6 Pa. Code § 21.54 - AAA care plan responsibilities
(a) The
AAA shall be responsible for the development and implementation of a plan of
care for each domiciliary care client.
(b) The care plan shall be developed in
consultation with the client and shall be signed by the client or the
designate, if appropriate, and the provider indicating their agreement with the
plan.
(c) The care plan shall
indicate problems or needs identified, desired outcomes (long and short term
goals), services or providers (informal or formal), pattern of service delivery
and follow-up monitoring and reassessment updates.
(d) Arrangements for service to supplement
service given by the provider shall be prescribed in the care plan and may be
made by the AAA directly or by referral to another agency. The purpose of the
supplemental service shall be to address special client needs which provide the
support necessary for the client to be maintained in the domiciliary care
home.
(e) The AAA shall orient the
provider to the client's care plan, secure the provider's approval and furnish
the provider with a copy of the plan.
(f) When the care plan is carried out by an
agency other than the AAA, that agency shall, with the concurrence of the AAA,
modify the care plan as required. This modification may include specification
of the client's role in providing for or assisting with laundry or meal service
as specified in §
21.74 (relating to basic
furnishings).
(g) When the care
plan is carried out by an agency other than the AAA, the AAA shall monitor as
necessary to insure that the care plan is being implemented.
(h) When an agency other than an AAA has the
primary care plan responsibility for a client, and the home in which that
client resides or is to be placed is operating under a joint certification
between the AAA and the agency with primary care plan responsibility, the
provider residency requirements in §§
21.26(2) and
21.27(b) (relating
to domiciliary care home provider eligibility; and domiciliary care home
certification and recertification standards) and determinations regarding the
apportionment of payments by clients to providers made in accordance with
§
21.41(6) (relating
to Departmental responsibilities) are not applicable.
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