1:15 1:15 to 1:30 1:15 to 1:30 1:15 to 1:30 1:15 to 1:30 1:15 to 1:30 1:15 to 1:30 1:15 to 1:30 1:30 to 1:45 1:30 to 1:45 1:30 to 1:45 1:30 to 1:45 1:30 to 1:45 1:30 to 1:45 1:30 to 1:45 1:45 to 2:00 1:45 to 2:00 1:45 to 2:00 1:45 to 2:00 1:45 to 2:00 1:45 to 2:00 1:45 to 2:00





6PM 6:00 to 6:15 6:00 to 6:15 6:00 to 6:15 6:00 to 6:15 6:00 to 6:15 6:00 to 6:15 6:00 to 6:15 6:15 to 6:30 6:15 to 6:30 6:15 to 6:30 6:15 to 6:30 6:15 to 6:30 6:15 to 6:30 6:15 to 6:30 6:30 to 6:45 6:30 to 6:45 6:30 to 6:45 6:30 to 6:45 6:30 to 6:45 6:30 to 6:45 6:30 to 6:45 6:45 to 7:00 6:45 to 7:00 6:45 to 7:00 6:45 to 7:00 6:45 to 7:00 6:45 to 7:00 6:45 to 7:00 7:00 to 7:15 7:00 to 7:15 7:00 to 7:15 7:00 to 7:15 7:00 to 7:15 7:00 to 7:15 7:00 to 7:15

Name: Page 19 of 20

7PM 7:15 to 7:30 7:15 to 7:30 7:15 to 7:30 7:15 to 7:30 7:15 to 7:30 7:15 to 7:30 7:15 to 7:30 7:30 to 7:45 7:30 to 7:45 7:30 to 7:45 7:30 to 7:45 7:30 to 7:45 7:30 to 7:45 7:30 to 7:45 7:45 to 8:00 7:45 to 8:00 7:45 to 8:00 7:45 to 8:00 7:45 to 8:00 7:45 to 8:00 7:45 to 8:00



10PM 10:00 to 10:15 10:00 to 10:15 10:00 to

10:15 10:00 to 10:15 10:00 to 10:15 10:00 to

10:15 10:00 to 10:15

10:15 to 10:30 10:15 to 10:30 10:15 to

10:30 10:15 to 10:30 10:15 to 10:30 10:15 to

10:30 10:15 to 10:30

10:30 to 10:45 10:30 to 10:45 10:30 to

10:45 10:30 to 10:45 10:30 to 10:45 10:30 to

10:45 10:30 to 10:45

10:45 to 11:00 10:45 to 11:00 10:45 to

11:00 10:45 to 11:00 10:45 to 11:00 10:45 to

11:00 10:45 to 11:00

11PM 11:00 to 11:15 11:00 to 11:15 11:00 to

11:15 11:00 to 11:15 11:00 to 11:15 11:00 to

11:15 11:00 to 11:15

11:15 to 11:30 11:15 to 11:30 11:15 to

11:30 11:15 to 11:30 11:15 to 11:30 11:15 to

11:30 11:15 to 11:30

11:30 to 11:45 11:30 to 11:45 11:30 to

11:45 11:30 to 11:45 11:30 to 11:45 11:30 to

11:45 11:30 to 11:45

11:45 to 12:00 11:45 to 12:00 11:45 to

12:00 11:45 to 12:00 11:45 to 12:00 11:45 to

12:00 11:45 to 12:00

Name: Page 20 of 20

Documents

ORC Safety Risk Assessment - Maine.gov€¦ · Web viewWithin 30 days of initial face to face contact, the care coordinator will support the member in creating measurable goals to