(Revised 5/1/2015 ML #3444)
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The Personal Care Services Plan (PCSP) SFN 662 documents the eligibility for personal care services and the amount of personal care services that will be provided to an eligible individual and the provider(s) selected by the individual to perform the services. The PCSP is required for all individuals assessed or receiving personal care services and is the outcome of the initial comprehensive assessment, annual assessment, or six-month review of the individual’s needs. No payment may be made to any provider until the PCSP is filed with the state office. A copy of all Authorizations to Provide Personal Cares Services SFN 663 must accompany the PCSP filed with the state office.
The PCSP is to be revised or updated as an individual's needs require. At a minimum it must be reviewed with the individual six months following an initial or annual assessment. The PCSP must be revised every time the individual’s service needs change or when a change in service provider(s) occurs.
The individual's case manager must complete the PCSP in conjunction with the individual or his/her legal representative. The signature of the individual or the legal representative on the PCSP is required before services can be authorized for payment. If the individual or legal representative refuses to sign the PCSP, the reason for the refusal must be noted in the case file. Any changes or revisions to a PCSP require the signature of the client with the exception of a change in provider. When a change in service provider occurs between case management contacts -- the client or legal representative may contact the case manager requesting the change in provider. The contact and approval for the change in provider must be verified in the case manager's documentation and noted on the PCSP which is sent to the Department. A copy of the updated care plan must be sent to the client or legal representative. However, changes in services, which include tasks, or the amount of service, which includes amount of units authorized for each task, must be signed by the client or legal representative and approved.
Section I – Client Information
Enter the individual’s name, address, Medicaid number, county of residence, and the date the comprehensive assessment is completed and the date the LOC was determined.
A LOC determination approval must be obtained whenever an individual has not had any LOC determination approved within 12 months of the start of a care plan period. If the individual does not meet NF or ICF/MR level of care then check PCS-A. The date of the next LOC determination is the responsibility of the case manager and needs to be scheduled to allow sufficient time in which to give the client a ten working day notice should personal care services be reduced because the individual no longer meets the criteria for LOC.
Instructions For Obtaining ICF/MR Level Of Care (LOC) Determination (for use by DD case managers)
An individual in need of Level B or Level C personal care services must have an ICF/MR LOC determination done whenever a comprehensive needs assessment is completed.
Individuals eligible to meet the ICF/MR level of care include individuals with a diagnosis of mental retardation as defined in NDAC 75-04-06 or persons with related conditions as defined in 42 CFR 435.1009.
The developmental disabilities case manager must complete a comprehensive needs assessment to determine whether the individual meets the minimum criteria for the ICF/MR level of care. The application of the Guidelines for ICF/MR level of care screening serve as the basis as to whether the individual qualifies for Level B of Level C personal care services.
Instructions For Obtaining Nursing Facility (NF) Level Of Care Determination
An individual in need of Level B or C personal care services who does not meet ICF/MR level of care criteria must have a NF level of care determination approved within 12 months of the start of any personal care service plan. The date of the next NF level of care determination is the responsibility of the case manager and needs to be scheduled to allow sufficient time in which to give the client a ten working day notice should personal care services be reduced or terminated.
The case manager shall use the existing and established procedures for requesting a NF level of care determination from Dual Diagnosis Management (DDM). The information needed for submission of information to DDM is usually obtained during the comprehensive needs assessment process.
It is the responsibility of the case manager to trigger the screening by submitting information to DDM. The basis of the information submitted is verified and documented in the completion of the materials identified in items 1 and 2 below. Item 2 below is the ONLY document that needs to be submitted to DDM.
- The comprehensive needs assessment
- ND LEVEL OF CARE/Continued Stay Review Determination Form
You are encouraged to submit by web based method; however you may fax the information.
Following are the screen types listed on the LOC Determination Form.
- MSP-PC
- HCBS Waiver/MSP-PC (check only if eligible for both)
DDM will send written confirmation of NF level of care determination to the case manager for filing in the client's record.
If you are unable to resolve NF determination issues with DDM, contact the Administrator of Long Term Care Projects at 328-2321.
Section II – Eligibility for Personal Care Service
Score the individual’s needs in accordance with the instructions for scoring ADLs and IADLs to determine if the individual qualifies for personal care services. Narratives in the individual’s file must verify the rationale for each score, and the determination for eligibility. Client must be scored impaired in the ADL or IADL before it can be authorized.
Choose the level of personal care needed based on the eligibility criteria outlined in Personal Care Eligibility Requirements 535-05-15.
Determine the type of provider that will be providing services based on the individual’s choice.
Check/complete the appropriate box:
PCS-A
PCS-B
PCS-C
Daily
Basic Care
If the individual chooses to receive services on a daily rate (T1020), the "Daily" check box must be checked. To determine the Daily rate send a completed SFN 662 and 663 to Medical Services and the rate will be calculated by Medical Services. The provider and case manager will receive a copy of a profile that documents the rate. The daily rate needs to be recalculated whenever there is an increase or decrease in units of service approved for a client.
The developmental disabilities case manager must complete a comprehensive needs assessment to determine whether the individual meets the minimum criteria for the ICF/MR level of care. The application of the Guidelines for ICF/MR level of care screening serve as the basis as to whether the individual qualifies for Level B personal care services.
If any of the QSPs are eligible for Rural Differential Rate check the appropriate RD boxes. When a QSP is no longer receiving rural differential for this client complete Date RD removed and submit the SFN 662 and SFN 663 to Medical Services and the QSP. See Rural Differential Rates 535-05-38.
Section III – Approved Services
For QSPs who will be paid based on 15 minute unit rate basis, enter the personal care service provider name, provider number, the units authorized on SFN 663, the 15-minute (T1019) procedure code, and the billable units (units will be the same as the authorized units) to be provided on a monthly basis. If multiple providers are listed on SFN 663 list all providers and provider numbers but complete only 1 line for authorized units, procedure code, and billable units. The procedure code for services must be T1019. The total number of units of service to be provided per month by all providers based on 15-minute increments must be entered. The total number of units per month for procedure code T1019 may not exceed 480 units if PCS – A is checked or 960 units if PCS – B is checked or 1200 units if PCS-C is checked.
For a QSP who elects to be paid a daily rate, enter the personal care service provider name, provider number, the authorized units from SFN 663, the per day (T1020) procedure code, and 31 in the billable units/day column. The procedure code for personal care services provided on a daily basis must be T1020. When the care plan is filed with the state, the daily rate will be calculated by the state office and the provider will be notified of the daily rate. In no case may a daily rate exceed the daily rate limit set forth in the state plan.
If personal care services are to be provided by a basic care assistance provider, enter the provider name, and provider number.
Section IV - Other Services
Record services which are not authorized as personal care services but are being provided or arranged for the individual. This section should include services such as home health, home delivered or congregate meals, transportation, SPED, EXSPED, waivered services, or family support services.
Section V – Signatures
The instructions for the completion of a reduction is outlined in Denials, Terminations, and Reductions 535-05-50
If the care plan for personal care services expires or services are terminated and a new care plan is not going to be issued, you must follow the policy for Termination. Complete the date of case closure and reason for case closure and submit to the client and Department and a copy of the canceled authorization SFN 663 to the client provider, and Department. If a care plan for personal care services is being terminated prior to the end of the effective date of the plan and a new care plan is being issued send a copy of the canceled care plan SFN 662 to the client and Department and a copy of the canceled authorization SFN 663 to the client, provider, and Department. The instructions for the completion of a Termination is outlined in Denials, Terminations, and Reductions 535-05-50.
If the individual was determined not to qualify for personal care services in Section II, then the individual must be informed of their rights. The instructions for the completion of a Denial is outlined in Denials, Terminations, and Reductions 535-05-50.
If the client is not in agreement with the PCSP, they should enter their initials indicating they are not in agreement with the plan of care. The Case Manager must provide the client with a completed SFN 1647, (Reduction, Denial, or Termination Form).
The individual (or the individual’s legal representative) and the case manager both must sign to signify agreement with the PCSP. If the individual refuses to sign the PCSP, the case manager must provide the client with a completed SFN 1647 and a copy of the unsigned plan must be forwarded to the state office.
If a care plan changed due to a change such as; a change in provider, or change in units approved, or other change prior to the end of an existing care plan period, check the reason for the change and describe if appropriate. Then send a copy of the canceled and updated care plan SFN 662 to the client and Department and send copy of the canceled and updated SFN 663 to client, provider, and Department.
The case manager should check the appropriate identification of the program case management, DDCM for Developmental Disabilities Case Manager or HCBS for Home and Community Based Waiver Case Manager.
Section VI – Six-Month Review and Continuation of Plan with No Changes
The case manager may complete this section only if no change in the individual’s status, authorized units, and provider(s) occurs at the six-month review or 3 month review for Level C Personal Care. The case manager must enter the new effective date continuing the plan for the next period that may not exceed 6 months or 3 month review for Level C Personal Care. The case manager and the individual both must sign for the continuation of the plan.
Distribution
The original PCSP and any changed PCSP is filed in the individual's case file. One copy is mailed or given to the individual or the legal representative when completed. A copy of SFN 662 and a copy of SFN 663(s) must be mailed within 3 days of completion to the respective state office (Developmental Disabilities or Medical Services).
The SFN 662 is available from Office Services and an electronic copy is available through the state e-forms.