Creating a Personalized CFSS Plan: Key Considerations

One of the first steps in receiving Community First Services and Supports (CFSS) is completing a CFSS service delivery plan. This is essential for ensuring you receive the care and support you need to live independently.

Let’s explore how to create a comprehensive plan that meets your needs and satisfies the requirements set forth by the Minnesota Department of Human Services.

CFSS Service Delivery Plan Basics

According to the Minnesota Department of Human Services, every individual receiving care under CFSS must maintain a detailed plan outlining their services. While this document was traditionally known as a “care plan” under the Personal Care Assistance (PCA) program, it is now called a “service delivery plan” in the new CFSS program.

While the names are different, both plans serve the same essential purpose: Documenting exactly how and what services will be provided based on individual needs.

For a template, refer to the CFSS Individual Service Delivery Plan, DHS-6893P.

Who Needs a CFSS Plan?

For individuals who are unable to manage their own care decisions, the state requires an adult representative to assist in directing services. This person must be at least 18 years old and capable of making care-related decisions.

The terminology differs slightly between programs. Under PCA, the caregiver was referred to as a “responsible party” (RP), whereas CFSS refers to them as a “participant representative.”

The Minnesota DHS outlines specific times when service delivery plans need to be created or updated. These include:

• When initially starting services.
• During annual reassessments.
• Any time there are significant changes to care needs.

Where Do You Need Copies of Your Care Plan?

Copies of the current plan must be maintained in several locations so care workers and responsible agencies have access to the plan. These locations include:

• The care recipient's home.
• The provider agency’s files.
• Any location where shared services take place.
• With the consultation services provider (for CFSS participants).
• In FMS provider records (when applicable for CFSS).

Under state law, all caregivers must be aware of the location of the care plan to ensure consistent and appropriate care delivery.

Creating Your CFSS Service Delivery Plan

When developing your CFSS service delivery plan, you will need to consider your goals, provide details of your care service, develop an emergency plan, and outline any safety measures you need to implement.

The Individual Service Delivery Plan template provided by the Minnesota Department of Human Services covers all of the details you will need to address in your plan. These include:

1. Personal Information and Goals

• Document your basic contact information and demographics.
• Identify your preferred language and any interpreter needs you may have.
• Describe your personal strengths and preferences.
• Define your specific goals and desired outcomes for care.

2. Service Details and Delivery Model

• Confirm your total eligible CFSS units.
• Determine if you qualify for enhanced rates.
• Choose between the budget and agency models.
• Document your consultation services provider's information.

3. Emergency Response Planning

• List the signs of medical emergencies specific to your condition.
• Describe what to do in the event of medical situations.
• Include contact information for your healthcare providers.
• Outline a plan for fire safety, severe weather, and power outages.
• Describe how to address other environmental emergencies.

4. Safety and Prevention Measures

• Identify any vulnerability concerns.
• Develop specific safety measures.
• Create clear protocols for reporting and responding to abuse.
• Document prevention strategies.

Remember, your consultation services provider can help you complete this plan. Once finished, submit it to them for review and approval. Your plan serves as a living document that can be updated as your care needs change.

For detailed guidance on developing your CFSS service delivery plan, visit the Minnesota DHS website or contact your consultation services provider. The DHS provides a list of CFSS Consultation Service Providers in Minnesota to aid your search.

How Best Care Can Help

Best Care is here to help you with additional questions or concerns that you have about transitioning to the CFSS program in Minnesota. Best Care offers CFSS services as both a budget model and an agency model provider, and we have numerous resources to help you get set up. Contact us today to learn how we can help!