Appendix 210-C Service Plan Documents | HCBS-5300-MANUAL

Georgia Division of Aging Services
Home and Community-Based Services Manual

Chapter:

200

Effective Date:

10/26/2021

Section Title:

Service Plan Documents

Reviewed or Updated in:

MT 2021-01

Section Number:

Appendix 210-C

Previous Update:

MT 2021-01

Case Managers will develop Service Plans using information gathered through the assessment of clients and their caregivers, when present and involved. Based on information gathered from the DON-R and other assessment instruments, staff develops a plan that identifies and documents immediate, short term, and ongoing needs, as well as where and how the care needs are to be met. The plan sets goals and time frames for clients and caregivers to accomplish goals that are appropriate to each individual and to which each party agrees. Ideally funding and/or community resources are available to implement the plan.

Measurements of effective Service Planning are:

Staff demonstrates ability to interview, do research, and otherwise gather information that provides a factual base for developing the plan
Staff demonstrates knowledge and understanding of the client’s condition, including any diagnoses of illness or chronic disease; the probable course and outcome or likelihood of recovery; care needs; remaining capacities of the client and/or the support system; the client’s values; and desired outcomes and goals of the Service Plan
Staff demonstrates the ability to critically analyze and evaluate situations to identify barriers to goal accomplishment

The Individual Service Plan captures information about problems and care needs; identifies responsibilities for activities generated by the plan; documents the establishment and degree of accomplishment of goals and outcomes; and reflects time frames for services and activities. Staff also will be able to track progress in attaining and maintaining goals to measure accomplishment.

Heading	Description
Client Name	Insert Client Name
Date Prepared	Insert date the Service Plan is Prepared
Service Plan End Date	Insert the latest completion date for any Action Step chosen for the Service Plan.
Service Plan Type:	Initial or Review
Next Service Plan Review:	This is the same as the Service Plan End Date
Risk Level:	This is derived from the Risk Assessment Tool. Choose Level I, Level II, Level III
Date Service Plan Provided to Client:	Insert the date that the Service Plan was provided to client, either in person, by mail, or by electronic transmission.
Desired Outcome(s) for Service Plan as Stated by Client	List up to three desired outcomes as stated by the client. For example: “I want more time for myself so I can care for my husband” or “I want to get healthier so I can play with my grandchild.”
Case Management Outcomes	Check any or all the program outcomes that relate to the outcome(s) stated by the client.
Problem or Need for Assistance	Staff will document problems, their origins/causes, indicators of the problems, and risk factors that contribute to the problems. The problem or need for assistance should document an issue that prevents or impairs the client achieving the desired outcome(s).
Goal	Staff will help the client to develop goals (short-term or long-term) that address the problem of need for assistance, and which will enable the client to achieve the desired outcome(s). A goal should be: S – specific M – measurable A – attainable R – realistic T – timely or time-specific (by when)
Action Step(s)	Staff will help the client to develop a series of incremental steps that will lead toward the goal. Action Steps should emphasize what the individual is going to do rather than what s/he is going to stop doing.
Who is Responsible?	Staff will record the name(s) of the participants in the plan who will take responsibility for each activity. Staff should develop plans based on the client’s remaining strengths and abilities, allowing clients to assume a greater portion of responsibility than a provider or the case manager,
Schedule	Staff will enter the date that each service or activity begins, how often it will occur, the duration of the service if known, how long it is expected to last, and, if appropriate, the payor source.
Status of Goal	During each Service Plan review, staff will evaluate and document progress to date using any established programmatic time frames for case review and reassessment. Using the criteria on the Service Plan, staff will note the client’s actual behavior relative to each goal or outcome. Monitoring staff may evaluate the percentages in each category as indicators of Service Planning capacity of individual staff and overall effectiveness of the case management organization’s interventions. This is not the sole criterion, however.
Notes	Staff will provide any notes relevant to the progress or lack of progress of that specific goal and/or action step(s).
Factors Facilitating or Hampering Progress to Meeting Action Steps/Outcomes	Staff will document any factors that facilitate or hamper progress toward the client meeting the action steps or goals. These may relate to the client’s support network, availability of resources, client’s skills and abilities, client’s motivation or resistance, or other factors. Staff should address these factors to determine the extent to which the overall goals and outcomes can be obtained and what, if any, additional resources may be needed.
Narrative Notes and Recommendations	Staff and supervisors will use this section to enter observations and recommendations for plan adjustments.

Heading

Description

Client Name

Insert Client Name

Date Prepared

Insert date the Service Plan is Prepared

Service Plan End Date

Insert the latest completion date for any Action Step chosen for the Service Plan.

Service Plan Type:

Initial or Review

Next Service Plan Review:

This is the same as the Service Plan End Date

Risk Level:

This is derived from the Risk Assessment Tool. Choose Level I, Level II, Level III

Date Service Plan Provided to Client:

Insert the date that the Service Plan was provided to client, either in person, by mail, or by electronic transmission.

Desired Outcome(s) for Service Plan as Stated by Client

List up to three desired outcomes as stated by the client. For example:

“I want more time for myself so I can care for my husband” or “I want to get healthier so I can play with my grandchild.”

Case Management Outcomes

Check any or all the program outcomes that relate to the outcome(s) stated by the client.

Problem or Need for Assistance

Staff will document problems, their origins/causes, indicators of the problems, and risk factors that contribute to the problems. The problem or need for assistance should document an issue that prevents or impairs the client achieving the desired outcome(s).

Goal

Staff will help the client to develop goals (short-term or long-term) that address the problem of need for assistance, and which will enable the client to achieve the desired outcome(s). A goal should be:

S – specific
M – measurable
A – attainable
R – realistic
T – timely or time-specific (by when)

Action Step(s)

Staff will help the client to develop a series of incremental steps that will lead toward the goal. Action Steps should emphasize what the individual is going to do rather than what s/he is going to stop doing.

Who is Responsible?

Staff will record the name(s) of the participants in the plan who will take responsibility for each activity. Staff should develop plans based on the client’s remaining strengths and abilities, allowing clients to assume a greater portion of responsibility than a provider or the case manager,

Schedule

Staff will enter the date that each service or activity begins, how often it will occur, the duration of the service if known, how long it is expected to last, and, if appropriate, the payor source.

Status of Goal

During each Service Plan review, staff will evaluate and document progress to date using any established programmatic time frames for case review and reassessment. Using the criteria on the Service Plan, staff will note the client’s actual behavior relative to each goal or outcome. Monitoring staff may evaluate the percentages in each category as indicators of Service Planning capacity of individual staff and overall effectiveness of the case management organization’s interventions. This is not the sole criterion, however.

Notes

Staff will provide any notes relevant to the progress or lack of progress of that specific goal and/or action step(s).

Factors Facilitating or Hampering Progress to Meeting Action Steps/Outcomes

Staff will document any factors that facilitate or hamper progress toward the client meeting the action steps or goals. These may relate to the client’s support network, availability of resources, client’s skills and abilities, client’s motivation or resistance, or other factors. Staff should address these factors to determine the extent to which the overall goals and outcomes can be obtained and what, if any, additional resources may be needed.

Narrative Notes and Recommendations

Staff and supervisors will use this section to enter observations and recommendations for plan adjustments.

Sample Care Plan

210 c sample care plan