DDRS Waiver Manual

Section 7.6: Service Plan implementation and Monitoring
Case Managers are responsible for the implementation and monitoring of the service plan (inclusive of
the Individualized Support Plan (ISP), Cost Comparison Budget POC/CCB) and, often, other non-funded
services) and participant health and welfare.
A minimum of one face-to-face contact between the case manager and the participant is required at least
every 90 calendar days in the home of the participant, and as frequently as needed to support the
participant. In each meeting, the participant’s Individual Support Team (IST) will review current
concerns, progress and implementation of the service plan (plan of care).
A 90-Day Checklist is utilized by the Case Manager and IST in order to systematically review the status of
the POC/CCB, the ISP, any behavioral support program, choice and rights, medical needs, medications,
including psychotropic medications (if applicable), seizure management (if applicable), nutritional/dining
needs, incident review, staffing issues, fiscal issues, risk plans and any other issues which may be
identified in regard to the satisfaction and health and welfare of the participant. The checklist is also
used to verify that emergency contact information is in place in the home, including the telephone
numbers for Adult Protective Services or Child Protective Services and the Bureau of Quality
Improvement Services. Case Managers educate the participant by offering examples of when the
emergency contact numbers should be called.
The case manager is required to enter a case note for each encounter (at least one per month) with the
participant indicating the progress and implementation of the service plan. The Case Manager also
maintains regular contact with the participant, family/guardian and the provider(s) of services through
home and community visits or by phone to coordinate care, monitor progress and address any
immediate needs. During each of these contacts the Case Manager assesses the service plan
implementation as well as monitors the participant's needs.
The monitoring and follow up method used by the Case Manager include conversations with the
participant, the parent/guardian, and providers to monitor the frequency and effectiveness of the
services through team meetings and regular face-to-face and phone contacts. The case manager asks:
Are the services being rendered in accordance with the plan of care?
Are the service needs of the participant being met?
Do participants exercise freedom of choice of providers?
What is the effectiveness of the crisis and back up plans?
Is the participant’s health and welfare being ensured?
Do participants have access to non-waiver services identified in the plan of care including access
to health services?
The implementation and effectiveness of the plan of care is reviewed at least once every 90 calendar
days in the 90-Day meetings of the IST meetings.
At all times, full, immediate and unrestricted access to the individual data is available to the State,
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