Individual Support Plans

PURPOSE: This rule prescribes procedures for development and implementation of individual support plans for all individuals receiving services from the Division of Developmental Disabilities. PUBLISHER’S NOTE: The secretary of state has determined that the publication of the entire text of the material which is incorporated by reference as a portion of this rule would be unduly cumbersome or expensive. This material as incorporated by reference in this rule shall be maintained by the agency at its headquarters and shall be made available to the public for inspection and copying at no more than the actual cost of reproduction. This note applies only to the reference material. The entire text of the rule is printed here. (1) Definitions. (A) Assessment—the process of gathering information about an individual for use by the individual support plan team as a basis for the individual support plan. Assessment, as used in this rule, does not include determination of eligibility by the Department of Mental Health (DMH) as set forth in 9 CSR 452.010. (B) Division—the Division of Developmental Disabilities. (C) Home and Community-based Waivers— also referred to as home and communitybased services (HCBS) in this rule; a set of long-term community-based supports and services authorized by the Centers for Medicare and Medicaid Services which are provided as an alternative to care in institutions such as nursing facilities and intermediate care facilities for individuals with intellectual disabilities. (D) Individual Support plan (ISP)—a document developed by the individual, with assistance as needed from a representative, in collaboration with the individual support plan team. The ISP identifies strengths, capacities, preferences, needs, and desired outcomes of the individual. The ISP encompasses a personalized mix of paid and non-paid services and supports that will assist him/her to achieve personally defined outcomes. Training, supports, therapies, treatments and/or other services to be provided for the individual become part of the ISP. ISP is also referred to as a person-centered service plan. (E) Individual support plan team—the individual, the individual’s guardian or designated representative(s), and the support coordinator. Providers of waiver-funded services may also participate in the support plan team if such participation is requested by the individual, guardian, or designated representative. (F) MO HealthNet—Missouri’s name for the state’s Medicaid program, authorized under Title XIX of the Social Security Act. (G) MO HealthNet participant—an individual enrolled with MO HealthNet. (H) Natural supports—any unpaid support including, but not limited to, immediate and extended family members, friends, co-workers, neighbors, and community services available to any individual regardless of disability. (I) Reassessment—data obtained from training programs, results of screenings, and formal or informal assessments completed since the previous ISP team meeting. (J) Waiver participant—individual receiving HCBS services. (2) Every individual referred to a qualified provider of targeted case management who is a participant of MO HealthNet or who receives any services funded by the division, including services under a home and community-based waiver or services funded only by general revenue, shall have an individual support plan (ISP). (3) Person-centered planning shall be done in accordance with 42 CFR 441.301(c)(1). The individual shall lead the person-centered planning process where possible. The individual's representative should have a participatory role, as needed and as defined by the individual or guardian, if applicable. In addition to being led by the individual receiving services and supports, the person-centered planning process shall— (A) Include people chosen by the individual; (B) Provide 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; (C) Be scheduled at times and locations of convenience to the individual; (D) Reflect cultural considerations of the individual and be conducted by providing information in plain language and in a manner that is accessible to individuals with disabilities and persons who are limited English proficient; and (E) Include strategies for solving conflict or disagreement within the process, including clear conflict of interest guidelines for all planning participants. (4) In accordance with 42 CFR 441.301(c)(2), the ISP shall reflect the services and supports that are important for the individual to meet the needs identified through an assessment of functional need, as well as what is important to the individual with regard to preferences for the delivery of such services and supports. Commensurate with the level of need of the individual and the scope of services and supports available through the division, the ISP shall— (A) Reflect the individual’s strengths and preferences; (B) Reflect clinical and support needs as identified through an assessment of functional need; (C) Include individually identified goals and desired outcomes; (D) Reflect the services and supports (paid and unpaid) to assist the individual to achieve identified goals, and the providers of those services and supports, including natural supports; (E) Reflect risk factors and measures in place to minimize them, including individualized back-up plans and strategies when needed; (F) Be understandable to the individual receiving services and supports, and the individuals important in supporting him or her. At a minimum, for the ISP to be understandable, it is written in plain language and in a manner that is accessible to individuals with disabilities and persons who are limited English proficient; (G) Identify the individual and/or entity responsible for monitoring the ISP; (H) Be distributed to the individual and any other individuals or providers who sign the plan, as specified in section (5) of this rule; (I) Include those services, the purpose or control of which the individual elects to selfdirect or designate an authorized representative to direct on his or her behalf; (J) Prevent the provision of unnecessary or inappropriate services and supports; and (K) Document that any restrictions of individual rights is supported by a specific assessed need and justified in the ISP in accordance with 42 CSR 441.301(c)(2). (5) The ISP shall be finalized and agreed to, with the informed consent of the individual in writing, and signed by all individuals and providers responsible for its implementation in accordance with 42 CFR 441.301(c)(2)(ix), with the exception of providers of assistive technology, dental, durable medical equipment, environmental accessibility adaptations, specialized medical equipment and supplies, and transportation. (A) Signatures may be added to the plan electronically using a format accepted by MO HealthNet. (B) If it is not possible to obtain a written signature from the individual or guardian, the Division Regional Office Director or his or her designee may approve an exception if the following steps are completed: 1. At least two (2) attempts to obtain the signature are documented. One (1) attempt may be either by phone or E-mail, and the other attempt documented through certified mail with delivery validated by a signed return receipt; 2. A justification is attached to the ISP describing these and any other efforts made to obtain the signature; and 3. The regional director may require additional efforts by the support coordinator to obtain the signature from the individual or guardian. (C) If the exception to the signature is approved by the regional director or designee, a copy of the approved exception request is sent to everyone to whom a copy of the ISP is distributed. (6) ISP Review: The ISP shall be reviewed and revised upon reassessment of functional need in accordance with 9 CSR 45-2.010 at least every twelve (12) months, when the individual's circumstances or needs change significantly, or at the request of the individual. The reassessment of functional need shall be completed within ninety (90) days before the ISP review. (7) ISP updates require prior written approval from the ISP team before implementation of the change and signatures in accordance with section (5) of this rule. ISP updates requiring prior written approval include: (A) Addition of a new service; (B) Increase or decrease in amount and/or frequency of a service already in place; (C) Termination of a service; (D) Limitation of rights as set forth in 9 CSR 45-3.030; and (E) Change in ISP outcomes. (8) Changes in legal information including, but not limited to, arrests, incarceration, court orders, and legal actions other than changes in guardianship shall be documented in the ISP but shall not require prior written approval or signatures if the change does not result in a change in services. (9) Denial, reduction, or termination of a service is subject to appeal as set forth in 9 CSR 45-2.020. (10) Changes in training plans or methods to ensure progress toward achievement of outcomes already documented in the ISP may be made by the provider of the related service as needed without approval of the ISP team. (11) The division may authorize emergency residential services, respite care, or crisis intervention for up to thirty (30) days without prior approval of the ISP team. (12) The division shall provide guidance and technical assistance to providers of support coordination in the person-centered planning process and the development and oversight of the ISP. (13) Individuals with developmental disabilities, as defined in 9 CSR 45-2.010, but who are not MO HealthNet participants and who do not receive services from the division funded by general revenue shall be provided with individualized information based on, but not limited to, their age, diagnosis, and geographic residence. AUTHORITY: section 630.655, RSMo 2016.* The rule was previously filed as 9 CSR 105.150. Original rule filed Nov. 30, 1990, effective April 29, 1991. Amended: Filed May 25, 1995, effective Dec. 30, 1995. Amended: Filed Jan. 22, 2019, effective Aug. 30, 2019. *Original authority: 630.655, RSMo 1980.