Form DHS-3244-ENG "Pca Assessment and Service Plan" - Minnesota

What Is Form DHS-3244-ENG?

This is a legal form that was released by the Minnesota Department of Human Services - a government authority operating within Minnesota. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on February 1, 2014;
  • The latest edition provided by the Minnesota Department of Human Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form DHS-3244-ENG by clicking the link below or browse more documents and templates provided by the Minnesota Department of Human Services.

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Download Form DHS-3244-ENG "Pca Assessment and Service Plan" - Minnesota

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DHS-3244-ENG
2-14
Personal Care Assistance (PCA)
Assessment and Service Plan
651-431-4300 or 866-267-7655
Attention. If you need free help interpreting this document, call the above number.
.‫مالحظة: إذا أردت مساعدة مجانية لترجمة هذه الوثيقة، اتصل على الرقم أعاله‬
kM N t’ s M K al’ . ebI G ~ k ¨tU v karCM n Y y k~ ¬ g karbkE¨bäksarenHeday²tKi t «f sU m ehATU r s& B Í t amelxxagelI .
Pažnja. Ako vam treba besplatna pomoć za tumačenje ovog dokumenta, nazovite gore naveden broj.
Thov ua twb zoo nyeem. Yog hais tias koj xav tau kev pab txhais lus rau tsab ntaub ntawv no pub dawb,
ces hu rau tus najnpawb xov tooj saum toj no.
ໂປຣດຊາບ. ຖ ້ າ ຫາກ ທ ່ າ ນຕ ້ ອ ງການການຊ ່ ວ ຍເຫຼ ື ອ ໃນການແປເອກະສານນ ີ ້ ຟ ຣ ີ , ຈ ົ ່ ງ ໂທຣໄປທ ີ ່ ໝາຍເລກຂ ້ າ ງເທ ີ ງ ນ ີ ້ .
Hubachiisa. Dokumentiin kun bilisa akka siif hiikamu gargaarsa hoo feete, lakkoobsa gubbatti kenname bibili.
Внимание: если вам нужна бесплатная помощь в устном переводе данного документа, позвоните по
указанному выше телефону.
Digniin. Haddii aad u baahantahay caawimaad lacag-la’aan ah ee tarjumaadda qoraalkan, lambarka kore wac.
Atención. Si desea recibir asistencia gratuita para interpretar este documento, llame al número indicado arriba.
Chú ý. Nếu quý vị cần được giúp đỡ dịch tài liệu này miễn phí, xin gọi số bên trên.
ADA1 (12-12)
This information is available in accessible formats for individuals with disabilities by calling 651-431-4300
toll-free 866-267-7655, or by using your preferred relay service. For other information on disability rights
and protections, contact the agency’s ADA coordinator.
DHS-3244-ENG
2-14
Personal Care Assistance (PCA)
Assessment and Service Plan
651-431-4300 or 866-267-7655
Attention. If you need free help interpreting this document, call the above number.
.‫مالحظة: إذا أردت مساعدة مجانية لترجمة هذه الوثيقة، اتصل على الرقم أعاله‬
kM N t’ s M K al’ . ebI G ~ k ¨tU v karCM n Y y k~ ¬ g karbkE¨bäksarenHeday²tKi t «f sU m ehATU r s& B Í t amelxxagelI .
Pažnja. Ako vam treba besplatna pomoć za tumačenje ovog dokumenta, nazovite gore naveden broj.
Thov ua twb zoo nyeem. Yog hais tias koj xav tau kev pab txhais lus rau tsab ntaub ntawv no pub dawb,
ces hu rau tus najnpawb xov tooj saum toj no.
ໂປຣດຊາບ. ຖ ້ າ ຫາກ ທ ່ າ ນຕ ້ ອ ງການການຊ ່ ວ ຍເຫຼ ື ອ ໃນການແປເອກະສານນ ີ ້ ຟ ຣ ີ , ຈ ົ ່ ງ ໂທຣໄປທ ີ ່ ໝາຍເລກຂ ້ າ ງເທ ີ ງ ນ ີ ້ .
Hubachiisa. Dokumentiin kun bilisa akka siif hiikamu gargaarsa hoo feete, lakkoobsa gubbatti kenname bibili.
Внимание: если вам нужна бесплатная помощь в устном переводе данного документа, позвоните по
указанному выше телефону.
Digniin. Haddii aad u baahantahay caawimaad lacag-la’aan ah ee tarjumaadda qoraalkan, lambarka kore wac.
Atención. Si desea recibir asistencia gratuita para interpretar este documento, llame al número indicado arriba.
Chú ý. Nếu quý vị cần được giúp đỡ dịch tài liệu này miễn phí, xin gọi số bên trên.
ADA1 (12-12)
This information is available in accessible formats for individuals with disabilities by calling 651-431-4300
toll-free 866-267-7655, or by using your preferred relay service. For other information on disability rights
and protections, contact the agency’s ADA coordinator.
Clear Form
PCA Assessment and Service Plan
ASSESSMENT DATE
Recipient Information Page
MMIS ENTRY DATE
Instructions
ASSESSMENT MAILING DATE
30-DAY NOTICE SPAN
RECIPIENT NAME
PMI #
This is your copy of the PCA Assessment and Service Plan. You will find the details of your assessment including
information about Complex Health Related Needs, Behavior Descriptions and Dependencies in Activities of Daily
Living (ADLs).
The assessor completed and reviewed the assessment findings with you. The amount of daily time for your PCA
services is determined according to Minnesota Statute 256B.0652, subdivision 6. A summary of your PCA
assessment results is on this page and on page 11 of this form. Please review all of the pages of this form to learn
more details about the assessment.
Home Care Rating
Total time/day
Consumer Support Grant Budget
UNITS
MINUTES
HOURS
$
/month
0.00
0
0
0.00
Overall assessment results since last
What is different from your last
assessment (Check all that apply)
assessment (Check all that apply)
Service Update
Assessment
Reassessment
You do not meet access criteria
Same
Initial
Same
You have a different Home Care Rating
Approve
Increase
You have less dependencies
Deny
Decrease
You meet criteria for additional time
Termination
You do not meet criteria for additional time
If you are enrolled with a managed care plan, you will receive a letter in the mail from your managed care plan. Please
contact your managed care plan if you have questions about that letter. If you are not enrolled in a managed care plan
you will receive a letter in the mail from the Minnesota Department of Human Services. The letter from DHS is
named MA Home Care Service Agreement. Here is an example of how to read the information on that letter.
Service Agreement #
Recipient ID
Recipient Name
Effective Date
Through Date
(Sample) 00000000000
12345678
Doe, John
02/1/10
01/31/11
Unique authorization
Your Medical Assistance
Your name
Begin date of service
End date of this service
Number
identity number
agreement
agreement
Line NBR
Status
Procedure Code
Mod 1-4
Procedure Description
01
Approved
T1019
Personal Care Services, 15 min
Quantity: 1,456 units
State Date: 2/1/10 End Date: 7/31/10
Line number on
Service is approved or denied.
Providers use the Procedure
Name of Home Care
End Date of the
service agreement.
Quantity is the total number of
Code to bill for PCA
Service.
service.
units approved.
services.
Start Date of the
To calculate the PCA hours per
Number of service units
service.
day:
available for the time period.
1. For each Line NBR, divide
(÷) the Quantity units by the
number of days between the
Start Date and End Date = the
number of units/day.
2. Divide (÷) number of units/
day by 4 = number of hours/day.
#000 Reason Code is a 3-digit number that gives a reason of action on a line number. There may be more than one reason code on a line number.
1
*DHS-3244-ENG*
DHS-3244-ENG
2-14
PCA Assessment and Service Plan
Instructions
DATE OF ASSESSMENT/SERVICE PLAN
Assessment/Service Plan
INITIAL
REASSESSMENT
REFERRAL SOURCE
PHONE NUMBER
DATE OF REFERRAL
Recipient (R) Information
NAME
GENDER
DATE OF BIRTH
MALE
FEMALE
ADDRESS
PMI NUMBER
CITY
STATE
COUNTY
ZIP
PHONE NUMBER
ELIGIBILITY VERIFICATION
PROGRAM
DATE: _____/_____/_________
EH
IM
KK
LL
MA
NM
RM
YOU CAN VERIFY RECIPIENT ELIGIBILITY ONLINE VIA MN–ITS (HTTP://MN-ITS.DHS.STATE.MN.US) FOR UP TO 50
BB01
RECIPIENTS AT ONE TIME.
PREPAID HEALTH PLAN
Y
N MEDICARE
Y
N
THIRD PARTY LIABILITY (INSURANCE)
Y
N
WAIVER/AC
Y
N
Physician Information
PHYSICIAN NAME
CLINIC NAME
ADDRESS
PHYSICIAN PHONE NUMBER
CITY
STATE
ZIP
PCA Provider(s) Information
AGENCY NAME
NPI/UMPI
AGENCY NAME
NPI/UMPI
TAXONOMY CODE
TAXONOMY CODE
PCPO
PCA CHOICE AGENCY
OTHER
PCPO
OTHER
EXPLAIN:
ADDRESS
ADDRESS
CITY
STATE
ZIP
CITY
STATE
ZIP
PHONE NUMBER
FAX NUMBER
PHONE NUMBER
FAX NUMBER
Language
LANGUAGE SPOKEN
LANGUAGE INTERPRETER NEEDED
Y
N
SIGN LANGUAGE INTERPRETER NEEDED
Y
N
Direct Own Care/Responsible Party (RP)
PERSON ABLE TO DIRECT OWN CARE
RESPONSIBLE PARTY NAME
PHONE NUMBER
Y
N
UNKNOWN
IF “NO” A RESPONSIBLE PARTY MUST BE PRESENT AT THE ASSESSMENT.
LIVES WITH RECIPIENT
Y
N
RP ADDRESS
CITY
STATE
ZIP
Recipient Specific Information (Must be completed)
Diagnosis: list primary diagnosis first
Comments
ICD Code
Date of onset if known
OTHER COMMENTS ABOUT THIS REFERRAL
2
PCA Assessment
ASSESSMENT DATE
RECIPIENT NAME
PMI #
and Service Plan
1.
Directing Own Care Determination — People must be able to direct their own care or have a
Responsible Party that provides the support needed to direct the PCA care.
Y
N
Can this person identify their own needs?
Y
N
Can this person direct and evaluate caregiver/PCA task accomplishments?
Y
N
Can this person provide and/or arrange for their health and safety?
Y
N
Responsible Party is required and present for assessment.
Y
N
Is this a new responsible party since the last assessment?
2.
Health Description – Describe the person’s overall health condition and ability to function in the
community including information about their living environment, sensory deficits, hospitalizations and
informal support available. Indicate any changes in health status, new diagnosis, date of onset or
exacerbation, and severity. Ask for demonstration and document thorough description of observation.
3
PCA Assessment
ASSESSMENT DATE
RECIPIENT NAME
PMI #
and Service Plan
3.
Medications — List all medications including nebulizer medications, oxygen, OTC and PRN medications
with the route, dosage and frequency. Add additional pages if more space is needed.
Medication
Route
Dosage
Frequency
Y
N
Needs assistance or help of another
Y
N
Uses pill caddy
Y
N
Needs help obtaining prescriptions
4.
PCA Recommendations to DHS
NOTE: If restricted, a recipient is limited to monthly use of PCA hours and must select a PCPO provider.
RESTRICTED MA
YES
NO
TOTAL # OF DAILY UNITS
TOTAL DAILY HOURS
FREQUENCY CODE
PERSON MEETS ACCESS CRITERIA
YES
NO:
DAILY (1)
FLEXIBLE (5)
TOTAL # OF ANNUAL UNITS
TOTAL ANNUAL HOURS
SERVICE AGREEMENT START DATE
SERVICE AGREEMENT END DATE
START DATE
END DATE
PERCENT
# OF UNITS
1ST DATE SPAN
T1019
START DATE
END DATE
PERCENT
# OF UNITS
2ND DATE SPAN
T1019
AVERAGE MONTHLY UNITS
TOTAL ANNUAL UNITS
SUPERVISION
T1019 UA
REASON CODES/COMMENTS
4
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