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Home Based Support Service Agreement

The Arc of Winnebago, Boone & Ogle Counties

HOME BASED SUPPORT PROGRAM

SERVICE AGREEMENT

The Home Based Support Program seeks to provide a full array of quality, outcome-based, person- and community-centered services and supports for individuals with developmental disabilities and their families in accordance with the program guidelines developed by the Illinois Department of Human Services, Division of Developmental Disabilities, Home Based Support Program.  

The Arc Coordinator

Duties and Responsibilities

You / Your Guardian

Duties and Responsibilities

Your coordinator will:

  1. Establish a service plan centered on individual’s goals and needs.

 

  1. Provide resources for personal support workers, if available.

 

  1. Assist, if needed, in filling out Medicaid application annually.

 

  1. Record in service plan and/or file any major changes or events that could affect the service plan goals or Home Based Support funding.

 

  1. Visit day-training sites and home of the individual at least 6 times per year.

 

  1. Ensure all agreements and releases are signed and kept up-to-date.

 

  1. Maintain an up-to-date and comprehensive file for you.

 

  1. Assist in resolving concerns or questions or refer you to a source that can help.

 

  1. Record service providers billing hours into ROCS in a timely manner.

 

  1. Provide service providers with time sheet copies for their records.

 

  1. Cooperate with your guardian, ISSA caseworker, employment staff and/or other agency providers.

 

            You/ your guardian will:

1.       Discuss your goals and interests and help your coordinator develop a service plan with goals you want to achieve.

 

2.       Hire and manage personal support staff who are qualified to meet your needs.                        

 

3.       Apply for and maintain Medicaid eligibility while receiving Home Based funding.

 

4.       Notify the HBS coordinator of any changes or events that could affect your service plan, Home Based Support funding, etc.

 

5.       Allow Home Base Support coordinator and ISSA monitor access to the home for necessary visits

 

6.       Participate actively in home visits and meetings, including signing agreements and releases

 

7.       Give your coordinator any documents needed to ensure a comprehensive and up-to-date file.

 

8.       Inform your coordinator or ISSA monitor of any concerns or questions.

 

9.       Ensure your service providers send in accurate timesheets in a timely manner.

 

10.   Keep accurate records of personal support workers and the hours they work.

 

11.   Cooperate with your coordinator, guardian, ISSA caseworker and/or other agency providers.

 

 

 Fees

The Arc will provide a minimum of 3 hours of service coordination, administrative work and visits.  The Arc bills $117.12 for this service each month. It is paid with Home Based Support funds.  Should you require additional service coordination, The Arc will bill at the rate of $9.76 for each additional 15 minutes of service provision. This is also paid with Home Based Support funds.   

Disclosure

I understand The Arc Home Based Support Services Program Policies and Procedures and I agree to comply with the terms and conditions.

I have received a Participant Handbook for The Arc of Winnebago, Boone & Ogle Counties, Home Based Support Program. 

Program Participant/Guardian:

Sign:_________________________________ Date:_____________________________      

 

The Arc of Winnebago, Boone & Ogle Counties Coordinator:

Sign:_________________________________Date:______________________________

 

    • *Discharge: You have the right to continue to receive services unless you voluntarily withdraw or you meet the criteria for discharge from the services, you have the right to terminate services at any time.
    • Should an individual terminate services, The Arc will notify the Illinois Department of Human Services Developmental Disabilities, Northwest Network Facilitator and Access Services as appropriate.
    • The Arc of Winnebago, Boone, and Ogle Counties enters into a Service Agreement with each individual enrolled in the Home Based Support Program.
    • Should The Arc of Winnebago, Boone & Ogle Counties determine it is unable to serve an individual, the individual/guardian will be notified and a referral will be made to the Department of Human Services Developmental Disabilities, Northwest Network Facilitator and to Access Services as appropriate.

 

 

 

* excerpt from Illinois Department of Human Services, Medicaid Home and Community-Based Services DD Adult Waiver form DD-1201  Rights of Individuals

 

 

 

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