Form 3628, Provider Agency Model Service Backup Plan

Effective Date
07/2015
Document
Document
3628.pdf (105.04 KB)

 

Instructions

Updated: 3/2021

 

Purpose

The Service Backup Plan documents the strategies implemented in the absence of the direct service provider or in an emergency. The services requiring a backup plan are identified by the Texas Health and Human Services Commission (HHSC) as outlined in the section below.

 

Procedure

When to Prepare

The service planning team (SPT) completes this form:

  • at least annually; and
  • any time a revision to the Service Backup Plan is needed based on problems with implementation of the plan or changes in the resources required to carry out the plan.

The following services and service codes require a backup plan in the following programs:

  • Community Living Assistance and Support Services (CLASS) – Habilitation Services (SVC 10), Habilitation Delegated (SVC 10A), Community First Choice Personal Assistance Services Habilitation (CFC PAS/HAB) (SVC 10CFC), Licensed Vocational Nursing (LVN) Nursing Services (SVC 13A), Registered Nursing (RN) Nursing Services (SVC 13B), RN Specialized Nursing (SVC 13C) and LVN Specialized Nursing (SVC 13D). A backup plan for nursing services is required only for services provided under a nursing category other than an annual nursing assessment or post hospitalization visits.
  • Deaf Blind with Multiple Disabilities (DBMD) – The SPT determines whether a backup plan is necessary for CFC PAS/HAB (SVC 10CFC), Residential Habilitation (SVC 17), LVN Nursing Services (SVC 13A), RN Nursing Services (SVC 13B), RN Specialized Nursing (SVC 13C) and LVN Specialized Nursing (SVC 13D), as identified on the Individual Plan of Care (IPC) with a check box . When a backup plan is indicated for nursing services, it is only for services beyond an annual nursing assessment or post hospitalization visits.

For the CLASS program, the direct services agency (DSA) is responsible for completing this form in conjunction with the SPT.

For the DBMD program, the DBMD provider agency is responsible for completing this form in conjunction with the SPT when the IPC indicates with an X in a check box that a service requires a backup plan.

Number of Copies

CLASS – The DSA maintains the completed form and provides a copy of the form to the case management agency, individual/legally authorized representative (LAR).

DBMD – The DBMD provider maintains the completed form and provides a copy of the form to each member of the SPT.

Transmittal

CLASS – All copies must be provided within seven calendar days from the date of form completion.

DBMD – All copies must be provided within 10 calendar days from the date of form completion.

Form Retention

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

DBMD – Retain this form according to the record retention requirements in the Texas Administrative Code, Chapter 49, Contracting for Community Care Services.

 

Detailed Instructions

Name of Individual — Enter the name of the individual receiving services.

Program — Check the appropriate program box.

Service — Enter the service requiring a service backup plan.

For CLASS – Form 3621, Individual Plan of Care (IPC), will identify services available to an individual that require a backup plan.

For DBMD – Form 6500, Individual Plan of Care (IPC), will identify services available to an individual that might require a backup plan, as identified by the SPT.

Case Management Agency (CLASS only) — Enter the name of the case management agency.

Direct Services Agency (CLASS only) — Enter the name of the DSA.

DBMD Provider Agency — Enter the name of the DBMD Provider Agency.

Type of Service Backup Plan — Check the type of service backup plan as applicable.

Date of Service Planning Team Meeting — Enter the date the individual's SPT met.

Effective Date of Service Backup Plan — Enter the date the service backup plan will be effective. The effective date of the enrollment/renewal backup plan should correspond with the effective date of the enrollment/renewal IPC. The effective date of a revision to the backup plan is determined by the SPT.

Backup Plan Strategies and Sequence — The SPT must develop a service backup plan that ensures the delivery of the service when the individual's regular service provider is not available to deliver the service or in an emergency. The plan may include the use of paid service providers; unpaid service providers, such as family members, friends or non-program services; or respite, if included in the authorized service plan.

Specific Action(s) to be Taken in Absence of Service Delivery — The SPT must list the steps the team will follow in order to implement the backup plan.

Signature of Resource Person, Area Code and Telephone No. — The resource person agreeing to provide backup services will enter and sign his/her name and telephone number to be contacted according to the backup plan.

Plan Approval Signatures — An individual's SPT must approve each service backup plan, as well as any revision, before implementation. Each member of the SPT, as applicable, must sign the service backup plan. The case manager may schedule an SPT meeting to review the proposed service backup plan.