Office for People With Developmental Disabilities

The Life Plan, Staff Action Plan and Delivery of Habilitation Services

This Question and Answer document provides clarification and guidance regarding the development of Life Plans and Staff Action Plans.

Additional resources, such as recorded training and PowerPoints are available here https://opwdd.ny.gov/providers_staff/care_coordination_organizations/msc_webinars.

 

Jump to a Question:

Questions and Answers:

How are OPWDD services identified within the Life Plan?

Services are identified in the Life Plan as follows:

  •   Habilitative, Home and Community Based Waiver services (HCBS)
    • Are listed in Section IV (HCBS Waiver Services and Medicaid State Plan Authorized Services) of the Life Plan.
    • The need for the service is explained in the Life Plan as a provider assigned goal or support in Section II (Outcomes and Support Strategies) and/or Section III (Individual Safeguards/Individual Plan of Protective Oversight).
  •   Non-habilitative waiver services (e.g., Respite, Support Broker, Fiscal Intermediary, Individuals Goods and Services):
    • Are listed in Section IV (HCBS Waiver Services and Medicaid State Plan Authorized Services) of the Life Plan.
    • The need for the service is explained in the Life Plan.  The need for the service is demonstrated by having a provider assigned goal or support in Section II (Outcomes and Support Strategies) and/or Section III (Individual Safeguards/Individual Plan of Protective Oversight).  If there are no provider assigned goals or supports, the need for the service is included in Section I (Assessment Narrative Summary).
  • OPWDD state-paid services (including Other Than Personal Services (OTPS). Family Reimbursed Respite (FRR) and Family Support Services (FSS):
    • Are listed in Section V (All Supports and Services; Funded and Natural/Community Resources) of the Life Plan.
    •   The need for the service is explained in Section I (Assessment Narrative Summary) of the Life Plan.
  •   Other Medicaid services not authorized by OPWDD (e.g., Article 16, 28 or 31 clinics), and federal, state or county funded resources (e.g., ACCES-VR, HUD, etc.):
    • Are listed in Section V (All Supports and Services; Funded and Natural/Community Resources) of the Life Plan.
    •   The need for the service is not required, but best practice is that Section I (Assessment Narrative Summary) of the Life Plan supports person’s comprehensive service needs.

Note: this reflects a change in Self Direction guidance for OTPS, which formerly required that OTPS be associated with a valued outcome.  

 

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How can disagreements in the person-centered planning process be resolved?

Please see ADM # 2018-06R “Transition to People First Care Coordination” page 5, “Dispute Resolution During the Life Planning Process” at this link:    https://opwdd.ny.gov/opwdd_regulations_guidance/adm_memoranda/2018-06

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What can the individual and his/her advocate do if they do not agree with the finalized Life Plan?

The individual and his/her advocate must follow the dispute resolution process as outlined in ADM #2018-06R (available at: https://opwdd.ny.gov/opwdd_regulations_guidance/adm_memoranda/2018-06R). If the conflict resolution is unsuccessful and the individual and/or his/her representative does not agree with the Life Plan, the individual and/or his/her representative may initiate an objection to the service plan per 14 NYCRR 633.12.

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What can a service provider do if there are inaccuracies in the finalized Life Plan?

Service providers are responsible for reviewing the finalized, acknowledged and agreed to Life Plan. Providers may occasionally find inaccuracies in the finalized, acknowledged and agreed to Life Plan. Providers should demonstrate due diligence in working with the Care Manager, Care Coordination Organizations (CCOs), OPWDD and/or others to correct the Life Plan as soon as possible. Service providers should document their timely efforts to correct any errors in the Life Plan. Examples of this documentation may include notes in the individual’s Monthly Summary, e-mails, phone calls, etc.  See ADM #2018-06R (https://opwdd.ny.gov/opwdd_regulations_guidance/adm_memoranda/2018-06) for more information.

 

 

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What can a service provider do if it does not agree with and/or cannot deliver the goals/supports within the Life Plan?

Coming to agreement on the Provider Assigned Goals/Supports and safeguards during the Life Planning meeting is important so that all parties leave the meeting with the same understanding. Through this collaboration, most disagreements about the Life Plan can be avoided. However, should there continue to be disagreement about the Life Plan, providers must participate in the dispute resolution processes described in ADM #2018-06R (https://opwdd.ny.gov/opwdd_regulations_guidance/adm_memoranda/2018-06).  

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What should the Care Manager and care planning team do prioritize Provider Assigned Goals/supports generated from the comprehensive assessment process?

The goals and supports in Life Plan Sections II and III are generated through the comprehensive assessment(s) of the individual. These assessment-generated goals and supports are a starting point for the Care Manager and the care planning team to work from. The individual and the care planning team can add additional goals to the Life Plan, while working to prioritize the goals through the person-centered planning process. 

Prioritizing the goals and supports in the Life Plan is necessary to ensure that the individual’s progress can be monitored and strategies developed/adjusted based on this progress. Once prioritized, a reasonable number of goals should be included in the individual’s Life Plan. Without prioritization, the Care Manager, providers and other team members will not be able to effectively monitor goal achievement and service delivery. The planning team can decide to defer some goals to be included in later Life Plans. Deferred potential goals should be listed in any of the following: Life Plan Section I (Assessment Narrative Summary); Life Plan Section II and/or III (Special Considerations section); Summary of Inter Disciplinary Team (IDT) meeting section; or the Care Manager’s notes from the Life Plan meeting.  

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How do providers address goals and/or supports that are not captured in the comprehensive assessment process or documented in the Life Plan?

The Life Plan development is a team effort driven by the person in collaboration with the entire care planning team to ensure that the Life Plan captures the individual’s comprehensive needs and meaningful goals/supports so that services and supports are tailored to help the person achieve what is most important to him/her. The provider, as a required member of the care planning team, should discuss any information that they think should be a part of the person’s Life Plan. This includes goals and supports for the individual. If the Life Plan does not address a major goal or support that the person wants or needs, it should be revised to do so.

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Does the Life Plan need to be updated if there is a change to a goal, support or safeguard?

Whether the Life Plan needs to be updated depends on the nature of the change. Care Managers continually review the individual’s preferences, goals, and need for supports and safeguards. Care Managers must evaluate whether there is a need to update the Life Plan when an individual’s circumstances change.

  • Immediate changes to the Life Plan. If there is a sentinel event, the Care Manager must immediately change the person’s Life Plan and communicate the change to the individual and his/her care planning team. Sentinel events include but are not limited to: accidents or events resulting in serious personal injury; major medical events; a major psychiatric event or decompensation resulting in extended inpatient psychiatric hospitalization; and/or significant changes or improvement in behavior or physical functioning.
  • Non-immediate changes to the Life Plan. There may be a change to the person’s health and safety that are not a sentinel event as described in the paragraph above. These changes to the individual’s health and safety support needs must be met immediately by providers and communicated effectively to the Care Manager and support providers. While an immediate change to the Life Plan is not required, the Care Manager should document the communication in his/her care management notes. The Care Manager may update the person’s Life Plan at the regularly scheduled Life Plan Review meeting.
  •   No Life Plan change required. Temporary changes, such as those related to an illness, do not require a Life Plan change. However, temporary changes may need to be communicated timely to the Care Manager, providers, and care planning team. Temporary changes may also be documented in the care management notes.  

 

 

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The Life Plan has supervision levels defined differently than how my agency has defined them. How should supervision be listed in the Life Plan and Staff Action Plan?

Supervision levels in the Life Plan may be generated from the information provided by the comprehensive assessment process and are considered a starting point for review and discussion during the person-centered planning process. The Life Plan provides information and guidance to meet the person’s general planning needs, therefore through the person-centered planning review and discussion, the appropriate overarching level of supervision is identified and documented in the Life Plan.  The Staff Action Plan will then further define/outline the person’s safeguard needs and how they will be implemented by the provider including any additional detail needed for the supervision levels identified in the Life Plan. It is the responsibility of the habilitation provider to ensure that staff working with a person are trained on his/her needs and deliver services and supports in accordance with the Staff Action Plan developed by that provider. For example, the Life Plan may say, “Frequent Checks less than every 30 minutes” and the Staff Action Plan would provide further detail as, “checks every 15 minutes” or “checks every 5 minutes”. The level of supervision defined in the Staff Action Plan cannot be less than the overarching level of supervision outlined in the Life Plan. 

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If there is disagreement about staffing during times of hospitalization for a person who resides in a certified setting, how is this documented in the Life Plan?

The dispute resolution process as outlined in ADM 2018-ADM-06R must be followed. However, in order to come to a resolution, the care manger and planning team may be required to review all clinical documentation in order to come to a final resolution. While the dispute is being resolved the Life Plan should refer to the previously finalized ISP or Life Plan for hospitalization coverage.

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The Life Plan in Section II and III captures “Frequency”, “Quantity, and “Timeframe” and in Section IV captures “Qty”, “Unit”, “Per”, and “Total Units”. What is intended to be documented for each of these categories in the different sections of the Life Plan and how are they determined?

Sections II (Outcomes and Support Strategies) and III (Individual Safeguards/Individual Plan of Protective Oversight) of the Life Plan outline the frequency, quantity, and timeframe of a support or service. The frequency, quantity, and timeframe describe how often, in a certain time period, the provider will deliver services related to a provider assigned goal (e.g., two times per week, one time per month, ongoing).  All members of the care planning team work together to determine this information.

 In Section IV of the Life Plan (HCBS Waiver Services and Medicaid State Plan Authorized Services) details the information required in the Home and Community Based Services (HCBS) waiver service-specific Administrative Directive Memoranda (ADMs). The “Unit” field captures the frequency of the service (e.g., “hour” or “hourly”, “Day”). The “Duration” field lists the duration (e.g., “ongoing”, “one-time”).

Section IV of the Life Plan also identifies the authorization information for HCBS services. For example, “Qty”, “per” and “total units” reflect the number of units a person has been authorized to receive for that particular service. For Self-Directed Services (Broker, IDGS, and FI), a zero “0” should be entered in the total unit’s column and “per approved Self-Direction budget” should be stated in the comments section, until system changes allow “per approved Self-Direction budget” to be entered in the total unit’s column.

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How is Section IV “total units” information completed if the Care Manager does not have documentation of this information?

If the planning team is uncertain of the specific total units authorized, Care Managers can find the information in the CHOICES application for services that were authorized from 2014 forward. If the authorized units are unknown, then the “total units” column will be documented as “99999” for that service. The correct number of authorized units should be entered for the service once known. The total unit’s field is for discussion and planning purposes only and is not included as a billing standard for service provision.  

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What are the requirements for the Council on Quality and Leadership (CQL) Personal Outcome Measures (POMs) in the Life Plan?

Care Management service and planning requires that an individual’s Life Plan (as a whole, not for each habilitative service) has at least two different CQL POMs identified and at least three different “My Goals/Valued Outcomes” identified within Section II of the Life Plan.  The three “My Goals/Valued Outcomes” can be identified in Section II of Life Plan as a goal (G) or support (S). This information can be found in the Care Coordination Organization/ Health Home (CCO/HH) Provider Policy Guidance and Manual within section 1.8 Additional CCO/HH Standards and Requirements and section 3.3 Performance Management and Quality Metrics at the following link: https://opwdd.ny.gov/providers_staff/care_coordination_organizations/providers/cco-manual.

Habilitation service provision and planning require that every habilitation service must be derived from at least one “My Goals/Valued Outcome” identified in the individual’s Life Plan. Habilitation provider assigned goals and supports identified in Sections II and III of the Life Plan must meet the requirements for habilitative goals described in the habilitative provider’s Staff Action Plan. This information can be found in Administrative Directive 18-ADM-09R at the following link: https://opwdd.ny.gov/opwdd_regulations_guidance/staff-action-plan-program-and-billing-requirements

 

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Does the language in the Staff Action Plan, related to the Provider Assigned Goal/Support need to be listed exactly as it is in the Life Plan?

Yes.  The Staff Action Plan must include the identification of the habilitation “My Goals/Valued Outcome” and Provider Assigned Goal(s) and/or support(s) as they are stated in the individual’s Life Plan. However, when developing the detail of the Staff Action Plan, the provider adds more detail to clarify the meaning and intent of the Provider Assigned Goal and/or support. The provider must ensure that staff are trained and deliver services and supports based on the information and detail within the Staff Action Plan.

For example, a person’s Life Plan has the provider assigned support “pursue my hobbies and interests.” The Staff Action Plan must identify the provider assigned support as “pursue my hobbies and interests,” then also describes how the support will be achieved.  For example, the Staff Action Plan details that staff will, “assist the person to attend craft fairs or art museums 4 times per month.”

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Who must receive the Staff Action Plan?

The Staff Action Plan must be provided to the Care Manager as required by ADM 2019-09R available at: https://opwdd.ny.gov/opwdd_regulations_guidance/staff-action-plan-program-and-billing-requirements).

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If the frequency of the Provider Assigned Goal/Support in Section II or III of the Life Plan is “as needed” or “ongoing” is it acceptable for the Staff Action Plan to list a more specific frequency?

Yes. When the frequency of a Provider Assigned Goal/Support in Section II or III of the Life Plan is “on-going” or “as needed”, the habilitation provider can include a more specific frequency when developing the Staff Action Plan that is consistent with the frequency in which the provider will be working with the individual on the specified goal or support.

 

The Staff Action Plan cannot include a frequency that is less than what is indicated in the Life Plan. The Staff Action Plan must include enough detail for any new habilitation staff to know what they must do, how to assist the individual to achieve his/her habilitation goals/valued outcomes, and how to address the individual’s safeguard needs. The provider must ensure that staff working with the person are fully trained to deliver services and supports for the person as they are detailed in his/her Staff Action Plan. For example, a person’s Life Plan has the provider assigned support “frequent checks (less than 30 minutes) with a frequency of as needed.” This support would be identified in the Staff Action Plan as follows: Provider Assigned support from Life Plan: “frequent checks (less than 30 minutes) with a frequency as needed.” The staff action detail might describe: “While I am at home, staff will check on me every 15 minutes.” 

 

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Can safeguards/Individual Plan of Protection (IPOP) information be documented in the Staff Action Plan as well as other guidance documents?

Yes. Individual safeguards/IPOP needs from the Life Plan must be identified and addressed in the Staff Action Plan(s), or the Staff Action Plan can reference another internal guidance document(s) that outlines the detailed implementation of protective oversight measures (e.g., Behavior Support Plan). Please refer to ADM #2019-09R “Staff Action Plan Program and Billing Requirements (https://opwdd.ny.gov/opwdd_regulations_guidance/staff-action-plan-program-and-billing-requirements) for further information.

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Is a Staff Action Plan required for individuals who are receiving state-paid habilitation services?

Yes. A Staff Action Plan is required for individuals who are receiving state-paid habilitation service(s). 

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Is a Staff Action Plan required if a goal or support is assigned to an individual, natural support, or non-habilitative service provider?

No. Only habilitation providers must have a Staff Action Plan

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Do all Provider Assigned Goals in Section II and III that are assigned to a particular provider need to be included in the Staff Action Plan?

Yes.  All assigned goals and supports must be included in the Staff Action Plan.  

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Staff Action Plans are due within 60 days of a Life Plan. Does the broker now have 60 days to sign off on a plan?

Yes. Per ADM # 2018-09R, one of the Staff Action Plan Billing Standards is “Evidence demonstrating the Staff Action Plan was distributed no later than 60 days after the start of the habilitation services; the life plan review date; or the development of a revised/updated Staff Action Plan, whichever comes first (which may include, but is not limited to: a monthly narrative note; a Health Information Technology System (HITS) upload; or e-mail).” The Staff Action Plan must also include the “Date (day, month, and year) that staff signed the Staff Action Plan.” The Staff Action Plan does need to be signed by the author (Support Broker for Self-Hired services). Support Brokers should not be waiting on a finalized Life Plan to start drafting the Staff Action Plan. Rather, they should have collected information and have established agreed upon means of communication with the Care Manager during the Life Plan review meeting to aid them in putting the document together

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Where Budget Authority allows people to shift funding between services in the Self-Direction Budget, how should the “Total Units” field be documented in Section IV for Self-Directed Services?

For all Self-Direction Services that are not Agency Supported or Direct Provider Purchased, a “0” should be entered in the “Total Units” field and the Care Manager must add “per approved Self-Direction budget” in the special instructions/comments field, until the system allows for selection of “per approved Self-Direction budget” in the Total Units field. For services in the Self-Direction Budget that are Agency Supported or Direct Provider Purchased, the fields should reflect the same authorized units as if the services were not self-directed.

 

 

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What are the effective dates of the Life Plan?

The Life Plan has a “from-to” date range that is based on an annual period.   The “from” date is the date of the Life Plan meeting.  The “to” date is the one-year date range that the Life Plan is in effect and the additional dates to get to the last day of the month that the Life Plan is in effect.  For example, a Life Plan review meeting takes place on March 16, 2019.   The Life Plan effective dates are from March 16, 2019 to March 15, 2020 or March 31, 2020 to get to the end of the calendar month in which the 365th day occurs.  The day of the Life Plan meeting is the beginning or “from” effective date. The annual review must occur within 365 days of the prior annual review or by the end of the calendar month in which the 365th day occurs.

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