YOUTH CONSULTATION SERVICE

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Site Specific Policy & Procedure Manual

DOCUMENT #: B-3Procedure Date: 6/1/10

Rev.: 11.15.10

TITLE: POLICY AND PROCEDURE FOR COMPLETING A SERVICE PLAN

  1. PURPOSE: To establish policies which assure that each consumer who is eligible for and

receive services from the Division of Developmental Disabilities (DDD) participate in the development and completion of an annual Division approved an IndividualService Plan. The Individual ServicePlan is a tool for the planning and implementation of generic and specialized services designed to achieve personal outcomes that are appropriate to the individual’s interests, strengths, needs and preferences.

  1. INTRODUCTION All individuals shall have an Individual Service Plan completed and/or

revised within 30 days of admission to services, reviewed and monitored monthly, and

revised, as necessary, annuallythereafter.

III. PROCEDURES

  1. Each Consumer shall have an Individual Service Plan (ISP) prior to admission, which has been completed by the DDD case manager (See #14 below). The Youth Consultation Service Site Administrator, responsible at admission as the Plan Coordinator for the ISP, shall review this consumer’s IHP prior to admission..

B. The ServicePlan is the written, Individualized ServicePlan, developed with the individual, and/or his or her legal guardian, and the Interdisciplinary Team (IDT). It is an outcome-based planning tool that, at a minimum, identifies each individualized program, support and/or service requested by and provided to the individual, for which the individual demonstrates a need. It identifies the person and/or agency responsible for its implementation. The complexity of the Habilitation Plan will vary according to the individual’s interests, preferences, and needs. The Individual Habilitation Planformat must be Division approved and mayinclude the following types of plans: Essential Lifestyle Plan (ELP), Self-Determination Plan and Individual Habilitation Plan (IHP).

C. SERVICE PLAN: REPORT STANDARDS:

  1. The Service Plan shall be based upon an assessment that identifies the individual’s interests, preferences and needs in the following areas, as determined appropriate by the individual, legal guardian and/or IDT: Note: Re listed in order of completion by DDD IHP Training Guide.
  2. Life Plan for the future, Residential (housing), Work/Program/School, Community and Recreation, Physical and Emotional Well-being, Clinical Information, Medication Administration, Guardianship Review, Financial Review, Supervision, Transportation, Additional Support Services, and any other areas important to the individual.
  3. Each YCS consumer shall have an IndividualServicePlan delineating the individual programs, supports and/or services identified by the person, his or her legal guardian and/or the Interdisciplinary Team to attain personal goals and to maximize his or her quality of life. All Plans shall address that which is important to the person as well as that which is important for the person and reflect his or her desired outcomes, goals and/or service objectives.
  4. In all cases, the QMRP must review and approvea Individual Service Plan developed and or revised by the IDT.
  5. The Plan Coordinator shall conduct a monthly review of the Individual Service Plan in order to, at a minimum; ensure the delivery of services and/or programs identified in the plan and the continuous progress toward stated goals. The individual or his/her legal guardian may request an IDT review of the Individual Service Plan at any time.
  6. Plans developed for consumers who are receiving educational services shall include goals related to transition to adult roles when educational entitlement ends.
  7. The Plan will identify the preferences of the individual receiving services for specific programs, supports, and/or services.
  8. The implementation of a Individual Service Plan that reflects the individual’s preferences may range from the provision of a single program, support or service to the development of a comprehensive plan, or result in a list of barriers that prohibit access to that preferred program, support or service and the means to address those barriers.
  9. When the individual’s preferences cannot be met, alternate services acceptable to theindividual shall be delineated in the Plan.
  10. If an individual is unable to verbally express his or her preferences, the IDT shall seek to understand the preferences of the individual through observation, alternate means of communication and by obtaining the input of the legal guardian, members of the individual’s family, and other interested persons, who have pertinent information regarding the individual’s interests, preferences and needs.
  11. Every program, support and/or service outlined in the Individual Service Plan shall operate in accordance with generally accepted professional standards in a setting that is least restrictive of personal liberty. When an individual's rights are restricted, each restriction and the justification for the restriction shall be documented in the Plan. The Plan shall also indicate when restrictions may be lessened or eliminated. The restriction shall be reviewed in accordance with Division Circular #5 “Human Rights.” The individual or legal guardian shall be advised of their right to appeal any restriction of rights.
  12. After receiving input from the individual served and/or the legal guardian and other members of the IDT, the YCS Plan Coordinator shall be responsible to update and or revise the Plan. Any disagreement between members of the IDT regarding the individual programs, supports and services contained in the Individual Service Plan shall be documented within the plan. Disagreements shall not delay the completion of the Service Plan.
  13. The Individual Service Plan is part of the Consumer record and is subject to confidentiality provisions defined in N.J.A.C. 10:41, Division Circular #30. Release of the Service Plan shall be made in accordance with Division Circulars #53, #53A and #53B, “Health Insurance Portability and Accountability Act (HIPAA).”
  14. The Individual Service Plan shall be reviewed and revised when appropriate, and at least every 365 days, in accordance with N.J.S.A. 30:10 through 12. Modifications to the Service Plan shall be completed when major changes occur at any point in the Service Plan cycle relative to the achievement or lack of achievement of goals, objectives, availability of services, programs, or supports, changes in the individual’s physical condition, cognitive functioning, needs, or preferences.
  15. The Plan Coordinator is responsible to schedule the consumers IHP and must consider the availability of the consumer, the Case Manager, the guardian family representative, and all other individuals who advocate for him/her.
  16. The Habilitation Plan shall specify that when a consumer is residing in a residentialplacement funded by DDD the consumer is required to contribute to the cost of his or her care and maintenance per the requirements of N.J.A.C. 10:46D “Contribution to Care and Maintenance”.
  17. The Individual Service Plan may be appealed in accordance with N.J.A.C. 10:48- Division Circular #37 “Appeal Procedure” or N.J.A.C. 10:49-9.14 “Provisions forappeals; fair hearings”, a Medicaid rule that would apply to waiver services.
  18. Except in emergency situations in accordance with N.J.A.C. 10:46B-3.3, aNIndividualService Plan shall be developed by the Division 30 days prior to admission to a residential placement or transfer between services.

D. Interdisciplinary Team (IDT)

The IDT is a group that shall minimally consist of the individual receiving services, the Plan Coordinator, the legal guardian, and/or the Division Case Manager. The IDT may include the parents or family member at the preference of the person served or guardian. In addition, members may include: advocates and friends, those persons who work most directly with the individual served, and professionals and representatives of service areas who are relevant to the identification of the individual's needs and preferences and the design and evaluation of programs to meet them.

E. MODIFICATIONS TO INDIVUDAL SERVICEPLANS

  1. Major proposed modifications to an IHP shall be recommended in writing to the Plan Coordinator.
  2. Except in an emergency, the proposed modification shall be discussed with the consumer and/or his or her legal guardian before the modification is implemented.
  3. Where the Plan Coordinator concludes that a proposed modification to the IHP results in a significant difference from the original intent of the IDT, he or she shall reconvene the IDT for discussion of the proposed modification.
  4. Where there is consensus, the modification to the IHP shall be documented and communicated to the appropriate team members by the Plan Coordinator for implementation.
  5. If, after receipt of the written IHP, there is a disagreement by any member of the IDT, the IDT shall reconvene within 30 days to discuss the content. The issue(s) under dispute shall not delay the implementation of agreed upon portions of the IHP.
  6. The DDD Case Manager shall review any modification to the IHP.
  7. The Plan Coordinator or designee is responsible to send written notification to all individuals invited to participate in the IndividualService Plan meeting indicating the date, time and location of the meeting, no less than 14 calendar days before the meeting.
  8. The Plan Coordinator shall attempt to honor requests to reschedule the Service Plan meeting, but in no case shall the Service Plan meeting be delayed beyond 30 days from the originally scheduled date, in accordance with the Medicaid DDD Waiver, except as under the following conditions:
  9. Upon initiation of Medicaid DD Community Care Waiver services;
  10. Upon transfer from developmental center to developmental center;
  11. Upon transfer from community based living arrangement;
  12. Upon transfer from a community based living arrangement to a developmental center;
  13. Upon transfer from LEA funded program to a community based living arrangement;
  14. Upon transfer from an out of state placement to a NJ residential placement, and
  15. For extraordinary circumstances.
  16. The designated DDD Case Manager shall monitor the IHP in accordance with the requirements of Division Circular #52, “Community Services System of Case Management.”
  17. Where progress is not achieved, the IDT shall reconvene to consider revisions to the plan.

F. IHP MEETINGS: MEETING STANDARDS

  1. The individual and/or his or her legal guardian may request an IDT review of the Service Plan at any time. The Site Administrator will coordinate the development and revisions of the individual’s Habilitation Plan.
  2. In order that all participants understand the Individual Service Plan process, the Habilitation Plan meeting shall be conducted with an emphasis on plain language.
  3. At the meeting, an individual receiving supports and services shall be encouraged to exercise the highest level of personal autonomy that is consistent with his or her capacity to understand the risks and consequences of his or her choices.
  4. The role of the IDT is to provide support, facilitate informed decision-making and complement, not supplement, the role of the individual and/or legal guardian.
  5. Whenever possible, decision-making shall be by consensus reached by the IDT regarding a specific course of action.
  6. At the annual Individual Service Plan meeting, the Plan Coordinator shall review the individual’s health and safety, rights and responsibilities, and the risks and benefits involved.
  7. The annual Individual Service Plan meeting shall address any recommendation of the need for a legal guardian to make decisions on behalf of an individual. Recommendations to consider include, but are not limited to:
  8. Current decisions being made by an individual;
  9. Goals to develop decision-making skills; and
  10. Where an individual has a legal guardian recommendations to change level ofguardianship from plenary to limited, limited to plenary or restore capacity.
  11. A review of the representative payee status shall be made at the Service Plan meeting. If the IDT has concerns about how the benefits are handled by a representative payee, the assigned payee may be reassigned.
  12. Where no funeral arrangements exist on record with the Division, and the individual served and/or his or her legal guardian is in agreement, information regarding the individual’s burial arrangements, including, but not limited to, prepaid burial arrangements, type of funeral service preferred and specific details regarding the funeral, shall be reviewed and documented. Where the burial plan has been established, changes shall be discussed. There can only be one established burial plan.
  13. The DDDCase Manager is responsible to ensure that copies of the IHPare sent to the following parties within 30 days of the IHP meeting:
  14. Consumer
  15. Legal guardian or family member
  16. Day Program
  17. Consumer Record
  18. Others (as indicated in the IHP)
  19. Subsequent to the development of the IHP, the Site Administrator is tomonitor the implementation of the IHP and to ensure that all servicesidentified as needed are being delivered. As part of the IHP, the Site Administrator is responsible to work with the individual and his or her legalguardian or family to develop the individual’s annual budget if he or she isresidentially placed.

IV. Definitions

*Case Manager means the Division or a contracted agency employee who coordinates the implementation of programs, supports and/or services to facilitate the achievement of the outcomes, goals and/or objectives identified in the Service Plan. A case manager provides assistance to the individual in gaining access to needed state plan services, medical, social, educational and other services, regardless of the funding source for the services. Activities of the case manager may include assessment, service/support planning, arranging for services, coordinating service providers, and/or monitoring and overseeing the provision of services.

V. ATTACHMENTS (OR DOCUMENTATION)

Attachment A- IHP TEMPLATE

Attachment B- Table of IHP Process Time Frames

VI. REGULATORY REFERENCES: CIRCULAR 52, CIRCULAR 35, 10:44A-4.3

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