OTHER RELATED CONDITIONS WAIVER Care Plan

SECTION 1. Participant Information /
Name: / Effective Plan Date:
Plan End Date:
DOB: / Medical Eligibility Date:
EIS ID # / Phone Number:
Gender: / ☐ Male / ☐ Female / MaineCare #:
Address: / Town: / ZIP
Legal Guardian/ Power of Attorney :
(Circle Applicable) / Contact Information:
Name:
Address:
Town: / State
Zip Code: / Phone:
ORC Care Coordinator : / Contact Information:
Name:
Address:
Town: / State
Zip Code: / Phone:
MFP/Homeward Bound Transition Coordinator : / Contact Information:
Name:
Address:
Town: / State
Zip Code: / Phone:
Representative Payee:
(If Applicable) / Contact Information:
Name:
Address:
Town: / State
Zip Code: / Phone:
Directions :
SECTION 2. DAILY LIVING SKILLS
PART A. Vision (describe need)
Setting / Describe Support Need / Primary Provider of Support for this Need / Back up Supports for this Need / Assistive Technology Used / Adaptations for Assistive Technology Needed
Home Setting / . / 1.
2.
Community Setting / 1.
2.
Other Settings / 1.
2.
PART B. Hearing (describe need)
Setting / Describe Support Need / Primary Provider of Support for this Need / Back up Supports for this Need / Assistive Technology Used / Adaptations for Assistive Technology Needed
Home Setting / 1.
2.
Community Setting / 1.
2.
Other Settings / 1.
2.
PART C. Communication (describe need)
Setting / Describe Support Need / Primary Provider of Support for this Need / Back up Supports for this Need / Assistive Technology Used / Adaptations for Assistive Technology Needed
Home Setting / 1.
2.
Community Setting / 1.
2.
Other Settings / 1.
2.
PART D. Phone Use (describe need)
Setting / Describe Support Need / Primary Provider of Support for this Need / Back up Supports for this Need / Assistive Technology Used / Adaptations for Assistive Technology Needed
Home Setting / 1.
2.
Community Setting / 1.
2.
Other Settings / 1.
2.
Section 3. Locomotion (describe need)
Setting / Describe Support Need / Primary Provider of Support for this Need / Back up Supports for this Need / Assistive Technology Used / Adaptations for Assistive Technology Needed
Home Setting / 1.
2.
Community Setting / 1.
2.
Other Settings / 1.
2.
SECTION 4. Transfers (Describe Need)
Setting / Describe Support Need / Primary Provider of Support for this Need / Back up Supports for this Need / Assistive Technology Used / Adaptations for Assistive Technology Needed
Home Setting / 1.
2.
Community Setting / 1.
2.
Other Settings / 1.
2.
SECTION 5. Environmental (describe need)
Situation / Describe Support Need / Primary Provider of Support for this Need / Back up Supports for this Need / Assistive Technology Used / Adaptations for Assistive Technology Needed
Falls / 1.
2.
Emergency / 1.
2.
Unexpected Illness / 1.
2.
SECTION 6. Mood and Emotional Well-Being (describe need)
Setting / Describe Support Need / Primary Provider of Support for this Need / Back up Supports for this Need / Assistive Technology Used / Adaptations for Assistive Technology Needed
Home Setting / 1.
2.
Community Setting / 1.
2.
Other Settings / 1.
2.
SECTION 7. Nutrition (describe need)
Setting / Describe Support Need / Primary Provider of Support for this Need / Back up Supports for this Need / Assistive Technology Used / Adaptations for Assistive Technology Needed
Home Setting / 1.
2.
Community Setting / 1.
2.
Other Settings / 1.
2.
SECTION 8. Managing Medication (describe need)
Setting / Describe Support Need / Primary Provider of Support for this Need / Back up Supports for this Need / Assistive Technology Used / Adaptations for Assistive Technology Needed
Home Setting / 1.
2.
Community Setting / 1.
2.
Other Settings / 1.
2.
SECTION 9. Transportation (describe need)
Setting / Describe Support Need / Primary Provider of Support for this Need / Back up Supports for this Need / Assistive Technology Used / Adaptations for Assistive Technology Needed
Home Setting / 1.
2.
Community Setting / 1.
2.
Other Settings / 1.
2.
Backup System.
1. In the event that staff does not report for a scheduled shift, (ORC MEMBER) will call the following number for back-up staff: / 1.
2.
2. If (ORC MEMBER) is unable to reach staff at the above numbers, they will call: / 3.

Name: Date :

ORC Care Plan Page 13 of 13

Revised 8/19/2016

SECTION 10:Goals
Goals for Strengthening Personal Relationships:
Goal 1:
Strategy / Primary Provider/Person Supporting this Strategy
1.
2.
3.
Goal 2:
Strategy / Primary Provider/Person Supporting this Strategy
1.
2.
3.
Goal 3:
Strategy / Primary Provider/Person Supporting this Strategy
1.
2.
3.
Goal 4:
Strategy / Primary Provider/Person Supporting this Strategy
1.
2.
3.
Goals for Strengthening Community Relationships:
Goal 1:
Strategy / Primary Provider/Person Supporting this Strategy
1.
2.
3.
Goal 2:
Strategy / Primary Provider/Person Supporting this Strategy
1.
2.
3.
Goal 3:
Strategy / Primary Provider/Person Supporting this Strategy
1.
2.
3.
Goal 4:
Strategy / Primary Provider/Person Supporting this Strategy
1.
2.
3.
Goals for Strengthening Family Relationships:
Goal 1:
Strategy / Primary Provider/Person Supporting this Strategy
1.
2.
3.
Goal 2:
Strategy / Primary Provider/Person Supporting this Strategy
1.
2.
3.
Goal 3:
Strategy / Primary Provider/Person Supporting this Strategy
1.
2.
3.
Goal 4:
Strategy / Primary Provider/Person Supporting this Strategy
1.
2.
3.
Goals for Strengthening Professional Relationships:
Goal 1:
Strategy / Primary Provider/Person Supporting this Strategy
1.
2.
3.
Goal 2:
Strategy / Primary Provider/Person Supporting this Strategy
1.
2.
3.
Goal 3:
Strategy / Primary Provider/Person Supporting this Strategy
1.
2.
3.
Goal 4:
Strategy / Primary Provider/Person Supporting this Strategy
1.
2.
3.
Other Goals:
Strategy / Primary Provider/Person Supporting this Strategy
1.
2.
3.

Name: Date :

ORC Care PlanPage 22 of 22

Revised 8/19/2016

Home Support Schedule Member Name: Date:

Sunday / Monday / Tuesday / Wednesday / Thursday / Friday / Saturday
12AM / 12:00 to 12:15 / 12:00 to 12:15 / 12:00 to 12:15 / 12:00 to 12:15 / 12:00 to 12:15 / 12:00 to 12:15 / 12:00 to 12:15
12:15 to 12:30 / 12:15 to 12:30 / 12:15 to 12:30 / 12:15 to 12:30 / 12:15 to 12:30 / 12:15 to 12:30 / 12:15 to 12:30
12:30 to 12:45 / 12:30 to 12:45 / 12:30 to 12:45 / 12:30 to 12:45 / 12:30 to 12:45 / 12:30 to 12:45 / 12:30 to 12:45
12:45 to 1:00 / 12:45 to 1:00 / 12:45 to 1:00 / 12:45 to 1:00 / 12:45 to 1:00 / 12:45 to 1:00 / 12:45 to 1:00
1AM / 1:00 to 1:15 / 1:00 to 1:15 / 1:00 to 1:15 / 1:00 to 1:15 / 1:00 to 1:15 / 1:00 to 1:15 / 12:00 to 12:15
1:15 to 1:30 / 1:15 to 1:30 / 1:15 to 1:30 / 1:15 to 1:30 / 1:15 to 1:30 / 1:15 to 1:30 / 1:15 to 1:30
1:30 to 1:45 / 1:30 to 1:45 / 1:30 to 1:45 / 1:30 to 1:45 / 1:30 to 1:45 / 1:30 to 1:45 / 1:30 to 1:45
1:45 to 2:00 / 1:45 to 2:00 / 1:45 to 2:00 / 1:45 to 2:00 / 1:45 to 2:00 / 1:45 to 2:00 / 1:45 to 2:00
2AM / 2:00 to 2:15 / 2:00 to 2:15 / 2:00 to 2:15 / 2:00 to 2:15 / 2:00 to 2:15 / 2:00 to 2:15 / 2:00 to 2:15
2:15 to 2:30 / 2:15 to 2:30 / 2:15 to 2:30 / 2:15 to 2:30 / 2:15 to 2:30 / 2:15 to 2:30 / 2:15 to 2:30
2:30 to 3:00 / 2:30 to 3:00 / 2:30 to 3:00 / 2:30 to 3:00 / 2:30 to 3:00 / 2:30 to 3:00 / 2:30 to 3:00
2:45 to 3:00 / 2:45 to 3:00 / 2:45 to 3:00 / 2:45 to 3:00 / 2:45 to 3:00 / 2:45 to 3:00 / 2:45 to 3:00
3AM / 3:00 to 3:15 / 3:00 to 3:15 / 3:00 to 3:15 / 3:00 to 3:15 / 3:00 to 3:15 / 3:00 to 3:15 / 3:00 to 3:15
3:15 to 3:30 / 3:15 to 3:30 / 3:15 to 3:30 / 3:15 to 3:30 / 3:15 to 3:30 / 3:15 to 3:30 / 3:15 to 3:30
3:30 to 3:45 / 3:30 to 3:45 / 3:30 to 3:45 / 3:30 to 3:45 / 3:30 to 3:45 / 3:30 to 3:45 / 3:30 to 3:45
3:45 to 4:00 / 3:45 to 4:00 / 3:45 to 4:00 / 3:45 to 4:00 / 3:45 to 4:00 / 3:45 to 4:00 / 3:45 to 4:00
4AM / 4:00 to 4:15 / 4:00 to 4:15 / 4:00 to 4:15 / 4:00 to 4:15 / 4:00 to 4:15 / 4:00 to 4:15 / 4:00 to 4:15
4:15 to 4:30 / 4:15 to 4:30 / 4:15 to 4:30 / 4:15 to 4:30 / 4:15 to 4:30 / 4:15 to 4:30 / 4:15 to 4:30
4:30 to 4:45 / 4:30 to 4:45 / 4:30 to 4:45 / 4:30 to 4:45 / 4:30 to 4:45 / 4:30 to 4:45 / 4:30 to 4:45
4:45 to 5:00 / 4:45 to 5:00 / 4:45 to 5:00 / 4:45 to 5:00 / 4:45 to 5:00 / 4:45 to 5:00 / 4:45 to 5:00
5AM / 5:00 to 5:15 / 5:00 to 5:15 / 5:00 to 5:15 / 5:00 to 5:15 / 5:00 to 5:15 / 5:00 to 5:15 / 5:00 to 5:15
5:15 to 5:30 / 5:15 to 5:30 / 5:15 to 5:30 / 5:15 to 5:30 / 5:15 to 5:30 / 5:15 to 5:30 / 5:15 to 5:30
5:30 to 5:45 / 5:30 to 5:45 / 5:30 to 5:45 / 5:30 to 5:45 / 5:30 to 5:45 / 5:30 to 5:45 / 5:30 to 5:45
5:45 to 6:00 / 5:45 to 6:00 / 5:45 to 6:00 / 5:45 to 6:00 / 5:45 to 6:00 / 5:45 to 6:00 / 5:45 to 6:00
6AM / 6:00 to 6:15 / 6:00 to 6:15 / 6:00 to 6:15 / 6:00 to 6:15 / 6:00 to 6:15 / 6:00 to 6:15 / 6:00 to 6:15
6:15 to 6:30 / 6:15 to 6:30 / 6:15 to 6:30 / 6:15 to 6:30 / 6:15 to 6:30 / 6:15 to 6:30 / 6:15 to 6:30
6:30 to 6:45 / 6:30 to 6:45 / 6:30 to 6:45 / 6:30 to 6:45 / 6:30 to 6:45 / 6:30 to 6:45 / 6:30 to 6:45
6:45 to 7:00 / 6:45 to 7:00 / 6:45 to 7:00 / 6:45 to 7:00 / 6:45 to 7:00 / 6:45 to 7:00 / 6:45 to 7:00
7AM / 7:00 to 7:15 / 7:00 to 7:15 / 7:00 to 7:15 / 7:00 to 7:15 / 7:00 to 7:15 / 7:00 to 7:15 / 7:00 to 7:15
7:15 to 7:30 / 7:15 to 7:30 / 7:15 to 7:30 / 7:15 to 7:30 / 7:15 to 7:30 / 7:15 to 7:30 / 7:15 to 7:30
7:30 to 7:45 / 7:30 to 7:45 / 7:30 to 7:45 / 7:30 to 7:45 / 7:30 to 7:45 / 7:30 to 7:45 / 7:30 to 7:45
7:45 to 8:00 / 7:45 to 8:00 / 7:45 to 8:00 / 7:45 to 8:00 / 7:45 to 8:00 / 7:45 to 8:00 / 7:45 to 8:00
8AM / 8:00 to 8:15 / 8:00 to 8:15 / 8:00 to 8:15 / 8:00 to 8:15 / 8:00 to 8:15 / 8:00 to 8:15 / 8:00 to 8:15
8:15 to 8:30 / 8:15 to 8:30 / 8:15 to 8:30 / 8:15 to 8:30 / 8:15 to 8:30 / 8:15 to 8:30 / 8:15 to 8:30
8:30 to 8:45 / 8:30 to 8:45 / 8:30 to 8:45 / 8:30 to 8:45 / 8:30 to 8:45 / 8:30 to 8:45 / 8:30 to 8:45
8:45 to 9:00 / 8:45 to 9:00 / 8:45 to 9:00 / 8:45 to 9:00 / 8:45 to 9:00 / 8:45 to 9:00 / 8:45 to 9:00
9AM / 9:00 to 9:15 / 9:00 to 9:15 / 9:00 to 9:15 / 9:00 to 9:15 / 9:00 to 9:15 / 9:00 to 9:15 / 9:00 to 9:15
9:15 to 9:30 / 9:15 to 9:30 / 9:15 to 9:30 / 9:15 to 9:30 / 9:15 to 9:30 / 9:15 to 9:30 / 9:15 to 9:30
9:30 to 9:45 / 9:30 to 9:45 / 9:30 to 9:45 / 9:30 to 9:45 / 9:30 to 9:45 / 9:30 to 9:45 / 9:30 to 9:45
9:45 to 10:00 / 9:45 to 10:00 / 9:45 to 10:00 / 9:45 to 10:00 / 9:45 to 10:00 / 9:45 to 10:00 / 9:45 to 10:00
10AM / 10:00 to 10:15 / 10:00 to 10:15 / 10:00 to 10:15 / 10:00 to 10:15 / 10:00 to 10:15 / 10:00 to 10:15 / 10:00 to 10:15
10:15 to 10:30 / 10:15 to 10:30 / 10:15 to 10:30 / 10:15 to 10:30 / 10:15 to 10:30 / 10:15 to 10:30 / 10:15 to 10:30
10:30 to 10:45 / 10:30 to 10:45 / 10:30 to 10:45 / 10:30 to 10:45 / 10:30 to 10:45 / 10:30 to 10:45 / 10:30 to 10:45
10:45 to 11:00 / 10:45 to 11:00 / 10:45 to 11:00 / 10:45 to 11:00 / 10:45 to 11:00 / 10:45 to 11:00 / 10:45 to 11:00
11AM / 11:00 to 11:15 / 11:00 to 11:15 / 11:00 to 11:15 / 11:00 to 11:15 / 11:00 to 11:15 / 11:00 to 11:15 / 11:00 to 11:15
11:15 to 11:30 / 11:15 to 11:30 / 11:15 to 11:30 / 11:15 to 11:30 / 11:15 to 11:30 / 11:15 to 11:30 / 11:15 to 11:30
11:30 to 11:45 / 11:30 to 11:45 / 11:30 to 11:45 / 11:30 to 11:45 / 11:30 to 11:45 / 11:30 to 11:45 / 11:30 to 11:45
11:45 to 12:00 / 11:45 to 12:00 / 11:45 to 12:00 / 11:45 to 12:00 / 11:45 to 12:00 / 11:45 to 12:00 / 11:45 to 12:00

Remote Support Staffing In-Person Support Staffing Backup Support Community Support

Name: Date :

ORC Care PlanPage 23 of 23

Revised 8/19/2016

Home Support Schedule Member Name: Date:

Sunday / Monday / Tuesday / Wednesday / Thursday / Friday / Saturday
12AM / 12:00 to 12:15 / 12:00 to 12:15 / 12:00 to 12:15 / 12:00 to 12:15 / 12:00 to 12:15 / 12:00 to 12:15 / 12:00 to 12:15
12:15 to 12:30 / 12:15 to 12:30 / 12:15 to 12:30 / 12:15 to 12:30 / 12:15 to 12:30 / 12:15 to 12:30 / 12:15 to 12:30
12:30 to 12:45 / 12:30 to 12:45 / 12:30 to 12:45 / 12:30 to 12:45 / 12:30 to 12:45 / 12:30 to 12:45 / 12:30 to 12:45
12:45 to 1:00 / 12:45 to 1:00 / 12:45 to 1:00 / 12:45 to 1:00 / 12:45 to 1:00 / 12:45 to 1:00 / 12:45 to 1:00
1AM / 1:00 to 1:15 / 1:00 to 1:15 / 1:00 to 1:15 / 1:00 to 1:15 / 1:00 to 1:15 / 1:00 to 1:15 / 12:00 to 12:15
1:15 to 1:30 / 1:15 to 1:30 / 1:15 to 1:30 / 1:15 to 1:30 / 1:15 to 1:30 / 1:15 to 1:30 / 1:15 to 1:30
1:30 to 1:45 / 1:30 to 1:45 / 1:30 to 1:45 / 1:30 to 1:45 / 1:30 to 1:45 / 1:30 to 1:45 / 1:30 to 1:45
1:45 to 2:00 / 1:45 to 2:00 / 1:45 to 2:00 / 1:45 to 2:00 / 1:45 to 2:00 / 1:45 to 2:00 / 1:45 to 2:00
2AM / 2:00 to 2:15 / 2:00 to 2:15 / 2:00 to 2:15 / 2:00 to 2:15 / 2:00 to 2:15 / 2:00 to 2:15 / 2:00 to 2:15
2:15 to 2:30 / 2:15 to 2:30 / 2:15 to 2:30 / 2:15 to 2:30 / 2:15 to 2:30 / 2:15 to 2:30 / 2:15 to 2:30
2:30 to 3:00 / 2:30 to 3:00 / 2:30 to 3:00 / 2:30 to 3:00 / 2:30 to 3:00 / 2:30 to 3:00 / 2:30 to 3:00
2:45 to 3:00 / 2:45 to 3:00 / 2:45 to 3:00 / 2:45 to 3:00 / 2:45 to 3:00 / 2:45 to 3:00 / 2:45 to 3:00