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) 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. The OMH approved forms must be used for the initial service plans and all service plan reviews.   Additional elements may be added with prior approval from OMH.   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 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 LGU.   A copy is then forwarded by the ICC Agency to OMH Operations Support Unit (OSU). This must be completed and submitted to OMH with other required documents within 30 days for issuance of an enrollment date which allows for maximum billing (see Chapter 500 for enrollment details).  When all necessary documentation is received, the OSU sends notification that a child is officially enrolled.

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 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 LGU.

Child and Adolescent Needs and Strengths (CANS)

The Child and Adolescent Needs and Strengths (CANS) 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 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 at the time of the 30 Day Service Plan Review and every 180 days thereafter (every other 90-day service plan review).  The CANS is additionally completed upon disenrollment and any time during enrollment when a significant change in identified risk factors or family strengths is observed.   The CANS 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) must be clearly integrated into the service plan narrative.   Also, risk factors rated 2 and 3 must be addressed in the goals and objectives.  CANS are filed in the child’s record with the associated service plan.

Goals, Objectives and Methods

Goals, objectives and methods are initially established in the Initial Service Plans based on the family and child’s identified needs and priorities and the CANS categories rated 2 and 3. These are closed, modified and new goals added over time at service plan review meetings and as needed.  Goals, objectives and methods are fluid and change as the strengths, needs and risk factors of the child and family change.

Goals are clear, measurable targets that the child and family want to achieve. The more concrete and specific the goal, the more likely it is to be actualized. For example, "(Child) will behave appropriately" does not sufficiently define the desired or undesired behaviors and is much too broad.  Exploration with the family about which specific behaviors are most problematic in which settings can assist in formulating a more viable goal. The above example would become more meaningful and measurable if written," "(Child) will demonstrate increased self-control (positive, desired behavior) at home (situation) when she does not get her own way (precipitating factor)". Goals must indicate date established and, as applicable, date attained, revised, continued or discontinued.

Objectives are developed for each goal to define the concrete steps that will be taken to achieve the goal. An objective must specifically state how success in meeting that objective will be measured and include a target date. For example, one objective for the above goal might be, "(Child) will not throw food at her parents at any time". The status -either established, continued, revised, discontinued or attained – for each objective must be noted.

Methods specifically describe what will be done to achieve the objective, which service(s) will be used (using the approved service codes printed on the Service Plans), and who will do what. The duration and frequency of the service must also be indicated. If the use of flex dollars is anticipated, this must be included in the method. Using the above example, a method could be, "IHH (responsible service) will meet with child and parents for one hour (duration) two times a week at meal time for two weeks (frequency) to model and assist parents in applying time out strategies when child throws food (purpose).    ICC will evaluate parents ability to consistently use this method within one month." 

Projected use of flex dollars must be specifically noted, when indicated, stating for what they will be used.  These are revised as needed.

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 standard HCBS Initial and Service Plan Review forms must be used by the ICC Agencies. 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 must be present. 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

Again, the enrollment date, issued by OSU, is the date used in calculating when the 30 Day Service Plan and Service Plan Reviews are due.  The Initial Service Plan and all Service Plan Reviews must occur and documentation must be completed with all required signatureswithin prescribed timeframes (see schedule that follows). However, 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). On rare occasions, untoward events can prevent timely completion of service plans. If, completion, including signatures, of any service plan is delayed, an explanation must be noted on the plan, as well as in a progress note, and the plan must be completed at the earliest possible time.

Service Plan Review and CANS Schedule with Sample Dates

(CANS completed prior to enrollment at time of referral)

Case Record Table of Contents