1. (1) The completion of the application form designated by the department is required in order for the PSA activity to be reimbursed from Federal and State financial participation.

2. (2) There will be those situations when the adult in need of protective services is unable or unwilling to sign the application or complete information that cannot be immediately obtained. In these situations, the application form shall be completed and, in accordance with department instructions, entries shall be made in the case record documenting the circumstances and reasons why the application form was not signed.

   (b) PSA assessment/services plan.

3. (1) The case record of each PSA client shall include a PSA assessment/services plan consisting of the following information:

   1. (i) source of referral;
   2. (ii) reason for referral;
   3. (iii) household composition;
   4. (iv) residence and living arrangements;
   5. (v) income and resources;
   6. (vi) medical and mental limitations;
   7. (vii) ability to manage resources;
   8. (viii) identification of significant other persons such as family members and friends and their willingness and capability to assist the individual;
   9. (ix) identification of other agencies involved with the individual;
   10. (x) assessment of problem(s) and needs and the names of agencies involved in the assessment;
   11. (xi) client specific objective(s) to be achieved;
   12. (xii) service(s) to be provided to obtain the objective(s) and name(s) of the agencies providing the services;
   13. (xiii) expected duration of the services;
   14. (xiv) frequency of contact with the client;
   15. (xv) concurrence and acceptance of services by the applicant or a notation that the client is involuntary;
   16. (xvi) in the case of a client who cannot or will not sign the application for services (DSS 2921), documentation as to why the worker is signing the application on behalf of the client;
   17. (xvii) frequency of review of the services plan;
   18. (xviii) progress evaluation at the time of review;
   19. (xix) changes made in the client's services plan as a result of the periodic reviews;
   20. (xx) signatures of worker and supervisor; and
   21. (xxi) such other information as the department shall require.
4. (2) The PSA assessment/services plan shall replace the individual service plan required in section 406.2(b) of this Title.

5. (3) The PSA assessment/services plan shall be prepared on a form prescribed by the department or on a local equivalent form approved by the department.

   1. (i) The PSA assessment/services plan must be completed within 60 days of the referral date. The date of completion will be determined by the date of the supervisor's signature on the form prescribed by the department or an approved local equivalent.
   2. (ii) Notwithstanding the time frames for completing the PSA assessment/services plan specified in subparagraph (i) of this paragraph, the services needs of individuals who are being assessed for PSA must be addressed promptly and appropriately, in accordance with the provisions of section 457.1(c) of this Part, regardless of the date the PSA assessment/services plan is completed.

   (4)

6. (5) The PSA assessment/services plan must be reviewed and updated:

   1. (i) within six calendar months of the date of referral and every six calendar months thereafter; or

   2. (ii) whenever a PSA case is closed or transferred to another service provided by the social services district, except that a form need not be completed when a case is closed due to the client's death. The date of review will be determined by the date of the supervisor's signature on the form prescribed by the department or an approved local equivalent.

      (c) Progress notes.

      Progress notes must be maintained as part of the PSA client record as prescribed by the department. Progress notes must be recorded in the PSA case record as soon as possible but no later than 30 days after date of the event which required the use of progress notes.

      (d) Other information.

      The PSA client record shall contain all other information required in section 406.2 of this Title, with the exception of the individual service plan, and any other information which the department may from time to time require.

The case record of a PSA client must include the following:

(a) Application.