Current through Register No. 40, October 3, 2024
(a) Preliminary
planning for services shall be done in accordance with
He-M
503.05(l).
(b) Within 15 days of an individual's
eligibility or conditional eligibility pursuant to
He-M
503.05(d) or level of care approval
pursuant to He-M 503.05(o),
for those for whom an application for home and community-based waiver services
has been submitted pursuant to
He-M
503.05(n), the area agency shall
assist the individual, guardian, or representative with resources to select a
service coordinator.
(c) In
instances when an individual has been determined eligible pursuant to
He-M
503.05(d), and declines services
available pursuant to
He-M
503.05(l) and (m), the area agency
shall assign a service coordinator within 30 days.
(d) In instances when a service coordinator
has been assigned pursuant to (c) above, the service coordinator shall, at
minimum, contact the individual annually to discuss ongoing needs and determine
if service planning is desired.
(e)
The service coordinator shall hold an initial person-centered service planning
meeting to determine the individual's goals and service needs in meeting those
goals with the individual, the individual's guardian or representative, and any
other person chosen by the individual within 15 business days of the selection
of and acceptance by, a service coordination agency.
(f) The service coordinator shall document
that they have maximized the extent to which an individual participates in and
directs their person-centered service planning process by:
(1) Explaining to the individual the
person-centered service planning process and providing the information and
support necessary to ensure that the individual directs the process to the
maximum extent possible;
(2)
Explaining to the individual their rights and responsibilities pursuant to He-M
310;
(3) Eliciting information from
the individual regarding their goals, personal preferences, and service needs,
including any health concerns, that shall be a focus of person-centered service
planning meetings;
(4) Determining
with the individual issues to be discussed during all person-centered service
planning meetings; and
(5)
Explaining to the individual the limits of the decision-making authority of the
guardian, if applicable, and the individual's right to make all other decisions
related to services.
(g)
The person-centered service planning process shall include a discussion
regarding whether or not there is a need for a limited or full guardianship,
conservatorship, representative payee for social security benefits, durable
power of attorney, durable power of attorney for healthcare, supported-decision
making, or other less restrictive alternatives to guardianship. The discussion
and any recommendations from the team shall be incorporated into the service
agreement.
(h) Service coordinators
shall facilitate service planning to develop service agreements in accordance
with He-M
503.10. Service agreements shall be prepared initially
according to the timeframe specified in
He-M
503.10(c) and annually thereafter, as
required by He-M
503.08(b)(10).
(i) The individual, guardian, or
representative may determine the following elements of the person-centered
service planning process:
(1) The number and
length of meetings;
(2) The
location, date, and time of meetings;
(3) The meeting participants; and
(4) Topics to be
discussed.
(j) Copies of
relevant evaluations and reports shall be sent to the individual and guardian
at least 5 business days before person-centered service planning
meetings.
(k) If people who provide
services to the individual are not selected by the individual to participate in
a person-centered service planning meeting, and the individual determines that
the provider would have information beneficial to service planning, the service
coordinator shall contact such persons prior to the meeting so that their input
can be considered.
(l) The service
coordinator shall contact all persons who have been identified to provide a
service to the individual and confirm arrangements for providing such
services.
(m) All service planning
shall occur through a person-centered service planning process that:
(1) Maximizes the decision-making of the
individual;
(2) Is directed by the
individual or the individual's guardian or representative, if
applicable;
(3) Facilitates
personal choice by providing information and support to assist the individual
to direct the process, including information describing:
a. The array of services and provider
agencies available; and
b. Options
regarding self-direction of services;
(4) Includes participants freely chosen by
the individual;
(5) Reflects
cultural considerations of the individual and is conducted in clearly
understandable language and form;
(6) Occurs at times and a location of
convenience to the individual, guardian, or representative;
(7) Includes strategies for solving conflict
or disagreement within the process, including clear conflict of interest
guidelines for all planning participants;
(8) Is consistent with an individual's rights
to privacy, dignity, respect, and freedom from coercion and
restraint;
(9) Includes the process
for the individual, guardian, or representative to request amendments to the
service agreement;
(10) Records the
alternative home- and community-based settings that were considered by the
individual, guardian, or representative;
(11) Includes information related to risk by:
a. Incorporating information obtained through
a comprehensive risk assessment, which shall be administered:
1. Initially, at the beginning of service
planning, or as needed to each individual with a history of, or exhibiting
signs of, behaviors that pose a potentially serious likelihood of danger to
self or others, or a serious threat of substantial damage to real property,
such as, but not limited to, the following:
(i) Problematic sexual behavior;
(ii) Violent aggression;
(iii) Fire-setting behaviors; or
(iv) Other similar violent or dangerous
behaviors or events;
2.
Prior to any significant change in the level of the individual's treatment or
supervision;
3. At any time an
individual who previously has not had a comprehensive risk assessment begins to
engage in behaviors referenced in 1. above; and
4. By an evaluator with specialized
experience, training, and expertise in the treatment of the types of behaviors
referenced in 1. above;
b. Ensuring that plans created pursuant to
He-M 505 are reviewed with evaluators to consider ongoing appropriateness and
opportunities for modification of restrictions following initiation of risk
management related strategies. Such considerations may be made through
reassessment or through a consultative review of other documentation and
updated data related to the individual's progress;
c. Ensuring documentation of activities and
progress in treatment relative to management of risk for an individual to help
inform development of person-centered service plans;
d. Making referrals for individuals
associated with high-risk incidents to participate in evaluations or planning
activities initially and ongoing;
e. Processing and analyzing incidents related
to violent aggression, problematic sexual behavior, or fire-setting behaviors;
and
f. Making referrals for
individuals associated with high-risk incidents to evaluations or planning
activities initially and ongoing;
(12) Includes information from specialty
medical and health assessments and clinical assessments as needed, including,
at a minimum, communication, assistive technology, and functional behavior
assessments, as applicable;
(13)
Includes strategies to address co-occurring severe mental illness or behavioral
challenges which are interfering with the person's functioning, including
positive behavior plans or other strategies based on functional behavior or
other evaluations or referrals to behavioral health services;
(14) Provides the individual with information
regarding the services and provider agencies available to enable the individual
to make informed decisions as to whom they would like to provide
services;
(15) Includes
individualized backup plans and strategies;
(16) Includes strategies for solving
disagreements;
(17) Uses a
strengths-based approach to identify the positive attributes of the
individual;
(18) Includes the
provision of auxiliary aids and services when needed for effective
communication, including low literacy materials and interpreters;
(19) Addresses the individual's concerns
about current or contemplated guardianship or other legal assignment of rights;
(20) Explores housing and
employment in integrated settings, and develops plans consistent with the
individual's goals and preferences;
(21) Includes a review of the past year that:
a. Includes the individual's:
1. Personal achievements;
2. Relationships;
3. Degree of community involvement;
4. Challenging issues or behavior;
5. Health status and any changes in health;
and
6. Safety considerations during
the year;
b. Addresses
the previous year's goals with level of success and, if applicable, identifies
any obstacles encountered;
c.
Identifies the individual's personal goals and the supports that will aid in
achieving their goals;
d.
Identifies the type and amount of services the individual receives and the
support services provided under each service category;
e. Identifies the individual's health
needs;
f. Identifies the
individual's safety needs;
g.
Identifies any follow-up action needed on concerns and the persons responsible
for the follow-up; and
h. Includes
a statement of the individual's and guardian's satisfaction with
services;
(22) Includes
the individual's paid employment and volunteer positions, as
applicable;
(23) Considers
historical information about the individual's experiences; and
(24) Includes a discussion of the need for
assistive technology that could be utilized to support all services and
activities identified in the proposed service agreement without regard to the
individual's current use of assistive technology.
(n) The information outlined in (m)(1)-(24)
above shall be entered into the service agreement outlined in
He-M
503.10 when the individual, guardian, or planning team
determine that such information is necessary for successful participation in
the services and supports outlined in the service agreement.
(o) All planning for home and community-based
waiver services shall include information from the following assessments:
(1) The American Association on Intellectual
and Developmental Disabilities', "SIS-A ®", (2023 edition), available as
noted in Appendix A, for individuals aged 16 or older, which shall be
administered:
a. Initially, within 60 days of
the determination of eligibility for waiver services pursuant to
He-M
503.05(o) for each
individual;
b. For individual's
receiving In Home Supports home and community-based waiver services within 60
days of when the individual reaches age 16;
c. Upon a significant change as defined under
SIS-A ® protocols;
d. Five
years following each prior administration; and
e. To individuals who have moved to New
Hampshire and are requesting home and community-based waiver services in the
next 12 months. If the individual has previously had a SIS-A ® completed in
another state within the last 5 years, however, then they may provide the
out-of-state SIS-A ® results in place of taking a new SIS-A ®;
and
(2) Information
obtained through the HRST (2015 edition), available as noted in Appendix A,
which shall be administered:
a. Initially,
upon determination of eligibility for waiver services pursuant to
He-M
503.05(o) or He-M 524 for each
individual; and
b. Annually or upon
significant change in an individual's status; and
(3) For residential services, includes
information from personal safety assessments pursuant to He-M 1001.
(p) In order to develop or revise
a service agreement to the satisfaction of the individual, guardian, or
representative, the person-centered service planning process shall consist of
periodic and ongoing discussions regarding elements identified in
He-M
503.07(b) that:
(1) Include the individual and other persons
involved in their life;
(2) Are
facilitated by a service coordinator; and
(3) Are focused on the individual's
abilities, health, interests, and achievements.
(q) Service agreements shall be reviewed by
the service coordinator with the individual, guardian, or representative at
least once during the first 6 months of service and as needed. The annual
review required by He-M
503.08(b)(10) shall include a service
planning meeting.
(r) Pursuant to
RSA
171-A:11, the reviews required in (q) above
shall include, at a minimum, the following:
(1) A thorough clinical examination including
an annual health assessment;
(2) An
assessment of the individual's capacity to make informed decisions;
and
(3) Consideration of less
restrictive alternatives for service.
(s) The individual, guardian, or
representative may request, in writing, a delay in an initial or annual service
agreement planning meeting. The area agency and provider agencies shall honor
this request.
(t) In the event an
individual, guardian, or representative requests an extension of the service
agreement meeting, the extension shall be documented and not exceed 60 days
after the expiration of the current service agreement.
(u) The service coordinator shall be
responsible for monitoring services identified in the service agreement
pursuant to He-M 503.10(1)
and for assessing individual, family, or guardian satisfaction at least
annually for non-waiver services and quarterly for waiver services.
(v) If an individual has a residency
agreement and there is notification of intended termination, the service
coordinator shall convene a person-centered service planning meeting as
follows:
(1) Within 10 days of receipt of
notification of the intended termination; or
(2) Within 24 hours of receipt of the
notification if the intended termination is within 72 hours due to the threat
of serious bodily injury by or to the resident.
(w) An area agency, service coordinator,
provider agency, provider, individual, guardian, or representative shall have
the authority to request a person-centered service planning meeting at any
time.
(x) Service agreement
amendments may be proposed at any time.
(y) If the individual, guardian, or provider
agency disapproves of the service agreement, or a service agreement amendment,
the dispute shall be resolved:
(1) Through
informal discussions between the individual, guardian, or representative and
service coordinator;
(2) By
reconvening a person-centered service planning meeting; or
(3) By the individual, guardian, or
representative filing an appeal to the bureau pursuant to He-C 200.
#1969, eff 2-25-82; ss by #2615, eff 2-6-84; ss by
#2962, eff 1-22-85; ss by #5211, eff 8-28-91; EXPIRED: 8-28-97
New. #6581, INTERIM, eff
9-19-97, EXPIRED: 1-17-98
New. #6932, eff 1-27-99; ss by
#8805, eff 1-27-07