A Person-Centered Service Plan is required for a Member
to receive HCBS waiver services. The following requirements shall apply to
person-centered planning.
A.
Person-Centered Planning Process. The Member will lead the
person-centered planning process where possible. The Member's representative
should have a participatory role, as needed and as defined by the Member
(unless state law confers decision-making authority to a legal representative)
All references to a Member or individual in this Section are intended to
include the role of the Member's representative. In addition to being led by
the Member, the person-centered planning process must:
(1) Include people chosen by the
Member;
(2) Provide necessary
information and support to ensure that the Member directs the process to the
maximum extent possible, and is enabled to make informed choices and
decisions;
(3) Be timely and occur
at times and locations of convenience to the Member;
(4) Reflect cultural considerations of the
Member and be conducted by providing information in plain language and in a
manner that is accessible to individuals with disabilities and persons who have
limited proficiency in English, consistent with
42 C.F.R.
§
435.905(b);
(5) Offer informed choices to the Member
regarding the services and supports they receive and from whom;
(6) Include a method for the Member to
request updates to the plan as needed;
(7) Record the alternative home and
community-based settings that were considered and accepted or rejected by the
Member; and
(8) Include a
discussion of strategies for resolving disputes or disagreements within the
planning process, including clear conflict of interest guidelines for all
planning participants.
Providers of HCBS services for the Member, or those who
have an interest in or are employed by a provider of HCBS services for the
Member, must not provide case management or develop the Person-Centered Service
Plan (PCSP), except when the Department determines that the only willing and
qualified entity to provide case management and/or develop PCSPs in a
geographic area also provides HCBS services.
B.
The Person-Centered Service
Plan. The Person-Centered Service Plan must reflect the services and
supports that are important for the Member to meet the needs identified through
an assessment of functional need, as well as what is important to the Member
with regard to preferences for the delivery of such services and supports.
Commensurate with the level of need of the Member, and
limited to the scope of services and supports available under the applicable
HCBS waiver, the Person-Centered Service
Plan must:
(1)
Reflect that the setting in which the Member is to reside is chosen by the
Member. The HCBS Setting chosen by the Member must be integrated in, and
support full access by the Member receiving HCBS services to the greater
community, including opportunities to seek employment and work in competitive
integrated settings, engage in community life, control personal resources, and
receive services in the community to the same degree of access as individuals
not receiving HCBS waiver services;
(2) Reflect the Member's strengths and
preferences;
(3) Reflect clinical
and support needs as identified through an assessment of functional need;
(4) Include individually
identified goals and desired outcomes;
(5) Reflect the services and supports (paid
and unpaid) that will assist the Member in achieving identified goals, and the
Providers of those services and supports, including natural supports. Natural
supports are unpaid supports that are provided voluntarily to the Member in
lieu of or in addition to HCBS waiver services and supports;
(6) Reflect risk factors and measures in
place to minimize them, including individualized back-up plans and strategies
when needed;
(7) Be understandable
by the Member and by the individuals important in supporting the Member. At a
minimum, the Person-Centered Service Plan must be written in plain language and
in a manner that is accessible to individuals with disabilities and persons who
have limited proficiency in English , consistent with
42 C.F.R.
§
435.905(b);
(8) Identify the individual and/or entity
responsible for monitoring the plan;
(9) Be finalized and agreed to, with the
informed consent of the Member in writing, and signed by all individuals and
Providers responsible for its implementation;
(10) Be distributed to the Member and other
people involved in the Person-Centered Service Plan;
(11) Include those services the purpose or
control of which the Member elects to self-direct where available;
(12) Prevent the provision of unnecessary or
inappropriate services and supports; and
(13) Document that any modification of the
requirements in Section 6.04(B) (Additional Requirements for Provider-Owned or
Controlled Residential Settings) must be supported by a specific assessed need
and justified in the Person-Centered Service Plan. The following requirements
related to the modification must also be documented in the Person-Centered
Service Plan:
(a) Identify the specific and
individualized assessed need that creates the need for the
modification;
(b) Document the
positive interventions and supports used prior to any modifications to the
Person-Centered Service Plan;
(c)
Document less intrusive methods of meeting the need that have been tried but
did not work;
(d) Include a clear
description of the modification that demonstrates that it is directly
proportionate to the specific assessed need;
(e) Include a regular collection and review
of data to measure the ongoing effectiveness of the modification;
(f) Include established time limits for
periodic reviews to determine if the modification is still necessary or can be
terminated;
(g) Include informed
consent of the Member; and
(h)
Include an assurance that interventions and supports will cause no harm to the
individual.
C.
Review of the Person-Centered
Service Plan. The Person-Centered Service Plan must be reviewed, and
revised upon reassessment of functional need as required by
42 C.F.R. §
441.365(e), at least every
12 months, when the Member's circumstances or needs change significantly, or at
the request of the Member.
