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Section K

Horizontales
Reassessment may be needed if waiver case was completely
MDHHS electronic data collection
Follow up and monitoring include contact between SC and
Person Centered Service Plan
Changes in physical function, cognition, informal support availability may require a
Death, moved, nursing home placement
30-60 or 90 days
RN/SW
SC provide in-person reassessments how often
Verticales
The participants must meet eligibility requirements for the
Nursing Facility Level of Care
Who monitors all services implemented