Person-Centered Planning

Section 120 Section 120.160  Person-Centered Planning a)         Individuals who are or who will be enrolled in an HCBS Waiver Program, guardians, ISC agencies, and provider agencies shall comply with Person-Centered Planning requirements pursuant to 42 CFR 441.301(c)(1) through (c)(3) and as set forth by the Department. The Person-Centered Planning process: 1)         Must be driven by the Individual who is or who will be enrolled in an HCBS Waiver Program. The ISC agency shall facilitate the process and the guardian must be included. Other persons invited by the Individual and agencies currently providing services shall be invited to contribute to the process. 2)         Provides necessary information and support to ensure that the Individual directs the process to the maximum extent possible and is enabled to make informed choices and decisions. 3)         Is timely and occurs at times and locations of convenience to the Individual. 4)         Reflects cultural considerations of the Individual and is conducted by providing information in plain language and in a manner that is accessible to Individuals with disabilities and persons who have limited English proficiency. 5)         Includes strategies for solving conflict or disagreement within the process, including clear conflict of interest guidelines for all planning participants. 6)         Is initiated and overseen by a conflict of interest-free case management entity as indicated in Section 120.65. Providers of HCBS Waiver services, or those who have an interest in or are employed by a provider of HCBS Waiver services must not provide case management or develop the Personal Plan. 7)         Offers informed choices to the Individual regarding the services and supports that they receive and from whom. 8)         Includes a method for the Individual to request updates to the plan as needed. 9)         Records the alternative home and community-based settings that were considered by the Individual. b)         ISC agencies shall initiate the Person-Centered Planning process for each Individual who is or who will be enrolled in an HCBS Waiver Program by conducting a discovery process designed to gather information about an Individual's preferences, interests, abilities, preferred environments, activities, and supports needed. 1)         The ISC agencies will be responsible for facilitating the discovery process, as outlined by the Department, and for documenting what they gather. 2)         This process should begin with the Individual and then include the guardian, advocate, family, and others chosen by the Individual. It must also include information from current providers. 3)         The information captured during this process is used to develop the Personal Plan, which summarizes key and critical areas of the Individual's life. c)         After the discovery process is complete, the ISC agency shall develop the Personal Plan. The Personal Plan must reflect the services and supports that are important for the Individual to meet the needs identified through the discovery process, as well as what is important to the Individual with regard to preferences for the delivery of such services and supports. The written plan must: 1)         Reflect that the setting in which the Individual resides is chosen by the Individual. The State must ensure that the setting chosen by the Individual is integrated in, and supports 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 Individuals not receiving Medicaid HCBS. 2)         Reflect the Individual's strengths and preferences. 3)         Reflect clinical and support needs, as identified through the discovery process. 4)         Include individually-identified and -desired outcomes. 5)         Reflect the services and supports (paid and unpaid) that will assist the Individual to achieve identified outcomes, and the providers of those services and supports, including natural supports. 6)         Reflect risk factors and measures in place to minimize them, including individualized back-up plans and strategies, when needed. 7)         Be understandable to the Individual receiving services and supports, and to those who are important in supporting the Individual. 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 and to persons who have limited English proficiency. 8)         Identify the person and/or entity responsible for monitoring the plan. 9)         Be finalized and agreed to, with the informed consent of the Individual in writing. The persons and providers responsible for its implementation shall sign the completed plan. 10)       Be distributed to the Individual and other people involved in the plan. 11)       Include those services which the Individual elects to self-direct. 12)       Prevent the provision of unnecessary or inappropriate services and supports. 13)       Include any modification of the conditions in Section 120.70(d)(6)(A) through (d)(6)(E). Modifications of these conditions must be supported by a specific assessed need and justified in the Personal Plan. The following requirements must be documented in the Personal Plan: A)        Identify a specific and individualized assessed need. B)        Document the positive interventions and supports used prior to any modifications to the Personal 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 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. H)        Include an assurance that interventions and supports will cause no harm to the Individual. d)         The Personal Plan must be reviewed and revised upon reassessment of functional need, as required by 42 CFR 441.365(e), at least every 12 months, when the Individual's circumstances or needs change significantly, or at the request of the Individual. e)         Provider agencies must comprehensively address the needs of Individuals enrolled in an HCBS Waiver and for whom they have signed a Personal Plan through the development of an Implementation Strategy as it relates to their Personal Plan. 1)         Within 20 calendar days of the provider's signature on the Personal Plan, an Implementation Strategy shall be developed that: A)        Is based on the Personal Plan developed by the ISC agency and on the assessment results. B)        Includes the participation of the Individual and guardian, and the ISC as necessary. C)        Reflects the Individual's and guardian's agreement, as indicated by a signature on the Implementation Strategy or staff notes indicating why there is no signature and why the Individual's and guardian's agreement is not reflected. D)        Describes and directs the activities and methods used to provide services and supports the areas of an Individual's Personal Plan for which the provider is responsible. E)        Addresses and accounts for the priorities, strengths, support needs, and risk factors identified in the Personal Plan for those areas of the provider's responsibility. F)         Justify and document the restriction of an Individual's HCBS Waiver rights, which are outlined in Section 120.70(d)(6)(A) through (E) G)        Addresses outcomes identified in the Personal Plan that the provider agency agreed to support the Individual in. H)        Identifies the agencies' services to support the Individual in attaining skills or achieving outcomes identified in the Personal Plan, detailing timeframes for completion, staff positions assigned responsibility, and benchmarks for determining the success of the strategies. I)         Identifies the services chosen by the Individual and guardian and indicates the type and the amount of supervision provided to the Individual. J)         Includes the names and titles of all employees and other persons contributing to the Implementation Strategy. K)        Is signed by the Individual, guardian, and provider agency representatives. 2)         The Individual, guardian and ISC shall be given a copy of the Implementation Strategy and subsequent updates. 3)         The Implementation Strategy and subsequent updates shall become a part of the Individual's record. 4)         At least monthly, the QIDP shall review the Implementation Strategy and shall document, sign, and date in the Individual's monthly summary that: A)        Services are being implemented, as identified in the Implementation Strategy. B)        Services identified in the Implementation Strategy continue to meet the Individual's needs or require modification to better meet the Individual's needs. C)        Outcomes are being supported as specified in the Personal Plan and Implementation Strategy. D)        Progress is being made toward outcomes, as identified in the Personal Plan and Implementation Strategy. In situations when there is no progress made, provider agencies must document barriers and/or reasons why progress was not made. 5)         Updates shall be made to the Implementation Strategy as the Personal Plan is modified, or more often if warranted by a change in functional status or at the request of the Individual or guardian. 6)         All services specified in the Implementation Strategy, whether provided by an employee of the agency, consultants, or sub-contractors, shall be provided by or under the supervision of a QIDP. 7)         The provider agency must ensure that current copies (digital or paper) of Individuals' Personal Plans and Implementation Strategies are kept at the provider agency. 8)         The provider agency must also ensure that direct care workers (including employees, contractual persons, and host family members) are knowledgeable about the Individuals' Personal Plans and Implementation Strategies, are trained in their implementation, and maintain records regarding the Individuals' progress toward the outcomes of the Personal Plans and Implementation Strategies.