Understanding Your Care Plan

Limitations

A website summary is not your individual plan. Only the plan in the client record authorizes tasks for a specific person. Eden educational resources are not a substitute for official Medicaid, waiver, or health-plan determinations. Rules vary by program, assessment, authorization, and plan. Confirm current details with DMAS, your MCO, and Eden intake.

Important definitions

Short definitions used on this page. Program manuals may phrase lists slightly differently.

• Plan of care: The documented service plan that describes authorized supports. Hours cannot exceed what the payer authorized.

Plain-English summary

Virginia personal-care regulation currently requires services to be delivered under a written plan developed by a registered nurse in collaboration with the client and family. Learn what a plan typically includes and why caregivers stay inside authorized tasks.

The personal-care plan rule

12VAC5-381-360 currently requires that personal care services be delivered based on a written plan of services developed by a registered nurse, in collaboration with the client and client's family. The plan is retained in the client record. Copies are provided to the client and reviewed with the assigned home attendant before delivering services.

What the plan must include (current regulation)

The current personal-care section says the plan shall include at least: assessment of the client's needs; functional limitations; activities permitted; special dietary needs; specific personal care services to be performed; and frequency of service.

Supervision

Supervision of personal care shall be provided as often as necessary as determined by the client's needs, the RN assessment, and the organization's written policies, not to exceed 90 days. A registered nurse or licensed practical nurse shall be available during all hours that personal care services are being provided.

What caregivers must stay within

The family may request help, but the caregiver must remain within authorized services, the care plan, training, competency, law, and Eden policy. If uncertain, contact the supervisor or RN. Do not take on a medical task because a family member asked.

Changes in condition

Personal-care attendants record and report to the supervisor any changes regarding the client's condition, behavior, or appearance. A website cannot give individual medical advice. Call 911 for emergencies.

Eligibility and applicability

Program rules, assessments, and payer authorization decide what can start. Medicaid enrollment, waiver enrollment, service eligibility, service authorization, and authorized hours are not the same status.

Assessment and documentation

Depending on the program and service, an assessment and supporting documentation may be required. A nurse does not automatically visit first for every request.

Authorization and approval

When authorization is required, the payer or MCO reviews the requested service and hours. Outcomes can include approval, partial approval, a request for more information, or denial. Eden does not approve the benefit.

Hours and limits

Requested, assessed, authorized, scheduled, and EVV-verified hours can all differ. This site does not invent a universal hour number.

How services can interact

Personal care, respite, companion, adult day, and transportation follow separate rules. A plan may authorize one, more than one, or none.

Family caregiver implications

A parent or spouse is not automatically a paid caregiver. Virginia LRI rules apply only in defined relationships and only when the current official policy and authorization allow it.

Agency-directed vs consumer-directed

Agency-directed: a licensed agency is the employer. Consumer-directed: the member or representative is the employer of record, with services-facilitator support where the waiver allows. Eden's typical public role is agency-directed care.

Insurance and MCO implications

Managed-care members usually follow their plan's authorization and appeal process. Fee-for-service members follow DMAS processes. A plan existing on the official roster does not mean Eden is in-network.