§ 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 clients care plan, secure the providers 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 clients 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.
This section cited in 6 Pa. Code § 21.52 (relating to AAA service responsibilities); 6 Pa. Code § 21.60 (relating to recordkeeping); 6 Pa. Code § 21.74 (relating to basic furnishings); and 6 Pa. Code § 21.76 (relating to personal care responsibilities).
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