Form 2060-A, Addendum to Form 2060 for Personal Assistance Services
Effective Date: 10/2009
This form is used by the Department of Aging and Disability Services (DADS) case manager to:
- serve as a worksheet for the initial and ongoing development of the personal assistance services (PAS) included in the individual service plan (ISP);
- update the form to reflect changes to the PAS services portion of the ISP; and
- record the estimated hours per week of PAS hours for:
- protective supervision;
- extension of therapy;
- delegated nursing tasks as identified on Form 3671-C, Nursing Service Plan;
- Consumer Directed Services (CDS); and
- other delegated nursing to PAS tasks not identified and listed on Form 3671-C, Nursing Service Plan, or Form 2060, Consumer Needs Assessment Questionnaire and Task/Hour Guide.
When to Prepare
The case manager completes this form each time:
- PAS services are requested when an individual is assessed for eligibility in the Community Based Alternatives (CBA) program (initial application/certification or annual redetermination); or
- there is an assessed need for a change in the PAS component on Form 2060 and/or services listed on this form.
The case manager may update an existing Form 2060-A by drawing a line through the information to be changed, entering the new information, and writing his initials and date by the change. The case manager completes the "UPDATE 2" portions in Items I. 7-8; IV. 1-9; and V. UPDATE 2 signature box, as necessary, when the information on the form changes or at the time of the redetermination.
Number of Copies
The original Form 2060-A is placed in the case record. Copies are given to the consumer, provider(s) (except the Emergency Response System (ERS) provider) and to each member of the interdisciplinary team (IDT).
A Home and Community Support Services (HCSS) provider representative reviews Form 2060 and Form 2060-A , which are sent with Form 3676, CBA Pre-Enrollment Home Health Assessment Authorization, to the HCSS provider when the assessment is authorized. The HCSS representative may request changes to the PAS service plan by identifying the changes needed on Form 2067, Case Information, and sending the form to the case manager after reviewing the initial application or annual redetermination assessment packet.
An HCSS representative is responsible for signing the form and returning the signed copy to the case manager upon receipt of the revised ISP changing the PAS service plan.
When there is a provider change, the case manager sends a copy of Form 2060-A to the new provider to inform the new provider of the ISP. The provider representative signs Form 3671-2, Individual Service Plan, to acknowledge agreement with the services identified on this form and the other applicable ISP forms.
Each provider must keep Form 2060-A in the consumer's case record according to the retention requirements found in the Community Based Alternatives (CBA) Provider Manual. The case manager will keep all originals of this form in the consumer's record for five years after services are terminated. One copy is given to the applicant/consumer.
This form is found on the DADS website.
I. Identifying Information
1. Applicant/Consumer Name — Enter the name of the applicant/consumer.
2. Medicaid No. — Enter the nine-digit Medicaid number of the applicant/consumer. Use the Social Security number for CBA applicants who do not have a Medicaid number.
3. Update 1 – Date Completed — Enter the date this form is completed.
4. Update 1 – ISP Date — Enter the effective date from Item 5 of Form 3671-1, Individual Service Plan, for the ISP submitted, which includes the PAS services indicated on this Form 2060-A.
5. Case Manager's Name — Enter the case manager's name.
6. Provider Vendor No. — Enter the CBA vendor number of the HCSS provider that will provide the PAS services.
7. Update 2 – Date Completed — Enter the date this form is updated.
8. Update 2 – ISP Period — Enter the effective date from Item 5 of the ISP, Form 3671-1, for the ISP submitted, which includes the PAS services indicated on this Form 2060-A.
II. Additional PAS Hours Not Identified on Form 2060
Check the "Not Applicable" box if additional PAS hours are not applicable and skip to Section IV.
If applicable, check the "Applicable as Follows" box and complete the following for each personal assistance service identified below (1, 2, 3 and 4). (These columns are not used for individuals residing in or expected to reside in Adult Foster Care (AFC) or Assisted Living/Residential Care (AL/RC) settings.)
A. Number of Minutes Per Day — Enter the number of minutes per day of service provision necessary to perform each task. (The PAS hours (Delegated Nursing Hours) from Form 3671-C must be converted from the monthly amount and entered in Column A for Item 3, Purchased Delegated Nursing Tasks, as weekly hours.)
B. Number of Days Per Week — Enter the number of days per week the consumer's task(s) is required. There is no entry for the Purchased Delegated Nursing Tasks included in Item 3.
C. Total Minutes Per Week — Enter the product of multiplying the figure in Column "A" by the figure in Column "B" and enter the result in this column.
D. Comments — Use this space, as necessary, to explain tasks, hours, schedule modifications and any specific provider or applicant/consumer needs, or to reference any attached documentation.
E. Total PAS Minutes Per Week — Enter the sum of the figures for Items 1-4 in Column C.
1. Protective Supervision — Complete accordingly Columns A, B and C (if applicable).
2. Extension of Therapy — Complete Columns A, B and C if providing therapy assistance. Specify type of therapy.
3. Purchased Delegated Nursing Tasks —
(This category of delegated tasks refers only to paid attendants. Family members and informal support providers are trained and the tasks and hours of their contribution are identified and calculated on Form 3671-C.) Complete Columns A and C after identifying nursing tasks to be delegated per Form 3671-C. Enter the number of hours per week for delegated tasks to be purchased as PAS hours. The number of weekly hours is obtained by converting the monthly hours shown in Section I, Item A, PAS Hours, of Form 3671-C to weekly hours dividing by 4.33. The resulting hours per week are rounded to the next higher half hour and entered in Column A for Purchased Delegated Nursing Tasks.
4. CDS and Other Delegated Nursing Tasks to PAS — For Consumer Directed Services (CDS), enter the weekly hours needed for consumer-directed tasks in Column A as identified on Form 3671-C. Calculate the weekly hours by dividing the monthly hours by 4.33. Round to the next highest half hour. Multiply by 60 minutes in Column B to calculate the total minutes per week in Column C. Specify in Column D, Comments, as necessary.
If there are other delegating nursing tasks to purchase, complete Columns A, B and C and specify the task(s) in Column D, Comments. This includes delegating nursing tasks not listed/identified on Form 3671-C or Form 2060, Client Needs Assessment Questionnaire and Task/Hour Guide.
Use this space for comments in addition to the comments entered above or to continue any explanation started in the II. D. Comments space.
Comments must be entered when making initial referral for assessment to indicate if protective supervision could be required, or would not be required depending on whether protective supervision has been requested or may be appropriate.
IV. PAS Time Totals
The case manager completes this section for the initial and reassessment ISP and any time there is a change in Form 2060 PAS hours and/or this form. The form may be updated one time, either for the annual reassessment or a change in PAS hours during the ISP year, by completing entries in the "UPDATE 2" column.
1. Minutes per Week from the Form 2060 — Enter the total of minutes from Form 2060, if applicable. This field must be completed before referring for initial assessment.
2. Minutes per Week from this Form 2060-A — Enter the total PAS minutes from this form, Section II, E. (above).
3. Total Minutes per Week — Enter the sum of the figures in Box 1 and Box 2 to get total minutes per week.
4. Total Hours — Divide the total minutes per week in Box 3 by 60 to determine the hours per week, round to the next higher half hour, and enter the total hours in Box 4.
5. A&A and TPR Hours — Add any Veterans Affairs (VA) Aid and Attendance (A&A) monetary amount (from Form 2060) to any payments from other third-party resources, Family and Community Supports (from Form 8598, Non-Waiver Services), and divide monthly total by 4.33 to determine a weekly amount. Divide weekly amount by PAS hourly rate and enter the total number of weekly hours in Box 5.
6. Adjusted Weekly Hours — Subtract the A&A/TPR hours entered in Item 5 from the weekly total hours entered in Item 4, and enter the remainder in Box 6. Round up to the next higher half hour.
7. Hours Authorized per Year — Multiply the adjusted weekly hours in Box 6 by the number of weeks remaining in the ISP year and enter the product in Box 7. (To determine the number of weeks remaining in the ISP, divide the number of remaining days by seven and round up to the next higher number. Example: 365 days divided by 7 = 52.14, round to 53 weeks. Round to a two-place decimal if the rounding to the next higher whole number will cause the ISP to exceed the ISP cost ceiling.)
8. Hours Previously Authorized this ISP Year — Enter the number of hours already authorized in the current ISP year that were scheduled to have been delivered before the time of this ISP change, if applicable. If none, enter 0.
9. Estimated Annual PAS Authorization — Enter the sum of the figures in Box 7 and Box 8, rounded up to the next higher hour in this box. This figure should be registered in Column 19 on ISP, Form 3671-1, for Service Code 17, Personal Assistance Services.
Note: The amount in adjusted weekly hours must be entered in the CBA Service Authorization System (SAS) wizard for the correct calculations to be performed. Form 2060-A calculations in 7, 8 and 9 will vary from the calculations in SAS.
V. Certification by Interdisciplinary Team Members
The case manager signs and dates the form to approve or disapprove the identified PAS services. The case manager's signature is required when PAS is requested at initial application/certification, annual redetermination and changes. The case manager signs and dates this form in the appropriate box for UPDATE 1 or 2 when the assessment is completed and each time a new Form 2060-A is completed or updated.
The applicant/consumer/responsible party and HCSS representative are not required to sign Form 2060-A at initial application or annual redetermination because their signatures and participation in the development of the ISP are documented on Form 3671-2. The case manager checks the box labeled "Applicant/consumer/responsible party and HCSS representative signatures on Form 3671-2 at initial certification and annual redetermination" to indicate the signatures are included on Form 3671-2.
For ISP changes, the case manager discusses the requested change with the consumer and obtains the consumer's signature or verbal agreement of the requested change. When the case manager obtains the applicant/consumer or responsible party's decision about the ISP change by telephone, the case manager writes "verbally approved" and the date on the signature line. If verbal approval for the change is not appropriate (such as if the consumer has no telephone or has a cognitive or communication impairment precluding understanding the change over the telephone), the case manager makes a home visit to obtain the consumer's approval.
The HCSS provider representative signs and dates this form to indicate agreement with the PAS services listed on Form 2060 and Form 2060-A, in the appropriate box for UPDATE 1 or 2, upon receipt of the revised ISP when the case manager completes a change in PAS services. Form 2067 may be submitted by the HCSS provider to the case manager if changes are needed in PAS services.
Informal support providing non-essential tasks of daily living must be documented on the Form 2060 assessment. Tasks essential to daily living functioning provided by informal support must be documented on Form 8598, and applicable signatures/verbal agreements obtained on Form 8598.