J. Implementation of the Approved Service Plan
In consultation with the SC, the RRDS must establish the effective date for services to begin and notify the SC. The SC must then contact the participant, waiver service providers, non-waiver providers, and other necessary parties as appropriate and arrange for services to begin.
Each approved waiver service provider must meet with the participant and anyone else selected by the participant to complete a Detailed Plan (refer to Section VII - Record Keeping).
The Detailed Plan includes:
- all assessment(s) conducted by the waiver service provider;
- participant's goals as it relates to the waiver service that is the subject of the Detailed Plan;
- milestones needed to meet the goals of the Detailed Plan;
- interventions needed by the waiver service provider to assist the participant in meeting his/her goals; and
- timeframes in obtaining the participant's individualized goals.
Waiver service providers must communicate with each other, informal supports and non-waiver providers at all times, especially when there is an overlap in the provision of services to the participant in achieving his/her milestone and/or goal. An example of this is the provider of Positive Behavioral Interventions and Supports (PBIS) communicating with other waiver service providers on methods of working with a participant with behavioral issues.
If at anytime a waiver participant or waiver service provider determines the need to change the amount, frequency or duration of services approved in the ISP, the SC must be notified. No changes may be made by the waiver service provider until receiving notification from the SC following approval of an Addendum or RSP by the RRDS, as appropriate.
Waiver service providers must recognize that Detailed Plans are ever-changing as the needs of the participant change. Therefore, re-assessments are a critical element of the Detailed Plan.