Current through Register Vol. 48, No. 38, September 20, 2024
A person-centered plan of care will be developed in
collaboration with the participant who is eligible for services using a
person-centered planning process with the CCU.
a) The person-centered planning process will
ensure:
1) the opportunity for the
participant/authorized representative to lead and direct the planning process,
whenever possible, and to select other persons to participate in
decision-making;
2) the scheduling
of timely meetings that occur at times and locations convenient to the
participant/authorized representative, preferably in the participant's place of
residence to assess the participant's environment to ensure the development of
a person-centered plan of care that considers the participant's
safety;
3) the provision of
necessary information and support to enable the participant/authorized
representative to make informed choices and decisions;
4) the inclusion of strategies for solving
disagreements within the planning process, including clear guidelines for
conflicts of interest on the part of all who participate in
decision-making;
5) the protection
of the rights of the participant/authorized representative to choose available
services, supports and providers/vendors; and
6) the sharing of contact information for the
CCU/Care Coordinator so the participant/authorized representative can request a
redetermination of eligibility, additional or new services, or other updates
and changes to the person-centered plan of care.
b) The CCU will provide all information and
support in a culturally-sensitive manner to ensure that the
participant/authorized representative is able to make informed choices and
decisions, including appropriate available options for limited
English-proficient persons and/or those with a disability.
c) The CCU will provide a copy of the final
person-centered plan of care and any subsequent revisions to the
participant/authorized representative and any other person identified as being
responsible for monitoring or implementing the plan, including the
providers/vendors.
d) The CCU will
monitor the participant to prevent unnecessary or inappropriate care.
e) Review of the Person-Centered Plan of Care
1) The CCU will review and revise a
person-centered plan of care:
A) at least
every 12 months following an assessment/reassessment of functional
needs;
B) when a participant's
personal circumstances or functional needs change significantly; and
C) at the request of a participant/authorized
representative.
2) The
CCU will document its periodic review of the participant and any information
that is collected under the measures being used to evaluate the effectiveness
of the services and supports based on the described needs and related
conditions of the participant.
3)
Revisions will be supported by a specific assessed functional need of the
participant and a written justification included in the revised person-centered
plan of care, indicating that the use of the previously identified adherence
interventions and risk strategies were unsuccessful before changing services,
supports and/or providers/vendors. Changes will be scaled as appropriate first
using the least intrusive options.
4) The CCU shall document that positive
interventions and supports were used prior to any modification and that less
intrusive methods were tried but were unsuccessful.
