Section 0465-02-19-.04 - PROFESSIONAL SERVICES(1) The licensee must ensure the support coordinator/case manager arranges and secures all services and supports as described in the ISP; the support coordinator/case manager provides information to potential and current providers, completes service authorization requests, assists with appeals and monitoring and follow-up to ensure that issues and problems are resolved so that the ISP can be implemented as written or amended as necessary.(2) The assessment process/information gathering must be completed prior to the development of the ISP.(3) Assessment information to be compiled by the independent support coordinator/case manager in preparation of the ISP for the Planning Meeting consists of the following: (a) Information about the services a person supported is receiving through all resources, such as DIDD programs, Managed Care Organization, Medicare, or other organizations;(b) Ideas and suggestions about what things the person supported can and cannot do, what things are important to the person supported, and what things are liked and disliked by the person supported;(c) Uniform Assessments- Information about the capabilities and support needs of the person supported. Assists in identifying needed services and supports and the activities for which a person may need assistance;(e) Clinical Assessments;(f) Medical Assessments; and(g) Vocational Assessments and Desire for Employment.(4) Assessments are to assist in identifying the strengths, interests and desired outcomes of the person supported, and aid in determining how to best meet those desired outcomes.(5) The licensee must ensure that an ISP team known as the Circle of Support is identified and provided for each person supported. The team may include the following as determined by the person supported:(a) The person supported, unless contraindicated by the ISP team;(b) The legal representative (conservator, parent, guardian, or legal custodian) of the person supported, if applicable, unless their inability or unwillingness to attend is documented;(c) Appropriate Provider staff;(d) Relevant professionals or individuals, unless their inability to attend is documented;(e) Friends, advocates and other non-paid supports, if applicable, and(f) The Independent Support Coordinator/Case Manager.(6) The licensee must ensure that a written ISP is provided and implemented for each person supported. The ISP must meet the following requirements:(a) Developed within sixty (60) calendar days from the date of initial service provision as determined by TennCare.(b) Developed by the ISP team of the person supported;(c) Includes the date of development of the ISP;(d) Includes the signatures of the person supported or his/her legal representative (conservator, parent, guardian, or legal custodian), and the appropriate staff;(e) Specifies the needs of the person supported, identified by assessments and to be addressed within the particular service/program component;(f) Includes outcomes and action steps of the person supported, which are related to his/her specific needs and desires identified, and which are to be addressed by the particular service/program component; and(g) Includes methods or activities by which the outcomes and action steps of the person supported are to be implemented.(7) The licensee must ensure that contacts with persons supported include: (a) One (1) contact shall be completed each calendar month;(b) One of the contacts each quarter must be face-to-face (pending CMS approval of 1915(c) HCBS waiver amendment, expected in January 2017);(8) Monthly reviews shall be documented by the licensee. Information contained within the monthly review shall include: ISP implementation status, including progress in completing action steps and achieving outcomes; information gathered from the monthly contact, interviews with the person supported, his/her family members, conservators or guardians. The monthly review shall also contain information from the quarterly progress notes submitted by the residential, day, or personal assistance providers of the person supported.(9) The Annual ISP meeting must be held prior to the ISP expiration date. The effective date of a new plan can be no more than one (1) year from the effective date of the previous plan.(10) The ISP must be amended when any of the following occur: (a) The action steps and outcomes change;(b) Services or service providers change;(c) There is a significant change in overall service and support needs of the person supported;(d) The person supported has made major changes to his/her preferred lifestyle.Tenn. Comp. R. & Regs. 0465-02-19-.04
New rules filed July 6, 2016; effective 10/4/2016.Authority: T.C.A. §§ 4-4-103, 4-5-202, 33-1-201, 33-1-302, 33-1-303, 33-1-305, 33-1-309, 33-2-301, 33-2-302, 33-2-404, 33-2-407.