In-Home Exception Request

Prime Branch: number: Case name:

Worker name: Aging and People with Disabilities Worker phone: Worker e-mail:

Type of request 1 Live-in Hourly cap (over 50 hours per week) Service plan hours

Effective Most recent CA/PS date: date: Request Provider Select one : Select one Select one type: Manager Manager e- name: mail:

In-Home Provider information 2 Details Hours Provider Allowed number of numbers: hours: Provider Requested exceptional names: hours: Number of providers: Total: Meets VDQ requirements?: Enhanced HCW’s?: Reasons for exceptions (check all that apply): Hourly3 cap reasons: HCW has quit or been Insufficient number of HCW’s to terminated until replacement provide needed care can be hired (no more than 30 days) Traveling out of town and needs Emergent or urgent need one HCW to accompany

of 2 TEMPORARY SDS 0514 (8/15) Back-up plans that include relief Unique or complex needs or substitute caregiving when requiring continuity of care the primary or scheduled caregiver is unavailable

Service plan hours reasons: Special technology (e.g. Additional service needs ventilator) (e.g. weight, unscheduled night Multiple shift providers needs, turning every two hours, Short term plan for restorative two-person transfers) care Service for terminally ill Other considerations 4 Have you discussed alternative living environment (e.g. AFH)? Yes No Have natural supports been discussed? Yes No Have assistive devices been explored? Yes No If this person has Dementia, or a related condition, who is managing the plan?

Summary of needs 5

E-mail to: [email protected] or Exceptions, SPD via Outlook

of 2 TEMPORARY SDS 0514 (8/15)