105 CMR 150.021
Support Services Plan for Level IV Community Support Facilities
(A) In Level IV facilities with Community Support Residents, the Support Services Coordinator
must develop a Support Services Plan. The plan shall be written as soon as possible but no later
than two weeks after admission for new resident admissions and as soon as possible for
Community Support Residents alreadyresidingin a facility. The Support Plan must describe the
service needs of the resident, including those service needs specified in his or her Mental Health
Treatment Plan. The Support Plan must be developed by the Community Support Resident and
the Support Services Coordinator, in consultation with the resident’s social worker, physician,
psychiatrist, and other staff.
(1) Each plan must include, but is not limited to, the following:
(a) A narrative statement describing the resident’s service needs. These needs must
include those specified in the mental health treatment plan. It should also include service
needs consistent with the mental health treatment plan but are not mental health needs,
such as other health needs, educational or vocational needs, and recreational or
socialization needs.
(b) Within each area of specified need, goals and objectives, as well as time frames for
the beginning of services and the achievement of objectives should be developed.
(2) Each plan should be reviewed 30 days after it is first developed, and every 90 days
thereafter. At the time of the plan review, goals and objectives should be evaluated, and
revised as needed. If objectives have not been met, new strategies mayneed to be developed.
The plan should be adjusted at any time a significant change is made in the resident’s mental
health plan that affects the service needs specified in the Support Plan, or requires new
service needs to be met. The Coordinator, in consultation with the social worker may revise
the Support Plan as often as the Coordinator feels it is inadequate.
No support services plan may be implemented without the written consent of the
resident or the resident’s guardian.
(4) If a support services plan is declined by a resident the attending Support Services
Coordinator, in consultation with the resident’s psychiatrist and physician, shall make all
efforts to meet with the resident to determine how a plan might be developed and/or modified
in order to accommodate the resident’s objections, concerns, and suggestions. Reasons for
partial or total rejection of the plan must be noted in the resident’s record.
(B) Support Services Coordinator. All Level IV facilities with Community Support Residents
shall employ a Support Services Coordinator. The Coordinator is responsible for arranging and
coordinating Support Services. Support Services is a term applied to a variety of services
including health and mental health visits, educational and vocational services, as well as
recreational services which are intended to enhance the psychosocial and physical functioning
of Community Support Residents. Some of these services will be specified in the resident’s
Mental Health Treatment Plan. Others can be identified by the resident, the Coordinator or other
staff. The Coordinator is responsible for ensuring all of the services received by a Community
Support Resident either within the facility or in the community, are consistent with the Mental
Health and Support Services plans. When questions or conflicts arise among the various staff
and consultants involved with these residents, it is the responsibility of the Coordinator to
arrange and facilitate communication among the others. This may involve arranging meetings
among facility staff, referring agency staff, consultant staff or others. It is the role of the
Coordinator to minimize duplication of service, and to ensure the Mental Health Plan required
by these regulations is the focus of a consistent and well organized care plan. The Coordinator
should meet regularly with Community Support Residents as well as with the social worker and
other facility staff. The Coordinator may also wish to visit other agencies and staff to facilitate
linkage and coordination.
Minimum Support Services Coordinator Personnel Requirements:
(1) Two hours of Support Services shall be provided to each Community Support Resident
per week (One full time equivalent per 20 Community Support Residents).
In the event a facility experiences a change in the number of Community Support
Residents by five residents more or less, the facility must notify the Department of Public
Health to discuss the need for a change in staffing.
(3) The Support Services Coordinator shall receive clinical supervision from the social
worker, and shall meet at least monthly, preferably weekly, with the social worker to discuss
the resident’s care plans.
(4) The Support Services Coordinator shall, prior to employment by a Community Support
Facility, possess a BA or BS degree in a human services field of study such as Psychology,
Nursing or Social Work, have documented evidence of having received appropriate training
in the psychosocial problems and needs of Community Support Residents, have knowledge
of the Support Services available to Community Support Residents, and have adequate
training, as determined by the Department, in the effects and side effects of those drug
therapies prescribed for Community Support Residents.
(5) Duties of the Support Services Coordinator shall be restricted to the day shift.