Person Centered Planning (PCP)

Person Centered Planning (PCP) A. Person-Centered Planning (PCP) is an ongoing process used to identify a beneficiary’s desired outcomes based on their personal needs, goals, desires, interests, strengths, and abilities. The PCP process helps determine the services and supports the beneficiary requires in order to achieve these outcomes and must: 1. Allow the beneficiary to lead the process where possible with the beneficiary’s guardian and/or legal representative having a participatory role, as needed and as defined by the beneficiary and any applicable laws. 2. Include people chosen by the beneficiary. 3. Provide the necessary information and support to ensure that the beneficiary directs the process to the maximum extent possible, and is enabled to make informed choices and decisions. 4. Be timely and occur at times and locations of convenience to the beneficiary. 5. Reflect cultural considerations of the beneficiary 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. 6. Include strategies for solving conflict or disagreement within the process, including clear conflict-of-interest guidelines for all planning persons. 7. Provide conflict free case management and the development of the PSS by a provider who does not provide home and community-based services (HCBS) for the beneficiary, or those who have an interest in or are employed by a provider of HCBS for the beneficiary, except when the only willing and qualified entity to provide case management and/or develop PSS in a geographic area also provides HCBS. In these cases, conflict of interest protections including separation of entity and provider functions within provider entities, must be approved by the Centers of Medicare and Medicaid Services (CMS) and these beneficiaries must be provided with a clear and accessible alternative dispute resolution process which ensures the beneficiary’s rights to privacy, dignity, respect, and freedom from coercion and restraint. 8. Offer informed choices to the beneficiary regarding the services and supports they receive and from whom. 9. Include a method for the beneficiary to request updates to the PSS as needed. 10. Record the alternative HCBSs that were considered by the beneficiary. B. The PSS must reflect the services and supports that are important for the beneficiary to meet the needs identified through an assessment of functional need, as well as what is important to the beneficiary with regard to preferences for the delivery of such services and supports and the level of need of the individual beneficiary and must: 1. Reflect that the setting in which the beneficiary resides is: a) Chosen by the beneficiary and/or their representative, b) Integrated in, and supports full access of beneficiaries receiving Medicaid HCBS to the greater community, including opportunities to: 1) Seek employment and work in competitive integrated settings, 2) Engage in community life, 3) Control personal resources, and 4) Receive services in the community to the same degree of access as individuals not receiving Medicaid HCBS. 2. Reflect the beneficiary's strengths and preferences. 3. Reflect clinical and support needs as identified through an assessment of functional need. 4. Include individually identified goals and desired outcomes. 5. Reflect the services and supports, both paid and unpaid, that will assist the beneficiary to achieve identified goals, and the providers of those services and supports, including natural supports. The Division of Medicaid defines natural supports as unpaid supports that are provided voluntarily to the beneficiary in lieu of 1915(c) HCBS waiver services and supports. 6. Reflect risk factors and measures in place to minimize them, including individualized back-up plans and strategies when needed. 7. Be written in plain language and in a manner that is accessible to beneficiaries with disabilities and who are limited English proficient so as to be understandable to the beneficiary receiving services and supports, and the individuals important in supporting the beneficiary. 8. Identify the individual and/or entity responsible for monitoring the PSS. 9. Be finalized and agreed to, with the informed consent of the beneficiary in writing, and signed by all individuals and providers responsible for its implementation. 10. Be distributed to the beneficiary and other people involved in the plan. 11. Identify those services, the purpose or control of which the beneficiary elects to self- direct. 12. Prevent the provision of unnecessary or inappropriate services and supports. 13. Document the additional conditions that apply to provider-owned or controlled residential settings. C. The PSS must include, but is not limited to, the following content: 1. A description of the beneficiary’s strengths, abilities, goals, plans, hopes, interests, preferences and natural supports. 2. The outcomes identified by the beneficiary and how progress toward achieving those outcomes will be measured. 3. The services and supports needed by the beneficiary to work toward or achieve his or her outcomes including, but not limited to, those available through publicly funded programs, community resources, and natural supports. 4. The amount, scope, and duration of medically necessary services and supports authorized by and obtained through the community mental health system. 5. The estimated/prospective cost of services and supports authorized by the community mental health system. 6. The roles and responsibilities of the beneficiary, the supports coordinator or case manager, the allies, and providers in implementing the plan. D. Each provider identified in the PSS must review and revise the PSS when any of the following occur: 1. At least twelve (12) months have lapsed since the provider’s last review, 2. The beneficiary's circumstances or needs change significantly, or 3. When requested by the beneficiary. E. All changes to the PSS require documented consent from the beneficiary either via current signature/date or via verbal consent with a witness’s signature/date on a change request.