Form 3595, IPP Service Review

Instructions for Opening a Form

Some forms cannot be viewed in a web browser and must be opened in Adobe Acrobat Reader on your desktop system. Click here for instructions on opening this form.

Documents

Effective Date: 11/2017

Instructions

Updated: 11/2017

Purpose

Case management is required to monitor services periodically during the Individual Plan of Care (IPC) year. The schedule for monitoring services is included in Appendix X, Quarterly Due Dates Chart, of the Community Living Assistance and Support Services (CLASS) Provider Manual.

Procedure

When to Prepare

The case manager must meet face to face with the individual in accordance with the schedule in Appendix X of the CLASS Provider Manual to:

  • review the services received as documented on the IPC;
  • review the service summary provided by the Direct Service Agency (DSA), if included on the list of services requiring a service summary in Section 3350, 90-Day Service Summaries, of the CLASS Provider Manual;
  • document progress or lack of progress towards goals/objectives as identified on the individual program plan (IPP)/IPC and the service summary, if applicable;
  • assess the individual's satisfaction with the provision of the CLASS and Community First Choice (CFC) program services; and
  • identify any changes to the individual's needs.

If the IPP service review is not completed within the scheduled period specified in the CLASS Provider Manual, document the reason in the comments section.

Transmittal

The case manager must complete this review and send a copy to the individual/legally authorized representative (LAR), DSA and the Financial Management Services Agency (FMSA), if applicable. The DSA representative and the FMSA representative, if applicable, should review and communicate with the case manager and/or individual, as appropriate, to make service corrections, as needed.

Form Retention

Keep this form according to record retention requirements documented in the CLASS Provider Manual.

Detailed Instructions

Name of Individual — Enter the name of the CLASS/CFC participant.

Medicaid No. — Enter the individual's Medicaid number.

Review Date — Enter the date of the service review.

Next Review Date — Enter the date that the next service review is due.

Case Management Agency (CMA) — Enter the name of the CMA.

Direct Service Agency (DSA) — Enter the name of the DSA.

Financial Management Services Agency (FMSA) — Enter the name of the FMSA, if applicable.

CMA Vendor Number — Enter the CMA vendor number.

DSA Vendor Number — Enter the DSA vendor number.

FMSA Vendor Number — Enter the FMSA vendor number, if applicable.

Service Categories 7 / 8 / 9 /  / 10B / 10CFC / 13A / 13B / 13C / 13D / 34 / 35B / 37 / 48 / 54 / 61 — For each service category, respond to the following:

  • Identify the services authorized on the IPP/IPC.
  • Identify the number of units authorized.
  • Was this service delivered in accordance with the IPP/IPC (Form 8606, Individual Program Plan (IPP) – CLASS, or Form 3621, CLASS – Individual Plan of Care, and Form 3629, Individual Program Plan Addendum.
  • Is this service meeting the individual's needs?
  • Document the progress of each service, goal, or objective as indicated on the IPP.  Additionally, the case manager must consider information in the individual service summary provided by the DSA for these services: Occupational Therapy (7, 7V), Physical Therapy (8, 8V), Speech and Language Pathology (9, 9V), Habilitation-Prevocational (10B), Dietary Services (34), Auditory Enhancement/Auditory Integration Training (35B) and Supported Employment (37).
  • In the "follow-up" section, document action taken on any issues identified when addressing the above items.
  • Any additional comments may be added to the general comments section found at the end of this form.

Service Category 10CFC — Respond to the following:

  • Identify the services authorized on the IPP/IPC.
  • Identify the number of units authorized.
  • Was this service delivered in accordance with the IPP/IPP Addendum/IPC (Form 8606, Form 3629 or Form 3621)?
  • Indicate the status of services provided.
  • In the "follow-up" section, document action taken on any issues identified when addressing the above items.
  • Document the progress of each service, goal, or objective as indicated on the IPP and the DSA service summary.
  • In the "follow-up" section, document action taken on any issues identified when addressing the above items.
  • Any additional comments may be added in the general comments section found at the end of this form.

Service Categories 10CFC / 13A / 13B / 13C / 13D – Respond to the following:

  • Did the Service Planning Team (SPT) determine any of these require a backup plan?
  • Did SPT create a backup plan for this service?
  • If the SPT did not create a backup plan for any of these services identified by the SPT as needing a backup plan, the case manager must convene the SPT to develop the backup plan immediately.
  • Was the service backup plan implemented?
  • Did the service backup plan meet the individual's needs?
  • If the backup plan was implemented and did not meet the individual's needs, the case manager must convene the SPT to revise the backup plan immediately.
  • In the "follow-up" section, document action taken on any issues identified when addressing the above items.
  • Any additional comments may be added in the general comments section found at the end of this form.

Service Categories 5A / 5B /11/ 11A — For each service category, respond to the following:

  • Identify the services authorized on the IPP/IPC.
  • Identify the number of units authorized.
  • Was this service delivered in accordance with the IPP/IPP Addendum/IPC (Form 8606, Form 3629 or Form 3621)?
  • Is this service meeting the individual's needs?
  • Indicate the status of services provided.
  • In the "follow-up" section, document action taken on any issues identified when addressing the above items.
  • Any additional comments may be added to the general comments section found at the end of this form.

Service Categories 15 / 16 — For each service category, respond to the following:

  • Identify the services authorized on the IPP/IPC.
  • Identify the amount authorized.
  • Identify if specifications have been obtained and if not, provide an explanation.
  • Was this service delivered in accordance with the IPP/IPP Addendum/IPC (Form 8606, Form 3629 or Form 3621)?
  • Is this service meeting the individual's needs?
  • List each adaptive aid/minor home modification authorized on the IPC and the status of each.
  • In the "follow-up" section, document action taken on any issues identified when addressing the above items.
  • Any additional comments may be added to the general comments section found at the end of this form.

Service Category 20CFC —   Respond to the following:

  • Was this service delivered in accordance with the IPP/IPP Addendum/IPC (Form 8606, Form 3629 or Form 3621)?
  • Is this service meeting the individual's needs?
  • In the "follow-up" section, document action taken on any issues identified when addressing the above items.
  • Any additional comments may be added to the general comments section found at the end of this form.

Service Categories 42A / 42B / 42C / 42D / 42E / 42F —  Respond to the following:

  • Identify the services authorized on the IPP/IPC.
  • Identify the number of units authorized.
  • Was this service delivered in accordance with the IPP/IPP Addendum/IPC (Form 8606, Form 3629 or Form 3621)?
  • Is this service meeting the individual's needs?
  • Document the progress of each service, goal or objective, as indicated on the IPP.  The case manager must include information regarding progress on goals and objectives documented in the individual service summary provided by the DSA.  Service summaries are required from the DSA for each Specialized Therapy included on the IPC to include Massage Therapy (42A), Recreational Therapy (42B), Music Therapy (42C), Aquatic Therapy (42D), Hippotherapy (42E) and Therapeutic Horseback Riding (42F).
  • Service summaries are also required from the DSA for each Specialized Therapy included on the IPC to include Massage Therapy (42A), Recreational Therapy (42B), Music Therapy (42C), Aquatic Therapy (42D), Hippotherapy (42E) and Therapeutic Horseback Riding (42F).
  • In the "follow-up" section, document action taken on any issues identified when addressing the above items.
  • Any additional comments may be added to the general comments section found at the end of this form.

Service Category 43A — Respond to the following:

  • Identify the services authorized on the IPP/IPC.
  • Identify the number of units authorized.
  • Was this service delivered in accordance with the IPP/IPP Addendum/IPC (Form 8606, Form 3629 or Form 3621)?
  • Is this service meeting the individual's needs?
  • Document the progress of each service, goal or objective, as indicated on the IPP.
  • Is a Behavior Support Plan in place?
  • Does the Behavior Support Plan include use of a restraint?
  • Was a restraint implemented since last IPP review?
  • Was medical attention provided after restraint used?
  • Was a service summary provided by the DSA?
  • Did service summary include required behavioral data?

Service Category 48 — Respond to the following:

  • Identify the services authorized on the IPP/IPC.
  • Identify the number of units authorized.
  • Was this service delivered in accordance with the IPP/IPP Addendum/IPC (Form 8606, Form 3629, or Form 3621)?
  • Is this service meeting the individual's needs?
  • Does the Transportation Plan require revision?
  • Have non-waiver resources, including Medicaid transportation for medical appointments, been accessed prior to using this service?
  • Document the progress of each service, goal or objective, as indicated on the IPP.
  • In the "follow-up" section, document action taken on any issues identified when addressing the above items.

Consumer Directed Services — If applicable, for each service category, respond to the following:

Service Categories 7V / 8V / 9V / 10CFV / 13AV / 13BV / 13CV / 13DV / 37V / 54V / 61V — For each service category respond to the following:

  • Identify the services authorized on the IPP/IPC.
  • Identify the number of units authorized.
  • Was this service delivered in accordance with the IPP/IPP Addendum/IPC (Form 8606, Form 3629 or Form 3621)?
  • Is this service meeting the individual's needs?
  • Did the individual receive a quarterly report from the FMSA?
  • Is the individual satisfied with the services/providers?
  • Document the progress of each service, goal, or objective as indicated on the IPP and the DSA service summary, if applicable.
  • In the "follow-up/other" section, document action taken on any issues identified when addressing the above items.
  • Any additional comments may be added to the general comments section found at the end of this form.

Service Categories  10CFV / 13AV / 13BV / 13CV / 13DV — For each service category, respond to the following:

  • Did the SPT determine any of these require a backup plan?
  • Did SPT create a backup plan for this service?
  • If the SPT did not create a backup plan for any of these services identified by the SPT as needing a backup plan, the case manager must convene the SPT to develop the backup plan immediately.
  • Was the service backup plan implemented?
  • Did the service backup plan meet the individual's needs?
  • If the backup plan was implement and did not meet the individual's needs, the case manager must convene the SPT to revise the backup plan immediately.
  • In the "follow-up" section, document action taken on any issues identified when addressing the above items.
  • Any additional comments may be added in the general comments section found at the end of this form.

Service Categories 11PV / 11AV — For each service category, respond to the following:

  • Identify the services authorized on the IPP/IPC.
  • Identify the number of units authorized.
  • Was this service delivered in accordance with the IPP/IPP Addendum/IPC (Form 8606, Form 3629 or Form 3621)?
  • Is this service meeting the individual's needs?
  • Did the individual receive a quarterly report from the FMSA?
  • Is the individual satisfied with the services/providers?
  • Document the progress of each service, goal, or objective as indicated on the IPP and the DSA service summary, if applicable.
  • In the "follow-up/other" section, document action taken on any issues identified when addressing the above items.
  • Any additional comments may be added to the general comments section found at the end of this form.

Service Category 48V — Respond to the following:

  • Identify the services authorized on the IPP/IPC.
  • Identify the number of units authorized.
  • Was this service delivered in accordance with the IPP/IPP Addendum/IPC (Form 8606, Form 3629, or Form 3621)?
  • Is this service meeting the individual's needs?
  • Does the Transportation Plan require revision?
  • Have non-waiver resources, including Medicaid transportation for medical appointments, been accessed prior to using this service?
  • Document the progress of each service, goal or objective, as indicated on the IPP.
  • In the "follow-up" section, document action taken on any issues identified when addressing the above items.

Service Category 57V/ 57CFV — Respond to the following:

  • Identify the services authorized on the IPP/IPC.
  • Identify the number of units authorized.
  • Did the support advisor deliver services based on needs and request of the individual?
  • Is the support advisor meeting the individual's needs?
  • In the "follow-up" section, document action taken on any issues identified when addressing the above items.
  • Any additional comments may be added to the general comments section found at the end of this form.

Service Category 63V / 63CFV — Respond to the following:

  • Identify the services authorized on the IPP/IPC.
  • Identify the number of units authorized.
  • Did the FMSA provide financial management services in accordance with the CDS rules?
  • Is the FMSA meeting the individual's needs?
  • Did the FMSA provide a report to the employer at least quarterly for each CLASS CDS service? If yes, what changes/problems have occurred? If no, explain what measures were taken to acquire the information
  • Did the FMSA provide a report to the CLASS case manager at least quarterly? If yes, what changes/problems have occurred? If no, explain what measures were taken to acquire the information
  • Has the FMSA reported any concerns or problems this quarter? If yes, provide an explanation.
  • Is the individual satisfied with the financial management services provided by the FMSA? If no, provide an explanation.
  • In the "follow-up" section, document action taken on any issues identified when addressing the above items.
  • Any additional comments may be added to the general comments section found at the end of this form.

Transition Assistance Services (TAS) / Support Family Services (SFS) / Continued Support Family Services (CFS) — If applicable, for each service category, respond to the following:

Service Categories 53 / 55 / 55A — For each service category respond to the following:

  • Identify the services authorized on the IPP/IPC.
  • Identify the dollar amount authorized on the IPC.
  • Was this service delivered in accordance with the IPP/IPP Addendum/IPC (Form 8606, Form 3629 or Form 3621)?
  • Is this service meeting the individual's needs?
  • Is the individual satisfied with the services delivered?
  • Provide the status of each service provided.
  • In the "follow-up/other" section, document action taken on any issues identified when addressing the above items.
  • Any additional comments may be added to the general comments section found at the end of this form.

Non-CLASS Resources Accessed — Document the non-CLASS resources accessed during the IPP service review.

General Comments — Use this area to document any general comments regarding CLASS services.

Individual Signature and Date — The individual signs and dates the form.

Case Manager Signature and Date — The case manager signs and dates the form.

Other Signature and Date — Other signature and date is to be used when another individual attends the quarterly review as desired by the individual/LAR.

DSA Acknowledgment or Receipt and Date — The DSA representative signs and dates the form.

FMSA Acknowledgment or Receipt and Date — The FMSA representative signs and dates the form.

Support Family Services/Client Financial Services Acknowledgment or Receipt and Date — The Support Family Services/Client Financial Services representative signs and dates the form.