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PERSON CENTERED DESCRIPTIONPLAN REVISIONS

By Ruth Bennett,2014-06-17 18:02
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PERSON CENTERED DESCRIPTIONPLAN REVISIONS ...

    NC Division of Mental Health, Developmental Disabilities, and Substance Abuse Services

    PERSON CENTERED DESCRIPTION/PLAN REVISIONS

    CROSSWALK

    (10/08 VERSION)

    (Refer to the PCP Instruction Manual for additional revised information)

    1. PCP COMPLETE PLAN

    PCP PAGE PCP TITLE/HEADING REVISIONS

     INSTRUCTION

    MANUAL PAGE

    Pg. 1 Pg. 16 ? Identifying Information ? Revised the Date of plan to state that it is the date the QP/Licensed Professional (per

    the Service Definition) completes the PCP AND signs and dates the signature page.

    (Provided additional instructions in the PCP Instruction Manual, including a detailed

    chart.)

    ? Included additional check box regarding CAP-MR/DD Waivers (Supports Waiver,

    Supports Waiver-Self Direction, and Comprehensive Waiver.

    ? Moved Allergies box to Summary of Assessments/Observations.

    Pg. 1 Pg. 18 ? Participants Involved in Plan ? Included additional question: “How long have you known each other?

    Development ? Included additional checkbox: Facilitator of PCP/CFT meetings.

Pg. 2 Pg. 18 ? Header ? No revisions

    Pg. 2 Pg. 19 ? Personal Dialogue/Interview ? Revised “What has happened in my life this past year?” to What is working best in my

    life right now? (What makes the most sense for me right now?)

    & What is not working in my life right now? (What does not make sense for me right

    now?)

    ? Revised Strengths: (What am I good at doing”? What do people admire about me? What

    are my talents/gifts?) to (Examples What are my special talents/traits? What do I

    like and admire about myself?)

    ? Revised Long Term Goals: to Long Term Outcomes. (Examples - What are the things I

    want to accomplish in the next year? What are my hopes/dreams for the

    future?)…Moved to the bottom of the page.

    ? Revised Preferences to What is important TO me: (Examples - What are the people,

    activities, things, places that matter to me in everyday life? What don’t I want in my

    life?)

    ? Deleted “Needs” box.

    ? Revised Supports: What is important TO me? (What do others need to know or do to

    support me best in relationships, in things I like to do, in work or school and ways to stay

    healthy and safe?) to (Examples - What do others need to know or do to support me

    best in relationships, in things I like to do, in work or school and ways to stay

    healthy and safe, taking into account what is important TO me?)

    NC Division of Mental Health, Developmental Disabilities, and Substance Abuse Services

    PCP PAGE PCP TITLE/HEADING REVISIONS

     INSTRUCTION

    MANUAL PAGE

    Pg. 3 Pg. 21 ? Family/Legally Responsible ? Revised “What has happened in this person’s life this past year?” to What is working

    best in his/her life right now? (What makes the most sense for him/her right now?) Person/Information Supports & What is not working in his/her life right now? (What does not make sense for Dialogue/Interview him/her right now?)

    ? Revised Strengths: (What is this person good at doing”? “What do people admire about

    this person? What are this person’s talents/gifts?) to (Examples What are this

    person’s special talents/traits? What do I like and admire about this person?) ? Revised Long Term Goals to Long Term Outcomes. (Examples - What are the things

    this person wants to accomplish in the next year? What are this person’s

    hopes/dreams for the future?)…Moved to the bottom of the page. ? Revised Preferences to What is important TO me: (Examples - What are the people,

    activities, things, places that matter to me in everyday life? What don’t I want in my

    life?)

    ? Deleted Needs box.

    ? Revised Supports: What is important FOR this person? (What do others need to know or

    do to support me best in relationships, in things I like to do, in work or school and ways to

    stay healthy and safe?) to (Examples - What do others need to know or do to support

    this person best in relationships, in things he/she likes to do, in work or school and

    ways to stay healthy and safe?)

    Pg. 4 Pg. 22 ? Service/Supports Providers ? Revised “What has happened in this person’s life this past year?” to What is working

    best in his/her life right now? (What makes the most sense for him/her right now?) Dialogue/Interview & What is not working in his/her life right now? (What does not make sense for

    him/her right now?)

    ? Revised Strengths: (What is this person good at doing”? “What do people admire about

    this person? What are this person’s talents/gifts?) to (Examples What are this

    person’s special talents/traits? What do I like and admire about this person?) ? Revised Long Term Goals: to Long Term Outcomes. (Examples - What are the things

    this person wants to accomplish in the next year? What are this person’s

    hopes/dreams for the future?)…Moved to the bottom of the page. ? Revised Preferences to What is important TO me: (Examples - What are the people,

    activities, things, places that matter to me in everyday life? What don’t I want in my

    life?)

    ? Deleted Needs box.

    ? Revised Supports: What is important FOR this person? (What do others need to know or

    do to support me best in relationships, in things I like to do, in work or school and ways to

    stay healthy and safe?) to (Examples - What do others need to know or do to support

    this person best in relationships, in things he/she likes to do, in work or school and

    ways to stay healthy and safe?)

    NC Division of Mental Health, Developmental Disabilities, and Substance Abuse Services

    PCP PAGE PCP TITLE/HEADING REVISIONS

     INSTRUCTION

    MANUAL PAGE

    Pg. 5 Pg. 23 ? Summary of ? Revised ASSESSMENTS COMPLETED (List the Comprehensive Clinical Assessment(s)

    that have been completed on the individual to COMPREHENSIVE CLINICAL Assessments/Observations ASSESSMENT(s) CCA: List evaluations completed.

    ? Included *(Not a comprehensive clinical assessment) for NC TOPPS, NC SNAP and

    Risk Assessment Tool (CAP-MR/DD Only)

    ? Included additional line for Risk Assessment Tool (CAP-MR/DD Only)

    ? Revised Recommendations for Services, Support, Treatment Based on Assessment to

    CHARACTERISTICS/OBSERVATIONS OF THIS PERSON: (Based on the interviews,

    dialogues, and assessments. Enter characteristics and observations that will result

    in Action Plans.)

    ? Deleted the Symptoms/Observations of this Person box.

    ? Included All Current Medications and List All Known Allergies.

    Pg. 6 Pg. 26 ? Action Plan ? Revised “Where am I now in relation to this outcome?” to Where am I now in the process

    of achieving this outcome?

    ? Revised Symptom/Observation # to Characteristics/Observations #.

    ? Revised Short Range Goal (Taken from Preferences & Supports Sections “What’s

    important TO and FOR me”) to Short Range Goal (Taken from - “What’s Important TO

    & FOR me” sections)

    ? Deleted the Action Plan Continuation Page and added statement “Copy and use as

    many Action Plan pages as needed” at the bottom of the Action Plan.

    Pg. 7 Pg. 28 ? Crisis Prevention/Crisis ? Revised Symptom/behaviors that may trigger the onset of a crisis (Include lessons learned

    from previous crisis events) to Health and behavioral concerns that may trigger the Response onset of a crisis (Include lessons learned from previous crisis events)

    ? Revised Specific recommendations for interacting with the person receiving a Crisis

    Service to Specific recommendations if person arrives at the Crisis and Assessment

    Service.

    ? Revised After the crisis, identify strategies for determining what worked and what did not

    work, and make changes to the plan to After the crisis, identify strategies for

    determining what worked and what did not work.

    ? Included additional box to include: Strategies identified to be followed after a crisis to

    determine what worked and what did not work, and make changes to the PCP

    including this Crisis Plan.

    ? Included additional box to include: CONSENT/RELEASES OF INFORMATION (For

    individuals or agencies included on the Contact List below).

    Pg. 8 Pg. 30 ? Crisis Prevention/Crisis ? Deleted boxes for Consent/Release of Information. (Information was included on

    Response Continuation the Crisis Prevention/Crisis Response initial page)

    ? Moved All Current Medications to Summary of Assessments/Observations.

    ? Revised Advance Directions to Yes No If no, I would like one.

    ? Combined Crisis Contact Information to 2 pages versus 3.

NC Division of Mental Health, Developmental Disabilities, and Substance Abuse Services

    PCP PAGE PCP TITLE/HEADING REVISIONS

     INSTRUCTION

    MANUAL PAGE

    Pg. 10 & 11 Pg. 33 ? Signatures ? Deleted Comments on the top of the Signature page.

    ? Revised Signature pages to include 5 sections:

    I. Service Orders Included additional information and boxes to attest to the

    following:

    (SECTION A): For services ordered by one of the Medicaid approved

    licensed signatories, the signature attests to the following:

    ? Medical necessity for services requested is present, and constitutes the

    Service Order(s).

    ? The licensed professional who signs this service order has had direct contact with the individual - Yes No

    ? The licensed professional who signs this service order has reviewed the individual’s assessment - Yes No

    ? License # required.

    (SECTION B): For Qualified Professionals (QP) / Licensed Professionals

    (LP) ordering:

    ? CAP-MR/DD or

    ? Medicaid Targeted Case Management (TCM) services (if not ordered in

    Section A)

    ? OR recommended for any state-funded services not ordered in Section A.

    The signature attests to the following

     Medical necessity for the CAP-MR/DD services requested is present, and

    constitutes the Service Order.

     Medical necessity for the Medicaid TCM service requested is present, and constitutes the Service Order.

     Medical necessity for the State-funded service(s) requested is present, and constitutes the Service Order.

    NC Division of Mental Health, Developmental Disabilities, and Substance Abuse Services

    PCP PAGE PCP TITLE/HEADING REVISIONS

     INSTRUCTION

    MANUAL PAGE

    Pg. 10 & 11 Pg. 33 II. Person Receiving Services No revisions Signatures

    III. Legally Responsible Person Included boxes to attest to the following:

     I confirm and agree with my involvement in the development of this

    PCP. My signature means that I agree with the services/supports to

    be provided.

     I understand that I have the choice of service providers and may

    change service providers at any time, by contacting the person

    responsible for this PCP.

     For CAP-MR/DD services only, I confirm and understand that I have

    the choice of seeking care in an intermediate care facility for

    individuals with mental retardation instead of participating in the

    Community Alternatives Program for individuals with mental

    retardation/developmental disabilities (CAP-MR/DD).

IV. Person Responsible for the PCP Included additional information and

    boxes to attest to the following:

    ? The following signature confirms the responsibility of the QP/LP for

    the development of this PCP. The signature indicates agreement

    with the services/supports to be provided. (*For Adults (21 years of

    age for Medicaid, 18 years of age for State funded services).

    ? An additional signature line that attests to the following: For

    individuals who are less than 21 years of age (less than 18 for State

    funded services) and who are receiving or in need of enhanced services

    and who are actively involved with the Department of Juvenile Justice

    and Delinquency Prevention or the adult criminal court system, the

    person responsible for the PCP must attest that he or she has completed

    the following requirements as specified below:

     Met with the Child and Family Team - Date: / /

     OR Child and Family Team meeting scheduled for - Date: / /

     OR Assigned a TASC Care Manager - Date: / /

     AND conferred with the clinical staff of the applicable LME to conduct care

    coordination.

V. Other Team Members - No revisions

    NC Division of Mental Health, Developmental Disabilities, and Substance Abuse Services

    2. SUPPLEMENTAL PCP PAGES

    PCP PAGE PCP TITLE/HEADING REVISIONS INSTRUCTION

    MANUAL PAGE

    (Supplemental) Pg. 38 ? Plan Update/Request ? Deleted the PCP Plan Update/Revision pages from the Complete PCP and it will now Pg. 1 serve as a Supplemental document. Issuing guidance regarding the Update/Revision of a PCP, is as follows:

    1. PCPs must be reviewed if the person’s needs change, if there is a change in provider and/or based on assigned target dates.

    2. If any review results in a new service being added or a new goal(s) being added, or

    anything that cannot be explained in the “Justification” space next to the Status Code, use the PCP Update/Revision page.

    3. Any time the Update/Revision page is used, the Update/Revision Signature page must

    also be completed.

    (Supplemental) Pg. 40 ? Plan Update/Request Signature ? Deleted the PCP Plan Update/Revision Signature Pages from the PCP Pgs. 2 & 3 Pages Update/Request and it will now serve as a Supplemental document. Issuing

    guidance regarding the Update/Revision Signature pages of a PCP, is as follows:

     For Medicaid funded services:

    1. When the Update/Revision includes a new service(s), a licensed physician,

    licensed psychologist, licensed physician’s assistant or licensed family nurse

    practitioner must sign and date the Update/Revision indicating that requested

    service(s) are medically necessary. The dated signature serves as the Service Order(s).

    2. This signature and the date of the signature are REQUIRED. The signature is authenticated when the individual signing enters the date next to his/her signature.

    3. Do not present the Update/Revision Signature Page to the LP to sign if not attached to a fully completed and dated Update/Revision.

    For State funded services:

    1. When the Update/Revision includes a new service(s), it is RECOMMENDED that a

    licensed physician, licensed psychologist, licensed physician’s assistant or licensed

    family nurse practitioner sign the Update/Revision indicating that the services

    contained in the plan are medically necessary. This signature serves as a Service

    Order and will prevent the possibility of services being provided without a service order should the individual move from State-funded services to Medicaid.

    ? If the recommended signatures above are not obtained, it is then RECOMMENDED that

    the person responsible for the plan/clinical home sign the Update/Revision indicating

    the medical necessity has been met and ordering the service(s). (Note: The person

    responsible for the plan/clinical home must sign the update/revision even if the service(s) is

    ordered per the Medicaid requirement above. In this case, the signature confirms

    involvement and agreement with the services and supports detailed in the update/revision, but does not constitute the service order.)

    NC Division of Mental Health, Developmental Disabilities, and Substance Abuse Services

    PCP PAGE PCP TITLE/HEADING REVISIONS

    INSTRUCTION

    MANUAL PAGE

    (Supplemental) Pg. 41 ? Learning Log ? It is recommended that providers use the new supplemental Learning Log in

    Pg. 4 order to understand how to better support the individual. It is to be used anytime

    there is a serious event or when a situation needs to be considered more closely.

    Additionally, it is recommended that the Learning Log accompany the PCP

    Update/Revision pages.

(Supplemental) Pg. 32 ? Did We Get it Right? ? New addition to the Complete PCP ( In supporting evidence based practice on Pg. 5 seeing the PCP as a “description” of someone’s life, 3 questions were designed

    as prompts to ensure commitment to the person-centered planning process.)

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