Rule 5160-44-02 | Nursing facility-based level of care home and community-based services programs: person-centered planning

What this rule requires your agency to do

• 1The plan shall be written in plain accessible language, identify who monitors it, be finalized with the individual's written informed consent and signed by all responsible parties, be distributed to the individual, and be reviewed/revised at reassessment, at least every twelve months, at significant change, or on request.(Rule 5160-44-02 | Nursing facility-based level of care home and community-based services programs: person-centered planning)
• 2Documentation of assessments and care coordination activities shall be written objectively, completed within three business days of the activity, and accessible to ODM in the system designated by ODM.(Rule 5160-44-02 | Nursing facility-based level of care home and community-based services programs: person-centered planning)
• 3Documentation for each assessment and care coordination activity shall include the individual's name, participants and relationships, date, location, type, and a detailed description including reason, actions, outcome, and next steps.(Rule 5160-44-02 | Nursing facility-based level of care home and community-based services programs: person-centered planning)
• 4Any modification of provider-owned/controlled residential setting conditions must be supported by a specific assessed need, document less-intrusive methods attempted, include data review and time limits, and include the individual's informed consent.(Rule 5160-44-02 | Nursing facility-based level of care home and community-based services programs: person-centered planning)
• 5Providers of HCBS for the individual (or those with an interest in a provider) shall not provide case management, provider oversight, or develop the person-centered services plan.(Rule 5160-44-02 | Nursing facility-based level of care home and community-based services programs: person-centered planning)
• 6The person-centered services plan shall identify the individual's chosen setting, strengths, preferences, clinical/support needs, goals, paid and unpaid services and providers, risk factors, and back-up plans.(Rule 5160-44-02 | Nursing facility-based level of care home and community-based services programs: person-centered planning)
• 7The person-centered planning process shall be led by the individual, include a team chosen by the individual, be timely and convenient, reflect cultural considerations in plain accessible language, and include conflict-of-interest guidelines.(Rule 5160-44-02 | Nursing facility-based level of care home and community-based services programs: person-centered planning)