SECTION 354.1367. Person-Centered Service Plan

(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; and

(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 significantly; or

(D) at the request of the individual or legally authorized representative through contact with the individual's person-centered plan facilitator.

Source Note: The provisions of this §354.1367 adopted to be effective June 2, 2016, 41 TexReg 3905