Person-Centered Planning Process

Section 240.550  Person-Centered Planning Process A person-centered plan of care will be developed in collaboration with the participant who is eligible for services using a person-centered planning process with the CCU. a)         The person-centered planning process will ensure: 1)         the opportunity for the participant/authorized representative to lead and direct the planning process, whenever possible, and to select other persons to participate in decision-making; 2)         the scheduling of timely meetings that occur at times and locations convenient to the participant/authorized representative, preferably in the participant's place of residence to assess the participant's environment to ensure the development of a person-centered plan of care that considers the participant's safety; 3)         the provision of necessary information and support to enable the participant/authorized representative to make informed choices and decisions; 4)         the inclusion of strategies for solving disagreements within the planning process, including clear guidelines for conflicts of interest on the part of all who participate in decision-making; 5)         the protection of the rights of the participant/authorized representative to choose available services, supports and providers/vendors; and 6)         the sharing of contact information for the CCU/Care Coordinator so the participant/authorized representative can request a redetermination of eligibility, additional or new services, or other updates and changes to the person-centered plan of care. b)         The CCU will provide all information and support in a culturally-sensitive manner to ensure that the participant/authorized representative is able to make informed choices and decisions, including appropriate available options for limited English-proficient persons and/or those with a disability. c)         The CCU will provide a copy of the final person-centered plan of care and any subsequent revisions to the participant/authorized representative and any other person identified as being responsible for monitoring or implementing the plan, including the providers/vendors. d)         The CCU will monitor the participant to prevent unnecessary or inappropriate care. e)         Review of the Person-Centered Plan of Care 1)         The CCU will review and revise a person-centered plan of care: A)        at least every 12 months following an assessment/reassessment of functional needs; B)        when a participant's personal circumstances or functional needs change significantly; and C)        at the request of a participant/authorized representative. 2)         The CCU will document its periodic review of the participant and any information that is collected under the measures being used to evaluate the effectiveness of the services and supports based on the described needs and related conditions of the participant. 3)         Revisions will be supported by a specific assessed functional need of the participant and a written justification included in the revised person-centered plan of care, indicating that the use of the previously identified adherence interventions and risk strategies were unsuccessful before changing services, supports and/or providers/vendors.  Changes will be scaled as appropriate first using the least intrusive options. 4)         The CCU shall document that positive interventions and supports were used prior to any modification and that less intrusive methods were tried but were unsuccessful.