Form WPA-2 "Plan of Care" - New Jersey

What Is Form WPA-2?

This is a legal form that was released by the New Jersey Department of Human Services - a government authority operating within New Jersey. Check the official instructions before completing and submitting the form.

Form Details:

  • Released on November 1, 2017;
  • The latest edition provided by the New Jersey 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 printable version of Form WPA-2 by clicking the link below or browse more documents and templates provided by the New Jersey Department of Human Services.

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Download Form WPA-2 "Plan of Care" - New Jersey

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New Jersey Department of Human Services
PLAN OF CARE
Division of Aging Services
1. Participant Name (print)
2. Plan of Care Date
2A. Closed Date
3. ID No. (JACC, SAMS, or Other)
(mm/dd/yyyy)
(mm/dd/yyyy)
4. Case Manager Name (print)
5. Plan of Care Renewal/ Reassessment Due (mm/dd/yyyy)
6. Program:
JACC
Area Plan Contract
Other
7. Residential Setting
Group Home
Room Rental
Apt.
7A. Alone
With Others
7B. Date of Birth:
Boarding Home Class
A,
B or
C
Shelter
House
Sr. Apt.
(mm/dd/yyyy)
Monitoring
Services
Costs
Providers
Updates*
8
9
10
Updates *
11
12
13
14
15
16
17
18
19
20
21
22
23
Problem Statement*:
Unit
Service(s)
Date
Identify Assessed Needs,
Cost
Provider
Date
Needed
Risk Factors and Personal Goals
(
JACC Only)
* See Code List on page 2.
WPA-2
NOV 17
Page 1 of 2
New Jersey Department of Human Services
PLAN OF CARE
Division of Aging Services
1. Participant Name (print)
2. Plan of Care Date
2A. Closed Date
3. ID No. (JACC, SAMS, or Other)
(mm/dd/yyyy)
(mm/dd/yyyy)
4. Case Manager Name (print)
5. Plan of Care Renewal/ Reassessment Due (mm/dd/yyyy)
6. Program:
JACC
Area Plan Contract
Other
7. Residential Setting
Group Home
Room Rental
Apt.
7A. Alone
With Others
7B. Date of Birth:
Boarding Home Class
A,
B or
C
Shelter
House
Sr. Apt.
(mm/dd/yyyy)
Monitoring
Services
Costs
Providers
Updates*
8
9
10
Updates *
11
12
13
14
15
16
17
18
19
20
21
22
23
Problem Statement*:
Unit
Service(s)
Date
Identify Assessed Needs,
Cost
Provider
Date
Needed
Risk Factors and Personal Goals
(
JACC Only)
* See Code List on page 2.
WPA-2
NOV 17
Page 1 of 2
PLAN OF CARE (Continued)
1. Participant Name (print)
2. Plan of Care Date (mm/dd/yyyy)
3. ID No. (JACC, SAMS, or Other)
[Include all of the following which apply – (1) Incorporate Client Preferences or Concerns; (2) Expound on Unmet Needs; and (3) Describe Back-up Plans, explaining any situations considered to be at-risk
25. Special Instructions/Comments:
concerns for the safety and/or well-being of the participant and listing the interventions to respond to such safety concerns (including who is responsible with emergency contact information).]
N/A upon completion of initial POC
Comment
Date
Comment
Date
Back-up Plan:
Safety / Emergency / Community-Wide Disaster:
Yes No
Signatures:
I agree with this Plan of Care.
I had the freedom to choose the services in this Plan of Care.
Care Manager (CM):
Date:
I had the freedom to choose the providers of my services based on available providers.
I helped develop this Plan of Care.
CM Supervisor:
Date:
I am aware of my rights and responsibilities as a participant of this program (as contained in
the Participant Agreement).
Other:
Date:
I am aware that the services outlined in this Plan of Care are not guaranteed.
Other:
Date:
I have been advised of the potential risk factors outlined in this Plan of Care.
I understand and accept these potential risk factors.
Signature______________________________________
____/____/____
Participant** /
Representative**
Date
** Note: All participants are evaluated at least annually to confirm that they continue to meet both the financial criteria and clinical eligibility requirements of this program (as applicable).
* C o d e L i s t
Problem Statement:
Need Codes, Continued
Need Codes, Continued
Frequency: (Column # 14)
Provider Type: (Column #17)
Monitoring Frequency:
Unmet Need Codes
(Column #9)
2. Perform IADL (specify letter)
9. Risk Factors
D- Daily (specify # of days per week)
J-
JACC Agency
(Column #20)
(Column # 21)
Briefly describe the client’s
a. Meal Preparation
a. Personal Safety Risk
W- Weekly
M-
Medicare
D- Daily
1. Not available
individual circumstances which
b. Housework
b. Health Condition Risk
B- Bi-weekly
PEP- Participant-Employed Provider
W- Weekly
2. Not affordable
serve as the basis for each
c. Managing Finances
c. Behavioral Risk
M- Monthly
P-
Private Provider
B- Bi-weekly
3. Waiting List
assessed need.
d. Medication Management
d. Environmental Risk
Q- Quarterly
F-
Facility
M- Monthly
4. Frequency not adequate
e. Phone Use
e. Medication Risk
A- Annually
I-
Informal Support
Q- Quarterly
5. Refused
Need Codes: (Column #10)
f. Shopping
f. Other Risk
O- Other (specify)
A- Annually
6. Other (specify) - expound
Identify the Code by which each
g. Transportation
(specify)
R- Random
on reason if necessary in
assessed need is best
Payment Source: (Column #16)
Monitoring Method:
h. Accessing Resources
O- Other (specify)
Column #26
categorized.
Desired Outcome Code:
1. Medicaid
(Column #19)
i.
Laundry
U- Upon reported completion
Client Unable to:
(Column # 12)
2. Medicare
C- Participant Record / Chart
Updates
j.
Personal Hygiene
1. Perform ADL (specify letter)
1. Maintenance
3. Other Third Party Liability (TPL)
R- Receipts
(Columns # 22 and 23)
3. Personal Goal
a. Bathing
2. Independence
4. Local Community-Based
S- On-Site Review
Completed only as necessary if
4. Communication Needs
b. Dressing
3. Rehabilitation
Organization
D- Documentation (specify)
changes are made throughout
5. Social Isolation
c. Toilet Use
4. Prevention
5. County Funded Program
T- Time Sheets
the duration of the Plan of
6. Caregiver Relief
d. Transferring
5. Caregiver Relief
6. State Funded Program
P- Phone Contact With
Care.
7. Mental Health
6. Other (specify)
O- Other (specify)
e. Locomotion
7. Informal Support
8. Other (specify)
f. Bed Mobility
8. Private Pay
g. Eating
9. APC Funded
10. Other (specify)
WPA-2
NOV 17
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