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Monitoring, reassessment and tier changes: the steps to remember

The short step lists from each lesson of Monthly monitoring, reassessment and tier changes, on one page. Print it for the station or the break room. Each list points back to its lesson, where the sources are linked.

Open the coursePrint a poster with a QR code

Decision guide

A change was reported: what is my next step?

Does the report include any sign of abuse or neglect?

  • Yes

    Report it immediately to APS and DHCS, and to CCL if the person lives in an RCFE or ARF. Then work through this guide again for the change itself.

  • No

    Can the home still safely meet the person's needs with the help it gives now?

    • Yes

      Has the help the person needs changed in daily activities, thinking, behavior, continence, communication, medications, skin or treatments?

      • Yes

        Is the six-month reassessment due within the next 30 days?

        • Yes

          Ask your CCA RN or supervisor whether to complete the scheduled reassessment now, inside its window, so that it reflects the change. Do not let it pass the window.

        • No

          Arrange a CCA RN reassessment with the Assessment Tool now. If it calculates a different tier, send the DHCS 1329 packet, with the tool within 60 days of the RN's signature.

      • No

        Did the participant or the representative ask to review or change the ISP?

        • Yes

          Review the ISP with them, update it where they want changes, and collect the signatures on the updated plan.

        • No

          Record the report in the case file, add any new risk to the ISP with a plan, and check it at your next monthly visit.

    • No

      Tell the CCA RN today and report the problem to DHCS. An RN reassessment shows the new needs, and DHCS decides what happens to waiver services.

This guide sorts a report. It does not decide a tier, eligibility or what happens to waiver services: the Assessment Tool and DHCS do. Call 911 in an emergency, and follow your agency's procedures.

Step through it one question at a time: alwbeta.com/training/courses/monitoring-reassessment-tier-changes#decision-guide

Lesson 1

The monthly contact the waiver requires

Every month you meet each participant you coordinate care for. The waiver sets who you meet, how often and what the meeting is for. This lesson prepares one decision: is this month's contact planned and recorded the way the waiver and the person's plan expect?

  1. Meet the participant or responsible parties every month
  2. Telehealth only by the person's choice, with consent first and needs met remotely
  3. Fill in the ISP monitoring section: requirements explained, contact preferences, who to notify
  4. Hospital stay: keep coordinating the return for up to 30 days
  5. A DHCS visit never replaces your monthly meeting

Lesson: alwbeta.com/training/courses/monitoring-reassessment-tier-changes#lesson-mon-monthly-contact

Lesson 2

What to look for and record at each visit

A monthly visit is more than a check mark. At each visit you look at whether the plan is working, what has changed and what must be reported now. This lesson prepares the note you write after the visit, and the calls you make before you leave.

  1. Ask the participant: are you getting each service in your ISP?
  2. Trade information with the home; note any new risk
  3. Abuse or neglect signs: report at once to APS, DHCS and CCL
  4. Other problems found at a visit: report to DHCS right away
  5. Verify Medi-Cal eligibility every month
  6. Write what you checked, heard, did and told

Lesson: alwbeta.com/training/courses/monitoring-reassessment-tier-changes#lesson-mon-visit-findings

Lesson 3

The six-month reassessment and its packet

Every participant has a reassessment due date. Miss the window and DHCS can ask your agency for a corrective action plan. Send a packet with a piece missing and it is not complete. This lesson prepares you to plan the reassessment: who does it, when, what goes to DHCS and what changes in the ISP.

  1. Due every six months, with the same Assessment Tool
  2. Window: 30 days before or after the due date, then seven more days for the ISP and documents
  3. Packet (DHCS 1330): checklist, Medi-Cal printout, RN-signed tool, updated ISP, signed Patient's Rights Form
  4. Mark the ISP as an update; pick the last tier from the list
  5. Copies to DHCS and the home; the agency keeps the original

Lesson: alwbeta.com/training/courses/monitoring-reassessment-tier-changes#lesson-mon-reassessment-cycle

Lesson 4

When a change calls for an earlier reassessment

Needs rarely change on the reassessment date. A fall, a hospital stay or new help at night can change what the person needs now. This lesson prepares one decision: does this change call for a reassessment before the six-month date, and who decides what follows?

  1. A change in condition does not wait for the six-month date
  2. Agree with the home how it tells you about changes
  3. Look at the areas the tool scores, not the diagnosis
  4. A request to review the ISP gets a review
  5. No promises: the tool calculates, DHCS decides
  6. Needs beyond what the home can safely manage: RN reassessment and DHCS

Lesson: alwbeta.com/training/courses/monitoring-reassessment-tier-changes#lesson-mon-change-triggers

Lesson 5

The tier change packet and closing the loop

A reassessment shows a different tier. Now the paperwork has to reach DHCS complete and on time, and the people who carry out the plan have to know what changed. This lesson prepares the packet, the updated ISP, the signatures and the steps that close the loop with the home and the participant.

  1. DHCS 1329: checklist, Medi-Cal printout, RN-signed tool, ISP, Patient's Rights Form, health care power of attorney if any
  2. Tool to DHCS within 60 days of the RN's signature
  3. Update every service in the ISP, not only the tier
  4. The participant signs and may disagree with any part
  5. DHCS decides; a reduction comes with a Notice of Action
  6. New ISP and assessment to the home, confirmed, checked at the next visit

Lesson: alwbeta.com/training/courses/monitoring-reassessment-tier-changes#lesson-mon-tier-change-loop

Beta’s ALW team, course version 2026.10.3, text checked against its sources on October 22, 2026. Educational only. Not continuing-education, licensure or regulatory credit. Follow your employer’s current procedure and the person’s current plan. Call 911 for a medical emergency.

Call the ALW teamFit check