Subsection 144-101-II-20.04 - CARE PLAN DEVELOPMENT20.04-1Procedures for Developing the Care PlanA member's Care Plan will be developed as part of the process of applying to receive services under the ORC waiver. The process for applying is as follows:
A.Choice Letter: The process begins by the member signing and submitting a "choice letter" to the Office of Aging and Disability Services (OADS) requesting services under the ORC waiver. The choice letter is a form that DHHS sends to individuals who may be eligible for services under this section requesting that the individual indicate their preference between receiving services in an institutional setting (such as a nursing facility) or receiving services in a community setting under this section.B.Application: After receiving the choice letter, the DHHS Care Monitor will meet with the member and guardian or legal representative (where applicable) and complete the initial ORC application. If the member appears to qualify and is interested in Money Follows the Person/ Homeward Bound MFP/HB, the member will be referred for MFP/HB determination for Money Follows the Person/ Homeward Bound MFP/HB. Enrollment and Transition coordination through MFP/HB will be provided per Money Follows the Person/ Homeward Bound MFP/HB program requirements as outlined in the CMS approved Operational Protocol for Money Follows the Person/ Homeward Bound MFP/HB.C.Functional and Medical Assessments: The Care Monitor will complete the BMS 99 (or current functional assessment, as approved by the DHHS). In addition, the Care Monitor will request the MED assessment to be completed by the ASA.D.Safety/Risk Assessment and Preliminary Care Plan: The Care Monitor will work with the member and guardian or legal representative (where applicable) and the MFP/HB Transition Coordinator (where applicable) to complete DHHS-approved safety/risk assessment and create a preliminary Care Plan to address all safety/risks needs identified by DHHS-approved safety/risk assessment, the MED assessment, and the BMS 99 (or current functional assessment approved by DHHS). Each safety/risk need identified will require a plan to safely support the member in the community with two forms of back-up support. The member will also select the member's service package and preliminary budget.E.Selection of Residential Option and Development of Final Care Plan:The final Care Plan must be developed by the member, the Care Monitor, guardian or legal representative (where applicable), the MFP/HB Transition Coordinator (where applicable), the provider for the Residential Option (where applicable) and the Care Coordinator. The member will work with the Care Monitor, guardian or legal representative (where applicable), and the MFP/HB Transition Coordinator (where applicable) to select an approved residential option as outlined in 20.05-9 and to select a Care Coordinator as outlined in 20.05-2. Once the residential option (where applicable) and Care Coordinator are selected, the provider for Care Coordination and Home Support or Personal Care (where applicable) will assist the member in developing the final Care Plan including the budget, selection of services, and safety/risk plan. The final Care Plan must: i. Include people chosen by the individual; ii. Provide necessary information and support to ensure that the individual directs the process to the maximum extent possible, and is enabled to make informed choices and decisions;iii. Be timely and occur at times and locations of convenience to the individual.F.Signatures: In order for the final Care Plan to be approved, the Care Plan must include signatures of (1) the member, or guardian, where applicable, and (2) the Care Coordinator.G.Department Review and Approval: All services must be Prior Authorized by OADS. Prior to implementation or start of residential services, the Care Plan must be reviewed and approved by OADS, and OADS must determine that the member is eligible for services as outlined in Section 20.03-1, 2 and 3. H.Utilization Review: All Care Plans must be reviewed and approved by OADS. OADS makes the determination that the member continues to be eligible for services as outlined in 20.03-1, 2 and 3.20.04-2Content of the Care PlanAt a minimum the Care Plan must:
A. Describe all MaineCare Benefit services determined medically necessary by DHHS;B. Include the frequency of provision of the services;C. Describe how services contribute to the member's health and well-being and the member's ability to reside safely in a community setting;D. Include a safety/risk plan, which shall describe the potential risks to the member's health and welfare while living in the community and the reasonable steps to alleviate those risks. Each identified safety need must be addressed by two back-up strategies for meeting the member's safety needs;E. Describe the member's goals for strengthening and cultivating personal, community, family, and professional relationships;F. Describe the role and responsibility of the member's providers in supporting the member's goals, including goals for strengthening natural and supportive personal, family, community and professional relationships;G. Include a budget for the services to be provided under this section.H. Reflect cultural considerations of the individual and is conducted by providing information in plain language and in a manner that is accessible to individuals with disabilities and persons who are limited English proficient, consistent with 42 C.F.R. § 435.905(b).I. Include strategies for solving conflict or disagreement within the process, including clear conflict of interest guidelines for all planning participants.J. Record the alternative home and community-based settings that were considered by the individual. The Care Plan may include other services not covered under this section that the member may choose to pursue.
20.04-3Review and Updating of the Care PlanThe Care Plan must be reviewed and updated at a minimum annually, or when the member requests it, or when there are significant changes in the member's condition sufficient to warrant a review whether the services in place are adequate.
C.M.R. 10, 144, ch. 101, ch. II, 144-101-II-20, subsec. 144-101-II-20.04