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Office of Mental Health

Home and Community Based Services Waiver
Guidance Document
Division of Children and Families

400.1 Service Plans


HCBS Waiver Service Plans are designed to document on-going assessment of the child’s progress and needs as well as to guide service provision. They are completed by the Individual Care Coordinator (ICC) with input from the child, the child’s family, the treatment provider, the child’s Waiver service workers and other significant collateral sources. Service Plans are family driven, individualized, culturally relevant, developmentally framed and correlated with ratings from the Child and Adolescent Needs and Strengths (CANS-NY) assessment tool. Waiver service plans address many areas in the child and family’s life including safety, resiliency, developmental tasks and the support of clinical treatment goals. Service plans are to be written in a manner that provides the reader with a clear picture of the child and family’s circumstances, dynamics and evolution over time. They must clearly describe the child’s progress in achieving each goal and each objective. Service planning meetings are convened by the ICC at prescribed intervals defined later in this section.

On-going communication between the Waiver Provider and the Treatment Provider inform both Waiver service planning and treatment planning. It is expected that Waiver service planning occur in collaboration with treatment providers. Treatment Providers and ICC Agencies should be familiar with, and have input into, each other’s plans. Communication may occur through a variety of venues. However, the ICC is encouraged to attend Treatment Reviews and case conferences for Waiver children and the Waiver child’s treatment provider is encouraged to participate in Waiver Service planning meetings.

Service planning occurs at predetermined intervals throughout the child’s enrollment. The HCBS Waiver requires an Initial Service Plan and Budget shortly after referral to the Waiver agency. A service plan review is then due 30 days from the enrollment date issued by OMH’s Operations Support Unit. Subsequent Service Plan Reviews are due every 90 days thereafter. Please see the OMH Children’s HCBS Waiver Form Policy in Section 100.2. Original initial service plans and service plan reviews must be kept in the child’s record.

The Initial Service Plan (ISP) and Budget Form 909 MED are created upon a child’s referral to Waiver generally soon after the signing of the Application/Freedom of Choice by the child and family. The ISP includes a comprehensive description of the child’s life domains, child and family strengths, priorities as defined by the child and family, a discharge profile and initial measurable goals, objectives and methods. Risk factors and strengths identified through the CANS-NY are addressed in the plan. A Budget Form is completed that projects costs associated with the child’s Medicaid reimbursable services. This is used to indicate projected estimated yearly service delivery costs for the individual child. (See Chapter 500 for information on how to complete the Budget) The ISP and Budget must be approved and signed by the Local Government Unit (LGU). The dates on which the ISP, Budget and all other required documents were signed must be submitted to OMH’s Operations Support Unit (OSU) by use of the CAIRS system. To ensure an enrollment date that allows for maximum billing (see Chapter 500 for enrollment details). OMH (OSU) must receive the respective Transmittal 2 in CAIRS within 30 days of the date that the Waiver application is signed.

As part of the planning process, the ICC assists the child and family in identifying which of the remaining Waiver services and providers will be useful in achieving goals. The child and family then complete the Choice of Provider Verification. This form is developed by each ICC Agency and lists their Waiver service providers. This is filed in the child’s record and updated as needed.

Service Plan Reviews (30 Day and 90 Days ) provide the opportunity for review and discussion of the child’s progress and the efficacy of the plan’s methods. A narrative summarizing the progress, as well as any significant events and additional information, is developed. Progress in terms of each goal and objective is individually described. Reasons for changing, adding or ending goals or objectives are explained. Modifications, with corresponding status/target dates, may be made to the goals/objectives. Changes in the CANS-NY ratings are integrated into the plan including ratings of 2 and 3. Flex fund expenditures are tracked and adjustments are made to the methods as indicated.

The Budget is reviewed and modified as needed at each Service Plan Review meeting. Child costs are monitored to assure that they stay within approved ceilings. Waiver services are reviewed to assure that they are being utilized as noted in the Service Plans and the Budget. Changes to projections are made accordingly.

If changes to the service plan result in a change in the child’s eligibility status, the ICC agency must immediately inform the IGU.

Child and Adolescent Needs and Strengths (CANS-NY)

The Child and Adolescent Needs and Strengths (CANS - NY) is an instrument designed by Dr. John Lyons to assist in assessing children for risks in a number of domains as well as in indicating family strengths. The CANS-NY is completed initially when the child is referred for services, usually by the SPOA (if SPOA does not complete, then the ICC does so).  The ICC completes a new CANS-NY within 30 days of enrollment  and every 90 days.   CANS NY informs and prescribes the goals within the Individualized Service Plan Reviews, therefore, completion of CANS NY shortly before the subsequent Service Plan Review is acceptable.

The CANS-NY is additionally completed upon disenrollment (unless a SPR was completed with-in 30 days of the discharge) and any time during enrollment when a significant change in identified risk factors or family strengths is observed. The CANS-NY is useful in assessing risk factors as well as in tracking progress over time. Information from the Child and Adolescent Needs and Strengths assessment instrument (CANS-NY) must be clearly integrated into the service plan narrative. Dimensions with ratings of 2 or 3 in the Risk Factors Domain must be addressed immediately with a corresponding goal and service in the child’s plan. In the remaining domains, any dimension that puts a child at risk that is rated 2 or 3 must also be addressed with a goal and service immediately. Other dimensions with rating of 2 or 3 may or may not be immediately addressed. If these are deferred for a later time, the reasons for deferral as well as how each will be addressed in the future must be discussed in the plan’s narrative section. This is true also for identified needs that another agency/system is or will be addressing. CANS-NY – Coding Definitions

Goals, Objectives and Methods

Writing functional, meaningful and person-centered goals and objectives are essential to not only tracking the child and family’s progress but also in understanding the natural opportunities within everyday routines and activities of the child and family’s life which highlight strengths and promotes competency.

The assessment of the child’s skills and priorities must be conducted in the real life context of family, culture and community which will lead to functional and relevant goals as opposed to isolated tasks irrelevant to daily life.

The goals and objectives are established after gaining contextually relevant information about the child’s strengths and needs. Part of this process includes the CANS-NY assessment which assists in providing perspective to culturally sensitive and individually focused information.  All ratings of 2 or 3 must be addressed in the child’s Service Plan unless deferred, in which case an explanation for the deferment and a resulting future plan to address the concern(s) must be outlined in the Service Plan narrative.

The functionality and fluidity of the goals, objectives and methods determines the availability of progress to the child and family. Goals, objectives and methods are established during the Initial Service Plan as a result of the CANS-NY assessment, observation, family and child input and any additional information gleaned from ancillary resources. These goals, objectives and methods are fluid and change as the strengths, needs and risk factors of the child and family change. Projected use of flex dollars must be specifically noted, when indicated, stating for what they will be used.

For additional assistance please review: Goals, Objectives and Methods.

Discharge Readiness: Preliminary plans for disenrollment begin during the initial service planning phase. The ICC discusses with the family and child what changes need to occur as well as which services may be needed to support the child in the community after disenrollment. These discussions must continue throughout the child’s enrollment and be reflected in the service plans and progress notes.

Signing the Service Plans

The child’s ICC, the ICC Supervisor and the LGU as well as the family and child, must approve and sign the Initial Service Plan and all parties, except the LGU, must sign each Service Plan Review thereafter. All required signatures and dates must be present. The dated signatures of the ICC and/or ICC supervisor should not be before the dated signatures of the child and family.If a child refuses or is unable to sign, this must be indicated with the reason why on the signature line.

Timeframes for Service Plan Completion

The enrollment date, issued by OSU, is the date used in calculating when the 30 Day Service Plan and subsequent Service Plan Reviews are due. The Initial Service Plan and all Service Plan Reviews must occur and documentation must be completed with all required signatures within prescribed timeframes (see sample schedule that follows). A revised plan can be made, with revision date and appropriate signatures, at any point in time to accurately incorporate the child’s needs and strengths (accompanied by a Progress Note explaining the change) but the original dates will still adhere. At no time should a service plan be completed, including signatures, more than five business days prior to its due date. All completed service plans, including signatures, after the due date will be considered late. ICC Supervisors will be allowed an extra three business days after the due date if needed, to review and sign the service plan.

On rare occasions, untoward events can prevent timely completion of service plans. Supervisory consideration and approval may be given if a service plan will be late, for extenuating circumstances, but it should not extend more than three business days. If, completion, including signatures, of any service plan is early or delayed, an explanation must be noted on the plan, as well as in a progress note, and the plan must be completed within the extended timeframes prescribed above.

Service Plan Review and CANS-NY Schedule with Sample Dates

(CANS-NY completed prior to enrollment at time of referral and shortly before each Service Plan Review)

Enrollment 4/18/2014
30 Day Service Plan Review (SPR) 5/18/2014
90 Day SPR 8/16/2014
90 Day SPR 11/14/2014
90 Day SPR 5/13/2015
90 Day SPR 8/11/2015

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