Current through Register Vol. 46, No. 39, September 25, 2024
The operator must ensure that:
(a) A person-centered care plan based on the
comprehensive assessment required by this Part, and, when applicable, a
transfer or discharge plan, is developed for each registrant and is in place
within five visits or within 30 days after registration, whichever is earlier.
The adult day health care program and the referring managed care plan must be
sure to coordinate with each other regarding the development of a registrant's
person-centered care plan.
(b) Each
registrant's person-centered care plan process must be commensurate with the
level of need of the registrant, and the scope of services and supports
available and must:
(1) include registrant
led input and include people chosen by the registrant;
(2) provide necessary information and support
to ensure the registrant directs the process to the maximum extent possible and
is enabled to make informed choices and decisions, with the registrant's
representative having a participatory role, as needed and as defined by the
registrant, unless State law confers decision-making authority to the legal
representative;
(3) be timely and
occur at times and locations of convenience to the registrant;
(4) reflect cultural considerations of the
registrant and be conducted by providing information in plain language and in a
manner that is accessible to individuals with disabilities and persons who are
limited English proficient;
(5)
include strategies for solving conflict or disagreement within the process,
including clear conflict of interest guidelines for all planning
participants;
(6) offer choices to
the registrant regarding the services and supports the registrant receives and
from whom;
(7) include a method for
the registrant to request updates to the care plan, as needed; and
(8) record the alternative home and
community-based settings that were considered by the registrant.
(c) The person-centered care plan
must reflect the services and supports that are important for the registrant to
meet the clinical and support needs as identified through an assessment of
functional need, as well as what is important to the registrant with regard to
preferences for the delivery of such services and supports. The written plan
must also:
(1) reflect the registrant's
pertinent diagnoses, including mental status, types of equipment and services
required, case management, frequency of planned visits, prognosis,
rehabilitation potential, functional limitations, planned activities,
nutritional requirements, medications and treatments, necessary measures to
protect against injury, instructions for discharge or referral if applicable,
orders for therapy services, including the specific procedures and modalities
to be used and the amount, frequency and duration of such services, and any
other appropriate item.
(2) reflect
the registrant's strengths and preferences, the medical and nursing goals and
limitations anticipated for the registrant and, as appropriate, the
nutritional, social, rehabilitative and leisure time goals and
limitations;
(3) set forth the
registrant's potential for remaining in the community;
(4) include a description of all services to
be provided to the registrant by the program, informal supports and other
community resources pursuant to the personcentered care plan, and how such
services will be coordinated;
(5)
reflect that the setting in which the registrant receives services is chosen by
the registrant;
(6) reflect risk
factors and measures in place to minimize them, including individualized backup
plans and strategies when needed;
(7) be understandable to the individual
receiving services and supports, and the individuals important in supporting
them. At a minimum, for the written plan to be understandable, it must be
written in plain language and in a manner that is accessible to individuals
with disabilities or with limited proficiency in English;
(8) identify the individual and/or entity
responsible for monitoring the plan;
(9) be finalized and agreed to, with the
informed consent of the registrant (and/or persons identified by the
registrant) in writing and signed by all individuals and providers responsible
for its implementation;
(10) be
distributed to the registrant and other people involved in the plan;
(11) include those services, the purchase or
control of which the registrant elects to self-direct; and
(12) prevent the provision of unnecessary or
inappropriate services.
(d) Development and modification of the
person-centered care plan is coordinated with other health care providers
outside the program who are involved in the registrant's care.
(e) The responsible persons, with the
appropriate participation of consultants in the medical, social, paramedical
and related fields involved in the registrant's care, must:
(1) record in the clinical record changes in
the registrant's status which require alterations in the registrant
person-centered care plan;
(2)
modify the person-centered care plan to reflect registrant physical and social
changes accordingly;
(3) review the
person-centered care plan at least once every six months and whenever the
registrant's condition warrants and document each such review in the clinical
record; and
(4) promptly alert the
registrant's authorized practitioner of any significant changes in the
registrant's condition which indicate a need to revise the person-centered care
plan.
