Person Centered Planning Process for Adults with Intellectual Disabilities and Autism

1. Person Centered Planning Process for Adults with Intellectual Disabilities and Autism Introduction to the Instruction Manual and Review of Federal Regulations and State Statutes 10/13/2016

2. The Instruction Manual

3. Phases of Planning • This Section is: • A compact overview of how the PCP Process operates. • A great reference for Case Managers and Providers to keep on their desk and refer to often.

4. Before the Meeting This section is a more detailed account of Phases 1-3.

5. During the Meeting This section is a more detailed account of Phase 4.

6. After the Meeting / Necessary Assessments This section details what the Case Manager must do after the Plan Meeting Date and throughout the year.

7. Format How planning should occur is listed on the left side. How the planning should be documented is listed on the right side.

8. In Depth Information This section goes into more detail regarding certain aspects of the plan, such as Service and Supports Planning, Goal Writing, and Behavioral Regulations/ISTs.

9. Appendices This section goes into more detail regarding which information should be entered within EIS, and what information changes when there is an update. This is great for Case Managers and Providers to use for a reference.

10. Appendix Example

11. 42 CFR 441.725 –Person-centered service plan 42 CFR 441.725 A – Person-centered service plan PCP Instruction Manual Phase 1 – Process Coordination Part 1 • Person identifies whom they would like to attend their Planning Meeting, such as families, friends, and providers. Case Managers must notify the Person of the option to invite the Disability Rights Maine advocate. • The process: • (1) Includes people chosen by the individual. Title 34-B §5470-B 1. Every adult with an intellectual disability or autism who is eligible for services must be provided the opportunity to engage in a personal planning process in which the needs and desires of the person are articulated and identified.

12. PCP Instruction Manual 42 CFR 441.725 A – Person-centered service plan Phase 1 – Process Coordination Part 1 • The Person, with help from their Case Manager and Guardian (if applicable): • Review services currently being received and the providers of those services. Case Manager will ensure Person is aware of their choice to add, end or change any services or providers (including Case Management). • Discuss alternative settings and services the Person may utilize, including non-waiver services and unpaid supports. Phase 3 – Process Coordination Part 2 • The Person, with help from their Case Manager and Guardian (if applicable): • Develop a personal planning agenda that includes, but is not limited to, the meeting discussion guidelines from the OADS Personal Plan Narrative: • A review of the previous plan and long-term goals. • The service needs and Goals the identified for the year. • Any additional goals identified which are not already listed on Goal Descriptions in EIS, such as those that may be attained with family or friends. • The Case Manager will: • Ensure the Person is offered choices regarding the services and supports they will be receiving and from who they will be receiving them. • The process: • (2) Provides 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.

13. PCP Instruction Manual 42 CFR 441.725 A – Person-centered service plan Phase 1 – Process Coordination Part 1 • The Person, with help from their Case Manager and Guardian (if applicable): • Will arrange location, date and time of Planning Meeting date, then coordinate with providers. Timelines • The process: • (3) Is timely and occurs at times and locations of convenience to the individual.

14. 42 CFR 441.725 –Person-centered service plan 42 CFR 441.725 A – Person-centered service plan PCP Instruction Manual During the Meeting • Required Conversations • Communication • If there are communication barriers, the narrative summary must describe how they are being addressed. If the communication barriers are such that they limit the Person’s direct input into the planning process, the narrative must describe how team members have attempted to understand the Person’s needs and desires. The planning process must be understandable to the Person and in plain language. If the Person is deaf, non-verbal or speaks a language other than English the process must include qualified interpreters. • The process: • (4) Reflects cultural considerations of the individual and is 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.

15. 42 CFR 441.725 –Person-centered service plan 42 CFR 441.725 A – Person-centered service plan PCP Instruction Manual Phase 2: Services and Supports Planning • The Person, with help from Agency Service Planner and Guardian (if applicable), will: • Share with the Agency Service Planner what their goals are for the upcoming year for this service area, including broad or long term goals, and identify their needs and desires. • In EIS PCP Assessment, the Case Manager will: • Review EIS documentation for potential obstacles and conflicts, for shared ideas of service coordination, and broader or more long-term goals. Phase 3: Process Coordination Part 2 • The Person, with help from Case Manager and Guardian (if applicable), will: • Review Service and Goal Descriptions of all services to ensure they reflect the Person’s services, needs, and goals, identifying any broad and long-range goals. • The process: • (5) Includes strategies for solving conflict or disagreement within the process, including clear conflict of interest guidelines for all planning participants.

16. 42 CFR 441.725 A –Person-centered service plan PCP Instruction Manual Phase 1: Process Coordination Part 1 • The Person, with help from their Case Manager and Guardian (if applicable): • Review services currently being received and the providers of those services. Case Manager will ensure Person is aware of their choice on whether they want to add, end or change any services or providers (including Case Management). • Discuss alternative settings and services the Person may utilize, including non-waiver services and unpaid supports. Phase 3: Process Coordination Part 2 • The Person, with help from Case Manager and Guardian (if applicable), will: • Review Service and Goal Descriptions of all services to ensure they reflect the Person’s services, needs, and goals, identifying any broad and long-range goals. • The Case Manager will: • Ensure the Person is offered choices regarding the services and supports they will be receiving and from who they will be receiving them. • The process: • (6) Offers choices to the individual regarding the services and supports the individual receives and from whom. Title 34-B §5470-B 2. Planning Must: B. Focus on the choices made by that person D. Be developed at the direction of that person and include people whom the person chooses to participate.

17. 42 CFR 441.725 A –Person-centered service plan PCP Instruction Manual • The process: • (7) Includes a method for the individual to request updates to the plan, as needed. During the Meeting • Required Conversations • Person Satisfaction/Grievance Process • Each plan must include a description of how the Person and Planning Team will evaluate the Person’s ongoing satisfaction with: • The planning process • The plan that is developed, and • The progress being made in accomplishing the goals in the plan. After the Meeting • Reversioning a Person Centered Plan • Updating the Current Plan • Over the course of the planning year a Person may want to add or remove services, and/or other life events may occur that require the plan to be updated. The following are examples of when a PCP should be reversioned to update the current plan: • Adding a Service (Example: John would like to add Career Planning) • Ending a Service (Example: Jane no longer wants to attend Community Supports) • Changing a Service (Example: John would like to receive Work Supports from a different agency) • Major Life Changes that Affect Services (Example: Jane’s sister Joyce is now her Guardian) Title 34-B §5470-B 2. Planning Must: E. Be flexible enough to change as new opportunities arise 4. Review of personal plans A. The review must include the person, the person's guardian, if any, and the person's case manager. Invitations to participate may also be sent to others who may be anticipated to assist the person in pursuing articulated needs and desires unless the person or a private guardian objects. B. Events that could lead to the loss of the person’s home, job or program and events defined in a departmental rule or in the person’s plan must lead to a plan review.

18. 42 CFR 441.725 A –Person-centered service plan PCP Instruction Manual • The process: • (8) Records the alternative home and community-based settings that were considered by the individual. Phase 1: Process Coordination Part 1 • The Person, with help from their Case Manager and Guardian (if applicable): • Discuss alternative settings and services the Person may utilize, including non-waiver services and unpaid supports. • In EIS PCP Assessment, Case Manager will: • Complete Case Management MaineCare Service Description Form, including Service Planning Narrative. Alternative home and community based settings and unpaid services considered by the Person must be recorded in the narrative. Phase 3: Process Coordination Part 2 • In EIS PCP Assessment, Case Manager will: • Document alternative Home and Community Based settings considered by the Person in the Service Planning Narrative of the Case Manager’s MaineCare Service Description Form. Title 34-B §5470-B 5.During personal planning, the department shall develop and record information about a person’s needs, identify anticipated needs without regard to service availability, define necessary support services, recommend optimal courses of action and include plans for the active and continued exploration of suitable program or service alternatives based on the person's needs.

19. 42 CFR 441.725 B –Person-centered service plan PCP Instruction Manual Phase 1: Process Coordination Part 1 • The Person, with help from Agency Service Planner and Guardian (if applicable), will: • Review services currently being received and the providers of those services. Case Manager will ensure Person is aware of their choice on whether they want to add, end or change any services or providers (including Case Management). • Discuss alternative settings and services the Person may utilize, including non-waiver services and unpaid supports. Phase 3: Process Coordination Part 2 • The Person, with help from Case Manager and Guardian (if applicable), will: • Review Service and Goal Descriptions of all services to ensure they reflect the Person’s services, needs, and goals, identifying any broad and long-range goals. • The Case Manager will: • Ensure the Person is offered choices regarding the services and supports they will be receiving and from who they will be receiving them. • The written plan must:  • (1) Reflect that the setting in which the individual resides is chosen by the individual.

20. 42 CFR 441.725 B –Person-centered service plan PCP Instruction Manual Before the Meeting • Personal Profile • A personal profile presents the Person in positive and personal terms rather than clinically and objectively. A personal profile is not a clinical description. The profile is more concerned with a Person’s abilities and supports that enable him or her to succeed, than with his or her deficits or limitations. The profile looks at the Person in the context of their life and their relationships, as well the Person’s individual characteristics. The best profiles are created by or with the Person. • The written plan must:  • (2) Reflect the individual’s strengths and preferences.

21. 42 CFR 441.725 B –Person-centered service plan PCP Instruction Manual Necessary Assessments • DS Comprehensive/Support Waiver (BMS 99) • This assessment, commonly referred to as the “BMS 99”, is an independent assessment completed face to face by the Case Manager for the purpose of determining eligibility for the Section 21 and Section 29 waiver. The Comprehensive Waiver assessment determines eligibility for the Section 21 Waiver. The Support Waiver assessment determines eligibility for the Section 29 Waiver. • The initial BMS 99 is completed when applying for either Section 21 or Section29 services. If the Person is placed on a waitlist, the assessment must be updated once they are removed from the waitlist and approved for funding. The BMS 99 must be completed annually 30 to 60 days prior to the Reclassification Date. • DS Services and Supports (V7) • This assessment, commonly referred to as the “V7”, must be completed every 90 days or less by the Case Manager. The V7 contains dimensions that cover many areas of a Persons’ life, from medical information to legal needs. The V7 should include not only paid services, but unpaid services and non-waiver services the Person is utilizing. Information within the V7 should be accurate as the entire assessment is updated, at a minimum, every 90 days. This consistent update is known as the 90 Day Review and is documented in the last dimension of the V7. The 90 Day Review ensures any changes to the Person’s services and life situation are documented and known by the Case Manager. The first 90 Day Review occurs within 90 days of the Effective Plan Date, and every subsequent review mast take place within 90 Days of the last 90 Day review. • The written plan must:  • (3) Reflect clinical and support needs as identified through an assessment of functional need.

22. 42 CFR 441.725 B –Person-centered service plan PCP Instruction Manual Phase 1: Process Coordination Part 1 • The Person, with help from Agency Service Planner and Guardian (if applicable), will: • Discuss the Person’s Needs and Desires, including broad or long range goals. Phase 2: Services and Supports Planning • The Person, with help from Agency Service Planner and Guardian (if applicable), will: • Share with the Agency Service Planner what their goals are for the upcoming year for this service area, including broad or long term goals, and identify their needs and desires. • The Case Manager will: • Work with all Planning Team Members (including Families and Friends) involved to ensure that all of the Person’s goals and needed services are included in the PCP. Phase 3: Process Coordination Part 2 • The Person, with help from Case Manager and Guardian (if applicable), will: • Review Service and Goal Descriptions of all services to ensure they reflect the Person’s services, needs, and goals, identifying any broad and long-range goals. • The written plan must:  • (4) Include individually identified goals and desired outcomes. Title 34-B §5470-B 2. Planning must: C. Reflect and support the goals and aspirations of that person G. Include all of the needs and desires of that person without respect to whether those desires are reasonably achievable or the needs are presently capable of being addressed

23. 42 CFR 441.725 B –Person-centered service plan PCP Instruction Manual Phase 1: Process Coordination Part 1 • The Person, with help from Agency Service Planner and Guardian (if applicable), will: • Discuss alternative settings and services the Person may utilize, including non-waiver services and unpaid supports. Phase 2: Services and Supports Planning • The Case Manager will: • Work with all Planning Team Members (including Families and Friends) involved to ensure that all of the Person’s goals and needed services are included in the PCP. Phase 3: Process Coordination Part 2 • The Person, with help from Case Manager and Guardian (if applicable), will: • Develop a personal planning agenda that includes, but is not limited to, any additional goals identified which are not already listed on Goal Descriptions in EIS, such as those that may be attained with family or friends. • The written plan must:  • (5) Reflect the services and supports (paid and unpaid) that will assist the individual to achieve identified goals, and the providers of those services and supports, including natural supports. Natural supports are unpaid supports that are provided voluntarily to the individual in lieu of State plan HCBS.

24. 42 CFR 441.725 B –Person-centered service plan PCP Instruction Manual Introduction: Person-Centered Planning in Maine • Planning documents and other information should be provided in plain language and in a manner as accessible to the Person as possible. During the Meeting • Required Conversations • Communication • If there are communication barriers, the narrative summary must describe how they are being addressed. If the communication barriers are such that they limit the Person’s direct input into the planning process, the narrative must describe how team members have attempted to understand the Person’s needs and desires. The planning process must be understandable to the Person and in plain language. If the Person is deaf, non-verbal or speaks a language other than English the process must include qualified interpreters. Services and Supports Planning in More Detail • Goal Description Sheets • Goal Writing • PCP goals must be written in plain language so the Person and their supporters understand what they will be working toward The written plan must:  (7) Be understandable to the individual receiving services and supports, and the individuals important in supporting him or her. Title 34-B §5470-B 2. Planning Must: A. Be understandable to that person and in plain language and, if that person is deaf or nonverbal, uses sign language or speaks another language, the process must include qualified interpreters.

25. 42 CFR 441.725 B –Person-centered service plan PCP Instruction Manual Phase 4: Process Coordination Part 2 • At the Meeting, the Person, with help from Case Manager and Guardian (if applicable), will: • Identify those responsible for monitoring Medical/Dental care and for reporting critical information to Case Manager at least monthly. During the Meeting • Medical/Dental Monitor • The Planning Team must designate the person responsible for monitoring the quality of medical and dental services. • Critical Information Monitor • The Planning Team must identify the person responsible for updating critical information and informing the Case Manager of any changes. • The written plan must:  • (8) Identify the individual and/or entity responsible for monitoring the plan.

26. 42 CFR 441.725 B –Person-centered service plan PCP Instruction Manual After the Meeting • Approval by the Team & Disseminating the PCP • The PCP must be approved by the Person or the Guardian (if there is one) before the plan is considered complete. The approval signatures of the Person (and/or the Guardian), the Case Manager, and all others who have agreed to provide services as identified in the PCP are required. Timelines • Complete PCP means the Face Sheet, Personal Plan Narrative, Service Descriptions and Goal Descriptions are completed for each service and entered into EIS; and that all required signatures approving the plan have been obtained on the Face Sheet and Signature Sheet. • The written plan must:  • (9) 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. Title 34-B §5470-B 6. As part of its implementation, the personal plan must be agreed to by the person or the person's legal guardian.

27. Agreement Sheet This Agreement Sheet must be physically signed by all Team Members responsible for implementing the Person Centered Plan prior to the Plan being effective. Case Manager, Guardian, and Consumer signatures must sign the Face Sheet.When sending the Face Sheet to Resource Coordinators for Reclassification or for an Authorization Request an updated Agreement Sheet must be sent as well. If the plan is being reversioned only the affected Services/Providers need to sign. The Case Manager, Guardian, and Consumer must sign the face sheet when a plan is reversioned. Case Managers must maintain the original signatures; Resource Coordinators will accept copied signatures.

28. 42 CFR 441.725 B –Person-centered service plan PCP Instruction Manual After the Meeting • Approval by the Team & Disseminating the PCP • The Case Manager distributes the approved PCP, along with the Developmental Services Grievance and Reportable Event insert, to the Person and Guardian (as applicable), as well as to any Planning Team members who do not have access to EIS to view the plan. • The written plan must:  • (10) Be distributed to the individual and other people involved in the plan.

29. 42 CFR 441.725 B –Person-centered service plan PCP Instruction Manual During the Meeting • Required Conversations • Person Satisfaction/Grievance Process • Each plan must include a description of how the Person and Planning Team will evaluate the Person’s ongoing satisfaction with: • The planning process • The plan that is developed, and • The progress being made in accomplishing the goals in the plan. • Planning Team Monitoring Schedule • The Case Manager must conduct a review of the PCP every 90 days. This is documented in the Services and Supports Assessment (V7). The Planning Team may meet more or less often, but must meet at least annually for the PCP Process. • The written plan must:  • (12) Prevent the provision of unnecessary or inappropriate services and supports. Title 34-B §5470-B 2. Planning Must: H. Include a provision for ensuring the satisfaction of that person with the quality of the plan and the supports that the person receives.

30. 42 CFR 441.725 B –Person-centered service plan PCP Instruction Manual Services and Supports Planning in More Detail • In the EIS PCP Assessment • Behavior Management Plans should be identified and expanded upon in the Summary of Process Coordination. • The written plan must:  • (13) Document that any modification of the HCBS conditions, under § 441.710(a)(1)(vi)(A) through (D) of this chapter, must be supported by a specific assessed need and justified in the person-centered service plan. Regulations Governing Behavioral Support, Modification and Management for People with Intellectual Disabilities or Autism in Maine

31. PCP Instruction Manual 42 CFR 441.725 C –Person-centered service plan • The person-centered service plan must be reviewed, and revised upon reassessment of functional need as required in § 441.720, at least every 12 months, when the individual’s circumstances or needs change significantly, and at the request of the individual. Introduction: Person Centered Planning in Maine • Personal planning must be flexible to accommodate changes as new opportunities arise and as the person’s needs and desires change. It must be offered at least annually, though the process includes the ability for the Person to request updates to the plan as needed Reversioning a Person Centered Plan • Planning for a New Annual Plan • The PCP needs to be reversioned at least once a year to allow for a new plan to be completed. • Updating the Current Plan • Over the course of the planning year a Focus Person may want to add or remove services, and/or other life events may occur that require the plan to be updated. The following are examples of when a PCP should be reversioned to update the current plan: • Adding a Service (Example: John would like to add Career Planning) • Ending a Service (Example: Jane no longer wants to attend Community Supports) • Changing a Service (Example: John would like to receive Work Supports from a different agency) • Major Life Changes that Affect Services (Example: Jane’s sister Joyce is now her Guardian) Necessary Assessments • DS Comprehensive/Support Waiver (BMS 99) • This assessment, commonly referred to as the “BMS 99”, is an independent assessment completed face to face by the Case Manager for the purpose of determining eligibility for the Section 21 and Section 29 waiver. The BMS 99 must be completed annually 30 to 60 days prior to the Reclassification Date. Title 34-B §5470-B 2. Planning Must: F. Be offered to that person at least annually or on a schedule established through the planning process and be reviewed according to a specified schedule and by a person designated for monitoring

32. PCP Instruction Manual Title 34-B §5470-B Phase 4: Process Coordination Part 2 • At the Meeting, the Person, with help from Case Manager and Guardian (if applicable), will: • Document any Unmet Needs and associated Interim Plan(s) if there are any. Services and Supports Planning in More Detail • Unmet Needs and Interim Plans • Each unmet need must be described on the Case Management Goal Description, and an Interim Plan must be developed for providing supports and services that come as close as possible to meeting the need while the team pursues the required resources for meeting the actual identified need. The interim plan must identify the interim objective, persons responsible, and timeframes. Necessary Assessments • DS Comprehensive/Support Waiver (BMS 99) • This assessment, commonly referred to as the “V7”, must be completed every 90 days or less by the Case Manager. The V7 contains dimensions that cover many areas of a Persons’ life, from medical information to legal needs. The V7 should include not only paid services, but unpaid services and non-waiver services the Person is utilizing. Action plans and unmet needs: F. In cases where resources required to address identified needs or desires are not available, the action plan must identify interim measures based on available resources that address the needs or desires as nearly as possible and identify steps toward meeting the person’s actual identified needs. Unmet needs must be documented continually, collated annually and used for appropriate development activities on a regional and statewide basis.

33. Questions? PersonCenterPlanning.DHHS@maine.gov