Day Habilitation Service Plan (DHSP)

(A) Interim DHSP. Within five business days after the member’s admission, the DH provider’s professional interdisciplinary team must design an interim DHSP. The plan must outline a temporary schedule of treatment and activities that will be used until the final DHSP is completed. (B) Final Day Habilitation Service Plan. Together with the SNA, the final DHSP must be completed within 45 business days from the date of the member’s admission and updated every two years and upon significant change and must be developed with participation of the member, the member’s authorized representatives, where applicable and appropriate, and must be derived from the SNA for each member. The final DHSP describes each training program, measurable goals, and objectives that address the need areas identified in the SNA. The DHSP must be designed in a manner that integrates the various activities, tasks, and, if appropriate, therapies recommended to meet the member’s areas of need. The final DHSP must include, but is not limited to, the following: (1) a medical plan of care; (2) a service plan coversheet that outlines the development of the member’s DHSP, based on the recommendations from the SNA; and (3) goals and objectives that are written in measurable terms. (a) Each goal must 1. be written without the use of ambiguous action verbs; 2. be member-driven; and 3. provide clear means for attaining the goal within an established time frame. (b) Objectives must address specific skill acquisition and retention as it relates to a goal and must 1. be written without the use of ambiguous action verbs; 2. be member-driven; 3. measure only one behavior; and 4. identify measurable outcomes performance and stability criterion. (C) Reviews. (1) The DHSM must review the member’s goals and objectives every six months or upon significant change and must inform the staff, using staff meetings, of any changes in the member’s status or DHSP. (2) The DHSM must ensure that monthly progress notes related to the member’s DHSP are completed by staff and reflect the member’s plan of care. Any significant changes in the member’s health status must be discussed with the DH staff. (3) The interdisciplinary team must, at least two times per year, conduct a semi-annual review to address the member’s overall progress. Components of this review, at a minimum, must include (a) a comprehensive review of the member’s goals and objectives (if a change in goals and objectives is indicated by the review, the member’s DHSP must be updated); and (b) comprehensive medical review based on the member’s DHSP.