Subsection 144-101-I-6.03 - PERSON-CENTERED PLANNINGA Person-Centered Service Plan is required for a Member to receive HCBS waiver services. The following requirements shall apply to person-centered planning.
A.Person-Centered Planning Process. The Member will lead the person-centered planning process where possible. The Member's representative should have a participatory role, as needed and as defined by the Member (unless state law confers decision-making authority to a legal representative) All references to a Member or individual in this Section are intended to include the role of the Member's representative. In addition to being led by the Member, the person-centered planning process must: (1) Include people chosen by the Member;(2) Provide necessary information and support to ensure that the Member directs the process to the maximum extent possible, and is enabled to make informed choices and decisions;(3) Be timely and occur at times and locations of convenience to the Member;(4) Reflect cultural considerations of the Member and be conducted by providing information in plain language and in a manner that is accessible to individuals with disabilities and persons who have limited proficiency in English, consistent with 42 C.F.R. § 435.905(b);(5) Offer informed choices to the Member regarding the services and supports they receive and from whom;(6) Include a method for the Member to request updates to the plan as needed; (7) Record the alternative home and community-based settings that were considered and accepted or rejected by the Member; and(8) Include a discussion of strategies for resolving disputes or disagreements within the planning process, including clear conflict of interest guidelines for all planning participants. Providers of HCBS services for the Member, or those who have an interest in or are employed by a provider of HCBS services for the Member, must not provide case management or develop the Person-Centered Service Plan (PCSP), except when the Department determines that the only willing and qualified entity to provide case management and/or develop PCSPs in a geographic area also provides HCBS services.
B.The Person-Centered Service Plan. The Person-Centered Service Plan must reflect the services and supports that are important for the Member to meet the needs identified through an assessment of functional need, as well as what is important to the Member with regard to preferences for the delivery of such services and supports. Commensurate with the level of need of the Member, and limited to the scope of services and supports available under the applicable HCBS waiver, the Person-Centered Service
Plan must:
(1) Reflect that the setting in which the Member is to reside is chosen by the Member. The HCBS Setting chosen by the Member must be integrated in, and support full access by the Member receiving HCBS services to the greater community, including opportunities to seek employment and work in competitive integrated settings, engage in community life, control personal resources, and receive services in the community to the same degree of access as individuals not receiving HCBS waiver services; (2) Reflect the Member's strengths and preferences;(3) Reflect clinical and support needs as identified through an assessment of functional need; (4) Include individually identified goals and desired outcomes;(5) Reflect the services and supports (paid and unpaid) that will assist the Member in achieving identified goals, and the Providers of those services and supports, including natural supports. Natural supports are unpaid supports that are provided voluntarily to the Member in lieu of or in addition to HCBS waiver services and supports;(6) Reflect risk factors and measures in place to minimize them, including individualized back-up plans and strategies when needed;(7) Be understandable by the Member and by the individuals important in supporting the Member. At a minimum, the Person-Centered Service Plan must be written in plain language and in a manner that is accessible to individuals with disabilities and persons who have limited proficiency in English , consistent with 42 C.F.R. § 435.905(b);(8) Identify the individual and/or entity responsible for monitoring the plan;(9) Be finalized and agreed to, with the informed consent of the Member in writing, and signed by all individuals and Providers responsible for its implementation;(10) Be distributed to the Member and other people involved in the Person-Centered Service Plan;(11) Include those services the purpose or control of which the Member elects to self-direct where available;(12) Prevent the provision of unnecessary or inappropriate services and supports; and(13) Document that any modification of the requirements in Section 6.04(B) (Additional Requirements for Provider-Owned or Controlled Residential Settings) must be supported by a specific assessed need and justified in the Person-Centered Service Plan. The following requirements related to the modification must also be documented in the Person-Centered Service Plan:(a) Identify the specific and individualized assessed need that creates the need for the modification;(b) Document the positive interventions and supports used prior to any modifications to the Person-Centered Service Plan;(c) Document less intrusive methods of meeting the need that have been tried but did not work;(d) Include a clear description of the modification that demonstrates that it is directly proportionate to the specific assessed need;(e) Include a regular collection and review of data to measure the ongoing effectiveness of the modification;(f) Include established time limits for periodic reviews to determine if the modification is still necessary or can be terminated;(g) Include informed consent of the Member; and (h) Include an assurance that interventions and supports will cause no harm to the individual. C.Review of the Person-Centered Service Plan. The Person-Centered Service Plan must be reviewed, and revised upon reassessment of functional need as required by 42 C.F.R. § 441.365(e), at least every 12 months, when the Member's circumstances or needs change significantly, or at the request of the Member. C.M.R. 10, 144, ch. 101, ch. I, § 144-101-I-6, subsec. 144-101-I-6.03