Individualized Plan of Care (IPC) Documents

IPC Forms

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• Habilitation Support  (New - effective  August 2012)
  
• ICAP Authorization (New - effective September 2012)
  
• Team Signature and Verification form (Revised April 2011)
  
• Verification form - used in EMWS last step for submitting IPC
  

Helpful IPC Tools

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• "About Me" worksheet (Revised September 2012)
  
  
• File Naming Convention - used in EMWS for uploading files
  
  
• Functional Assessment - sample
  (Template is sample that can be used to explore the reasons behaviors are occuring and can be used to develop Positive Behavior Support Plan.)
  
  
• Medication Assistance Record
  
  
• "My Medical Services" worksheet
  
  
• Participant Specific Training form
  
  
• Plan of Care Worksheet for EMWS
  - example completed Child IPC
  - example completed Adult IPC
  
  
• Planning Workbook for IPC
  
  
• Positive Behavior Support Plan - sample
  (Template is sample to guide in building a Positive Behavior Support Plan.  Other versions are acceptable provided the components of the IPC align with Chapter 45 of Wyo Medicaid Rules.) 
  
  
• Request Goods & Services through Self-Direction: Step by Step Instructions  
   
• Rights, Responsibilities, and Restrictions Guide  
  (Case Managers can use this tool to review the Participant and guardian's rights and responsibilities at least every six months or more as needed.)  
  
  
• Rights, Responsibilities, and Restrictions Worksheet  
   
  
• Services and Rates  
   
• Supervision Level and/or Intervention Request 
  (Use this form if requesting a higher or lower support tier in Residential or Day Habilitation or requesting intervention units)
  
  
• Waiver Application & Eligibility Guide - for Adult and Child DD Waivers 
  

Supplemental Service Forms   

For services included on a Participant's IPC, a supplemental form is completed by thePprovider and sent to the Case Manager before the IPC is submitted to the Division. Objectives are required for habilitation services but do not need to be sent to the Division with the IPC. 

• Checklist for requesting Specialized Equipment 
• Environmental Modifications 
• Goods & Services (Available if Self-Directing through PPL)
• Skilled Nursing 
• Specialized Equipment
• Unpaid Caregiver Training (Available if Self-Directing through PPL)

 

Sample Objectives and Schedules

These are only samples and are not required to be used. Providers may develop their own schedules with input from the participant and team, which align with the documentation requirements listed in Chapter 45.

• Sample Task Analysis Sheet
• Example of Completed Objective & Schedule
   
• Employment Objectives
• Habilitation Objectives (For Supported Living, Res & Day Hab, Special Family Hab Home, Child Hab Srvs)
  
• Personal Care Schedule - or PDF
• Residential Habilitation Training Schedule 
• Respite Schedule  - or PDF
• Special Family Hab Home Schedule - or PDF

• Sample Day Habilitation Schedule (With behavior plan and objective data collection components)
• Sample Intervention Hours Schedule
• Sample Residential Habilitation Schedule