Arizona Administrative Code
Title 9 - HEALTH SERVICES
Chapter 21 - ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM (AHCCCS) BEHAVIORAL HEALTH SERVICES FOR PERSONS WITH SERIOUS MENTAL ILLNESS
Article 3 - INDIVIDUAL SERVICE PLANNING FOR BEHAVIORAL HEALTH SERVICES FOR PERSONS WITH SERIOUS MENTAL ILLNESS
Section R9-21-307 - The Individual Service Plan
Universal Citation: AZ Admin Code R 9-21-307
Current through Register Vol. 30, No. 38, September 20, 2024
A. General provisions.
1. An individual service plan (ISP) shall be
developed by the clinical team and each client.
2. The ISP shall include the most appropriate
and least restrictive services, consistent with the client's needs and
preferences, as identified in the assessment conducted according to
R9-21-305, and
without regard to the availability of services or resources.
3. The ISP shall identify those services
which maximize the client's strengths, independence, and integration into the
community.
4. Generic services
available to the general public should be utilized, to the maximum extent
possible, when adequate to meet the client's needs and if access can be
arranged by the case manager or client.
5. If all needed services are not available,
a plan for alternative services shall detail those services which are, to the
maximum extent possible, adequate, appropriate, consistent with the client's
needs, and least restrictive of the client's freedom.
6. The clinical team shall solicit and
actively encourage the participation of the client and guardian.
7. The clinical team shall inform the client
of the right to have a designated representative throughout the ISP process and
to invite family members or other persons who could contribute to the
development of the ISP. The case manager shall seek to obtain a representative
for clients who need special assistance or otherwise have limited capacity to
articulate their own preferences and to protect their own interests in the ISP
process and shall advise the relevant human rights committee that the client
has been determined to need special assistance.
8. The ISP shall contain goals and objectives
which are measurable and which facilitate meaningful evaluation of the progress
toward attaining those goals and objectives.
9. The ISP shall incorporate a specific
description of the client objectives, services, and interventions for each
mental health agency which will provide services to the client. Each existing
service provider will bring to the ISP meeting a detailed written description
of the objectives and services currently in effect for the client.
10. For residents of an inpatient facility,
the facility's treatment and discharge plan shall be developed according to
R9-21-312
and shall be incorporated in the ISP.
11. Prior to the planned discharge of a new
client from an inpatient facility, the clinical team shall develop an ISP which
describes the community services, including alternative housing and residential
supports, that will be provided when the client leaves the facility.
12. The ISP shall be written in language
which can be easily understood by a lay person.
13. In developing the ISP, the case manager
shall facilitate resolution of differences among service providers and, if
resolution is not achieved, shall refer the matter to the regional authority,
which shall resolve the matter in accordance with the Administration's policy.
B. The individual service plan meeting.
1. Within 20 days of
the completion of the assessment report, the case manager shall convene an ISP
meeting at a convenient time and place for the client, guardian, clinical team,
and potential service providers.
2.
The case manager shall arrange for the client's transportation, if needed, to
the ISP meeting.
3. The case
manager shall notify in writing the following persons of the time, date and
location of the ISP meeting at least 10 days prior:
a. The client, any designated representative
and guardian, including an invitation to submit relevant information in writing
if their attendance is impossible;
b. Clinicians involved in the assessment or
further evaluation;
c. All current
and potential service providers;
d.
All members of the client's clinical team;
e. Family members, with the client's
permission;
f. Other persons
familiar with the client whose presence at the meeting is requested by the
client;
g. Any other person whose
participation is not objected to by the client and who, in the judgment of the
case manager, will contribute to the ISP.
4. The case manager shall chair the ISP
meeting which shall include a discussion of:
a. The client's supports or skills necessary
to achieve the client's long-term view in each of the areas listed in
R9-21-305(B);
b. The findings and
conclusions obtained during the assessment, further evaluations, including a
list of further evaluations to be completed, and any interim services
provided;
c. Any existing ITDP
according to R9-21-312;
d. The
client's preferences regarding services;
e. Recommended long-term or alternative
services;
f. Current or proposed
service providers, including the need to have service providers with staff who
have language and communications skills other than English if necessary to
communicate with the client;
g.
Recommended dates for commencement of each service or date each service
commenced;
h. The methods and
persons to ensure that services are provided as set forth in the ISP,
adequately coordinated, and regularly monitored for effectiveness;
i. The procedure for completion and
implementation of the ISP process, including the procedures for accepting,
rejecting, or appealing the ISP; and
j. The procedure for clients or service
providers to request changes in the ISP.
C. The individual service plan shall include:
1. A description of the client's long-term
view and the client's preferences, strengths, and needs in all relevant areas
listed in
R9-21-305(C),
including present functioning level and medical condition, with documentation
of any chronic medical condition which requires regular monitoring or
intervention.
2. A description of
the most appropriate and least restrictive services consistent with the
client's needs and without reference to existing resources.
3. A statement of whether the client requires
service providers with staff who are competent in any language other than
English in order to communicate with the client.
4. Target dates for commencement of each
service or date each service commenced and their anticipated
duration.
5. Long range goals for
each service which will assist the client in attaining the most
self-fulfilling, age-appropriate, and independent style of living possible for
the client, consistent with the client's preference, stated in terms which
allow objective measurement of progress and which the client, to the maximum
extent possible, both understands and adopts.
6. Short-term objectives that lead to
attainment of overall goals stated in terms which allow objective measurement
of progress and which the client, to the maximum extent possible, both
understands and accepts.
7.
Expected dates of completion for each objective;
8. Persons and service providers responsible
for each objective.
9.
Identification of each generic or service provider responsible for providing
the specific service required to meet each of the client's needs, including the
name and address and telephone number of the provider and the location where
the service will be provided.
10. A
detailed description of the client objectives and services for each mental
health agency which will provide services to the client.
11. Identification of any need for
alternative housing or residential setting, including the support and
monitoring to be provided after any change in housing or residential setting as
provided in R9-21-310(D).
12. Based
upon assessments and other available information, a determination of:
a. The client's capacity to:
i. Make competent decisions on matters such
as medical and mental health treatment, finances, and releasing confidential
information;
ii. Participate in the
development of the ISP; and
iii.
Independently exercise the client's rights under this Chapter.
b. The client's need for
guardianship or other protective services or assistance.
c. The client's need for special
assistance.
13. A list
of the assessments which were not completed due to the client's current mental
or physical condition or due to the clinical team's inability to access records
together with a statement of the causes and plans to obtain these
assessments.
14. A description of
the methods and persons responsible for ensuring that services are:
a. Provided as set forth in the
ISP;
b. Adequately coordinated;
and
c. Regularly monitored for
effectiveness.
15. A
statement of the right of the client, designated representative, or guardian to
accept or reject the ISP, request other services, or appeal the ISP or any
aspect of the ISP.
16. A statement
that the client's acceptance of the ISP constitutes consent to the services
enumerated in the ISP.
D. Preparation and distribution of the individual service plan.
1. Within seven days
of the ISP meeting, but no later than 90 days from the date of a referral or
request for an SMI eligibility determination, the case manager shall prepare
and distribute the ISP as provided herein.
2. The case manager or other clinical team
member shall personally deliver to and review the ISP with the
client.
3. The ISP shall be mailed
or otherwise distributed to the following persons:
a. The client's designated representative
and/or guardian;
b. The members of
the clinical team; and
c. All
existing or potential service providers.
Disclaimer: These regulations may not be the most recent version. Arizona may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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