Coordinated Support and Service Plan Addendum Form

* = Required Information

Descriptive Information

Name of Person Served *

Program *

Date of Development *

For the Annual Period *

Name and Title of Person Completing the CSSPA *

Scope of Services

Intensive Services per 245D

Unlicensed

Is the current setting the most integrated setting available and appropriate for the person served?

Yes

Describe what will be done to address this:

Does the person require the presence of staff at the service site while services are being provided?

Yes

Please provide information on when staff does not need to be present with this person (include community, home, or work) and for the length of time:

How will services be coordinated across other licensed providers serving this person to ensure continuity of care?

If there is a need for service coordination between providers, include the name of the service provider, contact person including title, telephone number, and the service being provided.

Service Provider

Staff Responsible for
Coordination/Title

Phone

Service Provided

Health and Medical Supports

I. Supports necessary to support the person’s health based upon the Self Management Assessment and the requirements of person centered planning and service delivery:

Health or Medical Area of Need:

Allergies

Supports Needed or Wanted per SMA
N/A Yes No

Describe the Supports Provided by A Helping Hand Senior Care Services
Seizures

Supports Needed or Wanted per SMA
N/A Yes No

Describe the Supports Provided by A Helping Hand Senior Care Services
Choking

Supports Needed or Wanted per SMA
N/A Yes No

Describe the Supports Provided by A Helping Hand Senior Care Services
Special Dietary Needs

Supports Needed or Wanted per SMA
N/A Yes No

Describe the Supports Provided by A Helping Hand Senior Care Services
Medical Appointments

Supports Needed or Wanted per SMA
N/A Yes No

Describe the Supports Provided by A Helping Hand Senior Care Services
Dental Appointments

Supports Needed or Wanted per SMA
N/A Yes No

Describe the Supports Provided by A Helping Hand Senior Care Services
Preventative Screening

Supports Needed or Wanted per SMA
N/A Yes No

Describe the Supports Provided by A Helping Hand Senior Care Services
Chronic Medical Condition:

Supports Needed or Wanted per SMA
N/A Yes No

Describe the Supports Provided by A Helping Hand Senior Care Services
Chronic Medical Condition:

Supports Needed or Wanted per SMA
N/A Yes No

Describe the Supports Provided by A Helping Hand Senior Care Services
Chronic Medical Condition:

Supports Needed or Wanted per SMA
N/A Yes No

Describe the Supports Provided by A Helping Hand Senior Care Services
Other:

Supports Needed or Wanted per SMA
N/A Yes No

Describe the Supports Provided by A Helping Hand Senior Care Services

II. Level of Support Provided with Medication Administration or Assistance, if assigned responsibility:

Medication Assistance

[Definition: Program staff opening the container of previously set-up medications, emptying the container into the person’s hand, or opening and giving the medication in the original container to the person so the person can self-administer their own medication or treatment.]

Medication Set Up

[Definition: Program staff arranging of medications to instructions from the pharmacy, the prescriber, or a licensed nurse, for later administration.]

Medication Administration

[Definition: Program staff are fully responsible for all aspects of medication administration.]

If A Helping Hand Senior Care Services LLC. is assigned responsibility for medication administration or medication set up, the following information will be reported to the legal representative and case manager as they occur, unless indicated here:

a dose of medication is not administered or treatment is not performed as prescribed, whether by error by the staff or the person or by refusal by the person
the occurrence of possible adverse reactions to the medication or treatment;
concerns about the person’s self-administration of medication or treatment

III. Does a staff person who is trained in CPR need to be available when the person is present and when the staff is required to be at the site to provide direct service?

Yes

Personal Safety Supports

I. Supports necessary to support the person’s Personal Safety based upon the Self Management Assessment and the requirements of person centered planning and service delivery:

Personal Safety Area of Need:

Risk of Falling

Supports Needed or Wanted per SMA
N/A Yes No

Describe the Supports Provided by A Helping Hand Senior Care Services
Mobility

Supports Needed or Wanted per SMA
N/A Yes No

Describe the Supports Provided by A Helping Hand Senior Care Services
Regulating Water Temperature

Supports Needed or Wanted per SMA
N/A Yes No

Describe the Supports Provided by A Helping Hand Senior Care Services
Community Survival Skills

Supports Needed or Wanted per SMA
N/A Yes No

Describe the Supports Provided by A Helping Hand Senior Care Services
Water Safety Skills

Supports Needed or Wanted per SMA
N/A Yes No

Describe the Supports Provided by A Helping Hand Senior Care Services
Sensory Disabilities

Supports Needed or Wanted per SMA
N/A Yes No

Describe the Supports Provided by A Helping Hand Senior Care Services
Other:

Supports Needed or Wanted per SMA
N/A Yes No

Describe the Supports Provided by A Helping Hand Senior Care Services

ADL and IADL Supports

I. Supports necessary to support the person’s ADL’s and IADL’s based upon the Self Management Assessment and the requirements of person centered planning and service delivery:

ADL’s and IADL’s Area of Need:

Bathing

Supports Needed or Wanted per SMA
N/A Yes No

Describe the Supports Provided by A Helping Hand Senior Care Services
Eating

Supports Needed or Wanted per SMA
N/A Yes No

Describe the Supports Provided by A Helping Hand Senior Care Services
Toileting

Supports Needed or Wanted per SMA
N/A Yes No

Describe the Supports Provided by A Helping Hand Senior Care Services
Grooming

Supports Needed or Wanted per SMA
N/A Yes No

Describe the Supports Provided by A Helping Hand Senior Care Services
Cleaning/Household Chores

Supports Needed or Wanted per SMA
N/A Yes No

Describe the Supports Provided by A Helping Hand Senior Care Services
Shopping for Food and/or Personal Needs Items

Supports Needed or Wanted per SMA
N/A Yes No

Describe the Supports Provided by A Helping Hand Senior Care Services
Laundry

Supports Needed or Wanted per SMA
N/A Yes No

Describe the Supports Provided by A Helping Hand Senior Care Services
Meal Planning and Preparation

Supports Needed or Wanted per SMA
N/A Yes No

Describe the Supports Provided by A Helping Hand Senior Care Services
Transportation

Supports Needed or Wanted per SMA
N/A Yes No

Describe the Supports Provided by A Helping Hand Senior Care Services
Other

Supports Needed or Wanted per SMA
N/A Yes No

Describe the Supports Provided by A Helping Hand Senior Care Services

Symptoms or Behaviors Supports

I. Supports necessary to support the person’s Symptoms or Behaviors based upon the Self Management Assessment and the requirements of person centered planning and service delivery:

Personal Safety Area of Need:

Mental Health Crisis that requires the program to call 911 or an intervention team

Supports Needed or Wanted per SMA
N/A Yes No

Describe the Supports Provided by A Helping Hand Senior Care Services
An act or situation that requires the program to call 911, law enforcement, or the fire department

Supports Needed or Wanted per SMA
N/A Yes No

Describe the Supports Provided by A Helping Hand Senior Care Services
Unauthorized or unexplained absence

Supports Needed or Wanted per SMA
N/A Yes No

Describe the Supports Provided by A Helping Hand Senior Care Services
Conduct against another person receiving services that interferes, induces a fear of harm or damage to property, or disrupts operation of program

Supports Needed or Wanted per SMA
N/A Yes No

Describe the Supports Provided by A Helping Hand Senior Care Services
Other [list]:

Supports Needed or Wanted per SMA
N/A Yes No

Describe the Supports Provided by A Helping Hand Senior Care Services

II. Permitted Actions and Procedures

On a continuous basis, does the person require the use of permitted actions and procedures that include physical contact or instructional techniques:

Permitted Procedure or Instructional Technique

To calm or comfort a person by holding that person with no resistance

Allowed?

Yes

To protect a person known to be at risk of injury due to frequent falls as a result of a medical condition

Allowed?

Yes

To facilitate the person’s completion of a task

Allowed?

Yes

To block or redirect an person’s limb or body without holding the person or limiting the person’s movement to interrupt the person’s behavior that may result in injury to self or others with less than 60 seconds of physical contact by staff

Allowed?

Yes

To redirect a person's behavior when the behavior does notpose a serious threat to the person or others and the behavior is effectively redirected with less than 60 seconds of physical contact by staff

Allowed?

Yes

To allow a licensed health care professional to safely conduct a medical examination or to provide medical treatment ordered by a licensed health care professional

Allowed?

Yes

To assist in the safe evacuation or redirection of a person in the event of an emergency and the persona is at imminent risk of harm

Allowed?

Yes

Use of adaptive aids or equipment, orthotic devices, or other medical equipment ordered by a licensed health care professional to treat a diagnosed medical condition

Allowed?

Yes

III. Does the person require a restriction of their rights as listed in 245D.04, subdivision 3 to ensure the health, safety, or well- being of the person?

Yes, see Rights Restriction

Person Centered Planning and Discussion

I. How will A Helping Hand Senior Care Services provide services that are reflected in my Snapshot and Individual Preferences and Satisfaction

II. Are there any additional requirements requested for staff to have or obtain in order to meet the needs of the person?

III.The person’s desired outcomes and methods or actions that will be use to support the person and to accomplish the service outcomes:

Outcome #1:

Outcome #2:

Outcome #3:

IV. A discussion of how technology may be used to meet the person’s desired outcomes has occurred:

Yes

Provide a summary that describes decisions made regarding the use of technology and a description of any further research that needs to be completed before a decision regarding the use of technology can be made:

Reporting and Notifications

Information received regarding reporting and notifications is completed with the personserved and his/her legal representative and case manager.

I. Frequency of Progress Reports, at a minimum of annually:

Annually

Other

II. Preference for receipt of Progress Reports or Pre-Annual reports

At the Support Team Meeting

At least five (5) workings days prior to the Support Team Meeting

III. Frequency of service plan review meetings, at a minimum of annually:

Quarterly

Semi-Annually

Annually

IV. The frequency of medication administration record reviews will be conducted quarterly unless otherwise specified

V. The legal representative and case manager will receive notification within 24 hours of an incident or emergency occurring while services are being provided OR within 24 hours of discovery or receipt of information that an incident occurred Please indicate any changes regarding this notification:

VI. Next Meeting

Date

Time

Location

Attendance

All team members in attendance will sign, identify their title or role, and indicate the date they attended. Signature below also indicates plan approval.

Signature

Title

Date

Indicate reason why the Guardian, Case Manager, or the Person Receiving Services was not present for the meeting

Per MN Statutes, section 245D.071, A Helping Hand Senior Care Services LLC. must distribute the CSSPA for signatures by the person and/or legal representative and case manager within 20 working days of the 45-day planning meeting [or within 10 working days of a service plan review meeting].

Date which the CSSPA was mailed to the person and/or legal representative, and the case manager