Person-centered services plan.
(1) The
person-centered services plan describes the person-centered goals, objectives
and interventions selected by the individual and team to support him or her in
his or her community of choice. The
person-centered
services plan addresses the assessed needs of the individual by
identifying medically-necessary services
,
and supports provided by natural supports,
medical and professional staff
, and community
resources. The
person-centered services plan
must
will:
(a) Identify the setting in which the
individual resides is chosen by the individual and
record
document the
alternative home and community-based settings that were considered by the
individual.
(b) Reflect the
individual's strengths.
(c) Reflect
the individual's preferences.
(d)
Reflect clinical and support needs as identified through the assessment
process.
(e) Include the
individual's identified goals and desired outcomes.
(f) Identify the services and supports (paid
and unpaid) that will assist the individual to achieve identified goals, and
the providers of those services and supports, including natural supports and
those services the individual elects to self-direct.
This includes all services and supports provided through
private insurance, medicare, medicaid state plan, and waiver
services.
(g) Address any
risk factors and measures in place to minimize them, when needed.
(h) Include back-up plans that meet the needs
of the individual.
(i) Reflect that
the setting chosen by the individual is integrated in, and supports the full
access of individuals receiving medicaid HCBS 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 people not receiving
medicaid HCBS.
(2) The
person-centered services plan
contains
documentation
will document that any
modification of the additional conditions for provider-owned or controlled
residential settings set forth in rule
5160-44-01 of the Administrative
Code
must be
is supported by a specific assessed need and justified
in the person-centered services plan.
The following
requirements must be documented in the person-centered services
plan:
In these cases, the person-centered
services plan will:
(a) Identify a
specific and individualized assessed need;
(b) Document the positive interventions and
supports used prior to any modifications to the person-centered services
plan;
(c) Document less intrusive
methods of meeting the need that have been
tried
attempted but
were unsuccessful;
did
not work;
(d) Include a
clear description of the condition that 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
individual; and
(h) Include an
assurance that interventions and supports will not cause any harm to the
individual.
(3) The
person-centered services plan
must
will:
(a) Be
understandable to the individual receiving services and supports, and the
people important in supporting him or her. At a minimum, it
must
will be
written in plain language and in a manner that is accessible to persons with
disabilities and persons who are limited english proficient, consistent with
42 CFR
435.905(b) (as in effect on
October 1,
2021
2023).
(b)
Identify the person and/or entity responsible for monitoring the
plan.
(c) Be finalized and agreed
to, with the informed consent of the individual in writing, and signed by all
people and providers responsible for its implementation. Acceptable signatures
include, but are not limited to a handwritten signature, initials, a stamp or
mark, or an electronic signature. Any accommodations to the individual's or
authorized representative's signature
shall
will be documented on the plan.
(d) Be distributed to the individual and
other people involved in the plan.
(e) Prevent the provision of unnecessary or
inappropriate services and supports.
(f) Be reviewed
, and revised upon reassessment of functional need
as required by 42 CFR
441.365(e) (as in effect on
October 1,
2021
2023), at least every twelve months, when the
individual experiences a significant change, or at the request of the
individual.