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.)