(a) Within ten working days of receipt of the referral for Personal Care services, the Personal Care Assessment/Service Planning Nurse completes a Service Authorization Model (SAM) visit in the home to assess the member's Personal Care service needs, completes a Service Authorization Model (SAM) packet based on the member's needs and submits the packet to the OKDHS nurse.  The member's Service Authorization Model (SAM) packet includes:

• (1) State Plan Personal Care Progress Notes (OKDHS form 02AG044E);
• (2) Personal Care Planning Schedule [OKDHS form 02AG030E (AG-5)];
• (3) Personal Care Plan [OKDHS form 02AG029E (AG-4)]; and
• (4) Personal Care Service Plan [02AG031E (AG-6)].

(b) If more than one person in the household has been referred to receive Personal Care services, all household members' Service Authorization Model (SAM) packets are discussed and developed with the eligible members so service delivery can be coordinated to achieve the most efficient use of resources.  The number of units of Personal Care service authorized for each individual is distributed between all eligible family members to assure that the absence of one family member does not adversely affect the family member(s) remaining in the home.

(c) The Personal Care service agency receives a certified Service Plan [OKDHS form 02AG031E (AG-6)] from OKDHS as authorization to begin services.  The agency delivers a copy of the care plan and service plan to the member upon initiating services.

(d) Prior to placing a Personal Care attendant in the member's home or other service-delivery setting, an OSBI background check, OKDHS Community Service Worker Registry check in accordance with Section 1025.2 of Title 56 of the Oklahoma Statutes, and as appropriate, the Certified Nurse Aide Registry Check must be completed.

(e) The Personal Care Assessment/Service Planning Nurse monitors their member's plan of care.

• (1) The Personal Care service provider agency contacts the member within five calendar days of receipt of the approved care Service Plan [OKDHS form 02AG031E (AG-6)] in order to make sure that services have been implemented and the needs of the member are being met.
• (2) The Personal Care Assessment/Service Planning Nurse makes a Service Authorization Model (SAM) home visit at least every 180 days to assess the member's satisfaction with their care and to evaluate the Service Authorization Model (SAM) packet for adequacy of goals and units authorized.  Whenever a home visit is made, the Personal Care Assessment/Service Planning Nurse documents their findings in the State Plan Personal Care Progress Notes (OKDHS form 02AG044E).  The personal care agency forwards a copy of the Progress Notes to the OKDHS nurse for review.  The monitoring visit may be conducted by an LPN.  If an LPN or social worker conducts the monitoring visit, an RN must co-sign the progress notes.
• (3) Requests by the Personal Care service agency to change the number of units authorized in the Service Authorization Model (SAM) packet are submitted to OKDHS and are approved or denied by the OKDHS area nurse, or designee prior to implementation of the changed number of units.
• (4) Annually, or more frequently if the member's needs change, the Personal Care Assessment/Service Planning Nurse re-assesses member's need and develops a new Service Authorization Model (SAM) eligibility packet to meet personal care needs.
• (5) If the member is unstaffed, the Personal Care service agency communicates with the member and makes efforts to restaff.  If the member is unstaffed for 30 calendar days, the agency notifies the OKDHS nurse on an OKDHS form 02AG032E (AG-7), Provider Communication Form.  The OKDHS nurse contacts the member and if the member chooses, initiates a transfer of the member to another Personal Care service agency that can provide staff.