The Arc of Northern Rhode Island

PASS SERVICE PLAN

Child’s Name:                                                DOB:                          Child’s Age:

Date of Plan Development:

Plan Start and End Dates:

PART A: ASSESSMENT OF FAMILY CIRCUMSTANCE AND PREPAREDNESS

I.                   Relationships:

a)      Family -  

b)      Friends –  

c)      Other Service Providers –  

II. Personal Resources

What are the child’s Strengths?:

·

What challenges the child?:

·

III. Respect

IV. Choices

V.  Home/Other Environments

VI.   Communication (Optional) 

VII.   Health (Optional)

VIII.   Daily Routine

7:30 AM – 

8:00 AM –

3:15 PM – 

3:30 PM – 

4:00 PM – 

4:30 PM – 

5:00 PM – 

5:30 PM – 

6:00 PM – 

6:30 PM – 

7:00 PM – 

7:30 PM – 

8:00 PM – 

8:30 PM – 

9:00 PM – 

9:30 PM  - 

Analysis - 

IX. What does the child need to learn about…

a) Activities of Daily Living 

·

b.)  Safety and Self-Preserving Decisions

·

c.)  Social Roles and Social Settings

· 

X.  What are Learning Opportunities in the child’s Community?

a) What do the siblings do outside of school hours?

·

b) What do other grade school age children do outside of school hours?

·         

d)c) What Community Opportunities Match the child’s interests, gifts, and

capacities?  What valued role or contribution would the child make in these settings?

1) Within walking distance?

·

2) Within five miles?

·

PART B: GOALS/OBJECTIVES AND OUTCOMES IN PASS DOMAINS

I.  Family’s Priorities for the child in Home and Community:

II. Goals and measurable objectives for the next six months

Domain A:  (Activities of Daily Living) 

Domain B:  (Safety and self-preserving decisions) 

2.1.

Domain C:  (Social roles and social settings)

5.1.

Interface with other supports and programs

III. Relationship of PASS Goals to the expected role of parent/caregiver

PART C:  INTENSITY, DURATION AND SERVICES SCHEDULE

Therefore, the PASS Plan would allow for the following schedule:

            Sunday

Monday          

Tuesday

Wednesday       

Thursday                       

Friday 

Saturday                                   Total   hours:

PART D: ROLES AND RESPONSIBILITIES IN DIRECT SERVICES

1)   Activities: 

5.1.

a).  Direct Service Worker Roles:

§          

b).  The Child’s Roles

§          

c.)  Family’s Roles

§          

d).  PASS Agency’s Roles

§         Hiring, training, and documenting processes

§         Promote ongoing training seminars and educational opportunities for families and workers

§         Ensure the continuity and quality of care and services through reporting and periodic evaluations as identified in the certification standards

§         Provide prompt conflict resolution

d).  Community’s Roles (Potential)

§          

PART E: IMPLEMENTATION STEPS AND TIMEFRAMES   

I. Recruitment Plan

4.1.

II. Personnel activities

1. PASS Worker(s) will complete all required personnel paperwork no later than one week after agency agrees to hire, including:

ü      Criminal background check

ü      Driving Record check

ü      W-4s and other tax documents

ü      Employment eligibility verification

2. PASS Agency will process employee paperwork in a timely fashion

III. Training Plan

1. Once recruited and hired, PASS worker will participate in PASS Agency’s required trainings (CPR, child development, etc.)

8.2.The family, PASS worker, and PASS Agency will participate in monthly meetings to assess progress, discuss any triumphs and/or challenges.

IV. Supervisory Roles of Family and PASS Agency

1).  PASS Agency

• Assist family with recruitment strategies if initial recruitment efforts fail
• Assist PASS worker with required personnel paperwork
• Conduct background checks and process other paperwork in a timely fashion
• Assist family in setting up data collection checklist
• Provide training required for all PASS workers
• Pay worker based on submitted timesheets in timely fashion
• Attend monthly meeting with family and PASS worker to monitor progress on

Plan

• Suggest strategies or further resources in areas that are showing little or no improvement

• Provide support to families, as requested, in supervision of worker

2).  Family

• Take agreed on steps toward recruitment of worker
• Follow through on recruitment suggestions of PASS Agency
• Apprise PASS Agency Coordinator when worker is found and put them in contact with each other
• Train worker in the child’s specific needs as outlined in training plan (above)
• Develop data collection checklist in collaboration with PASS Agency
• Check worker’s timesheets for accuracy and sign for submission
• Provide ongoing supervision of worker
• Attend monthly meetings with PASS Agency Coordinator and Direct worker to monitor progress of plan.
• Apprise PASS Agency Coordinator of any unmanageable or unacceptable difficulties experienced with Direct Worker
• Inform PASS Agency Coordinator if Direct Worker resigns or gives notice of resignation
• Engage in timely re-recruitment efforts, should Direct Worker need to be replaced

PART F: SAFETY ARRANGEMENTS

PART G:  SIGNED CONTRACTUAL AGREEMENT

The purpose of this agreement is to clearly state the responsibilities of the family and PASS Agency to assure everyone understands these responsibilities.

Your responsibilities as a Family:

1. Verify family preparedness to effective render consumer-directed PASS services.

2. Complete mandatory training provided by the PASS Agency.

3. Work with the PASS Agency to develop the Service Plan.

4. Designate a person who will be the responsible party for the family in decision-making activities with the PASS Agency and in managing the day-to-day work of the PASS worker(s).  The designated family supervisor(s) is/are _____________________________________________________________.

5. Find, interview and select the PASS worker(s).  Submit the employment forms package(s) for the PASS worker(s) to the PASS Agency.

6. Train the PASS worker(s) about their job duties and what is expected of them.

7. Develop an emergency back-up plan for coverage when your regular PASS worker(s) is /are absent because of illness, transportation problems or needing time off.

8. Be certain that all hours worked by the PASS worker(s) are within the number of hours approved in the Service Plan.

9. Make sure that the PASS worker(s)’ time sheet(s) reaches the PASS Agency on time which is every two weeks.  You must complete the time sheet(s) weekly.

10. Review monthly budget reports of the hours worked and paid from the PASS Agency.

11. Assess and document child’s progress toward Service Plan goals and objectives

12. Evaluate the PASS worker’s performance in accordance with the Service Plan.

13. Contact your PASS Agency Coordinator when you have questions.

14. Contact your PASS Agency Coordinator if you have concerns, so small problems won’t become big problems.

15. Maintain a safe and stable working environment in your home.

16. Follow proper reporting procedures (i.e. incidence reports).

Your PASS Agency’s Responsibilities to you:

1. Ascertain family preparedness to effective render consumer-directed PASS services.

2. Provide you with training about the PASS program and modify the training to meet your needs.  This includes information about consumer-directed services, Medicaid requirements, recruiting, selecting and managing PASS Workers.

3. Collaborate with you in the development of the Service Plan.

4. Support you in the selection and management of PASS workers.  Conduct Background Criminal Investigation (BCI) checks of PASS Workers.

5. Assure proper reporting of hours on timesheets & manage payroll for PASS workers.

6. Talk with you about your satisfaction regarding the quality of services you are receiving and assure that the PASS worker(s) activities are in accordance with the Service Plan.

7. Be available to you to answer questions or provide technical assistance in resolving problems or conflicts.

8. Work with you to develop a corrective action plan if there are difficulties managing your PASS worker(s).

9. Assure compliance with Federal and State employment laws.  Monitor compliance with Medicaid Rules and Regulations.

10. Maintain a case record.

11. Assure proper reporting procedures, i.e. incidence reports.

What the PASS Agency will not do:

1. Interview, train or directly supervise your PASS worker(s).

2. Fill out the employment forms package.

3. Find emergency back up direct service workers for you.

5.4.Approve additional hours beyond those authorized in the current Service Plan.

6.5.Provide your feedback to the PASS worker(s) regarding their job performance.

I understand, accept and agree to the responsibilities listed in this agreement and as delineated in the Service Plan

_______________________________                                  ________________________

Family Supervisor(s) Signature                                             Date

_______________________________                                  ________________________

Family Supervisor(s) Signature                                             Date

_______________________________                                  ________________________

PASS Agency Coordinator Signature                                   Date

_______________________________                                  ________________________

PASS Agency Clinical Coordinator                           Date

* Adapted from “Consumers/Consultant Agreement”, Consumers Directed Care Research Project, Florida Agency for Health Care Administration, December 1999