Title: Section 425.8 - Registrant person-centered care plan

425.8 Registrant person-centered care plan.

(a) The operator must ensure that: (a) A person-centered care plan based on the comprehensive assessment required by this Part, and, when applicable, a transfer or discharge plan, is developed for each registrant and is in place within five visits or within 30 days after registration, whichever is earlier. The adult day health care program and the referring managed care plan must be sure to coordinate with each other regarding the development of a registrant’s person-centered care plan.

(b) Each registrant's person-centered care plan process must be commensurate with the level of need of the registrant, and the scope of services and supports available and must:

(1) include registrant led input and include people chosen by the registrant;

(2) provide necessary information and support to ensure the registrant directs the process to the maximum extent possible and is enabled to make informed choices and decisions, with the registrant's representative having a participatory role, as needed and as defined by the registrant, unless State law confers decision-making authority to the legal representative;

(3) be timely and occur at times and locations of convenience to the registrant;

(4) reflect cultural considerations of the registrant 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;

(5) include strategies for solving conflict or disagreement within the process, including clear conflict of interest guidelines for all planning participants;

(6) offer choices to the registrant regarding the services and supports the registrant receives and from whom;

(7) include a method for the registrant to request updates to the care plan, as needed; and

(8) record the alternative home and community-based settings that were considered by the registrant.

(c) The person-centered care plan must reflect the services and supports that are important for the registrant to meet the clinical and support needs as identified through an assessment of functional need, as well as what is important to the registrant with regard to preferences for the delivery of such services and supports. The written plan must also:

(1) reflect the registrant's pertinent diagnoses, including mental status, types of equipment and services required, case management, frequency of planned visits, prognosis, rehabilitation potential, functional limitations, planned activities, nutritional requirements, medications and treatments, necessary measures to protect against injury, instructions for discharge or referral if applicable, orders for therapy services, including the specific procedures and modalities to be used and the amount, frequency and duration of such services, and any other appropriate item.

(2) reflect the registrant’s strengths and preferences, the medical and nursing goals and limitations anticipated for the registrant and, as appropriate, the nutritional, social, rehabilitative and leisure time goals and limitations;

(3) set forth the registrant's potential for remaining in the community; 

(4) include a description of all services to be provided to the registrant by the program, informal supports and other community resources pursuant to the person-centered care plan, and how such services will be coordinated.

(5) reflect that the setting in which the registrant receives services is chosen by the registrant;

(6) reflect risk factors and measures in place to minimize them, including individualized backup plans and strategies when needed;

(7) be understandable to the individual receiving services and supports, and the individuals important in supporting them.  At a minimum, for the written plan to be understandable, it must be written in plain language and in a manner that is accessible to individuals with disabilities or with limited proficiency in English;

(8) identify the individual and/or entity responsible for monitoring the plan;

(9) be finalized and agreed to, with the informed consent of the registrant (and/or persons identified by the registrant) in writing and signed by all individuals and providers responsible for its implementation;

(10) be distributed to the registrant and other people involved in the plan;

(11) include those services, the purchase or control of which the registrant elects to self-direct; and

(12) prevent the provision of unnecessary or inappropriate services.

(d) Development and modification of the person-centered care plan is coordinated with other health care providers outside the program who are involved in the registrant's care.

(e) The responsible persons, with the appropriate participation of consultants in the medical, social, paramedical and related fields involved in the registrant's care, must:

(1) record in the clinical record changes in the registrant's status which require alterations in the registrant person-centered care plan;

(2) modify the person-centered care plan to reflect registrant physical and social changes accordingly;

(3) review the person-centered care plan at least once every six months and whenever the registrant's condition warrants and document each such review in the clinical record; and

(4) promptly alert the registrant's authorized practitioner of any significant changes in the registrant's condition which indicate a need to revise the person-centered care plan.