Date: / to
PERSONAL INFORMATION
Client Name: / PMI #: / Phone: / Home:
(8 digit Medical Assistance #) / Work:
Case #: / Cell:
Date of Birth: / (10 digit Dakota County case #)
Address:
Email:
Waiver Type: / AC CAC CADI DD EW BI-NF BI-NB
County of Residence: / County of Financial Responsibility (CFR): Dakota
Parent/Legal Representative/Responsible Party (if any):
Address:
Phone: / Home: / Email:
Work:
Cell:
Social Worker/Public Health Nurse: / Phone:
Fax:
Address:
Email:
Fiscal Support Entity:(Agency that bills and reimburses) / Contact Name:
Address:
Phone: / Fax:
Email:
Common Law Employer(s): (Person or agency that hires & / Contact Name:
handles payroll. May be the same as the Fiscal Support Entity)
Address:
Phone: / Fax:
Email:
Support Planner, if any:
Address:
Phone: / Fax:
Email:
Support Planner, if any:
Address:
Phone: / Fax:
Email:
Annual Community Support Plan for:
You may want to refer to the “Dakota County Guide To Completing the Annual Community Support Plan” when completing this form.
When developing the Annual Community Support Plan, think about and describe the individual, his or her strengths and needs, likes and dislikes, and how the disability/condition impacts his or her life. Some people find these questions easy to answer and can do so without assistance. Others have found it helpful to participate in a facilitated person-centered planning process. Information about planning processes is included at the end of the guidebook. Remember all goods and services must be directly related to the disability and/or condition and based on the intended outcomes described in this Community Support Plan.
Brief Description(Age, disability/condition, how disability impacts life)
Brief Summary of Last Plan Year’s Progress(Describe the accomplishments or progress made on things you wanted to do or achieve.)
- What do you want to do?
- What unpaid and paid support will you need?
- PERSONAL ASSISTANCE (Support for personal care, relief of caregiver, etc.)
PROVIDER QUALIFICATIONS:
TRAINING:
- TREATMENT AND TRAINING (Support/services for training, therapy, etc.)
PROVIDER QUALIFICATIONS:
TRAINING:
- ENVIRONMENTAL MODIFICATIONS AND PROVISIONS (Supplies, equipment, modifications, special diets, chore services, mileage, etc.)
PROVIDER QUALIFICATIONS:
- SELF DIRECTION SUPPORT ACTIVITIES (Support Planner, Fiscal Support Entity fees, payroll costs, newspaper ads, etc.)
PROVIDER QUALIFICATIONS:
TRAINING:
How will the supports you listed in question #2 help you do what you want to do?(Describe the intended outcomes here.)
MONITORINGYour Community Support Plan must include who is responsible for monitoring. They may be paid or unpaid.
Indicate who will monitor Health and Safety along with the County.How often?
Who / Daily / Monthly / Quarterly / OtherIndicate who will monitor expenditures along with the county.How often?
Who / Monthly / Quarterly / OtherWho will be responsible for assuring the provider qualifications and training of the support people: (Check all that apply)
Individual
Parent/Spouse/Responsible Party
Support Planner
Licensed Agency
Other: (Indicate who)
For what positions, if any, do you want criminal background checks completed? See Employee List for Criminal Background Studies.
*All licensed agencies are required to complete criminal background checks, and most Agency with Choice providers will require them.
A written agreement is in place stating duties and responsibilities of (check all that apply):
Fiscal Agent (Payroll Model only)
Agency with Choice
Support Planner(Include Dakota County Support Planner Agreement)
HEALTH AND SAFETY PLANHow will your health and safety needs be met? Think about what supports and services are needed along with what skills and knowledge staff may need.
The Guide includes questions to help you think about your health and safety plan. Revise the plan as necessary. This section must be completed in detail, highlighting how all health and safety issues will be met.
Revision to Health and Safety Plan: / Date:WHAT WILL I DO IN CASE . . .
What will you do in case there is an emergency, such as staff not showing up for their shift, primary caregiver is ill, staff is late returning. The Guide includes questions to help you think about your Emergency Plan. Update the plan as necessary.
Emergency Contact / Alternate personName:
Home phone:
Work phone:
Cell Phone:
Revision to Emergency Plan: / Date:
CHOOSING COMMUNITY LONG TERM CARE
All Waivers/AC
- You can choose the provider you prefer for services
- Did the person who helped you with this plan give you a list of providers or tell youabout different providers that you could choose for services in the plan?
- Did you have the chance to help develop this plan including the kinds of services you want to receive?
- Do you agree with the services, and providers, as written in this plan?
NOTE: Client should always have current releases of information.
Long Term Care Waivers/AC Only
- You can choose to receive services in the community (your home) or in a nursingfacility. Were you offered this choice?
- Do you have an Advanced Directive?
- If no, would you like information?
- Application for MHCP submitted?
CHOOSING COMMUNITY LONG TERM CARE
DD Waiver Only – Additional Rule 185 Requirements
Rule 185 Case Management eligibility is complete. *If uncertain, complete DAK7180.
Related Conditions Checklist (DHS-3838-ENG) – File the form in the Screening tab in the case file. *Check this box if all the following apply:
1) The client is not Rule 185 eligible based on IQ and adaptive functioning scores.
2) The client has a diagnosis of a related condition.
3) A Checklist for Related Conditions Eligibility (on DakotaWorks under Assessment) is completed and in the file and
4)You have (annually) completed Page 2 of the Related Conditions Checklist (DAK-DHS) and it confirms that client IS/REMAINS eligible for case management as a person with a condition related to mental retardation.
ICF/MR Level of Care. *Must have form (DHS-4147) Guide to Determining ICF/MR Level of Care completed one time and filed in Screening tab in case file. In order to check the box, you must have reviewed the last form, DD Screening Document, and the psychological testing AND THEN ONLY if you have determined the client meets ALL of the following:
1) Has a DD or a related condition.
2) Needs a 24-hour plan of care.
3)Needs active treatment.
4) Is unable to apply skills learned in one environment to new environments without additional training or supervision AND
5) Is in need of ICF/MR level of care.
If client meets all criteria, they ARE eligible for ICF/MR services or DD waiver services and you may check the box.
Full Team DD Screening is completed annually. This plan is a review of client functioning/needs and goals. If further assessments are needed, please comment:
*NOTE: Monitoring and evaluation of the plan and services shall occur at least on a semi-annual basis, additional contact monitoring will be based on need to facilitate plan or health and safety.
CDCS Annual Community Support Plan
Date: / to
Client Name:
Client/Responsible Party/Guardian Signature / Date
Social Worker/Public Health Nurse Signature / Date
1
CLS/DD< DAK 7170.13 – CDCS (12/2017)