DHS-DD-810

REQUEST FOR SIGNIFICANT CHANGE

Purpose of SCR: Provisional Plan of Care Change in current services Provider change

Mark “initial plan of care” if this form is being used as the provisional plan for care for the initial level of care.

Name of person receiving services: Name of participant Case Management Provider:

Medicaid #: Medicaid # of the participant Community Support Provider:

Person submitting request: Name of the case management ISP Date (annual plan): Identified for CM change

submitting request to DDD. SCRs can only be submitted to

DDD by CM.

Date Submitted: Date SCR submitted to DDD

Is this an enhanced rate? Yes No

Add or Change Case Management Complete this section for the initial switch to a CFCM. After the initial switch this section can be used if a participant wants to change case management agencies.

Funding: Choose an item. Use the drop down box to identify the type of funding for the service.

Former Case Management Provider: / New Case Management Provider:
End Date: / Start Date:

Change Community Support Provider If there is a change in Community Support provider, CM will submit a SCR in place of discharge notice and summary/new funding request. Keep in mind that in the event of a termination a termination notice and summary are still required.

Former Community Support Provider: / New Community Support Provider:
End Date: / Start Date:

Add Residential Change Service: End Service:

Funding:Choose an item. Use the drop down box to identify the type of funding for the service.

Former Street Address:
County:
Type of Residential service: Choose an item. Use the drop down box to identify the type of residential service
Capacity change From: To: Indicate how the capacity is changing: from a capacity of __ to__
Does this create a capacity change in former address: Yes No If yes, please describe and attach names of all people affected by change:
End Date:
New Street Address:
County:
Type of Residential service: Choose an item. Use the drop down box to identify the type of residential service
Capacity change From: To: Indicate how the capacity is changing: from a capacity of __ to__
Does this create a capacity change in new address: Yes No If yes, please describe and attach names of all people affected by change:
Start date:

Add Day Hours (Segregated) Decrease: End Service:

Use the drop down boxes in these four categories to identify type of services

Category: Choose an item. Non Paid Activities: Choose an item.

Paid Employment: Choose an item. Funding: Choose an item.

Number of previous non-paid hours: / Number of new non-paid hours :
Number of previous paid hours / Number of new paid hours
Total number of Previous hours: / Total number of new hours:
Previous wage per hour: / New wage per hour:
End date: / Start Date:

Add Supported Employment Decrease: End Service:

Use the drop down boxes in these four categories to identify type of services

Category: Choose an item. Setting: Choose an item.

Type of Paid Employment: Choose an item. Wage Payer: Choose an item.

Funding: Choose an item.

Number of previous hours: / Number of new hours:
Previous wage per hour: / New wage per hour:
End Date: / Start Date:

Add Prevocational Decrease: End Service:

Use the drop down boxes in these four categories to identify type of services

Type of Paid Employment: Choose an item. Funding: Choose an item.

Total number of Previous hours: / Total number of new hours:
Previous wage per hour: / New wage per hour:
End date: / Start Date:

Other Services

Funding: Choose an item. Use the drop down box to identify the type of funding for the service.

Speech, Hearing & Language / Medical Equipment and Drugs / Other Medical
Start Date: / Start Date: / Start Date:
End Date: / End Date: / End Date:

ICAP (If there is an ICAP change and service change with different start/end dates, two SCRs must be completed)- ICAP booklet must be sent with change in this area.

·  Describe ICAP changes: In order to better identify ICAP changes that directly affect a participants rate, the above section has been added.
·  ICAP changes need to be described in detail including what specific questions were changed.
·  The entire ICAP booklet must be submitted with SCR,
If there is an ICAP change and service change with different end/start dates, two SCRs must be completed.

Describe why services/providers are being changed: This section should be utilized to describe the changes that the participant is making and why. The agency should describe what and why the services are being added/increased/decreased or discontinued.

Good example: Joe has been performing well at his current employment situation. He previously had a job coach and the job coach is no longer needed for 15 hours per week. The job coach will now be checking in on Joe for 8 hours per week and addressing issues as they arise. This will be done on a trial basis and if the job coach needs to increase/decrease hours a SCR will be submitted to request those changes.

Poor example: Joe needs job coach for 8 hours per week at his place of employment

Notice of Change in Services This section must be filled out for every SCR.
Was there a team meeting to discuss services changes with participant/guardian? / Yes Date:
No / Do ALL team members agree: Yes
No
Meeting Summary: Documentation of the team meeting specifically regarding changing services.
Notice of Reduction of Services ARSD 46:11:08:04:
Was the participant/guardian notified in writing of the intent to reduce services? ARSD / Yes Date:
No / N/A (Explain):
Was the participant/guardian notified of the right to appeal the reduction in services? / Yes
No / N/A (Explain):

·  ARSD 46:11:08:04 Notice of Reduction of Services

The CSP shall inform the participant in writing of the intent to reduce services and the participant's right to appeal the reduction of services to the division, ten calendar days prior to the date of the CSP initiated action. This notice must be documented and can only be waived if the participant or legal representative provides to the CSP a clear written statement signed by the participant or legal representative stating that the participant or the participant's legal representative agrees with the reduction of services. When reduction of services is being appealed services cannot be reduced until a decision is reached after a hearing pursuant to SDCL chapter 1-26.

·  Per ARSD 46:11:08:04 the agency must notify the participant and/or guardian, if applicable, of a reduction of services. This section has been added to assure compliance with the new requirement that was promulgated December 2013.

·  This is verified during individual monthly SMART file review.

SCR APPROVAL In order for SCRs to be approved and processed by DDD both the CM and the CSP need to sign off that they agree to the changes that are being made. If participant is changing CSP or CM, then both the new and the previous CSP (or CM) will need to sign the SCR. This is so that the previous CSP (or CM) are made aware of the participant stopping services with them

New/Current CSP: ______

Signature/ Title Date

New/Current CM: ______

Signature/ Title Date

*Former CSP: ______

Signature/ Title Date

*Former CM: ______

Signature/Title Date

*Only need signature of former CSP or former CM if providers are being changed.

For DDD use only. Changes Verified in Service Record
Rate Information:
Current Rate:
New Rate:
Difference in Rate:
Date Rec’d / Processed and Initials / Entered in Tracking / Action / Comments

Updated 05/16