Individualized Back Up Plan

Department of Human Services

Division of Developmental Disabilities

Information Bulletin



This Information Bulletin provides information and guidance for the development of the Individualized Back Up Plan. The requirement to develop an Individualized Back Up Plan is effective 7/1/22 in accordance with the waiver renewals.


Federal Centers for Medicare and Medicaid Services (CMS) requires the development of a Back Up Plan in specific instances via their "Application for a §1915(c) Home and Community-Based Waiver (Version 3.6, January 2019) Instructions, Technical Guide and Review Criteria". The manual states:

"When individuals are supported in their own private residence or other settings where staff might not be continuously available, the service plan should include a backup plan to address contingencies such as emergencies, including the failure of a support worker to appear when scheduled to provide necessary services when the absence of the service presents a risk to the participant's health and welfare. An effective back-up plan is one that is crafted to meet the unique needs and circumstances of each waiver participant. The response to this item should also describe the types of back-up arrangements that are employed. Such arrangements may include arranging for designated provider agencies to furnish staff support on an on-call basis as necessary."

Requirement to Develop a Back Up Plan:

  • Back Up Plans are required beginning 7/1/22 and developed as part of the Person-Centered Planning (PCP) process. These plans are required to be developed when the Personal Plan (PP) is due in Fiscal Year (FY) 23 (July 2022 - June 2023). If the PP was developed between July 1, 2022 and the issue date of this Information Bulletin (IB) and the Back Up Plan was not developed as required, the Independent Service Coordination (ISC) Agency must develop it during the next quarterly monitoring visit.
  • If the individual is receiving services from an agency (all Community Integrated Living Arrangement (CILA) types, Community Day Services (CDS), Personal Support Worker (PSW) Agency), the agency is required to provide back up personnel as needed. In situations where an individual purchases personal support services from a PSW Agency, the individual should communicate with the PSW Agency to confirm a Back Up Plan is in place. If not or the individual doesn't know if their PSW Agency has a Back Up Plan, the ISC Agency should work with the individual and PSW Agency to develop a Back Up Plan utilizing the Individualized Back Up Plan form (IL462-4125).
  • If it's determined the PSW Agency has a Back Up Plan in place and the individual is aware of the Plan, the ISC Agency has two options:

(1) Develop a Q-note indicating the ISC Agency confirmed with the individual and PSW Agency that a Back Up Plan is established, and the individual has been informed of the Back Up Plan; or

(2) Complete the Back Up Plan form and notate the PSW Agency's plan.

Note: For Agency-Based PSW reviews, BQM will be looking for either a Q-note or the completed Back Up Plan form.

  • When the individual is exercising employer authority, the ISC Agency shall ensure a Back-Up Plan is completed because the absence of the service may present a risk to the health, welfare and/or safety of the individual.


  • The individual served will work with their ISC Agency and anyone else they want to participate in the process ("planning team") to include a legal guardian if applicable to develop the Back Up Plan.
  • The Back Up Plan should be specific to the individual's needs and preferences. A sufficient Back Up Plan is not just to rely on calling 911, but rather one that utilizes other formal social service agencies, as well as family, neighbors and friends, and assistive technology devices.
  • Once the form is complete, copies will be kept with the ISC Agency in the individual's file, provided to any agency identified as part of the plan, given to the Self Direction Assistance (SDA) Agency if the individual purchases this service, and kept on hand at the home of the individual with easy access.

Completing the Form:

  • The INDIVIDUALIZED BACK-UP PLAN form is available in English PDF.
  • The INDIVIDUALIZED BACK-UP PLAN form is available in Spanish PDF.
  • Instructions for completing the form (IL462-4125) are listed on the second page.
  • Enter the name of the individual who is receiving services and his/her telephone number.
  • If the individual served has communication needs such as sign language, a communication board, a language other than English, etc., check the "Yes" box and identify the specific communication needs. If not, check the "No" box.
  • Use the second section to detail the plan for how the situation will be handled when the individual's support worker doesn't arrive to provide services when scheduled. The planning team should evaluate the need and type of Back Up Plan taking into consideration natural supports and available waiver services. Individuals residing with family members can enter into agreements with providers who can provide services in an emergency situation or provide staff substitutes when regular staff cannot work assigned hours. The planning team will detail who is to be notified, how they should be contacted and what the individual served is to do when the support worker isn't available. If the plan is to contact a backup support worker, the Back Up Plan must identify the support worker's name and contact information. If the plan is to contact an unpaid caregiver, the Back Up Plan must identify the unpaid caregiver's name, relationship, and contact information. If the plan is to use an agency based PSW, the Back Up Plan must identify the agency's name and contact information.

NOTE: If paid support worker(s) are used as part of the Back Up Plan, the back up support worker must be an enrolled provider. The individual served/Employer of Record must contact ACES$ to begin the provider enrollment process and ensure they are identified on the Service Authorization

NOTE: If you're utilizing agency-based services as part of the Back Up Plan, the individual served/Employer of Record must have a Service Agreement with the agency and ensure the Employer of Record is accounting for their services when managing the individual's monthly budget. If an agency is identified to provide support as part of the Back Up Plan, they should immediately become part of the conversation to ensure they are aware and can fulfill the obligation.

  • The next section of the form is used to develop a plan when the Employer of Record (EOR) is unable to be reached. If the individual receiving services wishes to have an individual identified to temporarily act as an EOR, the planning team must complete this section.

NOTE: Temporary EORs and PSWs cannot be the same person. The temporary EOR cannot make permanent changes to the individual's approved PSWs or Service Authorizations. ACES$ can only have 1 individual in their system who is identified at the EOR. It's recommended you complete a Release of Information form and identify the temporary EOR on this form so ACES$ can share budget and PSW information with them. This person is only intended to be contacted and utilized in emergency situations when the primary EOR is unreachable, and the individual's health and welfare is at risk if a decision is not made.

  • In the Emergency Contacts section, identify anyone who must be contacted when an emergency situation presents itself.
  • The bottom section of the form provides public emergency contact and reporting information. This section is also used to identify additional contact information for other supports received by the individual.
  • The individual's primary pharmacy contact information should be provided so this can be used if an emergency arises such as the individual needing to refill important medications. The person who typically sets up the individual's medication should be identified in this section too.
  • If a person has meals delivered as part of a meal delivery service, the contact information should be provided for this service in case a meal isn't delivered as scheduled to ensure the individual receives proper nutrition. If this isn't a service the individual receives, this section should be left blank.
  • The last section of the form is for critical incident reporting (refer to the top of the second page of the form). The Division recognizes an individual receiving services, and/or their family, does not have the ability to report a critical incident to the Division's Critical Incident Reporting and Analysis System (CIRAS). If any of the critical incidents identified should occur, the individual and/or family should report the incident to their ISC Agency or any of their agency service providers so the incident can be entered into CIRAS. If it's an issue of abuse, neglect, or exploitation, APS should also be contacted.
  • Lastly, the ISC Agency should be identified by their main contact phone number, the person completing the Back Up Plan form, and a secondary contact phone number in case no one can be reached at the main contact phone number.

If you have questions about the above information or the Back Up Plan form, please contact Derek Hedges,

Effective Date:

This Information Bulletin is effective 07/01/2022