Current through Register Vol. 43, No. 39, September 26, 2024
(a) The provider
shall prepare a written person-centered support plan for each person served
that shall meet these requirements:
(1) Be
developed only after consultation with the following:
(A) The person;
(B) the person's legal guardian, if one has
been appointed; and
(C) other
individuals from the person's support network as the person or the person's
guardian chooses;
(2)
contain a description of the person's preferred lifestyle, including describing
the following:
(A) In what type of setting
the person wants to live;
(B) with
whom the person wants to live;
(C)
what work or other valued activity the person wants to do;
(D) with whom the person wants to socialize;
and
(E) in what social, leisure,
religious, or other activities the person wants to participate;
(3) list and describe the
necessary activities, training, materials, equipment, assistive technology, and
services that are needed to assist the person to achieve the person's preferred
lifestyle;
(4) describe how
opportunities of choice will be provided, including specifying means for the
following:
(A) Permitting the person to
indicate the person's preferences among options presented to the person, by
whatever communication methods that person may possess, including a description
of the effective communication methods utilized by the person;
(B) providing the necessary support and
training to allow the person to be able to indicate the person's preferences,
including a description of any training and support needed to fully participate
in the planning process and other choice making; and
(C) assisting the person or the person's
guardian to understand the negative consequences of choices the provider knows
the person might make and that may involve risk to that person;
(5) describe when it is necessary
to do so, to the person and the person's support network, how the preferred
lifestyle might be limited because of imminent significant danger to the
person's health, safety, or welfare based on an assessment of the following:
(A) The person's history of decision-making,
including any previous experience or practice the person has in exercising
autonomy, and the person's ability to learn from the natural negative
consequences of poor decision-making;
(B) the possible long-and short-term
consequences that might result to the person if the person makes a poor
decision;
(C) the possible
long-and short-term effects that might result to the person if the provider
limits or prohibits the person from making a choice; and
(D) the safeguards available to protect the
person's safety and rights in each context of choices;
(6) prioritize and structure the delivery of
services toward the goal of achieving the person's preferred lifestyle;
(7) contribute to the continuous
movement of the person towards the achievement of the person's preferred
lifestyle. In evaluating this outcome, the provider may include assessments
made by professionals and shall perform either of the following:
(A) Include consideration of the expressed
opinions of the person, the person's legal guardian, if one has been appointed,
and other individuals from the person's support network; or
(B) account for the following:
(i) The financial limitations of the person
and the provider;
(ii) the
supports and training needed, offered, and accepted by the person; and
(iii) matters identified in
paragraph (a)(5). Next best options may be considered as responsive if the
person cannot specifically have what the person prefers due to limitations
identified by this methodology; and
(8) be approved, in writing, by the person or
the person's guardian, if one has been appointed. Requirements for approval
from or consultation with the person's guardian shall be considered to have
been complied with if the provider documents that it has taken reasonable
measures to obtain this approval or consultation and that the person's guardian
has failed to respond.
(b) Whenever two or more providers provide
services to the same person, the providers shall work together to prepare a
single person-centered support plan. Each provider shall be responsible for the
preparation and implementation of any portion of the plan relating to its
services. The person, the guardian if one has been appointed, a member of the
person's support network, or a provider shall take the lead coordination role
in preparation of the plan, and a designation of that person or entity shall be
noted in the plan.
(c) The
provider shall regularly review and revise the plan, by following the same
procedures as set out above, whenever necessary to reflect any of the
following:
(1) Changes in the person's
preferred lifestyle;
(2)
achievement of goals or skills outlined within the plan; or
(3) any determination made according to the
methodology provided for in paragraph (a)(7) above that any service being
provided is unresponsive.
(d) The provider shall deliver services to
the person only in accordance with the person's person-centered support plan.
(e) This regulation shall take
effect on and after October 1, 1998.