CMS-Appendix B.6: Evaluation & Reevaluation of Level of Care MFP-Waiver, State Plan, Complex Case Level of Care Sub-assurance a. - Determine NF LOC at TM reviews LOC, Tracking # enrolled by Continuous Monthly Preliminary An evaluation for Assessment time of transition; TC MDS, readiness form target group LOC is provided to assigns to appropriate assessment, and (type of needs Process all applicants for Assessing Services Agency self-assessment (ADLs, nursing, Transition whom there is (ASA) based on service complex) Planning reasonable needs (waiver or complex Process indication that case services) Reason for Transition services may be Process needed in the future. CMS-Appendix D: Participant-Centered Planning and Service Delivery MFP-Individual Transition Plan (ITP) Sub-assurance a. - TC develops TM reviews and ITP % of plans that Ongoing Monthly and Transition Service plans comprehensive Individual approves meet needs and Quarterly Planning address all Transition Plan (ITP) that transition plan. personal goals; Process participant needs includes Risk Assessment, # where needs and personal goals Backup Plan, and all TM documents cannot be met, either by provision support services needed; approval in reasons needs of waiver services tracking system. cannot be met Convenes MDT as or through other needed; means % of services by category (HCBS, ITP documented in a informal, tracking system Medicare, MFP Demonstration services, etc.) Sub-assurance b. - TC follows checklist TM reviews Transition # and % by Ongoing Monthly and Transition State monitors Planning procedure for completing checklist, service checklist transition Quarterly service plan Process all aspects of transition plan and risk outcome development in plan, including timeline assessment prior ITP Transition accordance with its for transition, service to discharge. Process policies and delivery, and follow-up
CMS-Appendix B.6: Evaluation & Reevaluation of Level of Care MFP-Waiver, State Plan, Complex Case Level of Care Sub-assurance a. - An evaluation for LOC is provided to all applicants for whom there is reasonable indication that services may be needed in the future. Preliminary Assessment Process Transition Planning Process Transition Process Determine NF LOC at time of transition; TC assigns to appropriate Assessing Services Agency (ASA) based on service needs (waiver or complex case services) TM reviews LOC, MDS, readiness assessment, and self-assessment Tracking form # enrolled by target group (type of needs (ADLs, nursing, complex) Reason for Continuous Monthly CMS-Appendix D: Participant-Centered Planning and Service Delivery MFP-Individual Transition Plan (ITP) Sub-assurance a. - Service plans address all participant needs and personal goals either by provision of waiver services or through other means Transition Planning Process TC develops comprehensive Individual Transition Plan (ITP) that includes Risk Assessment, Backup Plan, and all support services needed; Convenes MDT as needed; ITP documented in a tracking system TM reviews and approves transition plan. TM documents approval in tracking system. ITP % of plans that meet needs and personal goals; # where needs cannot be met, reasons needs cannot be met % of services by category (HCBS, informal, Medicare, MFP Demonstration services, etc.) Ongoing Monthly and Quarterly Sub-assurance b. - State monitors service plan development in accordance with its policies and Transition Planning Process Transition Process TC follows checklist procedure for completing all aspects of transition plan, including timeline for transition, service delivery, and follow-up TM reviews checklist, service plan and risk assessment prior to discharge. Transition checklist ITP # and % by transition outcome Ongoing Monthly and Quarterly