R510-400-11. Case Management

  (1) Case Management shall be provided to all recipients of Home and Community Based Alternatives services.

  (2) PROCEDURES-Case Management:

  (a) Case Management shall include an assessment, annual reassessment, three quarterly review and monthly contacts. Other visits or contacts shall be made and documented in accordance with the client's need or as directed in the Care Plan.

  (b) A monthly or more frequent contact shall be made with the client, service provider, and/or the client's family.

  (c) Assessment and quarterly review, reduction and/or termination of service should be done face to face when possible, with the exception of when the client moves out of the area, enters a nursing facility or dies. Telephone and electronic contacts can be used to communicate adjustments to care plans or service orders, or changes of status.

  (d) The Case Manager will record all client contacts and significant changes with a progress note.

  (e) The Case Manager is expected to maximize the client's informal support systems.

  (f) The Case Manager shall make quarterly reviews during the third month following the Assessment and every third month thereafter. Quarterly Reviews shall be conducted in the client's home and will document the following:

  (i) A review of the services being delivered.

  (ii) Changes in the client's condition.

  (A) Progress toward Care Plan objectives and goals.

  (B) Appropriateness of services.

  (3) The client's satisfaction and concerns with the service provision.

  (4) Status of rental/purchased equipment.