24 Miss. Code. R. 2-17.2 - Development of Individual Plans
A. Agency providers
must utilize planning approaches that are considered to be best practices or
evidence-based by their respective areas of focus (i.e., adults with serious
mental illness, children/youth with serious emotional disturbance, people with
co-occurring disorders, people with substance use disorders and people with
intellectual/developmental disabilities, the elderly, etc.). Planning
approaches must be documented and implemented through the development of
policies and procedures specific to this process and the population being
served.
B. Planning approaches must
address the following, at a minimum:
1. The
development of an individualized treatment/support team that includes the
person, service providers and other supports (as appropriate) that may be
identified and utilized by the person or team members;
2. A focus on recovery/resiliency and/or
person-centeredness, depending on the population;
3. A focus on individual strengths and how to
build upon strengths to achieve positive outcomes; and,
4. Proactive crisis planning, depending on
the person receiving services.
C. The Plan of Services and Supports for
people with intellectual/developmental disabilities:
1. Each person has only one (1) Plan of
Services and Supports across all IDD Services (regardless of funding source).
The Plan of Services and Supports is developed by Support Coordination or
Transition Coordination for people enrolled in ID/DD Waiver. Targeted Case
Management develops the Plan of Services and Supports for people enrolled in
IDD Community Support Program. If a person receives an IDD Service and is not
enrolled in ID/DD Waiver or IDD Community Support Program, the IDD agency
provider must develop the Plan of Services and Supports.
2. The person will lead the person-centered
planning process where possible. The person's legal representative(s) should
have a participatory role, as needed and as defined by the person. The meeting:
(a) Includes people chosen by the
person.
(b) Provides necessary
information and support to ensure the person directs the process to the maximum
extent possible and is enabled to make informed choices and
decisions.
(c) Is timely and occurs
at times and places convenient to the person.
(d) Reflects the cultural considerations of
the person.
(e) Includes strategies
for resolving conflict or disagreement within the process including clear
conflict-of-interest guidelines for all planning participants.
(f) Offers informed choices to the person
regarding the services and supports they receive and from whom.
(g) Includes a method for the person to
request updates to the plan as needed.
(h) Records the alternative home and
community-based settings that were considered by the person.
3. The Plan of Services and
Supports must:
(a) Reflect the services and
supports that are important to the person to meet needs identified through an
assessment of functional need as well as what is important for him/her with
regard to preferences for the delivery of such services and supports.
(b) Reflect that the setting in which the
person resides is chosen by the person. The setting must be integrated in and
support full access 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 a person not receiving IDD services.
(c) Reflect the person's strengths and
preferences.
(d) Reflect clinical
and support needs as identified through the functional assessment.
(e) Include individually identified outcomes
for services.
(f) Reflect the
services and supports (paid and unpaid) that will assist the person to achieve
identified outcomes and the agency providers of those services and supports,
including natural supports.
(g)
Reflect risk factors and measures in place to minimize them, including
individual back-up plans and strategies when needed.
(h) Be understandable to the person receiving
services and supports, and the people important in supporting him/her. At a
minimum, for the Plan of Services and Supports to be understandable, it must be
written in plain language and in a manner that is accessible to people with
disabilities and people who have limited English language
proficiency.
(i) Identify the
person and/or entity responsible for monitoring the Plan of Services and
Supports.
(j) Be finalized and
agreed to, with the informed consent of the person in writing, and be signed by
all people and service providers responsible for its implementation.
(k) Be distributed to the person and others
involved in implementing the Plan of Services and Supports.
(l) Prevent the provision of unnecessary or
inappropriate services and supports.
(m) Document that any modifications made to a
person's ability to access the community or make choices about his/her daily
life:
(1) Identify a specific and
individualized assessed need.
(2)
Have documentation of the positive behavior interventions and supports used
prior to any modification of the person-centeredness of the Plan of Services
and Supports.
(3) Have
documentation that less intrusive methods have been tried and did not
work.
(4) Include a clear
description of the condition that is directly proportionate to the specific
assessed need.
(5) Include regular
collection and review of data to measure the ongoing effectives of the
modification.
(6) Include
established time limits for periodic reviews to determine if the modification
is still necessary or can be terminated.
(7) Include the informed consent of the
person.
(8) Include an assurance
that interventions and supports will cause no harm to the person.
(n) Be reviewed and revised upon
reassessment of the functional need, at least annually, when the individual
circumstances or needs change significantly, or at the request of the person.
Notes
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