Personal Support Plan

Transcription

1 HIGHLIGHT AND PLACE NAME HERE Date f PSP: Date f Disseminatin: Persnal Supprt Plan Residential and Vcatinal/Day Services Residential Services Only Vcatinal/Day Services Only Self-Directed Services (must als cmplete the Self-Direct with Emplyer Authrity Plan f Care) Case Management Only Initial Annual Review/ Revisin Exit Other Residential Services = Residential Habilitatin (grup hme and supprted living), Adult Cmpanin, Adult Fster Supprt, Assisted Living, and Live-in Caregiver. This plan is appr v ed. It is pers n -center ed a nd th e i ndivi dua l was inv l ved in its d eve l pm en t. Th e plan was dev el ped bas ed n assess men ts f t he p ers n s need s, vis i n, p re fe re nces and hea lt h a nd s af et y r is k factrs. In ad diti n, a l l services lis ted n the pers n s c st plan a re ide n ti fi ed in actins in t his pla n f car e. Case Manager Signature: Date:

2 Mntana Department f Public Health & Human Services Develpmental Disabilities Prgram 111 Nrth Sanders Helena, MT Phne: Fax: D nt alter this dcument except where indicated. Mark n/a r therwise if there is n infrmatin fr a given sectin. I n d e x S E C T I O N I (Required fr all PSPs) General Infrmatin Infrmatin Sheet Peple/Agencies Wh Supprt Me Case Manager respnsible fr cmpleting S E C T I O N V (Required fr all PSPs can be brief if nt in a Residential and/r Vcatinal/Day Services ) Wellness Health Summary Allergies/Sensitivities Equipment, Supplies & Technlgy Medicatins Health Care Prviders Prvider respnsible fr cmpleting as necessary t the services prvided Case Manager respnsible fr cmpleting if there is n prvider S E C T I O N I I (Required fr all PSPs) Persnal Intrductin Case Manager respnsible fr cmpleting S E C T I O N I I I (Required fr all PSPs) Persnal Prfile Imprtant T Imprtant Fr Instructins Fr Supprters What thers need t knw r d S E C T I O N V I (Required fr all PSPs) Persnal Finance Case Manager respnsible fr cmpleting based n input frm thers such as payee and/r prvider S E C T I O N V I I (Required fr all PSPs) Visins Case Manager respnsible fr cmpleting Case Manager respnsible fr cmpleting using assessment infrmatin cmpleted by the prvider Case Manager respnsible fr cmpleting assessment tls as well as Persnal Prfile when n prvider

3 S E C T I O N I V (Required fr all PSPs can be brief if nt in a Residential and/r Vcatinal/Day Services ) Lifestyle Cmmunicatin Hme Vcatinal/Retirement S E C T I O N V I I I (Required fr all PSPs) Outcmes Case Manager respnsible fr cmpleting based n input at team meeting Prvider respnsible fr cmpleting as necessary t the services prvided Case Manager respnsible fr cmpleting if there is n prvider S E C T I O N I X (Required fr all PSPs) Signatures Case Manager respnsible fr btaining

4 Address: P e r s n a l S u p p r t P l a n Sectin I. General Infrmatin Infrmatin Sheet City: State: Zip Cde: Hme Phne: Wrk Phne: Peple/Agencies Wh Supprt Me Nte: Please list any Guardian r POA in the service/supprt prvided sectin and Health Care Prviders in the Wellness Sectin Agency and/r cntact persn Service/Supprt Prvided Address Phne # Address Emergency Cntact Y r N 1

5 Sectin II. Persnal Intrductin Please see the PSP Prcedure Manual fr the type f infrmatin t be included in this sectin. 2

6 Sectin III. Persnal Prfile Please see the PSP Prcedure Manual fr the type f infrmatin t be included in this sectin. Imprtant T: Includes things which help the persn t be satisfied, cntent, cmfrted and happy Imprtant Fr: Includes things related t health and safety Instructins Fr Supprters What thers need t knw r d: 3

7 Cmmunicatin: Sectin IV. Lifestyle Please see the PSP Prcedure Manual fr the type f infrmatin t be included in this sectin. What is Happening Persn Des This What we think it means We Shuld Hme: Mvement: Eating/Nutritin: Fun/Relatinships: Vcatinal/Day/Retirement : Mvement: Eating/Nutritin: Fun/Relatinships: 4

8 Health Summary: Sectin V. Wellness Please see the PSP Prcedure Manual fr the type f infrmatin t be included in this sectin. Physical Health: Mental Health: Hearing/Visin/Dental: Allergies/Sensitivities Allergy/Sensitivity Reactin Treatment Precautins, Preventatives Equipment, Supplies & Technlgy Item Purpse Hw Maintained/ Wh Maintains Date f Purchase 5

9 Sectin V. Wellness Medicatins Include ALL PRN's and OTC's and attach PRN prtcls. Medicatin Time(s) f Day Taken Dsage/ Rute Purpse f Medicatin fr this persn Start Date Prescribing Prfessinal Additinal Medicatin Infrmatin (e.g. precautins, preferences, interventins, presence f side effects, etc.): 6

10 Sectin V. Wellness Health Care Prviders Name/Title Type f Services Clinic (Facility) Name/Address Phne Last Significant Appintment 7

11 Sectin VI. Persnal Finance Instructins: This frm is intended t identify all the resurces available t the persn including their Individual Cst Plan (ICP) fr DDP services. It can be used as an aid in the identificatin f slutins fr any that may be lacking. This frm can als be used t help identify ptins that may nt have been used previusly. Other may be used t identify such things as Veteran s Administratin benefits r Railrad Retirement benefits. Funding Surce/Resurce Yes N Amunt Funding Surce/Resurce Yes N Amunt ICP SSI Title XIX (Waiver) SSDI Title XX (nn-medicaid) SSA Medicaid State Supplement Medicare TANF Family Educatin & Supprt LIEAP Private Pay Fd Stamps (SNAP) Representative Payee Husing Assistance Checking Accunt Wages/perid Savings Accunt Retirement/perid Medicaid Qualifying Burial Trust Medicaid Self- Sufficiency Trust Individual Indian Mnies Bureau f Indian Affairs Credit Check Other Questins t cnsider: Are there any mnetary resurces in safekeeping that might affect Medicaid eligibility? Have there been any changes in the past year that wuld affect the persn s benefits (i.e. parent s death)? Des the persn s incme meet his r her expenses? Identify the Medicaid authrized representative, if there is ne. 8

12 Sectin VII. Visin Please see the PSP Prcedure Manual fr the type f infrmatin t be included in this sectin. 9

13 Sectin VII. Outcmes Visin Statement: Outcme: Written t answer this questin,: What d I want t d this year? Assessment tl/s used: Actins (Apprach): Hw d I get there? Hw will this be accmplished? Include name f prvider agency and title f respnsible persn. Start Date/ Cmpletin Date Status/Prgress Quarterly Status: Nte: Quarterly schedule may be based n the actual date f the PSP r the calendar year. Indicate the schedule fr this PSP belw. Calendar Year Submitted by: Jan-Mar April 30th Apr-Jun July 30th Jul-Sep Octber 30th Oct-Dec January 30th PSP Date Submitted within 30 days f the end f the quarter; fill in quarter date ranges abve. Updated by: Agency/Dept: Additinal Infrmatin: 10

17 Sectin IX. Signatures Initial PSP Annual PSP PSP review/revisin Exit PSP My plan has been explained t me. I have been tld what my rights are under my plan and I knw that I may request anther meeting, at any time, t make changes t my plan. It has als been explained t me that the Department f Public Health and Human Services checks my prgress in the plan. I have been assured that this infrmatin is kept cnfidential. Each member f my planning team will receive a cpy f this plan. Signature Date The Persn did nt attend the meeting after attempting n tw separate ccasins. Please dcument abve in the signature line the reasns the persn did nt attend and accmmdatins made t supprt the persn in attending. As a member f this team, my signature reflects my understanding f the cnfidential nature f the infrmatin cntained and discussed in this plan. All decisins f the PSP team must be in cnsensus. My signature indicates that I cnsent t this plan. If attending meeting but nt cnsenting, print name but leave signature line blank. Signature indicates agreement with plan Relatinship t persn Printed Name indicates attendance at meeting Fr Self-Directed Services nly: I understand that failure t abide by the plan f care and perfrmance benchmarks written t address prblems identified in managing self-directed services may result in the invluntary terminatin f self-directed services. In this event, agency-based services may be made available. initials f individual/legal representative 14