Title 7 . Health and Social Services

Chapter 43 . Hearings

Section 1030. Screening, assessment, plan of care, and level of care determination

7 AAC 43.1030. Screening, assessment, plan of care, and level of care determination

(a) An applicant for home and community-based waiver services must obtain an initial, informal screening, for use by the department to determine whether an assessment is warranted under (b) of this section. The department will offer the applicant a choice of care coordination agency providers. The applicant must obtain the screening from one of those providers. A care coordinator shall perform the screening.

(b) If warranted by the screening under (a) of this section and supportive diagnostic documentation, and to determine if the applicant meets the level of care required under 7 AAC 43.1010(d)(2), the department will authorize the care coordinator to prepare a complete assessment of the applicant's physical, emotional, and cognitive functioning and need for care and services. If the assessment is to determine if the applicant falls within the recipient category for

(1) individuals with mental retardation and developmental disabilities, the

(A) department will make a level of care determination under 7 AAC 43.300(c) - (d); and

(B) level of care determination must incorporate the results of the Inventory for Client and Agency Planning (ICAP), as revised as of 1986 and adopted by reference, that is administered under 7 AAC 43.300(c) - (d); or

(2) adults with physical disabilities or older adults, the

(A) department will make a determination to determine whether the applicant requires skilled care under 7 AAC 43.180 or intermediate care under 7 AAC 43.185; and

(B) level of care determination under (A) of this paragraph must incorporate the results of the department's Consumer Assessment Tool (CAT), revised as of 2003 and adopted by reference.

(c) After the level of care is established, the care coordinator shall

(1) prepare, in writing, a plan of care addressing the comprehensive needs of the recipient, the availability of enrolled providers, types of services that have been agreed to by specific enrolled providers, family and community supports, and the number of units, frequency, projected duration, and projected cost of each home and community-based waiver service;

(2) include in the plan of care an analysis of whether the type, amount, duration, and scope of services in the plan of care is consistent with the findings of the assessment in (b) of this section and with any other treatment plan for the recipient;

(3) make a recommendation whether the services in the plan of care meet the identified needs of the recipient;

(4) support the plan of care with appropriate and contemporaneous documentation that

(A) relates to each medical condition that places the recipient into a recipient category listed in 7 AAC 43.1010(d)(1); and

(B) describes, supports, or justifies the recipient's request and need for home and community-based waiver services; and

(5) present the plan of care to the department for consideration and approval, and for consideration and approval of the home and community-based waiver services requested in the plan of care.

(d) If a plan of care is for a recipient who falls within the recipient category for children with complex medical conditions or for individuals with mental retardation and developmental disabilities,

(1) the care coordinator shall convene a comprehensive planning team to participate in preparing the plan of care;

(2) the comprehensive planning team must consist of the

(A) recipient;

(B) recipient's;

(i) family members, including parents, guardians, siblings, and others similarly involved in providing general oversight of the recipient; or

(ii) legal guardian, if any;

(C) care coordinator; and

(D) enrolled providers that are expected to provide services;

(3) each individual who participates on the comprehensive planning team shall verify that participation by signature on the recipient's plan of care; and

(4) any disagreement among participants about outcomes or service levels, or any suggestion by a participant for an outcome or service level that differs from what is in the plan of care, must be documented and attached to the plan of care when that plan of care is submitted to the department for consideration and approval.

(e) Before the submission of a plan of care to the department for consideration and approval, the recipient or recipient's representative must indicate by signature that individual's agreement with the plan of care.

(f) The department will approve a plan of care if the department determines that each service listed on the plan of care

(1) is of sufficient amount, duration, and scope to prevent institutionalization;

(2) is supported by the documentation required in (c)(4) of this section; and

(3) cannot be paid for under 7 AAC 43.005.

(g) A recipient's need for home and community-based waiver services must be reviewed annually in accordance with 7 AAC 43.1010, a new assessment must be prepared in accordance with (b) of this section, and the recipient's plan of care must be changed accordingly, unless the department determines that an earlier review is necessary due to changing and significant events in the health and welfare of the recipient. The care coordinator shall submit in writing, for the department's consideration and approval, any change to a recipient's plan of care, shall document the need for changes to the plan of care, and shall relate those changes to findings in the current assessment. If a comprehensive planning team is required under (d) of this section, the team must participate in preparing, in accordance with that subsection, any subsequent changes to the plan of care. If the department determines that adequate documentation is not provided, the department may cap service levels at prior year levels, or reduce service levels to reflect the recipient's historical usage. Before the submission of any change to a plan of care to the department for consideration and approval, the recipient or the recipient's representative must indicate by signature that individual's agreement with that change. The department will approve changes to a plan of care if the department determines that

(1) the amount, scope, and duration of services to be provided will reasonably achieve the purposes of the plan of care, and are sufficient to prevent institutionalization;

(2) each service to be provided is supported by documentation as required by (c)(4) of this section; and

(3) the services to be provided cannot be paid for under 7 AAC 43.005.

(h) The plan of care required in (c) of this section must be completed within 60 days after completion of an initial assessment required in (b) of this section, or within 30 days after the completion of a new assessment required in (g) of this section, unless the care coordinator submits written documentation of unusual circumstances that would prevent timely completion of the plan of care.

(i) Notwithstanding (a), (b), (c), or (g) of this section, the department may perform the screening, assessment, or plan of care development for an applicant or recipient itself.

(j) Screenings, assessments, and plans of care under this section must be completed on a form or in a format approved by the department.

History: Eff. 12/19/93, Register 128; am 5/15/2004, Register 170; am 5/19/2004, Register 170

Authority: AS 47.05.010

AS 47.07.030

Editor's note: The Inventory for Client and Agency Planning (ICAP), and the Consumer Assessment Tool adopted by reference in 7 AAC 43.1030, are available for inspection at the Department of Health and Social Services, Division of Senior and Disabilities Services, Court Plaza Building, 240 Main Street, Suite 602, Juneau, Alaska.