Ariz. Admin. Code § 9-21-307

Current through Register Vol. 30, No. 45, November 8, 2024

Section R9-21-307 - The Individual Service Plan

A. General provisions.

1. An individual service plan (ISP) shall be developed by the clinical team and each client.

2. The ISP shall include the most appropriate and least restrictive services, consistent with the client's needs and preferences, as identified in the assessment conducted according to R9-21-305, and without regard to the availability of services or resources.

3. The ISP shall identify those services which maximize the client's strengths, independence, and integration into the community.

4. Generic services available to the general public should be utilized, to the maximum extent possible, when adequate to meet the client's needs and if access can be arranged by the case manager or client.

5. If all needed services are not available, a plan for alternative services shall detail those services which are, to the maximum extent possible, adequate, appropriate, consistent with the client's needs, and least restrictive of the client's freedom.

6. The clinical team shall solicit and actively encourage the participation of the client and guardian.

7. The clinical team shall inform the client of the right to have a designated representative throughout the ISP process and to invite family members or other persons who could contribute to the development of the ISP. The case manager shall seek to obtain a representative for clients who need special assistance or otherwise have limited capacity to articulate their own preferences and to protect their own interests in the ISP process and shall advise the relevant human rights committee that the client has been determined to need special assistance.

8. The ISP shall contain goals and objectives which are measurable and which facilitate meaningful evaluation of the progress toward attaining those goals and objectives.

9. The ISP shall incorporate a specific description of the client objectives, services, and interventions for each mental health agency which will provide services to the client. Each existing service provider will bring to the ISP meeting a detailed written description of the objectives and services currently in effect for the client.

10. For residents of an inpatient facility, the facility's treatment and discharge plan shall be developed according to R9-21-312 and shall be incorporated in the ISP.

11. Prior to the planned discharge of a new client from an inpatient facility, the clinical team shall develop an ISP which describes the community services, including alternative housing and residential supports, that will be provided when the client leaves the facility.

12. The ISP shall be written in language which can be easily understood by a lay person.

13. In developing the ISP, the case manager shall facilitate resolution of differences among service providers and, if resolution is not achieved, shall refer the matter to the regional authority, which shall resolve the matter in accordance with the Administration's policy.

B. The individual service plan meeting.

1. Within 20 days of the completion of the assessment report, the case manager shall convene an ISP meeting at a convenient time and place for the client, guardian, clinical team, and potential service providers.

2. The case manager shall arrange for the client's transportation, if needed, to the ISP meeting.

3. The case manager shall notify in writing the following persons of the time, date and location of the ISP meeting at least 10 days prior:

a. The client, any designated representative and guardian, including an invitation to submit relevant information in writing if their attendance is impossible;

b. Clinicians involved in the assessment or further evaluation;

c. All current and potential service providers;

d. All members of the client's clinical team;

e. Family members, with the client's permission;

f. Other persons familiar with the client whose presence at the meeting is requested by the client;

g. Any other person whose participation is not objected to by the client and who, in the judgment of the case manager, will contribute to the ISP.

4. The case manager shall chair the ISP meeting which shall include a discussion of:

a. The client's supports or skills necessary to achieve the client's long-term view in each of the areas listed in R9-21-305(B);

b. The findings and conclusions obtained during the assessment, further evaluations, including a list of further evaluations to be completed, and any interim services provided;

c. Any existing ITDP according to R9-21-312;

d. The client's preferences regarding services;

e. Recommended long-term or alternative services;

f. Current or proposed service providers, including the need to have service providers with staff who have language and communications skills other than English if necessary to communicate with the client;

g. Recommended dates for commencement of each service or date each service commenced;

h. The methods and persons to ensure that services are provided as set forth in the ISP, adequately coordinated, and regularly monitored for effectiveness;

i. The procedure for completion and implementation of the ISP process, including the procedures for accepting, rejecting, or appealing the ISP; and

j. The procedure for clients or service providers to request changes in the ISP.

C. The individual service plan shall include:

1. A description of the client's long-term view and the client's preferences, strengths, and needs in all relevant areas listed in R9-21-305(C), including present functioning level and medical condition, with documentation of any chronic medical condition which requires regular monitoring or intervention.

2. A description of the most appropriate and least restrictive services consistent with the client's needs and without reference to existing resources.

3. A statement of whether the client requires service providers with staff who are competent in any language other than English in order to communicate with the client.

4. Target dates for commencement of each service or date each service commenced and their anticipated duration.

5. Long range goals for each service which will assist the client in attaining the most self-fulfilling, age-appropriate, and independent style of living possible for the client, consistent with the client's preference, stated in terms which allow objective measurement of progress and which the client, to the maximum extent possible, both understands and adopts.

6. Short-term objectives that lead to attainment of overall goals stated in terms which allow objective measurement of progress and which the client, to the maximum extent possible, both understands and accepts.

7. Expected dates of completion for each objective;

8. Persons and service providers responsible for each objective.

9. Identification of each generic or service provider responsible for providing the specific service required to meet each of the client's needs, including the name and address and telephone number of the provider and the location where the service will be provided.

10. A detailed description of the client objectives and services for each mental health agency which will provide services to the client.

11. Identification of any need for alternative housing or residential setting, including the support and monitoring to be provided after any change in housing or residential setting as provided in R9-21-310(D).

12. Based upon assessments and other available information, a determination of:

a. The client's capacity to:

i. Make competent decisions on matters such as medical and mental health treatment, finances, and releasing confidential information;

ii. Participate in the development of the ISP; and

iii. Independently exercise the client's rights under this Chapter.

b. The client's need for guardianship or other protective services or assistance.

c. The client's need for special assistance.

13. A list of the assessments which were not completed due to the client's current mental or physical condition or due to the clinical team's inability to access records together with a statement of the causes and plans to obtain these assessments.

14. A description of the methods and persons responsible for ensuring that services are:

a. Provided as set forth in the ISP;

b. Adequately coordinated; and

c. Regularly monitored for effectiveness.

15. A statement of the right of the client, designated representative, or guardian to accept or reject the ISP, request other services, or appeal the ISP or any aspect of the ISP.

16. A statement that the client's acceptance of the ISP constitutes consent to the services enumerated in the ISP.

D. Preparation and distribution of the individual service plan.

1. Within seven days of the ISP meeting, but no later than 90 days from the date of a referral or request for an SMI eligibility determination, the case manager shall prepare and distribute the ISP as provided herein.

2. The case manager or other clinical team member shall personally deliver to and review the ISP with the client.

3. The ISP shall be mailed or otherwise distributed to the following persons:

a. The client's designated representative and/or guardian;

b. The members of the clinical team; and

c. All existing or potential service providers.

Ariz. Admin. Code § R9-21-307

Adopted under an exemption from A.R.S. Title 41, Chapter 6 pursuant to Laws 1992, Ch. 301, § 61, effective October 7, 1992; received in the Office of the Secretary of State October 14, 1992 (Supp. 92-4). Amended under an exemption from A.R.S. Title 41, Chapter 6 pursuant to Laws 1992, Ch. 301, §61, effective September 30, 1993 (Supp. 93-3). Amended by exempt rulemaking at 9 A.A.R. 3296, effective June 30, 2003 (Supp. 03-2). Amended by final rulemaking at 22 A.A.R. 2019, effective 7/12/2016.