Person-Centered Plan of Care

Section 240 Section 240.730  Person-Centered Plan of Care a)         A person-centered plan of care will be developed using the person-centered planning process in accordance with Section 240.550. b)         The person-centered plan of care, and any subsequent revisions, shall be written in plain language and shall reflect the participant's goals, preferences and desired outcomes, indicating services and supports important to the participant, based upon the functional needs identified by the comprehensive assessment, including: 1)         a description of the conditions that directly correspond to the assessed functional needs, including: A)        the strengths and preferences of the individual, and resources available to that individual; B)        the clinical and support needs as identified through a comprehensive assessment of functional needs; C)        paid and unpaid services and supports that will assist the participant to achieve identified goals, and natural supports and vendors available to meet those needs; D)        risk factors and measures in place to minimize harm, including possible interventions that may be used if aid is necessary for adherence to program requirements, and the customized strategies and back-up plans to minimize any risk factors for the individual; E)        identification of the Care Coordinator and other individuals/vendors responsible for monitoring the person-centered plan of care; F)         any measures that will be used to support how to evaluate the effectiveness of the services and supports; and G)        the time limits for periodic reviews to determine if services and supports are still appropriate, need to be modified, or can be terminated. 2)         a summary of the alternatives and settings considered by the participant/authorized representative and their final selections of services, supports and providers/vendors as reinforcement that the right of freedom of choice may be exercised. A)        The CCU will list all providers or programs in the service area and document the available options discussed with the participant/authorized representative. B)        The CCU will also afford the participant/authorized representative an opportunity to visit all of the adult day facilities in their service area before finalizing any selections. 3)         an acknowledgement of informed consent by the participant/authorized representative. c)         Services are to be offered to each participant who meets the minimum required scores on the DON; who meets all other eligibility requirements; for whom an adequate person-centered plan of care has been developed; and whose service costs are within the allowable maximums. Care coordinators and participants/authorized representatives shall develop the person-centered plan of care in the best interest of the participant/authorized representatives, based on services selected by the participants/authorized representatives from among those available in the community.  Maximum monthly service dollars are only available to fund services provided through the CCP. d)         If a person-centered plan of care cannot be developed that adequately meets the participant's needs within the allowable maximums for cost of service, CCP services shall be denied or services terminated, as appropriate to the case. e)         Each participant/authorized representative must be advised by the CCU of their right to refuse the offered services, to choose to enter a long-term care facility or to choose neither. f)         The allowable monthly cost for services provided to an eligible participant and paid for through the CCP cannot exceed the maximum monthly cost as determined by the score attained on the CCP DON that is determined by the CCU based on current, full and complete information on the specific needs of the participant.  A person-centered plan of care shall be based upon the number of days in a month.