Sec. 07.02.19.05. Delivery of CARE Services by the Case Manager

A. Selection of a CARE Home.

(1) The case manager shall identify an appropriate CARE home and, with the applicant and the provider, make a placement plan.

(2) The selection of an appropriate CARE home shall include consideration of the following:

(a) The possibility of a same room assignment for both spouses if both require CARE services;

(b) Whether the CARE home can accommodate the needs of the applicant;

(c) The location of the CARE home, and whether the CARE home is in:

(i) The geographic area requested by the applicant;

(ii) The community where the applicant has established supports; or

(iii) A community which can provide access to specialized resources that the applicant wants or needs; and

(d) Whether the care available from the provider is:

(i) Sufficient to supervise the resident; and

(ii) The least restrictive setting which meets the resident's needs.

(3) If the CARE home is located outside the jurisdiction served by the local department:

(a) The local department in the jurisdiction where the home is located shall assign a case manager; and

(b) The new case manager shall work cooperatively with the original case manager to serve the applicant until:

(i) Placement is made; and

(ii) The case is transferred to the local department in the jurisdiction where the home is located.

B. Completed Application for Public Assistance to Adults (PAA). The case manager shall:

(1) If needed, ensure that an application for PAA is made by, or on behalf of, the applicant;

(2) Provide confirmation to the local department PAA worker of the placement plan including date, address of CARE home, and level of care; and

(3) Obtain a decision on eligibility for assistance.

C. Development of an Individualized Service Plan Agreement. The case manager, in consultation with the resident and service team, shall develop a service plan which includes the following:

(1) The specific goals to be accomplished by the resident;

(2) A list of the services needed to meet the goals as determined by the resident, the case manager, provider, and the service team;

(3) The specific plan for completing the tasks to meet the service needs of the resident, including identifying the individual, either the service team member or the resident, who will perform the task;

(4) A time line for completing tasks;

(5) The expected frequency of contact between the case manager and the resident; and

(6) The schedule for the local department to:

(a) Monitor the delivery of service;

(b) Redetermine eligibility for service; and

(c) Reassess the resident's needs.

D. Facilitation of Placement. Before placing the applicant in the CARE home, the case manager shall establish a residential agreement with the applicant and provider which shall determine the:

(1) Method and amount of payment;

(2) Level and type of service to be provided by the CARE home; and

(3) Provider's specific house rules.

E. Facilitation of Agency Linkage. The case manager shall:

(1) Complete referrals to services specified in the individualized service plan agreement following the resident's placement in the CARE home; and

(2) Follow-up on referrals as needed, until the delivery of service begins.

F. Monitoring the Implementation of the Individualized Service Plan Agreement. The case manager, with the resident, shall monitor the service plan through contact with the provider and others providing services, to ensure delivery and coordination of services and activities as specified in the service plan.

G. Reconsideration of the Individualized Service Plan Agreement.

(1) Reconsideration of the individualized service plan agreement shall occur:

(a) Within 90 days after placement, and at least every 6 months thereafter; or

(b) As required in Regulation .06B of this chapter.

(2) At the time of reconsideration, the case manager with the resident and service team shall:

(a) Reassess the resident's service needs; and

(b) Revise the individualized service plan agreement as needed.

H. Advocating on Behalf of the Resident. The case manager:

(1) Shall explore all possible community resources to provide needed services to the resident; and

(2) May convey unmet needs and barriers to service delivery in writing to the local department's program supervisors or administrators.

I. Coordination of Resident Entitlements. The case manager shall coordinate all applications or reapplication activities necessary to ensure that the resident receives or retains federal and State benefits.

J. Referral to Adult Protective Services (APS). The case manager shall report in writing to the local department's APS any instances of suspected abuse, neglect, self-neglect, or exploitation of a resident.

K. Arrangement of a New CARE Placement.

(1) The case manager, with the resident, shall arrange a new CARE placement when the:

(a) Resident or the provider requests a change because difficulties in the placement cannot be resolved;

(b) Local department finds the CARE home to be in violation of the requirements of this chapter, and revokes or does not recertify the home; or

(c) Case manager has determined that the current provider is unable to provide adequately for the resident's needs and safety.

(2) Time Requirements of Local Department. The local department shall:

(a) Pursue a new placement and provide appropriate transition planning and service for the resident within 30 days of the request or the decision to change the placement; or

(b) In case of emergency, attempt to move the resident immediately.

(3) Placement in Another Jurisdiction.

(a) If the resident moves or intends to move to another local jurisdiction, the case manager shall consult with the local department serving the other local jurisdiction.

(b) If the other local department has an appropriate and available placement and a case management capacity to serve the resident, the other local department shall assign a case manager to work cooperatively with the resident's current case manager to arrange placement.

(c) If the new placement is arranged, the case shall be transferred to the local department in the jurisdiction where the new home is located.

L. Maintaining Contact With the Resident and Provider.

(1) The case manager shall have face-to-face visits individually with the resident and with the resident and provider together.

(2) The case manager shall visit the resident:

(a) At least every 2 weeks in the following circumstances:

(i) During the first 3 months after placement;

(ii) During the first month following the assignment of a new case manager; and

(iii) When the resident's case plan does not include contact at least every 2 weeks with other service providers or appropriate friends or relatives; or

(b) At least once a month under all other circumstances unless a different schedule is warranted, in which case the case manager shall request a schedule change for approval by the Supervisor after the resident has been in placement for 90 days.

(3) Under no circumstances shall the resident be seen less than every 2 months.

(4) During each 6-month period, the case manager shall visit the resident and the provider together in the CARE home at least once.

(5) The case manager, with the supervisor's documented approval, may alter the required visitation schedule if the resident's situation requires or permits it.