Home and Community Based Services Manual
4.00 Appendix 2 Participant Choice Statement Instructions
The Participant Choice Statement shall be completed at each initial and subsequent (re)assessment used to determine eligibility for Home and Community Based Services (HCBS). Upon completion of the assessment and authorization of HCBS, the Participant Choice Statement shall be uploaded to the participant’s electronic case record. The Participant Choice Statement provides documentation of the participant’s involvement in the selection of services and providers, and development of the Person Centered Care Plan (PCCP), as well as education regarding available community services and supports and reporting abuse, neglect, or exploitation. It is also used to assess the continued compliance with the HCBS Final Rule based upon participant feedback.
Instructions
Participant Name: Enter the participant’s name.
DCN: Enter the participant’s Departmental Client Number (DCN).
County Name: Enter the participant’s county of residence.
The Division of Senior and Disability Services (DSDS) shall utilize the guidance below to explain each item detailed in the Participant Choice Statement. Self-explanatory items are not included.
#1 Explain and offer all services the participant is in need of and eligible to receive.
#2 Explain that the participant may choose from any provider in their area. Offer a list of providers if the participant is unsure which to select.
#6 Review the applicable Rights and Responsibilities document(s) with the participant. Reiterate by signing the Participant Choice Statement, the participant is agreeing to the Rights and Responsibilities.
- There are five (5) different Rights and Responsibilities forms. Staff shall review and leave the participant with the appropriate Rights and Responsibilities form(s) based upon the participant’s proposed or authorized PCCP.
#7 Notify the participant that a copy of DHSS’ Notice of Privacy Practices is available and will be provided to them upon request. They can request a copy of the privacy practices at their annual assessment or by contacting the Person Centered Care Planning (PCCP) team.
#8 Explain abuse, neglect, and exploitation as defined below and provide the information to report an incident.
Abuse: The infliction of physical, sexual, or emotional injury or harm, including financial exploitation by any person, firm, or corporation and bullying (192.2400, RSMo).
Neglect: The failure to provide services to an eligible adult by any person, firm or corporation with a legal or contractual duty to do so, when such failure presents either an imminent danger to the health, safety, or welfare of the client or a substantial probability that death or serious physical harm would result (192.2400, RSMo).
Exploitation: The Crime of Financial Exploitation involves allegations that a person (whether a family member, joint tenant, caregiver/attendant, or someone who has assumed fiduciary responsibility) has knowingly by deception, intimidation, undue influence, or force obtained control over an eligible adult’s property with the intent to permanently deprive the eligible adult benefit or possession of his or her property as directed in 570.145, RSMo.
Other Critical Incident: A negligent event that led to an emergency visit or hospitalization.
#9 Discuss all identified risks and needs. Explain the services and referral options available to meet their unmet needs or risks. It is the participant’s choice whether to proceed with the presented options or decline the option to address a specific risk(s) or need(s).
#10 In order to meet Centers of Medicare and Medicaid Services (CMS) standards, this section shall be used to assess continued compliance with the HCBS Final Rule based upon participant feedback. DSDS staff or their designee shall pay particular attention to participants in an Adult Day Care setting or a provider owned or controlled setting. If a participant indicates to DSDS staff, or their designee, concerns regarding the participant’s setting, the staff should utilize the HCBS Final Rule Participant Survey to prompt further discussion. If necessary, DSDS staff, or their designee, shall forward all settings concerns to the Bureau of Federal Programs (BFP). Additional information regarding the HCBS Final Rule transition plan is available.
Assessor Signature and Date: The individual completing the assessment shall sign and date the Participant Choice Statement reflecting when the assessment was completed.
Assessor Name (Printed): Print the name of the Assessor.
Employed By: Enter the name of the Assessor’s employer.
Participant Signature and Date: Obtain the participant’s/responsible person’s signature and date. When the participant is unable to sign the form, DSDS staff or their designee shall document this information in the case notes section of the participant’s electronic case record or on the Participant Choice Statement itself. In the event of a refusal, the participant should be informed the services may not be authorized without consent and the case should be closed. Documentation of this should be included in the case notes.
Distribution: A copy shall be provided to the participant. A copy shall be uploaded and maintained in the participant’s electronic case record. If the participant does not meet eligibility and is therefore, not authorized for HCBS, it is not necessary to obtain a signature from the participant or upload the form.