{"ref":"MO-HC-SP-01","title":"Care Plans, Care Plan Changes, and Communication with DSDS","category":"Service delivery","summary":"Explains that the care plan is the state-approved plan DSDS authorizes and the Agency delivers strictly in accordance with it; requires the Agency always to have an active care plan for each participant; sets how workers, the administrative supervisor and the Agency's registered nurse identify an ongoing need for more or fewer units or different tasks, how the supervisor approves changes in advance and the Agency recommends them to DSDS, and how the Agency puts DSDS changes into effect without billing more than the higher authorization or any units not delivered.","inShort":["The care plan comes from DSDS. Do the tasks on your task sheet, as often as it says.","Record the tasks you do in EVV at every visit.","Only DSDS can add units. Never work or bill more than the units authorized.","If the participant often needs more or less help than the care plan allows, tell your supervisor. The Agency will ask DSDS to change the plan.","Do not add tasks that are not on the plan, even if asked. Tell your supervisor instead."],"primaryCitation":"19 CSR 15-7.021(15)","citations":["19 CSR 15-7.021(15)(A)-(C)","19 CSR 15-7.021(18)(K)","19 CSR 15-7.021(20)(D)","19 CSR 15-7.021(21)(C)","13 CSR 70-91.010(1)(B)2, 3","13 CSR 70-91.010(3)(H)4-6","13 CSR 70-91.010(5)(D), (5)(E)7, (5)(F)2.A","RSMo 192.2475.13","MMAC In-Home Services Program Requirements 2.2","MO HealthNet Personal Care Provider Manual §§2.1, 2.5 (Required Documentation), 2.6, 2.7, 2.17, 3.1, 3.6"],"federalCitations":[],"surveyorAsks":["Show me this participant's current care plan and how the worker's visits match the task frequency on it.","When did you last recommend a care plan change to DSDS? Show me the recommendation and the supervisor's advance approval in the file."],"forms":[{"ref":"MO-HC-SP-01-A","title":"Care Plan Change Recommendation to DSDS"}],"headings":["Terms of Reference","1. Purpose","2. Scope","3. Definitions","4. Policy Statement (19 CSR 15-7.021(15))","5. The Care Plan","6. Delivering the Care Plan","7. Keeping an Active Care Plan","8. When to Recommend a Change","9. How the Agency Makes a Recommendation","10. When DSDS Changes the Care Plan","11. Advanced Personal Care Plans","12. Responsibilities","13. Records and Compliance Monitoring","14. Staff Training","15. References","16. Related Policies and Forms","17. Approval","18. Revision History"],"version":"1.0","sample":false,"pack":"mo-hca","state":"Missouri","service":"Home care","guides":[{"path":"/guides/home-care-agency-policies/","h1":"What policies does a home care agency need?"}],"agency":{"name":"Sample Agency","legalName":"Sample Agency, LLC","logo":null}}