Form 3629, Individual Program Plan Addendum

Effective Date
05/2015
Document
Document
3629.pdf (117.48 KB)

Instructions

Updated: 5/2015

PURPOSE

Form 3629 is completed for applicants/individuals being assessed for Community Living Assistance and Support Services (CLASS)/Community First Choice (CFC) services. The form is used as an instrument for collecting and documenting essential information about individuals in the CLASS program.

Form 3629:

  • is developed through a person-centered planning process;
  • occurs with the support of  a group of people chosen by the individual (and the legally authorized representative (LAR) on the individual's behalf); and
  • accommodates the individual's style of interaction, communication and preferences regarding time and setting.

Form 3629 is used to:

  • identify the individual’s strengths, preferences, support needs and desired outcomes;
  • identify what is important to the individual;
  • document the individual’s preferences for when to receive CLASS/CFC services; and
  • identify any special needs, requests or considerations staff should know when supporting this individual.

PROCEDURE

When to Prepare

Form 3629 is completed by the CLASS case manager in its entirety when an individual is applying for CLASS/CFC services and at least annually for individuals receiving CLASS/CFC services. The form is also updated whenever the individual’s needs have substantially changed.

If an individual or LAR does not know the information requested or refuses to answer, document that in the space provided.

 

Form Retention

The case management agency (CMA) must keep the original copy of the form in the individual's case record and provide a copy to the direct services agency.

The CMA must keep this form according to record retention requirements documented in the CLASS Provider Manual.

 

DETAILED INSTRUCTIONS

Individual’s Name — Enter the individual’s name. (Required on each page of the assessment).

Individual’s Medicaid No. — Enter the individual’s nine-digit Medicaid number. (Required on each page of the assessment).

Date of Assessment — Enter the date this assessment is completed.

Participants — List each person, other than the individual, who participated in this assessment.

Type of AssessmentCheck the type of assessment being conducted: enrollment, renewal or revision.

Note: The information contained in this form is obtained through an information gathering conversation (the discovery process) about the individual’s abilities, preferences and goals, in line with person centered planning principles.

Section I:  Individual’s Profile

One Page ProfileThe “One-Page Profile” format is based on work by The Learning Community for Person Centered Practices.

Insert Photo Here (optional)If available, insert one or two recent photos of the individual or photos of people, places or things that are important to the individual. This is optional, but provides additional information about the individual.

A little about myself Enter a descriptive narrative including general information you have learned about this individual through the discovery process.

What people like and admire about meEnter a descriptive narrative including what you have learned through the discovery process that others like and admire about the individual.

What's important to me (“Important To”) — Enter what you have learned through the discovery process that is important to the individual. “Important to” reflects what is important from the individual’s perspective and is based on conversation with and/or observation of the individual. The information might include important relationships, how the individual prefers to interact, things the individual likes to do or not do, preferred routines, relevant background information that may affect how the service should be delivered and what the individual wants to do in the future. Remember the individual’s response is limited to the knowledge and experiences he/she has to date. Additional efforts should be explored to increase his/her awareness of additional possibilities and experiences to increase his/her options of choice.

What others need to know and do to support me (“Important For”) Enter important information you have learned through the discovery process about the individual, such as how the individual communicates and how to best communicate with him or her.  Include what you have learned through the discovery process that is important for the individual, as identified by those who know him or her best. “Important for” reflects information that is important for the service provider to know and understand about the individual. This information should be related to health, safety and any supports regarded as necessary to enhance the individual to be a valued individual of the community. Enter information such as health needs, supervision requirements, specific behavioral needs and special instructions for those who support the individual. This section includes contraindications and special justifications for deviating from typical routines or activities (for example, adult day care three days a week, four hours a day, or a job four days a week, five hours a day). List any barriers that could prevent the outcomes/purposes from being achieved. Things identified as “important for” are not usually included as “important to” the individual.

What the people are like who support me best Enter important information about the type of people in the individual’s life who provide support to him or her, including characteristics and traits that make those people most supportive (for example, someone with a gentle voice who enjoys the same activities as the individual, etc.). Provide any information that may be important to a successful match between the individual and the CFC personal assistance services (PAS)/habilitation provider. You may also include types and characteristics that do not support the individual well.

How I like to spend my day Enter important information you have learned through the discovery process about the individual, such as what the individual enjoys doing during the day and important routines or rituals for the individual. Indicate if the individual enjoys being in the community, staying home, being with large groups or being alone.

The services I am currently receiving are Enter important information you have learned through the discovery process about the individual’s current services, both professional and non-professional. This may include therapies, waiver and non-waiver supports.

Section II:  Important People in the Individual’s Life

(“Important Because”) List the people who are close to the individual and who know and care about him or her. This will help the provider in determining who to speak with in certain situations. It will also help to ensure that the individual does not lose contact with important people in his or her life (Additional rows may be added, if necessary.)  Enter the names, relationships, telephone numbers, addresses, email addresses and the reason the individual/LAR has identified this individual as being important to list on this form. Physicians and professionals should be included in the Community/Other section.

Examples of important people are:

  • He takes the individual to work.
  • She is a friend the individual calls every weekend.
  • He stays with the individual until mom comes home from work.
  • She is the individual’s favorite teacher and helps tutor on weekends.
  • He takes the individual to Special Olympics practices and out to eat.
  • The individual stays with him during the holidays.

Section III - Acknowledgement

Signing this page affirms the individual/legally authorized representative (LAR)/provider representative/case manager participated in the service planning process.

Signature of Individual or Legally Authorized Representative and Date The individual or LAR must sign and date Form 3629 after completion. Any updates to the form must be initialed and dated by the individual/LAR. If the individual/LAR refuses to sign the form, the case manager should note this on the signature line of the form.

Printed Name Print or enter the individual’s or LAR’s name.

Signature of CLASS/CFC Case Manager and Date The case manager must sign and date Form 3629 after completion. Any updates to the form must be initialed and dated by the assessor.

Printed Name of Case Manager Print or enter the case manager’s name.

Signature of Provider Representative and Date — If a representative participates in the completion of the assessment, he or she must sign and date Form 3629 after completion. Any updates to the form must be initialed and dated by the representative, if applicable.

Printed Name of Provider Representative Print or enter the representative’s name.

Signature of Other Person and Date If there is another person who participates in the completion of the assessment, he or she must sign and date Form 3629 after completion.

Printed Name of Other Person Print or enter the other person’s name.