AGENCY OR CONSUMER DIRECTION PROVIDER PLAN OF CaRE a a a ‘ic Current DMAS-99° LD Agency-Directed Services [] Consumer-Directed Services Hate: Participant: Medicaid ID#: Provider: Provider ID¥: Cat me Fe ADL's Bathin a “Toilet ‘Transfer ‘Assist Eating ‘Assist Ambulate Te Position ‘Grooming ‘Total ADE Time: ‘Special Maintenance Vital Sis Supervise Meds “Range of Motion *Wound Care "Bowel Bladder Pro MD order required “Total Maint. Time: ‘Supervision Time, TADLS Meal tion ‘Clean Kitchen. ‘Make/Change Beds ‘Clean Areas Used by Participant | ‘Supplies (Deal Money Max Medical Appointments. Work/Schoolocial “Total JADLS Time: "TOTAL DAILY TIME: | ‘This Section Must Be Completed in its Entirety for Agency & Consumer-Directed Services [Composite ADL Score = (Te sum ofthe ADL ratings that describe this participant) BATHING SCORE ni Baths witout help o with MH only ° “Transfers wthut por with MH only ° Baths win HH or with HH & Mi 1 Teast: w/ HE or wl & ML 1 stated 2 Istransteed or does ot tance 2 DRESSING SCORE Barina Dress without lp o wit MH only ° Eats witout helo wih MH only ° Dreecs ith HH o with I & MH 1 swith HH or HIE & MH 1 screed or docs not dress 2 Is fed: spoontaberts 2 AMBULATION SCORE. CONTINENCY SCORE WallsWhecs witouthelpwMHonly 0 Continetinontneat< whly sel ear of intemal Wala Whelsw/ Hit or HE a MEE 1 ‘extra devies ° Fully dependent fr mobili 2 Incontnentwesky or > Noselfcare 2 Lever oF Care {CLA (Score 0 - 6) 3 B (Score 7-12) 1D C (core 9 + wounds, rube feedings, etc.) Loc) Maximum Hours of 25/Week Maximum Hours 30/Week | Maximum Hours 35/Week Page | of 2 - DMAS.97AJB - Revised 04/2019Participant Medicaid ID#: Provider: Provider ID#: Tail Fan of Gave Hours must be pre-authorized & chould not exceed the mani forthe specified LOC category. i} ‘Documentatioa must suppor the amount of hours provided tothe pertcipant. Reason Pian of Care Submitted: C) New Admission Of invous 0 | intours 0 transfer ‘Reason for change/addlitional instructions for the aide: [Required Backup Plan (Person’s name, relation and phone #) for Services: Plan of Care Effective Date: Total Weekly Hours: Participant / Primary Caregiver ‘Signature: Date: RN, LPN or SF Signamure Date: Instructions for the DMAS-97A/B Provider Noditcation to Participant ‘This Plan of Care has been revised based on your current nceds and available support. Ifyou agree with the changes, n0 action is reared on your part. Ifyou do not agree withthe changes, please contact the RN Supervisor who hes signed the plan of care to ‘isouss the reason that you disagree with the change. ‘ifthe provider agency s unwilling or unable to change the information, and you sill disagree, you have the right to an appeal! by | notifying, in writing, The Client Appeals Division, The Department of Medical Assistance Services, 600 East Broad Steet, Suit 1300, Richmond, Viggnia 23219. The request foran appeal mus be ied within hit (30) days ofthe time you recive this notification. If you flea request fran appeal befor he effective date ofthis action, (ener effetve date), services may continue ‘mchanged during the appeal process Category/Tasks Place a check mark foreach task and put the total time foreach category. foreach day. Writing the amount of time foreach task tothe nearest 15 ‘minutes isnot necessary, ut it greatly asists in the review of authorization requests. Level of Care Determination for Maximum Weekly Hours Enter seore foreach activity of daly living (ADL) based on the participant's curent functioning. Sum each ADL. rating & enter the composite score under the appropiate eategory: A, B, oF C. The smount of time allocated under TOTAL DAILY TIME to coraplet all tasks MUST NOT. ‘EXCEED the manimam weekly hours forthe specified LOC of A,B, or C. Service Authorization ($A) must be obtained prior to initiating a change outside the authorized LOC category. Provider Notification to Participant ‘Any time the RN Supervisor or Services Facilitator (SF) changes the plan of cars that results in a change i the total number of weekly hours, he Nor SF must complet the entice front section ofthis form. Ifthe change the agency is making doesnot require SA approval, the RN Supervisor ‘or SF is required to enter the effective date onthe Provider Agency Participant Notification Section which gives the participant their right 19 appeal. The participant should get a copy ofboth the front and back ofthe form. ‘SA Contractor Notification to Participant If the changes othe Plan of Care require SA approval, the enie front portion of this form and the DMAS.98 must be completed and forwarded to the SA contracor for approval. Hfsupervision is requested, atach the Request for Supervision form (DMAS-100). Once received by the SA ‘contractor, the SA analyst will review the cae plan and indicate whether the request is pended, approved, or denied. The participant wll receive by mail the decision letter rom the SA Contractor. Participant / Caregiver Signature “The petcipant’s signature is necessary onthe original plan of eare and decreases tothe hous of caret isnot needed ifthe hous inerease in a ‘new plan of care. The provider may substitute the signature with documentation inthe participant's record tat shows acceptance ofthe plan of Page 2 of 2 - DMAS.97A/B - Revised 04/2019