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

This document contains official instructions for Form WPA-2, Plan of Care - a form released and collected by the New Jersey Department of Human Services. An up-to-date fillable Form WPA-2 is available for download through this link.

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

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New Jersey Department of Human Services
Division of Aging Services
INSTRUCTIONS FOR COMPLETING THE
PLAN OF CARE (WPA-2) FORM
Plan of Care Document Instructions: Top of Page 1
Print the participant‟s full (first and last) name.
1.
Participant Name
2.
Plan of Care Date
Enter the full date (Month, Day, Year) the Plan of Care is developed. This is the first
date the Plan contents are discussed with the participant. This is not necessarily the
same date that the participant signs the Plan of Care once it is completed.
2A.
Closed Date
Enter date this Plan of Care was closed.
Enter the participant‟s or JACC (SAMS or Other) identification number.
3.
Identification No.
Print the Care Manager‟s full (first and last) name.
4.
Care Manager Name
5.
Plan of Care Renewal Due
Enter the estimated date (Month and Year) that the Plan of Care renewal is due for
completion. Plans of Care are to be updated annually and revised as necessary
when warranted by changes in the program participant‟s needs. For example, the
annual Plan of Care is due one year (12 months) from the initial Plan of Care Date
(indicated in #2).
JACC Only: The Long Term Care Re-Evaluation (level of care assessment) form
(WPA-1), is to be completed prior to the annual Plan of Care renewal date. Separate
instructions cover this document.
6.
Program
Indicate the Program in which the participant is currently enrolled.
7.
Residential Setting
Indicate the type of location where the participant is currently residing.
7 A.
Occupancy
Select if the participant resides alone or with others, i.e., family, friends, roommate.
Plan of Care Document Instructions: Body of Page 1
8.
Date
Enter the full date (Month, Day, Year) that each of the assessed needs (Problem
Statements) is identified and written into the Plan of Care.
9.
Problem Statement
The Problem Statement is to illustrate the reason(s) for the assessed need. It should
briefly describe the participant‟s health condition, personal goals, risk factors, and/or
individual circumstances that serve as the basis for each assessed need and the way
in which these impact the participant‟s functioning.
For example, a Column #9 entry should NOT state „Locomotion‟ as the Problem
Statement. Rather, it would describe the condition of the participant and his or her
circumstances that have resulted in his or her limited mobility. Furthermore, the
participant‟s diagnosis alone is not a sufficient summary of a Problem Statement
justifying the assessed need. Rather, the impact of the diagnosis on the participant‟s
day-to-day functioning should be indicated.
10.
Need Code(s)
Enter the Need Code(s) by which each assessed need is best categorized. For
example, if the Problem Statement reads “Participant experienced a stroke and as a
result has a poor hand grip, minimal use of her right arm, and is easily fatigued,” the
Need Code may be „2d‟ if the participant, as a result of this condition, needs
assistance with ‘Medication Management.’ When „Option 8 – Other‟ is used, the
assessor shall specify the Need in the blank provided.
WPA-2 Instructions
NOV 17
Page 1 of 8 Pages.
New Jersey Department of Human Services
Division of Aging Services
INSTRUCTIONS FOR COMPLETING THE
PLAN OF CARE (WPA-2) FORM
Plan of Care Document Instructions: Top of Page 1
Print the participant‟s full (first and last) name.
1.
Participant Name
2.
Plan of Care Date
Enter the full date (Month, Day, Year) the Plan of Care is developed. This is the first
date the Plan contents are discussed with the participant. This is not necessarily the
same date that the participant signs the Plan of Care once it is completed.
2A.
Closed Date
Enter date this Plan of Care was closed.
Enter the participant‟s or JACC (SAMS or Other) identification number.
3.
Identification No.
Print the Care Manager‟s full (first and last) name.
4.
Care Manager Name
5.
Plan of Care Renewal Due
Enter the estimated date (Month and Year) that the Plan of Care renewal is due for
completion. Plans of Care are to be updated annually and revised as necessary
when warranted by changes in the program participant‟s needs. For example, the
annual Plan of Care is due one year (12 months) from the initial Plan of Care Date
(indicated in #2).
JACC Only: The Long Term Care Re-Evaluation (level of care assessment) form
(WPA-1), is to be completed prior to the annual Plan of Care renewal date. Separate
instructions cover this document.
6.
Program
Indicate the Program in which the participant is currently enrolled.
7.
Residential Setting
Indicate the type of location where the participant is currently residing.
7 A.
Occupancy
Select if the participant resides alone or with others, i.e., family, friends, roommate.
Plan of Care Document Instructions: Body of Page 1
8.
Date
Enter the full date (Month, Day, Year) that each of the assessed needs (Problem
Statements) is identified and written into the Plan of Care.
9.
Problem Statement
The Problem Statement is to illustrate the reason(s) for the assessed need. It should
briefly describe the participant‟s health condition, personal goals, risk factors, and/or
individual circumstances that serve as the basis for each assessed need and the way
in which these impact the participant‟s functioning.
For example, a Column #9 entry should NOT state „Locomotion‟ as the Problem
Statement. Rather, it would describe the condition of the participant and his or her
circumstances that have resulted in his or her limited mobility. Furthermore, the
participant‟s diagnosis alone is not a sufficient summary of a Problem Statement
justifying the assessed need. Rather, the impact of the diagnosis on the participant‟s
day-to-day functioning should be indicated.
10.
Need Code(s)
Enter the Need Code(s) by which each assessed need is best categorized. For
example, if the Problem Statement reads “Participant experienced a stroke and as a
result has a poor hand grip, minimal use of her right arm, and is easily fatigued,” the
Need Code may be „2d‟ if the participant, as a result of this condition, needs
assistance with ‘Medication Management.’ When „Option 8 – Other‟ is used, the
assessor shall specify the Need in the blank provided.
WPA-2 Instructions
NOV 17
Page 1 of 8 Pages.
INSTRUCTIONS FOR COMPLETING THE PLAN OF CARE (WPA-2) FORM
(Continued)
For all Activities of Daily Living (ADL) and Instrumental Activities of Daily Living
(IADL), use the alphanumeric combination indicated in the Code List. Also, it is
possible for the assessor to enter more than one Need Code for each Problem
Statement.
If the Problem Statement is best described as a Personal Goal of the participant
(Option 3), please be sure that the participant‟s preference is clearly described and a
Desired Outcome goal is also indicated in Column #12.
Some examples of a
participant‟s goal or preference are a) to be able to stay at home as long as possible
rather than relocate to a nursing facility, b) to remain as independent as possible with
the help of a home health aide, c) to obtain a personal computer to work out of his or
her home, or d) to be able to go outside regularly or find transportation for preferred
outings.
If the Problem Statement is best described as a Risk Factor (something that is likely
to increase the chances that a particular event will occur), please describe these
concerns on the last page of the Plan in Column #25. For example, a condition or
behavior that increases the participant‟s chances for injury or the possibility of
disease, such as the fact that smoking could lead to heart disease, lung cancer,
eviction, or a serious fire hazard.
Assigned codes are used to identify the ADLs or IADLs with which the participant
needs assistance or is unable to perform.
1.
ADLs identify the specific Activity of Daily Living with which the participant needs
assistance or is unable to perform.
a.
Bathing: Bathing includes how the participant takes a full-body bath/shower
or sponge bath. Includes how each part of the body is bathed: arms, upper
and lower legs, chest, abdomen, and perineal area.
b. Dressing:
Upper Body Dressing includes how participant dresses /
undresses (street clothes and underwear) above the waist, including
prostheses, orthotics, fasteners, pullovers, etc. Lower Body Dressing
includes how the participant dresses/undresses (street clothes and
underwear) from the waist down, including prostheses, orthotics, belts,
pants, skirts, shoes, socks, and fasteners.
c.
Toilet Use:
Including using the toilet or commode, bedpan, urinal,
transferring on/off toilet, cleaning self after toilet use or incontinent episode,
changing pad, managing special devices required (ostomy or catheter), and
adjusting clothes.
d. Transferring: Including moving to and between surfaces – to/from bed,
chair, wheelchair, standing position.
e.
Locomotion: Including inside and outside of home. Note: If a wheelchair is
used, regard self-sufficiency once in wheelchair.
f.
Bed Mobility: Including moving to and from lying position, turning side-to-
side, and positioning body while in bed.
g. Eating: Including taking in food by any method, including tube feedings.
2.
IADLs identify the specific Instrumental Activity of Daily Living (IADL) with which
the participant needs assistance or is unable to perform.
a.
Meal Preparation: The ability to obtain and prepare routine meals. This
includes the ability to open containers and use kitchen appliances, and how
meals are prepared (e.g. planning meals, cooking, assembling ingredients,
setting out food, utensils), with assistive devices, if used. If person is fed via
tube feedings or intravenously, treat preparation for the tube feeding as meal
preparation and indicate level of help needed.
b. Housework: The ability to maintain cleanliness of the living environment
and how ordinary work around the house is performed (e.g. doing dishes,
dusting, making bed, tidying up).
WPA-2 Instructions
NOV 17
Page 2 of 8 Pages.
INSTRUCTIONS FOR COMPLETING THE PLAN OF CARE (WPA-2) FORM
(Continued)
c.
Managing Finances:
The ability to handle money, plan budget, write
checks or money orders, exchange currency, handle coins and paper, do
financial management for basic household necessities (food, clothing,
shelter), pay bills and balance a checkbook.
d. Medication Management: How medications are managed and ability to
follow prescribed medication regime (e.g., remembering to take medicines,
opening bottles, taking correct drug dosages, giving injections, applying
ointments).
e.
Phone Use:
How telephone calls are made or received (with assistive
devices such as large numbers or telephone amplification).
f.
Shopping: The ability to run errands and shop, physically acquire, transport
and put away groceries. How shopping is performed for food and household
items (e.g. selecting appropriate items, getting around in a store).
g. Transportation: The ability to drive and/or access transportation services in
the community. How participant travels by vehicle (e.g. gets to places
beyond walking distance).
h. Accessing Resources: The ability to identify needs and locate appropriate
resources; the ability to complete phone calls, set up and follow through with
appointments, and complete paperwork necessary to acquire services or
participate in activities offered by the resources.
i.
Laundry: The ability to maintain cleanliness of personal clothing and linens.
j.
Personal Hygiene:
Personal hygiene may include ability to perform
grooming such as combing hair, brushing teeth, shaving, nail care, applying
makeup, and washing/drying face and hands.
Assigned codes are used to identify other areas in which the participant requires
assistance. The phrases in parentheses serve only as limited examples. Many more
instances could be used to illustrate examples of each Need Code.
3.
Personal Goal: Something that is a personal aspiration or objective stated by
the participant (e.g. accessing transportation to attend social events, enrolling at
a local community college, obtaining a personal computer, regularly attending
religious services or functions, writing a book, or remaining in his or her own
home for as long as possible rather than moving into a nursing facility).
4.
Communication Needs
(e.g. communication disorders, hearing or speaking impairments)
5.
Social Isolation
(e.g. lives alone, home in an area inaccessible to visitors)
6.
Caregiver Relief
(e.g. at risk for reduction of informal supports, caregiver burnout)
7.
Mental Health
(e.g. cognitive impairment, low self-esteem, depression, hopelessness, rage,
emotional instability)
8.
Other (specify)
9.
Risk Factors
a.
Personal Safety Risk
(e.g. supervision needed for personal safety; participant is self-neglecting,
abusive of alcohol or other substance)
b. Health Condition Risk
(e.g. needs medical attention; visual impairments, obese, sedentary lifestyle,
chronic illness, poor nutrition, sleep disturbance, poor health/hygiene, lack of
oral/dental care, skin condition/bed sores, improper foot care, at risk of falls,
at risk of long term institutional care in nursing facility)
c.
Behavioral Risk
(e.g. risky or inappropriate behaviors or lifestyle habits)
WPA-2 Instructions
NOV 17
Page 3 of 8 Pages.
INSTRUCTIONS FOR COMPLETING THE PLAN OF CARE (WPA-2) FORM
(Continued)
d. Environmental Risk
(e.g. home environment, living conditions are insecure or hazardous;
neighborhood is unsafe)
e.
Medication Risk
(e.g. unable to appropriately manage medications; multiple medications
and/or prescribing physicians)
f.
Other Risk (specify)
SERVICES
11.
Service(s) Needed
Service(s) Needed is used to identify distinct services. Enter the type of Service(s)
that is required to address each of the assessed needs (e.g., Home Health,
Transportation, Meals on Wheels).
12.
Desired Outcome Codes
Desired Outcome Code identifies the general objective of the service in terms of
participant functioning in the need area.
Enter the appropriate Desired Outcome from the Code List. Indicate the meaning of
“Option 5 - Other” if used, in the space provided.
The Code answers the following types of questions regarding the participant‟s
functioning:
1.
Maintenance:
Does the participant want his current level of functioning
maintained?
2.
Independence: Does the participant want to gain independent functioning in the
area?
3.
Rehabilitation: Does the participant want to restore functional ability?
4.
Prevention: Does the participant want to prevent the problem from recurring?
5.
Caregiver Relief: Does the services provide respite to the caregivers?
6.
Other (specify):
Does the participant want to resolve the issue, e.g. the
installation of a ramp resolves the lack of access in and out of the home?
13.
Units Per Visit
Units refer to the number of units of service authorized/arranged for during an
occurrence/visit.
For APC: Use current unit of service as specified in the taxonomy.
For JACC Only: Enter the units of service per visit/occurrence. (See JCN 407
form.)
14.
Frequency
Frequency codes are used to distinguish the number of times a service should
occur. Indicate the frequency, from the list below, which best describes how often the
support is provided/required.
D– Daily, specifying the number of days per week (e.g. 3x). If the participant
wants services on the weekends or specific weekdays that preference can be
indicated in the Problem Statement.
W– Weekly: Once every week
B– Bi-Weekly: Once every two weeks
M– Monthly: Every month (once within 30/31 days)
Q– Quarterly: Once every three months
A– Annually: Every year (once within 12 months)
O– Other (specify)
WPA-2 Instructions
NOV 17
Page 4 of 8 Pages.
INSTRUCTIONS FOR COMPLETING THE PLAN OF CARE (WPA-2) FORM
(Continued)
COSTS
15.
Unit Cost
For JACC Only: Enter the Rate per Unit of service. (See JCN 407 form) Rates,
where applicable, may not exceed those established. Specify the authorized cost for
each service.
16.
Payment Source
Payment source codes are used to identify the source of funding for a service.
Enter code, from the list below, for service payment source.
1.
Medicaid: Medicaid is medical assistance (health insurance) provided to certain
persons with low incomes and limited resources as authorized under Title XIX
(Medicaid) of the Social Security Act. Can include both traditional State Plan
Medicaid services provided through a Managed Health Plan as well as non-
medical services when provided under special Medicaid Waiver programs as
authorized under section 1915(c) of the Social Security Act.
2.
Medicare: Health Insurance generally for individuals over 65 and/or disabled.
Part A-Hospital Insurance: Helps cover inpatient care in hospitals, including
critical access hospitals, and skilled nursing facilities (not custodial or long-term
care) and also helps cover hospice care and some home health care.
Part B-Medical Insurance:
When medically necessary, helps cover doctors'
services and outpatient care, often requiring a premium. It also covers some
other medical services that Part A doesn't cover, such as some of the services of
physical and occupational therapists, and some home health care.
Part D-Prescription Drug Coverage:
Insurance which may help lower
prescription drug costs.
Private companies provide the coverage and
beneficiaries choose the drug plan and may pay a monthly premium.
NJ
Medicaid Waiver participants do not have a premium.
3.
Other Third-Party Liability (TPL): Private Health Insurance.
4.
Local, Community-Based Organization:
A church organization may be
involved, or a local township or city community action program may be used.
5.
County Funded Program: The county health department or a county human
services office may use funds to maintain programs for seniors and persons with
disabilities.
6.
State Funded Program: Can include programs such as the Jersey Assistance
for Community Caregiving (JACC) program, the Congregate Housing Services
Program (CHSP), the Alzheimer‟s Adult Day Health Services Program (AADHS),
or some other state-funded program.
7.
Informal Support: Any free or uncompensated support given by a relative or
immediate family member, friend, neighbor or other informal companion.
8.
Private Pay: Any payment made directly by the participant out of his or her own
income, resources or personal needs allowance.
9. APC Funded: Any service supported by funds from the County Office on Aging
(AAA/ADRC) under the area plan contract.
10. Other (specify)
WPA-2 Instructions
NOV 17
Page 5 of 8 Pages.
Page of 8