Free Form 02AG031E (AG-6) Instructions - Oklahoma

Personal Care (PC) Service Plan Purpose of form

02AG031I (AG-6)

Form 02AG031E is a plan for a client receiving personal care (PC) services. The plan is completed by the provider agencies accepting clients under the Service Authorization Model (SAM) or the OKDHS nurse for clients electing to use the Independent Contractor Model (ICM). The nurse is to indicate the type(s) of service, provider (agency or independent) delivering the service(s) and number of units required to complete the duties or tasks. The plan is revised or amended as service needs are identified. Any time a change is made in the service plan other than an agency or individual provider change, a new service plan is completed. This form is used with the Service Authorization Model (SAM) of State Plan Personal Care services and by OKDHS nurses for use with independent contractors (ICM). Instructions Copy to: Check appropriate entity and enter the date the form is sent to each entity. Enter client name, client case number, and residence address or finding address including city, state, and zip code. Enter Unique ID number, phone number, and the county name where the client resides. Services. Type of service: Enter type of service. Provider: Enter name of provider agency delivering services or name of independent contractor. Hours per week: Enter the total number of hours required for weekly service delivery. Units per week: Enter the total number units required for weekly service delivery. One unit is equal to 15 minutes. Duties or tasks: Enter duties, or tasks, or list reference to tasks listed on Form 02AG029E, Personal Care Plan. Other services. SAM visit: Up to five service monitoring visits per year are authorized per agency for State Plan Personal Care clients. Other: Enter name of additional provider(s) where two agencies or one agency and one individual contractor are required to provide services to meet the needs of a client on the same service plan. Enter the date the plan was reviewed and signed by client. · · SAM: This date is entered by the agency nurse. ICM: This date is entered the OKDHS nurse.

Revised 6-15-2009

Page 1 of 2

02AG031E (AG-6) Signatures

Personal Care (PC) Service Plan

Client's signature: The provider or OKDHS nurse initiates Form 02AG031E with the client. The client marks the check box to indicate if he or she accepts or denies the service plan and signs on the client signature line. Witness signature: If the client cannot sign his or her name, the service plan requires the signature of two witnesses. Agency nurse/OKDHS nurse signature: The agency nurse or OKDHS nurse enters their signature when initiating the plan with the client. Area nurse/designee signature: The area nurse or designee enters their signature when the plan is approved. Service plan period Effective date: · · SAM: Enter date Form 02AG044E, State Plan Personal Care (SPPC) Progress Notes, is completed and the home visit conducted. This date is entered by the agency nurse. ICM: Enter date the service plan is approved by the area nurse or designee. The OKDHS nurse enters this date. SAM: This date is entered by the agency nurse. ICM: This date is entered by the OKDHS nurse.

End date: Enter date that is 364 days from the end of the effective date. · ·

Certification period Effective date: Enter date the case is established. · · SAM: Enter date the referral is sent to the agency. This date is entered by the OKDHS nurse after receiving Form 02AG031E from the agency. ICM: Enter date the case is established and approved by the area nurse or designee. This date is entered by the OKDHS nurse.

End date: Enter date for length of certification period. The length of up to 36 months (1 - 3 years) is determined and entered by the OKDHS nurse. Comments/concerns: Enter other pertinent information to the plan or plan dates. This is entered by the agency nurse or the OKDHS nurse. Routing Original ­ Copy Copy ­ ­ Provider agency file or OKDHS nurse case file. Original is kept by entity initiating the form. Client OKDHS nurse if form initiated by agency.

Page 2 of 2

Revised 6-15-2009