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1 Module 4 will cover the state and federal requirements related to person-centered planning. Person-Centered Planning 3/29/2021 Person-Centered Planning Training State and Federal Requirements Module 4 1

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Module 4 will cover the state and federal requirements related to person-centered planning.

Person-Centered Planning 3/29/2021

Person-Centered Planning Training

State and Federal Requirements

Module 4

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Code of Federal Regulation, Section 441.301

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Federal law has specific requirements for person-centered planning for consumers served by home and community-based waiver programs. These requirements can be found in the Code of Federal Regulation, Section 441.301. The next several slides describe these requirements which help support a person-centered process.

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Person-Centered Planning Process

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Consumer Drives the

Process

Include people

chosen by consumer

Ensure consumer directs the

process

The person-centered planning process is driven by the individual and includes people chosen by the individual. It provides necessary information and support to the individual to ensure that the individual directs the process to the maximum extent possible.

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Person-Centered Planning Process

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Offers choice in services/supports

Includes conflict resolution strategies

Written in plain language

Reflects cultural considerations

Times/Locations Convenient to

Consumer

• The person-centered process is timely and occurs at times or locations of convenience to the consumer.

• It reflects cultural considerations and uses plain language. • Person-Centered planning includes providing information in plain language

that is clear to people for whom English is not their primary language. • The plan includes strategies for solving a disagreement and offers choices to

the consumer regarding services and supports that the individual receives.

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Documents living setting

of consumer’s

choice

Method to request updates

Choice in services and

providers

Person-Centered Planning Process

During the person-centered planning process, the consumer must be offered a choice in services and who provides those services. The person-centered plan includes a method to request updates and documents community-based living settings considered by the individual.

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Support Plan

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The person-centered support plan is the written plan that guides the person-centered

planning process

Support PlanThe person-centered support plan is the written plan that guides the person-centered planning process. The support coordinator should complete the support plan with the individual and legal representative using the format provided by the APD. There are additional federal requirements related to the support plan document discussed on the next several slides.

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Support Plan

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Needs Assessment

(QSI)

Consumer’s Supports

and Services

The support plan must reflect the supports and services important to the consumer to meet needs that are identified through an assessment of their functional needs. The APD approved needs assessment is the Questionnaire for Situational Information (also known as the QSI).

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Support Plan

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What is important

to the consumer?

Delivery of supports

and services

The support plan must reflect what is important to the individual related to the delivery of their supports and services.

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Integrated in the community

Opportunities for employment

Control personal resources

Home and Community-Based Living Setting

The support plan must reflect the setting where the individual lives, and that the setting is his or her choice. Federal rules require that home and community-based living settings be integrated in the community and also supports full access to the greater community. For adults, living settings must allow for opportunities to seek employment and work in competitive integrated settings. When choosing a living setting in the community, all consumers must have the opportunity to engage in community life, control personal resources, and receive services in the community to the same degree of access as individuals not receiving waiver services.

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Support Plan Goals

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Unpaid Supports

Strengths and

Preferences

Goals

Paid Supports

Federal law requires that the support plan reflect the strengths and preferences of the individual. It must include individually identified goals and outcomes. With the goals identified, the support plan will reflect both paid and unpaid services and supports to help the consumer achieve their goals. The WSC must document services provider and natural (or unpaid) supports on the support plan.

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Risk factors Individualized backup plans

Important people

Plan monitoring

Plain language

A person-centered support plan must also identify risk factors and measures in place to minimize risk. It must include individualized backup plans and strategies when needed. The support plan must be understandable to the consumer as well as individuals responsible for supporting the consumer. Individuals responsible for monitoring the plan must be identified.

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Which of the following is a person-centered goal?

a. John Doe would like to move into his own apartment this year.

b. John Doe wants to be transported to his Adult Day Training.

c. John Doe would like to visit the community.

d. John Doe would like to have personal care for supervision.

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Which of the following is a person-centered goal?

a. John Doe would like to move into his own apartment this year.b. John Doe wants to be transported to his Adult Day Training.c. John Doe would like to visit the community.d. John Doe would like to have personal care for supervision.

The correct answer is a

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Which of the following is a person-centered goal?

a. Jane Doe’s mother would like to have respite to help at home.

b. Jane Doe would like to make new friends and have opportunities to spend time with them outside of school.

c. Jane Doe needs adult day training when she graduates this summer.

d. Jane Doe wants to manage her behavior better.

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Which of the following is a person-centered goal?

a. Jane Doe’s mother would like to have respite to help at home.b. Jane Doe would like to make new friends and have opportunities

to spend time with them outside of school.c. Jane Doe needs adult day training when she graduates this

summer.d. Jane Doe wants to manage her behavior better.

The correct answer is b.

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Support plan is signed by individuals and providers

Support plan is signed by individuals and providers

WSC provides copies of the support plan

WSC provides copies of the support plan

State and Federal Requirements

Informed Consent

In regards to Informed Consent and the Support Plan, the consumer and/or his or her legal representative must make informed consent to the support plan. This means that they have agreed in writing . The support plan is signed by all individuals and providers who are responsible for its implementation. The WSC must provide the support plan to the consumer, legal representative, and others involved in the plan.

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A WSC is planning for the annual support plan meeting for an consumer who lives in a licensed residential facility and has a legal guardian. The WSC would like to have the meeting on Wednesday morning, but the legal guardian is at work. What is the appropriate action for the WSC to take?

a. Proceed with the meeting as scheduled, but make sure that the group home operator who knows the consumer attends.

b. Ask the guardian if they can have the meeting by telephone instead.

c. Schedule the meeting at an alternate time chosen by the consumer when the legal representative can be present.

d. Write the support plan on Wednesday morning and mail a copy to the legal representative to sign.

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A WSC is planning for the annual support plan meeting for an consumer who lives in a licensed residential facility and has a legal guardian. The WSC would like to have the meeting on Wednesday morning, but the legal guardian is at work. What is the appropriate action for the WSC to take?a. Proceed with the meeting as scheduled, but make sure that the

group home operator who knows the consumer attends.b. Ask the guardian if they can have the meeting by telephone

instead. c. Schedule the meeting at an alternate time chosen by the

consumer when the legal representative can be present.d. Write the support plan on Wednesday morning and mail a copy to

the legal representative to sign.

The correct answer is c.

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The WSC is responsible for helping to prevent the provision of unnecessary or inappropriate services and supports.

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State and Federal Requirements

When engaging in person-centered planning, the WSC is responsible for helping to prevent the provision of unnecessary or inappropriate services and supports. The next several slides will discuss additional WSC responsibilities. For comprehensive WSC requirements, please refer to the iBudget Waiver Handbook.

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WSC is responsible for:• Completing the person-centered support

plan every year• Making updates to the plan if needs

change or at the request of the consumer.• Finalizing the plan and ensuring that it is

signed by the consumer and legal representative (informed consent)

• Providing copies to providers responsible for its implementation and to the consumer.

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State and Federal Requirements

The WSC is responsible for:• Completing the person-centered support plan every year• Making updates to the plan if needs change or at the request of

the consumer.• Finalizing the plan and ensuring that it is signed by the consumer

and legal representative (informed consent)• Providing copies to providers responsible for its implementation

and to the consumer.

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Determine that services meet expectations

•Ensure service documentation reflects the person-centered plan

•Ensure services are scheduled in accordance with consumer’s needs

•Ensure consumer exercises choice with providers and services

The WSC must determine if the services being provided meet the consumer’s expectations. This can be accomplished through conversations with the consumer and those who know and support them, through reviews of service providers’ documentation, and by monitoring the consumer’s involvement in and satisfaction with the services being provided. Things to consider include:• Ensuring that service documentation, such as implementation plans reflect activities

related to the consumer’s person-centered support plan• Ensuring that services are scheduled at times and locations that are convenient to

the consumer• Ensuring that the consumer is exercising choice with providers and their services.

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State and Federal Requirements

http://apd.myflorida.com/ibudget/rules-regs.htm

According to the iBudget handbook, providers must participate in and support the Person-Centered planning and implementation for each consumer receiving services

According to the iBudget handbook, providers must participate in and support the person-centered planning and implementation for each consumer receiving services. Providers will use the recommendations from the person-centered planning to:

• Implement person-centered supports and services• Support development of informed choices through education,

exposure, and experiences in activities of interest to the person served• Enhance service delivery in a manner that supports the achievement

of individually determined goals; and • Make improvements in your service delivery system

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Changes in service that require the WSC to adjust and make changes on the support plan must be discussed with the consumer and/or legal representative.

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Any change in services that requires the WSC to adjust and make changes on the support plan must be discussed with the consumer or legal representative. Contact the consumer or legal representative, explain the change, and discuss all the options.

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A provider is changing from solo to agency and contacts the WSC to adjust services to accommodate for the increased rate. What should the WSC do to ensure person-centered planning of services and supports?

a. Immediately adjust the cost plan to accommodate for the rate.

b. Contact other providers to make adjustments.

c. Contact the consumer or legal representative, explain the change, and discuss all options.

d. Call the owner of the provider Agency and ask for an extension.

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A provider is changing from solo to agency and contacts the WSC to adjust services to accommodate for the increased rate. What should the WSC do to ensure person-centered planning of services and supports?

a. Immediately adjust the cost plan to accommodate for the rate.b. Contact other providers to make adjustments.c. Contact the consumer or legal representative, explain the

change, and discuss all options.d. Call the owner of the provider agency and ask for an extension.

The correct answer is c.

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