Intellectual Disabilities (ID) Waiver HCBS Rights Modification Support Plan Addendum to Person-Centered Plan

Background Information

Support Coordinators use this form:

When a person is receiving or will start receiving services in a Residential Habilitation services; AND

The person receiving Residential Habilitation services requires a modification to their HCBS rights during the time they are receiving these services.

These HCBS rights include:

A. Right to freedom/support to control individual schedule and activities.

B. Right to have access to food (and drink) at any time.

C. Right to choose visitors and times when visits occur, taking into account respect for others sharing unit.

D. Right to choose housemate(s) if sharing a living unit and roommate if sharing a bedroom.

E. Right to furnish & decorate living unit & bedroom as desired, consistent with terms of lease or residency agreement

F. Right to lockable entrance door(s) to living unit (and bedroom door if sharing with other unrelated persons). With only the individual and appropriate staff shall have keys/codes for door(s).

To implement an HCBS Modification, the HCBS Modification must be:

Based on specific and individualized assessed needs identified in a current assessment of the individual.

Necessary to ensure the health, safety, and well-being of the person.

Approved by the person and/or legal guardian through informed consent.

This Addendum must be completed and uploaded to ADIDIS case file for person
to make it integral part of the Person-Centered Plan.

Support Coordinator Responsibilities:

When a specific need for a modification to one of the above rights is identified for a person and supported by an assessed need related to health and/or safety, the Support Coordinator completes Part A and Part B.

The Support Coordinator then forwards this electronic form to the HCBS Provider (to complete Part C) via secure email. The Support Coordinator also provides a due date for the HCBS Provider.

When the provider returns the form, the Support Coordinator confirms the provider fully completed Part C.

The Support Coordinator then reviews this Plan with the person (and legal guardian if applicable) and completes Part D. This part indicates if the person (and/or legal guardian, if applicable) consents to the modification being implemented by the provider. Signature(s) are required.

If consent is given by the person (or legal guardian, if applicable), the Support Coordinator then ensures:

The HCBS Rights Modification Support Plan Addendum is documented in the Person-Centered Plan (PCP). This is done by checking the appropriate box in the Community Living Domain of the PCP template.

The Support Coordinator uploads this signed document to ADIDIS by attaching it to a Note in ADIDIS. The note type is “Attachment” and the note description is “HCBS Modification Addendum”.

The Support Coordinator ensures that the provider implementing this HCBS Modification Support Plan receive a copy of this Plan with the PCP.

HCBS Provider Responsibilities

The provider will receive the form from the Support Coordinator with Part A and B complete.

The provider completes Part C and returns the form to the Support Coordinator using secure email.

If the Support Coordinator obtains consent for the provider to implement the modification, the provider will receive this completed Support Plan with the signed PCP. The provider implements the modification according to this Plan.

Part A. Basic Information [Completed by Support Coordinator]

Person
Last Name:	Enter Value	First Name:	Enter Value
ADIDIS #:	Enter Value	Effective Date of Modification(s):	Enter Value
Support Coordinator
Agency Name:	Enter Value
Last Name:	Enter Value	First Name:	Enter Value

Part B. HCBS Modification [Completed by Support Coordinator]

Then forwarded via secure email to Provider operating the setting where the HCBS Modification will be implemented.

The Support Coordinator documents required modifications of the person’s HCBS right(s) here. (The modification must be based on an assessed need, and necessary to ensure the health and/or safety of the person.)

Identify each HCBS right that requires a modification based on assessed needs. (Check all that apply):

☐ A.	Right to freedom and support to control individual schedule and activities

☐ B.	Right to have access to food and drink at any time.

☐ C.	Right to choose visitors and times when visits occur, taking into account respect for others sharing unit

☐ D. Right to choose housemate(s) if sharing a living unit and roommate if sharing a bedroom

☐ E.	Right to furnish and decorate living unit and bedroom as desired, consistent with terms of lease or residency agreement

☐ F.	Right to lockable entrance door(s) to the person’s living unit (and bedroom if the person shares a living unit with unrelated individuals), with only the individual and appropriate staff having keys/codes to door(s).

(Part B is continued on the next page.)

(Part B is continued below.)

Identify why the person needs the modification(s) to the specified HCBS right(s)—Detail how the assessed need for each modification has been identified. (The modification must be based on the person’s health and/or safety need(s) identified in a current assessment. This may be an initial assessment or reassessment by the Support Coordinator, an assessment by an HCBS Provider or a Specialist Provider involved with the person.)

Modification (Fill in row below if letter checked in Question 1 above.)	Assessed Need What is the specific assessed health and/or safety need(s) Who completed the assessment that identified the need(s) When was the assessment completed that identified the need(s) Include diagnosis/condition, if applicable
Example: B. Right to have access to food at any time	Matt has Prader-Willi syndrome, a condition that causes him to ingest large quantities of food. Matt’s physician, Dr. Smith confirmed his diagnosis in his annual physical exam on 6/20/2020.
Right to freedom and support to control individual schedule and activities	Enter Value
Right to have access to food and drink at any time	Enter Value
Right to choose visitors and times when visits occur, taking into account respect for others sharing unit	Enter Value
Right to choose housemate(s) if sharing a living unit and roommate if sharing a bedroom	Enter Value
Right to furnish and decorate living unit and bedroom as desired, consistent with terms of lease or residency agreement	Enter Value
Right to lockable entrance door(s) to living unit (and bedroom if person shares unit with unrelated individuals); with only the individual and appropriate staff have key(s)/code(s) to door(s)	Enter Value
Setting and HCBS Waiver Provider*
Describe Setting where modification(s) will be used:	Provider Name (Organization, if applicable):
Enter Value	Enter Value
Provider contact to receive this form (First & Last Name):	Primary contact email:
Enter Value	Enter Value

Part C. HCBS Provider Responsibility [Completed by the Waiver Service Provider]

Then this Addendum is returned to the Support Coordinator via secure email.

The Service Provider must complete this section. The person (and legal guardian if applicable) and Support Coordinator will review the modification plan proposed by the Service Provider and consider its approval. The provider plan must:

Ensure the HCBS modification is implemented in the least restrictive manner necessary to protect the person, as described in this Plan.

Provide support to reduce or eliminate the need for the modification as soon as feasible.

Provide updates on the implementation and effectiveness of this Plan to the person and Support Coordinator when requested.

Setting and HCBS Waiver Provider
SETTING ADDRESS WHERE MODIFICATION WILL BE USED:	PROVIDER NAME (ORGANIZATION IF APPLICABLE):
Enter Value	Enter Value
PRIMARY CONTACT FIRST NAME:	PRIMARY CONTACT LAST NAME:
Enter Value	Enter Value

Service Provider should select (click on) the HCBS Right(s) listed below that are selected in Part B.1
above as needing modification. Complete the five required questions to create the plan for implementation of the HCBS Modification.

A.	Right to freedom and support to control individual schedule and activities

B.	Right to have access to food and drink at any time

Right to choose visitors and times when visits occur, taking into account respect for others sharing unit

Right to choose housemate(s) if sharing a living unit and roommate if sharing a bedroom

Right to furnish and decorate their living unit and bedroom as desired, consistent with terms of lease or residency agreement

Right to lockable entrance door(s) to the person’s living unit (and bedroom if the person shares a living unit with unrelated individuals), with only the individual and appropriate staff have keys/codes to door(s)

Part D. Person’s Informed Consent

Your signature (or mark) shows that you participated in and understand the Modification(s) of your HCBS Right(s) that your Support Coordinator and Provider documented in this form. You decide whether to agree to or not agree to each Modification to your HCBS Rights. If you agree, you can change your mind at any time. You also can ask your Support Coordinator for a review discussion on a Modification at any time.

The reason for a Modification of my HCBS Rights has been explained to me in a way that I understand. I also understand how my Provider will provide the Modification to ensure my health, safety, and well-being.

Your options:

☐ I approve of the Modification(s) of my Rights identified in this Plan, which is part of my PCP.

or

☐ I refuse for my Rights to be modified.

Person	Date
Legal Guardian (Legally Appointed Decision-Maker)	Date