Rule 24-2-17.2 - Development of Individual PlansA. Agency providers must utilize planning approaches that are best practices or evidence-based by their respective areas of focus (i.e., adults with serious mental illness, children/youth with serious emotional disturbance, people with co-occurring disorders, people with substance use disorders and people with intellectual/developmental disabilities, elderly people, etc.). Planning approaches must be documented and implemented through the development of policies and procedures specific to this process and the population being served.B. Planning approaches must address the following, at a minimum:1. The development of an individualized treatment/support team that includes the person, service providers, and other supports (as appropriate) that may be identified and utilized by the person or team members.2. A person-centered, recovery/resiliency-oriented focus, depending on the population.3. A focus on individual strengths and how to build upon strengths to achieve positive outcomes.4. Proactive crisis planning, depending on the person receiving services.5. Discharge planning and continuity of care.C. The Plan of Services and Supports for people with intellectual/developmental disabilities: 1. Each person has only one (1) Plan of Services and Supports across all IDD Services (regardless of funding source). The Plan of Services and Supports is developed by Support Coordination or Transition Coordination for people enrolled in the ID/DD Waiver Program. Targeted Case Management develops the Plan of Services and Supports for people enrolled in the IDD Community Support Program. If a person receives an IDD Service and is not enrolled in the ID/DD Waiver or the IDD Community Support Program, the IDD agency provider must develop the Plan of Services and Supports.2. The person will lead the person-centered planning process when possible. The person's legal representative(s) should have a participatory role, as needed, and as defined by the person. The meeting:(a) Includes people chosen by the person.(b) Provides necessary information and support to ensure the person directs the process to the maximum extent possible and is enabled to make informed choices and decisions.(c) Is timely and occurs at times and places convenient to the person.(d) Reflects the cultural/linguistic considerations of the person.(e) Includes strategies for resolving conflict or disagreement within the process including clear conflict-of-interest guidelines for all planning participants.(f) Offers informed choices to the person regarding the services and supports they receive and from whom.(g) Includes a method for the person to request updates to the plan as needed.(h) Records the alternative home and community-based settings that were considered by the person.3. The Plan of Services and Supports must:(a) Reflect the services and supports that are important to the person to meet needs identified through an assessment of functional need as well as what is important for the person regarding preferences for the delivery of such services and supports.(b) Reflect that the setting in which the person resides is chosen by the person. The setting must be integrated in and support full access 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 a person not receiving IDD services.(c) Reflect the person's strengths and preferences.(d) Reflect clinical and support needs as identified through the functional assessment.(e) Include individually identified outcomes for services.(f) Reflect the services and supports (paid and unpaid) that will assist the person to achieve identified outcomes and the agency providers of those services and supports, including natural supports.(g) Reflect risk factors and measures in place to minimize them, including back-up plans and strategies when needed.(h) Be understandable to the person receiving services and supports, and the people important in supporting the person. (i) Identify the person and/or entity responsible for monitoring the Plan of Services and Supports.(j) Be finalized and agreed to, with the documented informed consent of the person, and be signed by all people and service providers responsible for its implementation.(k) Be distributed to the person and others involved in implementing the Plan of Services and Supports.(l) Prevent the provision of unnecessary or inappropriate services and supports.(m) Document that any modifications made to a person's ability to access the community or make choices about daily life: (1) Identify a specific and individualized assessed need.(2) Have documentation of the positive behavior interventions and supports used prior to any modification of the person-centered aspect of the Plan of Services and Supports.(3) Have documentation when less intrusive methods have been tried and did not work.(4) Include a clear description of the condition that is directly proportionate to the specific assessed need.(5) Include regular collection and review of data to measure the ongoing effectiveness of the modification.(6) Include established time limits for periodic reviews to determine if the modification is still necessary or can be terminated.(7) Include the informed consent of the person.(8) Include an assurance that interventions and supports will cause no harm to the person. (n) Be reviewed and revised upon reassessment of the functional need, at least annually, when circumstances or needs change significantly, or at the request of the person.