Person Centered Service Plan (PCSP)

Person Centered Service Plan (PCSP)

Service Plan of PCSP

The Service Plan section of the PCSP is used to capture all current services and new services that are being requested for the participant. For explanations of the different services, refer to the “Services Explained” training module.

The following all need to be included in the PCSP:

  • All currently authorized services
    • Use the authorization spreadsheet for reference
    • Use the guide below to document any requested changes to current services (Increases, Decreases and Termination)
  • Any other services the participant receives
    • i.e. Transportation services, DME/SME, and any other Medicare and other payor covered services
  • Any new Medicaid services being requested
  • Informal Support information

PA Health and Wellness will make the final determination for types and amounts of services that are approved.  The participant will be notified via a determination letter from PHW and will have grievance and appeal rights if they do not agree with the decision.

Service Plan Breakdown

  • Service or Item Type – the needed service
    • Select Yes to enter the rest of the information
    • Select New Service if this is a new service the participant is requesting
    • Select Annual Review if this is an existing service
    • Select the appropriate service type
  • Service Amount/Frequency – the amount of service authorized based on the frequency
    • Frequency and amount is specific to each service. See guide below.
  • Service Details – A brief description of what the service provides. Be specific.
  • Service Dates – Dates when the service will be received
    • See guide below on putting in dates for different scenarios (services staying the same as prior, new services, changes, terminations)
  • Service Provider and Delivery – The provider chosen by the participant (if applicable) and delivery method
    • If the provider is Tempus (PDO), select Participant Directed – Employer Authority
    • If the provider is any other agency, select Agency Option

Entries for common services

Personal Assistance Services (PAS)

AGENCY OPTION

Service Type: Personal Assistance Services

Service Details: State the specific ADL’s and IADL’s the participant requires (see example below)

Service Dates: See guide below

Amount: total hours CURRENTLY authorized (regardless of request/SPG tool) per week

Frequency: Weekly

Delivery: Agency Option

Provider: Agency Name, Agency phone number, and agency NPI #

Ptp authorized for 35 hours with Ameribest Home Care

PARTICIPANT DIRECTED OPTION (PDO)

Service Type: Personal Assistance Services

Service Details: State whether it is Regular Time or Overtime and state the specific ADLs and IADLs that this participant requires caregiver assistance with, this should be different for every participant.

Service Dates: See guide below

Amount: Amount of hours CURRENTLY authorized (regardless of request/SPG tool) per week

Frequency: Weekly

Delivery: Participant Directed – Employer Authority

Provider: Tempus (PDO) 844-983-6787

PCSP Input

OP3068502595PAS – PERSONAL ASSISTANT SERVICES CONSUMERW1792TEMPUS UNLIMITED, INC10.3261

Personal Emergency Response System (PERS)

EXISTING SERVICE

Service Type: Personal Emergency Response System

Service Details: Monthly Maintenance + description

Service Dates: See guide below

Amount: 1

Frequency: Monthly

Delivery: Agency Option

Provider: Agency Name and phone number

NEW SERVICE

When putting in a new PERS unit request you will need to have 2 separate services.

1. Same as the prior Monthly Maintenance Request

2. Additional One Time Installation Request

Service Type: Personal Emergency Response System

Service Details: One Time Installation + description

Service Dates: Start Date – Date of assessment; End Date – One year minus a day from start date (Ex. 10/26/2021 and 10/25/2022)

Amount: 1

Frequency: One Time

Delivery: Agency Option

Provider: Agency Name and phone number


Home Delivered Meals

Service Type: Home Delivered Meals

Service Details: Description + diet requirements/preferences

Service Dates: See guide below

Amount: # of meals received per week (Max 14)

Frequency: Weekly

Delivery: Agency Option

Provider: Agency Name and phone number


Transportation Services

NON-MEDICAL TRANSPORTATION (MTM RIDES)

Service Type: Non-Medical Transportation

Service Details: Service description + average amount of round trips needed per week

Service Dates: See guide below

Amount: Average amount of trips needed per month (average amount of round trips x 8)

Frequency: Monthly

Delivery: Agency Option

Provider: Medical Transportation Management (MTM) | 888-561-8747

NON-MEDICAL TRANSPORTATION (SEPTA KEYCARD)

Service Type: Non-Medical Transportation

Service Details: Service Description + Zone ptp requires

Service Dates: See guide below

Amount: 1

Frequency: Monthly

Delivery: Agency Option

Provider: Medical Transportation Management (MTM) | 888-561-8747

NON-MEDICAL TRANSPORTATION (CCT PASS)

Service Type: Non-Medical Transportation

Service Details: Service Description + Zone 2 + Utilizes CCT

Service Dates: See guide below

Amount: 1

Frequency: Monthly

Delivery: Agency Option

Provider: Medical Transportation Management (MTM) | 888-561-8747

MEDICAL TRANSPORTATION (MATP)

Service Type: Other

Service Details: Service description

Service Dates: See guide below

Amount: 1

Frequency: Monthly

Delivery: Agency Option

Provider: Medical Assistance Transportation Provider (MATP) | 877-835-7412


Adult Day Care/Center

Service Type: Adult Daily Living

Service Details: Service description

Service Dates: See guide below

Amount: number of days attending per week

Frequency: Weekly

Delivery: Agency Option

Provider: Agency name and Phone Number


Home Mods

Each requested Home adaptation requires its own service entry.

Service Type: Home Adaptations

Service Details: “Home adaptations evaluation is required …” then state the barrier the home mod is meant to overcome (ex. participant cannot go up and down steps to the second floor where the bedrooms and bathrooms are)

Service Dates: See guide below

Amount: 1

Frequency: One Time

Delivery: Agency Option

Provider: TBD


Durable Medical Equipment (DME)

Each DME and SME requires their own service entry. DMEs and SMEs should NOT be added to the PCSP until AFTER they are being received.

Service Type: Specialized Medical Equipment and Supplies

Service Details: description of item including size if applicable

Service Dates: See guide below

Amount: 1

Frequency: One Time

Delivery: Agency Option

Provider: Name and phone number of provider


Specialized Medical Equipment (SME)

Each DME and SME requires their own service entry. DMEs and SMEs should NOT be added to the PCSP until AFTER they are being received.

Service Type: Specialized Medical Equipment and Supplies

Service Details: description of item including size if applicable and average amount being used per day.

Service Dates: See guide below

Amount: average amount needed per day

Frequency: Daily

Delivery: Agency Option

Provider: Name and phone number of provider


Exceptional Durable Medical Equipment

Any item that is custom to the participant (i.e. it cannot be used straight out of the box) and the cost is equal to or greater than $5,000 is considered Exceptional DME (EDME) and is required to be added to the PCSP and an SRT must be completed

Service Type: Exceptional DME

Service Details: item being requested and specific details if applicable

Service Dates: See guide below

Amount: 1

Frequency: One Time

Delivery: Agency Option

Provider: name and number of chosen provider or TBD


Informal Support

Service Type: Other

Service Details: ADLs and IADLs that informal support assists with AND description of how/when informal support confirmed their role. Ex. “During assessment, Example verbally stated they are willing, able, and available to provide informal support”

Service Dates: See guide below

Amount: Amount of hours Informal support agreed on per week

Frequency: Weekly

Delivery: Agency Option

Provider: Name and phone number of Informal supporter(s)


Service Format based on scenarios

Services Staying the same as prior Service Plan

If SC has completed an assessment with a participant and services and providers are all staying the same as last assessment, then the Service Plan in the PCSP should reflect the following:

  • Start Date: Date of assessment/visit
  • End Date: One Year from start date minus 1 day
  • Amount: The amount currently authorized
    • If PHW makes a change to the PAS hours that will be approved moving forward (e.g. increase or decrease), at the next visit with the participant the SC will update the PCSP Service plan to reflect what is currently approved.

Ex. Assessment done with participant on 8/12/2020


Increase/Decrease Procedure

FOR PAS

If SC has completed an assessment with a participant and the hours for PAS indicated by the new assessment are either an increase or a decrease from what the participant has currently, then the Service Plan in the PCSP should reflect the following:

  • Start Date: Date of assessment/visit
  • End Date: One Year from start date minus 1 day
  • Amount: The amount currently authorized (this does not have to match the SPG Tool)
    • If PHW makes a change to the hours that will be approved moving forward (e.g. increase or decrease), at the next visit with the participant the SC will update the PCSP Service plan to reflect what is currently approved.

FOR NON-PAS 

This will result in two separate entries on the PCSP for the same type of service

If SC has completed an assessment with a participant and an increase or decrease in a Non-PAS service are being requested, then the Service Plan in the PCSP should reflect the following:

  • 1st Entry
    • Start date: first date in current year that participant began receiving this service
      • (eg. if the participant had HDM for this entire year then 1/1/20 is listed, if the participant started receiving HDM on 3/2/20 then 3/2/20 is listed).  You will need to look at the authorizations in FP to determine the appropriate start date.
    • End date: Day of current visit with participant
    • Amount: Current amount of service approved
  • 2nd Entry
    • Start date: Day after your current visit with participant
    • End date: One year from the start date minus 1 day
    • Amount: Increase/decrease amount being requested

New service request

FOR PAS

If SC completes an assessment with the participant and a request is made for PAS and the participant does not currently have PAS hours, then the Service plan in the PCSP should reflect the following:

  • Start date: Day of visit with the participant
  • End date: one year from date of visit, minus one day
  • Amount: will be left blank
    • PA Health and Wellness will make the final determination of hours.
    • At next visit with the participant SC will update assessment to reflect currently authorized PAS hours

FOR PERS

For a PERS installation, you need to also make two separate services. 

  • First service: PERS installation
    • Start Date: Date of Visit
    • End Date: One year from date of visit, minus one day 
    • Amount: 1
    • Frequency: One time
  • Second Service: PERS Monthly Monitoring
    • Start Date: Date of Visit
    • End Date: One year from date of visit, minus one day
    • Amount: 1
    • Frequency: Monthly

FOR EVERY OTHER SERVICE

If SC completes an assessment with the participant and a request is made for a Non-PAS service (e.g. HDM’s, transportation, etc) and the participant does not currently have that service, then the Service plan in the PCSP should reflect the following:

  • Start date: Day of visit with the participant
  • End date: one year from date of visit, minus one day
  • Amount: amount that is being requested

Ending a Current Service

DO NOT just leave the service off of the service plan

If SC has completed an assessment with a participant and it has resulted in a request to end a service that is already in place.

  • Start date: first date in current year that participant began receiving this service (eg. if the participant had HDM for this entire year then 1/1/20 is listed, if the participant started receiving HDM on 3/2/20 then 3/2/20 is listed).
    • You will need to look at the authorizations in FP to determine the appropriate start date.
  • End Date: Date that service is requested to be terminated
  • Amount: Current amount of service approved

Ex. Participant was assessed on 8/12/20 and has picked a future date of 8/31/20 to stop meals.


Change in Provider

This will result in two separate entries on the PCSP for the same type of service

If SC has completed an assessment with a participant and a change in any type of provider is being requested, then the Service Plan in the PCSP should reflect the following:

  • 1st Entry
    • Start date: first date in current year that participant began receiving this service (eg. if the participant had HDM for this entire year then 1/1/20 is listed, if the participant started receiving HDM on 3/2/20 then 3/2/20 is listed).  You will need to look at the authorizations in FP to determine the appropriate start date.
    • End date: Future date that new provider can begin, minus 1 day (SC will need to confirm this with new provider)
    • Amount: Current amount of service approved
  • 2nd Entry
    • Start date: Future day that new provider can begin (SC will need to confirm this with new provider)
    • End date: one year from the date of your visit minus 1 day
    • Amount: Current amount of service approved

Needs, Goals, and Outcomes Overview

Overview

The Needs, Outcomes, and Goals are made based on the participant’s services and their personal goals.  There must be a Need, Outcome, and Goal for each service (except Service Coordination*) until you run out of available Needs/Outcomes/Goals.  If you have a N/G/O for each service and there is additional room, then the participants personal goals should be listed.

 

Needs

Details why the participant Needs the service or what they need help with specifically requiring the service. Always ask the participant “Why do you need this service?” or “what does this service help you with?”

Examples

These are meant as a guide to the format of the Needs.

 
PAS

Why does the participant need a caregiver/what is the caregiver going to help them with?

  • Ms. Amcord needs to eat diabetic appropriate meals to prevent hospitalizations for high glucose levels
  • Ms. Amcord needs to take her medications as prescribed
  • Ms. Amcord needs to improve mobility
  • Ms. Amcord needs to improve personal hygiene
  • Ms. Amcord needs to decrease hospitalizations related to falls that take place while completing bathing, dressing, and ambulation
PERS

Why does the participant need a PERS unit/what will the device do for them?

  • Ms. Amcord is unable to dial her phone due to arthritis and needs to be able to access EMS as needed
  • Ms. Amcord needs to be able to attain assistance from EMS should a fall/injury take place
HDM

Why does the participant need home delivered meals/what will the meals provide them?

  • Ms. Amcord needs to better manage her health through diet and nutrition
  • Ms. Amcord needs to better manage her diet and food portion intake
  • Ms. Amcord needs to have access to 2 meals per day to maintain her physical well being
  • Ms. Amcord needs to prevent hospitalizations due to high glucose levels
ADC

Why does the participant need to attend ADC?

  • Ms. Amcord needs to improve her socialization skills
  • Ms. Amcord is diagnosed with dementia and needs constant supervision and assistance with bathing, dressing, and toileting throughout each day
  • Ms. Amcord needs to improve her depression and anxiety

Status of Need: 

Met: This indicates that the Need is already being addressed fully, through either informal, formal, or a combination of both types of assistance.  

  1. If there is already a service in place (ie. PAS) to meet the need and there is no area of the need being unmet, then you would select “met”
    1. Ie. Participant has PAS provide verbal reminders during shifts to take medications, participant is taking medications 100% of the time.

Partially Met: This indicates that the Need is only partially met at the time of assistance

  1. If there is already a service in place (ie. PAS) to meet the need, but it is not fully met, then you would select “partially met”
    1. ie. Participant has PAS provide verbal reminders during shifts to take medications, but the participant is forgetting to take medications during times when PAS is not present. 
  2. Service Coordinator should ensure a service is put into place to meet the need moving forward 

Unmet: This indicates that the Need is unaddressed by either formal or informal assistance at this time.

  1. If there is no service in place yet and the need is not met OR there is a service in place but it is not meeting the need, then you would select “unmet”.
    1. ie. Participant has no services yet that assist with medication reminders and is currently forgetting to take medications each day, the participant does not have family or friends to assist.
    2. Ie. Participant previously wanted PAS to remind them to take medications daily, but the participant wants the PAS schedule to be at times when the participant would not be taking medications.  Participant is currently forgetting to take medications and does not want to move the PAS schedule.
  2. Service Coordinator should ensure a service is put into place to meet the need moving forward 

Outcomes

Details the Outcome on the participant’s life/health/well-being if the Need is satisfied. 

Always ask the participant, “What are you hoping to achieve by satisfying the previously stated need?“

Examples

PAS

If the need was “Ms. Amcord needs to improve personal hygiene” then how will improving the daily hygiene affect the participant’s life/health?

  • Ms. Amcord is attending church on Sundays and going to her local senior center on Tuesdays and Thursdays each week, now that her hygiene is improved
  • Ms. Amcord will improve her personal hygiene and will be able to go to activities in the community, such as bingo and church.
PERS

If the need was to have access to EMS in the event of a fall/injury, how will having this constant access help/benefit the participant?

  • Ms. Amcord will have access to EMS 24/7
  • Ms. Amcord will receive prompt care/treatment of injuries, reducing the long-term impact with quick access to contact EMS in the event of an emergency. 
HDM

If the need was “manage her health through diet and nutrition” then how will improving diet and nutrition affect the participant’s life/health?

  • Ms. Amcord will have a reduction from 4 to 2 hospitalizations in the next year
  • Ms. Amcord will lose 10lbs in the next 6 months, with pre-made, pre-portioned, nutritious meals.
ADC

If the need was “to improve socialization” then how will increased socialization help the participant in life?

  • Ms. Amcord will have socialization opportunities with her peers Monday through Saturday each week for the next year at the ADC
  • Ms. Amcord will be able to participate in activities she likes doing with her peers, such as bingo and arts/crafts, while at the ADC Monday through Friday each week  

Goals

Details the participant’s Goal in having, receiving, or utilizing the service to satisfy the Need for it and obtain the desired Outcome.  All Goals have to be SMART, meaning it must include statements pertaining to each letter of the SMART acronym.

Get S.M.A.R.T details from the participant/responsible party! Do NOT try to complete this without participant input.

1. Start with a basic goal for the service such as:

**Hint: this can or likely will be similar to the NEED of the service**

  • Prevent hospitalization
  • have assistance in case of falls or emergencies
  • improve socialization
  • improve diet/nutrition
  • continue living independently

2. Go through each letter of the SMART acronym to add onto the goal

S – Specific

The goal must be clearly stated and detailed using person-centered statements.  When reading a completed goal it should have information that is relevant to only this particular participant.

Ask the ptp: “What causes the need for help?” (ie. is there a specific diagnosis or symptom that makes it difficult for them to complete the task), “How will the service assist you with reaching the goal” (ie. participant might say they need hands on help with some aspects of the task and maximum help with others)

Goal example: To receive assistance with bathing and personal hygiene

Specific example: 

  • I need help because I have pain in my knees and shoulders from my arthritis and I need someone to help me get into the shower chair and then wash my legs, hair, and back
  • I have MS and some days I am weaker than others, at minimum I need help getting in the shower and setting up everything for me to wash myself
  • I keep getting infections in my wounds, so I need help so I can bathe every day
M – Measurable

The goal must have Definable/Quantifiable supports for when/how often the goal will be done

Ask the ptp: How often/when do you need to do the goal?

Goal Example: To improve socialization by going to the community/senior center more often

Measurable example: ask the participant how often they’d like to go to the community center and their answer could be something like:

  • I want to go to bingo every Tuesday night
  • I want to go out twice a week to the Senior Center
A – Attainable 

The goal needs to be realistic for them to complete. Make sure it is realistic to the participant’s capabilities.  For example, a participant might say they want to lose 80lbs in the next 6 months and their doctor has told them 20lbs is a more reasonable goal.

Goal example: to lose 20 lbs in the next year by eating HDM’s and decreasing sugar intake

Attainable check example: Confirm the participant’s current weight, if this is all that’s needed to lose the weight, and if a physician agreed this would be able/safe to be done. Things to consider:

  • A participant that only weighs 200 lbs might not be able to lose that much weight
  • Exercise may also be needed for a participant to lose weight
  • A physician may feel that HDM won’t be able to provide enough nutrition to a participant or that the weight loss the participant would like to lose is not a realistic amount
R – Relevant 

The goal must be relevant to what the service actually can provide.

Things to consider:

  • PAS providers/HHAs provide assistance with ADLs and IADLs. They aren’t responsible for improving mobility, but they could remind a participant to do their PT exercises each day
  • PERS units provide access to calling EMS. They can’t prevent falls or help a participant walk, they are only to gain access to assistance.
  • HDM provides pre-made meals. It is not necessarily going to help the participant lose weight.
  • Transportation gets participants to and from appointments, they do not remind the participant to schedule or attend appointments.
 
T – Time bound 

There must be a timeframe for completing or reassessing the goal, they are updated at each visit.  Ask the participant if this is a long term, or short term goal, when they would like it to be completed by, or when we should reassess the goal to either continue it, or change it.  There should be a reasonable amount of time to make progress or complete the goal.

Goal example: to have assistance if a fall occurs when they are home alone.

Timebound example: ask the participant how long they intend on having the PERS unit

  • for the next 6 months
  • for the next year

3. Pull all the information together to make the SMART goal

EXAMPLES:

PAS example: Goal is to have help with bathing, dressing, and grooming so that Ms. Smith feels comfortable going out into the community to socialize

S – Specific – Ms. Smith needs helps because she is diagnosed with arthritis and states the pain stops her from doing those tasks herself

M – Measurable – once a day, 7 days a week

A – Attainable – with assistance from an HHA the participant should be able to meet this goal

R – Relevant – Ms. Smith will receive hands on assistance from her HHA, which is relevant to the role of an HHA

T – Time Bound – for the next year 

SMART GOAL:

Ms. Smith is diagnosed with arthritis and reports to experience pain that prevents her from completing personal care (S).  Ms. Smith will bathe, dress, and groom daily with hands-on assistance from HHA (R) with transferring into shower, washing body, drying off, getting dressed, and with brushing her teeth and hair once per day 7 days per week (M, A) for the next year (T).

PERS example: goal is to have assistance if they fall when their HHA or informal support are not home.

S – Specific – Ms. Smith has fallen 3 times in the past month when she was home alone

M – Measurable – Ms. Smith will wear her PERS unit when she is alone from 3p-8p every evening

A – Attainable – Ms. Smith can be wear a PERS unit at any time

R – Relevant – the purpose of a PERS unit is to call for assistance

T – Time Bound – for the next year

SMART GOAL:

Ms. Smith has a history of 3 falls in the month prior to the assessment and is diagnosed with arthritis and uses a walker for all mobility (S).  Ms. Smith will wear her PERS from 3p-8p every day (M, A), after her HHA leaves and before her informal support returns home to be able to access emergency assistance (R) for the next year (T), should a fall take place.

Transportation example: goal is to go to the community/senior center more often to improve socialization

S – Specific – Ms. Smith is diagnosed with depression and reports having not left her house in months

M – Measurable – Ms. Smith would like to attend bingo at least once a week at the Senior Center

A – Attainable – Ms. Smith is mentally and physically capable of using public transportation

R – Relevant – Non-medical transportation is able to provide transportation to the Senior center

T – Time Bound – for the next 6 months

SMART GOAL: 

Ms. Smith is diagnosed with depression and reports she has not left her home in the past few months which is making her feel worse (S).  Ms. Smith will go to the Senior Center once per week(M, A), for the next 6 months(T), using the zone 2 Septa transpass(R).

SMART-goal-practiceDownload

You can practice building SMART goals with this:

  • Agree/Disagree- If both the participant and the Service Coordinator agree on the goal then “Agree” is selected.  If either the SC or the participant do not agree to some aspect of the goal then “disagree” should be selected.  
  • Start Date– Goals should be built upon from one PCSP to the next.  If the participant has just chosen the goal to work on for the first time at the visit then “Start Date” would be the date of the visit.  If the participant has been working on this goal from prior PCSP’s then the true start date of the goal should be obtained from the prior PCSP.
  • End Date– The end date must always be current and should be based off of the
    “Time Bound” portion of the actual goal.  If at the visit/assessment the participant states that they want to work on the goal for 6 months then the end date should be six months from the date of the visit.
    • There must always be a CURRENT goal, this means goals can not have an end date prior to the next visit, so discuss this with the participant when setting the end date.  
  • Barriers – Something that prevents the participant from achieving their goals.  If a participant has no informal supports this needs to be documented in the barriers.  Any cognitive issues must be addressed in the barriers.
    • Ex. Veronica is unable to cook without assistance due to pain in her back, preventing her from standing for longer than 5 minutes. 
    • Ex. Dan forgets to charge and wear his PERS until when his HHA is not around. 
    • Ex. John has no informal support to be able to assist him with bathing, dressing, and grooming.
    • Ex. Beth is low income and is unable to purchase diabetic appropriate foods to meet her medical needs.
    • Ex. Elizabeth has cognitive issues and is diagnosed with Dementia, she requires assistance with medication management
  • Intervention – What can/will be done to overcome the barrier and proceed with achieving the goal.  If a participant has informal support they need to be listed in the interventions with the specifics of what they will be assisting with.
    • Ex. Veronica’s HHA will assist with meal prep in the morning and afternoon and will have HDM ready for Veronica to heat up for dinner when she is not around.
    • Ex. Dan’s HHA will ensure the PERS unit is charging while they are there to supervise Dan’s walks, and will remind him to wear the PERS unit when they leave for the weekend. 
    • Ex. John’s daughter/Jane will assist him with dressing and grooming before bed each night, Monday-Sunday. 
    • Ex. Beth’s son/David will do grocery shopping for heart healthy foods each Sunday 

Cognitive Issues Guide

Cognitive Issues

We are responsible for ensuring that when we document that a participant has a cognitive issue that we are also documenting how those cognitive issues will be addressed, inside of the HEDIS note. There needs to be consistency between all of the different assessments.


This applies to both Nursing Facility participants and Home and Community Based Services participants.  

NF participants- if there is a cognitive issue indicated in any part of the HEDIS then the PCSP 

must address the cognitive issue.

HCBS participants- if there is a cognitive issue indicated in any part of the HEDIS or InterRAI then 

the PCSP must address the cognitive issue.


There are a few different ways that we might be able to show that we addressed the issue:

  1. Medication Management- ptp may use Telecare, blister packets, or someone to assist with verbal 

reminders to take medications.

  1. Financial Management- ptp may have someone else paying the bills due to confusion.
  2. Phone use- ptp may receive assistance with setting up medical appointments due to forgetfulness.
  3. Other- the ptp may have a unique situation where their cognitive issue affects one of the other ADL/IADL’s.

Below you will find some examples of how to handle the documentation for participants with a cognitive issue.


Example if ptp who does NOT have cognitive issues:

  1. The “cognitive issue” box is not selected on pg 7 of PCSP.
  2. In “Barriers to any of the above” it clearly states there are no cognitive issues, pg 7 PCSP.
  3. No portion of the InterRAI and/or HEDIS related to cognition or memory issues is selected

You must ensure that ALL steps are completed for a ptp with no cognitive issues.

Example InterRAI for a participant with no cognitive issues:

Example PCSP pg 7 for a participant with no cognitive issues:

Example of HEDIS for participant with no cognitive issues:


Example if ptp who has cognitive issues:

  1. “Cognitive issues” box is checked off on pg 7 of PCSP
  2. In “Barriers to any of the above” the cognitive issue is stated along with what ADL/IADL it affects and how it is addressed, pg 7 of PCSP.
  3. InterRAI and/or HEDIS have corresponding information in regards to cognitive issues.
  4. Even if a participant reports that they have a cognitive impairment that does not impact their daily functioning (ie. only cognition issues in new situations), this MUST be treated as a cognitive issue.

Example of InterRAI for participant with cognitive issues:

Example of HEDIS for participant with cognitive issues:

Example of PCSP for participant with cognitive issues:


Mental Health Plan

  1. We need to ensure that for all participants that have a Mental health diagnosis that we are capturing the plan for how their mental health is being managed.
    1. Examples of Mental Health Diagnosis
      1. Depression
      2. Anxiety
      3. Schizophrenia
      4. Borderline personality Disorder
      5. Post Traumatic Stress Disorder (PTSD) 
      6. Bipolar Disorder
    2. If you are unsure if a current diagnosis that the participant has falls into the category of Mental Health, then please follow up with your supervisor for guidance. 
  2. Mental Health information is captured in the PCSP
    1. You will need to gather information from the participant/POA during the visit to document a plan.
      1. Examples of questions to ask at the visit
        1. Do you currently take any medications to treat the diagnosis?
        2. Who prescribes the medication? (ie. Psychiatrist or PCP)
        3. How often do you see the prescribing physician? 
        4. Does anyone assist you with taking or remember to take these medications?
        5. Does anyone help monitor the effectiveness of your medication?
        6. Do you see a Therapist? If so, how often do you see them?
    2. Examples of ways that Mental health plan can be documented appropriately
      1. Mrs. Smith is diagnosed with anxiety and depression.  Mrs. Smith sees her PCP/Dr. Doe every month to review the effectiveness of her mental health medications.  Mrs. Smith has assistance from her HHA to remember to take her MH medications each day.  Mrs. Smith reports that her current medications are managing her diagnosis effectively at this time.
      2. Mr. Smith is diagnosed with schizophrenia and sees his Psychiatrist/Dr.Wright once every other month for medication review.  Mr. Smith’s daughter/Betty Smith provides supervision to ensure Mr. Smith is not exhibiting any unsafe behaviors and also monitors for medication effectiveness. A medication dispenser is used each day to ensure Mr. Smith takes his MH medications as prescribed.
      3. Mrs. Smith is diagnosed with depression and anxiety.  Mrs. Smith reported that she is not taking medication for these diagnoses and is not interested in a Behavioral health referral at this time.  Mrs. Smith feels she is managing her symptoms effectively at this time and is aware of the Mental health services available to her, but she is not interested at this time.
  3. You will need to document this information in the PCSP, currently on page 14 in the following question:

Writing that the Participant has Mental health Diagnosis and writing that there is no plan or indicating that the plan is not fully effective to meet the participants needs would not be considered sufficient.

If during the discussion of the Mental Health Plan with the participant they express that they would like to attain Mental Health services (ie. Therapist, Psychiatrist, etc) then a Behavioral Health Referral can be done. The Service Coordinator will email their Supervisor with the participants name, the best phone number where providers for these services will be able to reach the participant, the Diagnosis that is related to the referral (ie. Depression, Anxiety, etc), what specific service they would like to be referred for and a small explanation of why the participant would like the service (ie. Therapy to help learn to manage Depression symptoms OR Psychiatry to discuss medications for Anxiety). The Supervisor will then ensure the referral to PA Health and Wellness is done and the specified Provider being requested will then reach out directly to the participant.

PHW PCSP Videos

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