HCBS Lead Agency Review
List of Items Reviewed
Programs
Required Items
All
A support plan (ISP, CSSP, etc.) that was competed in
the last year including being signed by all required parties.
AC
Alternative Care Program Client Disclosure Form (DHS-3548) and
Alternative Care Program Eligibility Worksheet (DHS-2630 or DHS2630A) are completed and signed annually.
All
A person’s individualized outcomes and goals are
documented in the person’s support plan.
All
A Release of Information allowing the lead agency to share private
information is signed by the person annually.
All
The needs that were identified in the
assessment/screening process are documented in the
support plan.
Service details such as provider name, type, frequency,
and cost are included in the support plan.
All
Right to Appeal information has been provided to the person in the
last year. Evidence of person’s signature and date is required.
All
A person’s health and safety concerns identified in the
assessment/screening process are documented in the
support plan.
The services a person is receiving are documented in the
support plan.
The person acknowledges choices in support planning
process, including choices in community settings,
services, and providers.
Information on competitive employment opportunities
is provided to people (aged 16 to 64) annually. This may
include referrals to providers, enrolling in an HCBS
vocational service, or a conversation about future plans.
An emergency back-up plan completed within the last
year and includes: a primary doctor or admitting hospital &
phone numbers; an emergency contact person & a phone
number, and a plan to address an absence of staffing.
All
Notice of Privacy Practices/HIPAA information has been provided to
the person when private information is collected. Evidence of person’s
signature and date is required.
Documentation that face to face visits with persons have occurred
within the required timelines for each HCBS program.
Current assessment/screening documents which are
signed and dated by all required parties, such as the
legacy LTCC assessment (DHS- 3428) or the DD
screening document (DHS – 3067). Note DHS has access
to MnCHOICES summary reports.
Supplemental Form for Assessment of Children Under
18 (DHS-3428C) is completed at the time of assessment.
All
All
All
All
CAC,
CADI, BI,
DD
All
All
CAC,
CADI, BI
All
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HCBS case manager is not also performing the duties for
public guardianship, including signing documentation.
BI
CAC
BI Waiver Assessment and Eligibility Determination form (DHS –
3471) is completed annually and signed by the person or MnCHOICES.
CAC Application (DHS-3614) or Request for Physician Certification
of Level of Care (DHS-7096) is completed annually by the physician.
DD
Level of Care for ICF/DD and DD Waiver Services document ((DHS4147A) is completed and signed with in the last year or MnCHOICES.
DD
Related Conditions Checklist (DHS - 3848) is completed annually for
people with a related condition, as indicated by a “V code” diagnosis
listed on the DD screening document.
CAC,
CADI, BI,
EW, AC
OBRA Level One Screening form is completed via (DHS-3426) or
MnCHOICES.
CAC,
CADI, BI,
DD
Application for Title XIX HCBS Waiver Services (DHS 2727) is
completed and signed annually by the person.
HCBS Lead Agency Review
Programs
Other Items Reviewed in Support Plan
All
All
All
All
All
Support plan identifies and has a plan to reduce personal
risks.
Support plan is written in first person language.
Support plan is written in plain language.
The type of preferred work activities are identified.
Natural supports and caregiver supports are included.
Programs
Other Items Reviewed
All
All
All
All
Person’s satisfaction with vendors or choice in vendors is
discussed/documented
Case file check lists or audit tools
Paper or electronic visit sheets and/or monitoring forms
Person’s level of involvement in the planning process
Programs
Positive Support Transition Plan (PSTP) Items
All
PSTP is present and completed on the required form
(DHS-6810)
PSTP is complete and signed by all required parties
PSTP modified according to team’s recommendations
Integration between PSTP, PSTP review form(s), and
HCBS Support Plan
All
All
All
All
All
All
All
All
All
Provider reports and communication
All
All
School and/or IEP information
Case notes document life events of the person
All
PSTP review form(s) (DHS- 6810A) is present, completed and signed
by all required parties
PSTP modifications were completed timely
PSTP reviews completed at the stated intervals
All
All
Programs
Jensen Settlement Member Items
All
All
Brief history of the person included in the plan.
Person’s preferred method of communication is
documented in the plan.
Persons preferred living setting is described, including
who the person wants to live with.
Social/leisure activities the person wants are described
including with whom the person wants to socialize.
Barrier’s a person faces are documented in the plan.
Process for monitoring the plan is documented in the plan.
All
All
Person’s goals and skills are described in the plan,
including the activities needed to achieve the goals.
All
All
All
All
All
All
Support plan identifies who is responsible for monitoring
implementation of the plan.
Support plan includes a person’s strengths.
The type of preferred living setting is identified.
Support plan includes a global statement about the person’s dreams.
Support plan incorporates other health concerns (e.g. mental health,
chemical health, chronic medical conditions, etc.).
All
All
All
All
Person’s rituals and routines are described.
A global statement about the person’s dreams is in documented in the
plan.
Work and/or school activities the person wants are described in the
plan.
Skills and leisure activities a person wants to learn are described in the
plan.
All participants in planning process are documented.
The person has both a current HCBS Support Plan (CSSP, ISP, etc.)
and a separate Person Centered Plan which is dated within 366 days.
Evidence that Person Centered Plan was revised if goals not achieved
or services unresponsive.
If you have additional questions, please contact the Lead Agency Review Team at dhs.leadagencyreviewteam@state.mn.us or visit the project website at
www.minnesotahcbs.info .
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