N.M. Admin. Code § 8.314.5.17

Current through Register Vol. 35, No. 23, December 10, 2024

Section 8.314.5.17 - INDIVIDUALIZED SERVICE PLAN (ISP)

A. CMS requires a person-centered service plan for every individual receiving HCBS. The ISP must be developed annually through an ongoing person-centered planning process. The ISP development must:

(1) Involve those whom the participant wishes to attend and participate in developing the service plan and are provided adequate notice;

(2) Use assessed needs to identify services and supports;

(3) Include individually identified goals and preferences related to relationships, community participation, employment, income and savings, healthcare and wellness, education and others;

(4) Identify roles and responsibilities of IDT members responsible for implementing the plan;

(5) Include the timing of the plan and how and when it is updated, including response to changing circumstances and needs; and

(6) Outline how the individual is informed of available services funded by the DDW as well as other natural and community resources.

B. The IDT must review the eligible recipient's person-centered plan every 12 months or more often if indicated.

C. The IDT is responsible for compiling clinical documentation to justify the requested services and budget to the OR for adult recipients excluding class members of Walter Stephen Jackson, et al vs. Fort Stanton Hospital and Training School et. al, (757 F. Supp. 1243 DNM 1990).

D. The person-centered service plan must consist of the following:

(1) identifies risks and includes a plan to reduce any risks;

(2) incorporates other health concerns (e.g. mental health, chemical health, chronic medical conditions, etc.);

(3) is written in plain language;

(4) records the alternative HCBS that were considered by the person;

(5) includes natural supports and services;

(6) includes strategies for solving conflict or disagreement within the process, including any conflict of interest guidelines for planning participants;

(7) identifies who is responsible for monitoring implementation of the plan;

(8) includes the person's strengths;

(9) describes goals or skills that are related to the person's preferences;

(10) includes a global statement about the person's self-determined goals and aspirations;

(11) details what is important to the person; and

(12) includes a method for the individual to request updates to the plan, as needed.

E. Upon completion of the ISP by the IDT, the case manager shall develop a budget to be evaluated in accordance with the TPA process; see Subsection D of 8.314.5.18 NMAC.

F. All services must be provided as specified in the ISP.

G. The case manager must conduct a pre ISP meeting annually with the recipient to evaluate and plan for upcoming ISP term. The CM is required to meet with the DD Waiver participant and guardian prior to the ISP meeting. The CM reviews current assessment information, prepares for the meeting, creates a plan with the person to facilitate or co-facilitate the meeting if desired, discusses the budget, reviews the current secondary freedom of choice forms, and facilitates greater informed participation in ISP development by the person.

N.M. Admin. Code § 8.314.5.17

8.314.5.17 NMAC - Rp, 8.314.5.17 NMAC, 11-1-12; 8.314.5.17 NMAC - Rn & A, 8.314.5.16 NMAC, 6-15-14, Amended by New Mexico Register, Volume XXVI, Issue 02, January 30, 2015, eff. 2/1/2015, Adopted by New Mexico Register, Volume XXVII, Issue 04, February 29, 2016, eff. 3/1/2016, Adopted by New Mexico Register, Volume XXIX, Issue 22, November 27, 2018, eff. 12/1/2018, Amended by New Mexico Register, Volume XXXIII, Issue 06, March 22, 2022, eff. 4/1/2022, Amended by New Mexico Register, Volume XXXV, Issue 05, March 12, 2024, eff. 4/1/2024