Job aids

The care plan meeting: the steps to remember

The short step lists from each lesson of The care plan meeting: how to take part, 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 course Print a poster with a QR code

Decision guide

The plan does not fit. What now?

Did your loved one get a Notice of Action from DHCS that denies, cuts or stops a service?

Yes
Read it today. It says why, and how to ask for a State Hearing, with free legal aid numbers. The waiver gives 90 calendar days after the notice is mailed. Asking before the date printed at the top keeps services already in place going. Think about calling legal aid.
No
Does the plan or the home limit a right, like visitors, food, privacy or their schedule, without your loved one's agreement?
- Yes
  Ask the coordinator what specific need the limit is for and where your loved one's consent is. A diagnosis alone is not enough. If they live in a care home, the Ombudsman can help with rights, for free.
- No
  Have you and your loved one told the care coordinator what does not fit?
  - Yes
    Is the problem how the agency coordinates care, such as missed visits or no answer?
    Yes
    Call the supervisor named on the Patient's Rights Form. If that does not help, file a grievance with DHCS. The DHCS ALW page lists how.
    No
    A concern about ALW services goes to the agency. Ask again for a review, in writing if you can. When your loved one signs, they can mark the parts they disagree with. A concern about the home itself goes to Community Care Licensing at CDSS.
  - No
    Help your loved one tell the coordinator and ask for a plan review. They may ask at any time. The coordinator's phone and email are on the Patient's Rights Form.

This guide helps you choose a next step. It does not decide any service or right. The care coordinator, DHCS, the home and Community Care Licensing each decide their own part, and your loved one leads their plan. It is not legal advice.

Step through it one question at a time: alwbeta.com/training/courses/the-isp-meeting#decision-guide

Questions to ask

Questions worth asking

To the care coordinator: Can we hold the plan meeting at a time and place that suit her, and how will you explain the plan in her language?
To the care coordinator: Who will be at the meeting, and how does he invite the people he wants there?
To the care coordinator: Which of her own goals are in the plan, and who helps with each one?
To the care coordinator: For each need, who helps, how often, and does it match how he likes things done?
To the care coordinator: What does the back-up plan say she needs in an emergency?
To the care coordinator: How do we ask for a plan review before the six-month review, and how do we reach you or your supervisor?
To the care coordinator or the home: Does any part of the plan limit his rights, like visitors or food? What is the reason, and did he agree?
To the agency or DHCS: If a service is denied, cut or stopped, where is the Notice of Action, and how do we ask for a State Hearing?

Lesson 1

What the care plan is, and who writes it

If your loved one uses ALW, their care follows a written plan. Many families first see it at a meeting, with little time to read. This lesson gets you ready to know what the plan is, who writes it, and what should be in it, so you can help your loved one check it.

The ISP is the written plan for ALW care
The agency's care coordinator writes it with your loved one
Goals and likes come from your loved one
Each need: who helps, how often, how they like it
Family help is written in only if you agreed to it
Risks and a back-up plan for emergencies

Lesson: alwbeta.com/training/courses/the-isp-meeting#lesson-fam-plan-what-it-is

Lesson 2

The plan meeting: who comes, what to bring, what to ask

The plan is made at a meeting with the care coordinator. It may be in your loved one's room, with you there or on the phone. This lesson gets you ready to help your loved one take part: who leads, who comes, what to bring, and what to ask before anyone signs.

Your loved one leads; a legal representative leads with them
Your loved one chooses who comes
Ask for a time, place and language that suit them
Bring contacts, legal papers and notes on their day
Ask how to reach the coordinator and the supervisor
Ask for a copy of the plan

Lesson: alwbeta.com/training/courses/the-isp-meeting#lesson-fam-plan-the-meeting

Lesson 3

Reviews, changes, and what to do if you disagree

A plan can change. Needs change, and families sometimes disagree with what a plan says. This lesson gets you ready to know when the plan is reviewed, how your loved one can ask for a change, and where to go if talking with the coordinator does not fix it.

Reviewed at least every six months, sooner if needs change
Your loved one can ask for a review at any time
Sign and mark any part they disagree with; keep a copy
A limit on a right: a specific need and their consent
Services: the agency. Coordination: DHCS. Other: CDSS
Notice of Action: read it now; legal aid is listed

Lesson: alwbeta.com/training/courses/the-isp-meeting#lesson-fam-plan-review-and-change