|(a) Compliance with federal law. A person-centered
service planning process is provided in accordance with 42 CFR §441.540.
(b) Person-centered service plan facilitators. A person-centered
service plan facilitator must complete HHSC-approved training on person-centered
service planning by June 1, 2017, or within two years of hire date.
Person-centered plan facilitators include:
(1) those that conduct the functional assessment for
CFC in the DBMD and CLASS waiver programs;
(2) LIDDAs in the HCS, TxHmL, and STAR+PLUS programs;
(3) MCOs in the STAR+PLUS and STAR Health programs;
(4) DSHS case workers.
(c) Development of the person-centered service plan.
The person-centered service plan is created simultaneously and in
conjunction with the functional needs assessment.
(1) The person-centered service planning meeting is
conducted face-to-face and occurs at a time and location convenient
to the individual receiving services.
(2) The person-centered service plan is developed by
the service planning team, which consists of the individual, the individual's
LAR, the person-centered service plan facilitator, and any other individuals
selected by the individual or the individual's LAR. The provider may
be a participant on the person-centered service planning team. Other
program rules may require certain other participants (for example,
the program director or a registered nurse designated by the program
provider in DBMD).
(3) As the individual's functional needs are assessed
simultaneously, the person-centered service plan facilitator works
with the individual to identify the individual's goals, needs, and
preferences with regard to his or her services.
(4) The person-centered service plan facilitator ensures
consideration of information from the individual or LAR to determine
any risks that might exist to the health and welfare of the individual
as a result of living in the community, and identifies and documents
in the person-centered service plan those services that are critical
to the health and welfare of the individual for which a backup plan
must be developed.
(5) The person-centered service plan incorporates cultural
considerations of the individual.
(6) The person-centered service plan includes documentation
on whether the individual has chosen to receive services through Consumer
Directed Services or the Service Responsibility Option.
(7) The person-centered service plan is finalized and
agreed to in writing by the individual and signed by all persons and
providers responsible for its implementation.
(8) The person-centered service plan and functional
needs assessment must be made available to the direct service providers
delivering CFC services.
(9) The person-centered service plan reflects that
the setting in which the individual lives meets the criteria outlined
in 42 CFR §441.530 and is chosen by the individual.
(10) The person-centered service plan is reviewed and
revised by the person-centered service planning team:
(A) at least annually;
(B) upon reassessment of functional need;
(C) when the individual's circumstances or needs change
(D) at the request of the individual or legally authorized
representative through contact with the individual's person-centered