All needs identified on the comprehensive assessment are to be included in the service plan. The needs identified are to be individualized to the client including preferences where the client indicates. Each item is to include the identification of goals/outcomes relevant to the problems which are medical, rehabilitative, or behavioral objectives that are observable or measurable. (WAC 388-15-205, LTCM Ch 4). Items that need to be included in the service plan are as follows:

àServices & activities are to specify who, what and when (include formal and informal supports, primary health/LTC services providers including telephone numbers, etc.) (LTCM Ch 4, WAC 388-15-205, RCW 74.39A-095)

· Identify Formal and Informal caregivers by name using a User Topic or a Common Topic in the automated CA database. This is done for each provider and placed at the beginning of the service plan. For home care agency services the name of the agency providing the service is sufficient.

· For all formal caregivers paid under CHORE, COPES or MPC services document the authorized amounts of care. At a minimum, the number of hours per month authorized or the daily or monthly authorization is to be included. The degree of scheduling specificity in days of the week or number of hours to be served each day should be based on expressed client preferences for service plan detail. (LTCM Ch 4, WAC 388-15-205, RCW 74.39A-095, HCFA)

· Then in the remaining body of the plan reference these individuals as “formal” and “informal” caregivers.

· Plan to identify how supervision and/or monitoring of services will occur if client is unable to supervise the care or his/her ability to supervise the care provider varies.

· Medication management/administration needs and who is performing the assistance/administration (LTCM Ch 4, WAC 388-15-205)

· Treatments, therapies and/or programs identified on the CA (LTCM Ch 4, WAC 388-15-205, HCFA). This includes documenting the name and telephone number of the provider as well as what and when the service is being provided.

· Any other services/tasks recommended by an attending physician, RN or other professional, not included in treatments or therapies (HCFA, WAC 388-15-205). An example might be nurse delegation or an activity recommended by Nursing Services.

· Skin care treatments if the client has current skin breakdown or preventative plan if client is at high risk of skin breakdown (LTCM Ch 4, WAC 388-15-095, HCFA) e.g.

* Caregiver will monitor condition of the individual’s skin when assisting with bathing and report any concerns to the primary heath care provider or home health nurse if involved;

* Caregiver will remind/assist client to reposition themselves every two hours if the client is unable to perform this independently;

* Caregiver will assist and monitor that the client’s skin is clean and dry

· If MPC or COPES client is receiving assistance from a formal caregiver with personal care tasks outside the home, this must be documented in the SP (MB 00-51, HCFA, LTCM Ch 4, WAC 388-15-205, 33-71-0420) For example, Caregiver will provide assistance with authorized activities of daily living while client attends classes at the local community college.

· Self-directed care tasks (RCW 74.39.050, LTCM Ch 4)

Including health care provider name and number whom the client is working with on the SDC task.

Description of task being self-directed, including who, what and when

àIf additional hours are authorized for cognitive support due to the individual’s impaired judgment and/or unmet need for unscheduled tasks (which relates only to assistance needed with the following ADL’s: Ambulation, toileting, transfer, positioning and unscheduled medication assistance), document:

· the assistance required for these ADL tasks within the specific ADL in the Service Plan and/or

· the reason for these additional hours being authorized for protective supervision under impaired judgment in the Service Plan. (HCFA, LTCM Ch 4, WAC 388-15-205, RCW 74.39A-095)

àDocument the use of assistive devices and/or durable medical equipment within the appropriate section of the service plan (LTCM Ch 4, WAC 388-15-205), e.g.

· The formal caregiver will cue John to use his walker when ambulating;

· The formal caregiver will put John’s hearing aide in his left ear to ensure that he can hear when someone is talking to him.

àAnything authorized on SSPS payment must be listed on the service plan (HCFA) e.g.

· The Personal Emergency Response (PERS) unit

· Home Delivered Meals

· Adult Day Care (level 1)

· Transportation

· Home Health Aide

· Skilled Nursing

· Client Training

· Environmental Modification

àSpecial diet or supplement needs (LTCM Ch 4, WAC 388-15-205)

àIdentify psych/social/cognitive and behavioral issues when they present a significant issue for care planning:

· What the caregiver(s) are to do to address these issues or

· If referrals are made to address these issues, document to whom the referral was made. (LTCM Ch4, WAC 388-15-205)

àCommunication/sensory impairment needs if applicable, that could impact the ability of the caregivers to provide care and should be identified on the service plan in the communication skills/sensory topic area (LTCM Ch 4, WAC 388-15-205) e.g.

· Mr. Smith uses a communication board to communicate his needs and wants.

· Sally is only able to answer yes or no questions.

àCase Manager/Social Worker name and contact information with statement as to how the CM/SW can be contacted about any concerns related to client well being or adequacy of the care being provided (WAC 388-15-205, RCW 74.39A-095)

· Create a Common Service Plan Topic identifying at least the name of the AAA/ HCS office and their telephone #.

· If you know the name of the CM include this.

· Create a Common Service Plan Topic for each AAA/HCS office you work with.

àEmergency contact information

àSubstitute decision maker, if applicable

àLanguage /interpreter information, if applicable

àAn Emergency Plan, this should include:

· the evacuation plan that describes the assistance needed, if applicable (examples might be the paid provider will assist in evacuation, the client will call a neighbor, PERS unit will be used by the client or that the client understands there is a risk as 24-hour coverage is not available);

· back-up plan of care if lack of immediate care would pose a serious threat to the health and welfare of the client (i.e. usual care giver unavailable, natural disaster, inclement weather, etc. (HCFA)

àNecessary Supplemental Accommodation Plan , if applicable (LTCM Ch 4, WAC 388-472-005-0010)

This only needs to be addressed in the Service Plan if the client has a special need (mental, neurological, physical or sensory impairment) that prevent them from getting program benefits in the same way that an unimpaired person would get them. Examples of this might be that the client relies on another person to follow-up on financial eligibility items, needs printed materials in large print, is unable to communicate on the phone or has significant cognitive impairments. When a client does have special needs in this area this is to be documented in the service plan and communicated to the HCS financial worker.

àDocumentation within the Service Plan of other options offered and discussed with the client.

· This is especially important if the plan the client is willing to accept will not meet all their identified needs and the client has been made aware of the risks associated with the choice (s) they are making and they want to remain in their home (for example) with out the 24 hour care that they need, instead of moving to an Adult Family home, Boarding home or Nursing facility setting.

*The client or the client’s representative must consent to the services outlined in the service plan prior to authorization or reauthorization of services. Every effort will be made to obtain the client or client representative’s signature on the service plan (See MB 01-30).

àUniversal Precautions statement (inclusion is optional):

· Create a common Service Plan Topic to be included in every service plan:

Universal Precautions	Services: Who, What , Where	Outcomes/ Client Preferences
When caregiver is exposed to body fluids such as urine, vomit or blood, there is a possibility of infection being passed from one person to another.	The formal and informal caregiver will use latex/plastic gloves when in contact with any secretions to prevent spread of infection. Thorough hand washing with soap will be done before and after gloving. Gloves will be removed and discarded at the end of each task. If the primary care provider orders these gloves they can be paid for through the medical coupon	Safe practice will assure infectious conditions are contained to their point of origin and prevented from spreading by maintaining a clean environment.