O. Development of the RSP
The SC works with the participant and anyone he/she selects to participate and other necessary parties in the development of the RSP. It is a time when the activities of the current service plan period are reviewed to assess the participant's current status and to determine whether goals have been met successfully. The continued need for participation in the waiver program to avoid nursing home placement is also determined by the SC.
At least eight (8) weeks prior to last day of current Service Plan period, the SC establishes a date, time and location for the Team Meeting with the participant. The SC completes and distributes a written notice to the participant, all required waiver service providers, and other necessary parties with Team Meeting information. Included in this notice is a reminder regarding the submission of timely Individual Service Reports (ISR) (refer to Appendix C - form C.16). A copy of this notice is maintained in the participant's record by the Service Coordinator.
It is essential that all proposed RSPs be submitted to the RRDS by the SC at least thirty (30) calendar days prior to the end of the current Service Plan period for review and final decision. This is necessary to prevent delays in service which would adversely affect the health and welfare of the participant.
To ensure this is done, the SC must:
- work with the participant to arrange for and facilitate a Team Meeting that must be held approximately six (6) weeks prior to the end of the current Service Plan period to develop the proposed RSP. Attendees include the participant, legal guardian and anyone invited by the participant, waiver service providers and other non-waiver providers involved in the Service Plan. The Team Meeting provides an opportunity to discuss issues that cut across services and discuss/resolve concerns regarding health and welfare; and
- receive all current required waiver service provider's ISR prior to or at the time of the Team Meeting. For the SC to appropriately develop the RSP, it is imperative that all current required waiver service provider ISRs are complete and submitted timely.
Information is gathered from ISRs submitted by each current required waiver service provider (refer to Section VII - Record Keeping). Each ISR contains the information:
- Identifying each of the participant's goal(s) for this service which have been addressed during the current Service Plan;
- Identifying the interventions used to address each goal as described in the Detailed Plan;
- Identifying any progress made for each goal;
- Identifying any barriers to progress for each goal;
- Identifying the participant's goal(s), expected interventions and outcomes for this service in the next Service Plan;
- Providing recommendations for amount, frequency and duration of this service in the next Service Plan; and
- Explaining why this service is necessary to assure health and welfare in the next Service Plan.
The SC also uses information from the current Service Plan, including Addenda submitted during the Service Plan period. For new services, the SC must collaborate with the provider(s) selected by the participant to assure appropriate documentation of information into the RSP, including the justification for the new service.
For plans that include non-waiver service providers, the review of the plan must include timely outreach to and coordination with all non-waiver providers identified in the Service Plan (e.g. review of plans including personal care, certified home health agency, or private duty nursing must be considered with those providers and the agencies responsible for approving/authorizing services).
The SC must discuss any proposed changes to the Service Plan with the participant and the individual(s) who participated in the development of the Revised Service Plan.
Once the RSP is completed, the SC must review it with the participant. The RSP must be signed by the participant or participant's legal guardian to indicate that the participant understands its contents and purpose as written.
The SC must have the SC supervisor review and sign the completed Service Plan prior to submission to the RRDS for review. This provides a level of professional review identifying any inconsistencies or problems in the Service Plan which could impede the approval process. If the SC supervisor is the SC for the participant whose RSP is being submitted to the RRDS for review, the SC supervisor is not required to obtain an additional supervisory signature. In this instance, the SC supervisor must sign the Signature page of the RSP as both SC and SC Supervisor.
As previously stated, the SC submits the completed and signed RSP and any required documentation to the RRDS for review at least thirty (30) calendar days prior to the end of the current Service Plan period.