Section 11-800-25 - Service plan(a) The service plan shall be based upon comprehensive assessments of the individual by appropriate case managers.(b) The case management agency shall develop and authorize a service plan prior to the individual's admission to a residential care facility.(c)The service plan shall be written in a language that is understandable to the individual, the individual's family, the individual's legal representative, and the primary and substitute caregivers.(d) The service plan shall: (1) Identify the problems and needs of the client, including any need to purchase specialized medical equipment and supplies;(2) Establish realistic measurable goals to be attained for each problem identified in the social and nursing assessments;(3) Identify specific interventions and tasks to be implemented to address each problem and to ensure achievement of the goals specified in the service plan;(4) Identify specific types of services needed, the number of units, duration, and the frequency of service provision;(5) Specify the service provider or providers, primary and substitute, formal or informal, medicaid waiver or non-waiver, needed to address each problem and achieve each goal to safely maintain and support the client in a residential care facility;(6) Be agreed to by the client or the client's legal representative;(7) Establish the frequency of case manager contacts, with a minimum frequency of once a month face-to-face contacts with the client;(8) Be reviewed, updated, and authorized, minimally once every six months or sooner when changes occur, to reflect the client's current status and needs; and(9) Include a transportation plan to meet the non-medical transportation needs of the client as provided in section 11-800-41(b)(5).(e) The case management agency shall ensure that a current service plan is in place when a client moves from one residential care facility to another, and that if the client is moved into another community care foster family home, that the home has a current certificate.(f) When a client chooses to transfer from one case management agency to another, a new service plan shall be developed by the new case management agency chosen by the client.[Eff 11/13/2018] (Auth: HRS §§ 321-481, 321-482, 321-485, 346-14) (Imp: HRS §§ 321-481, 321-482, 321-485, 346-14)