K. Ongoing Review of the Service Plan
The SC should regularly review the Service Plan with the participant. This review is a natural component of the meetings between the participant and SC. For new participants to the waiver, the SC must meet with him/her face-to-face at a minimum once a month for the first six (6) months. The frequency of visits thereafter will be determined by the participant and SC and described in subsequent Service Plans. It is expected that at least one face-to-face visit per six (6) months is made in the participant's home.
These reviews should focus on all aspects of the participant's life, including:
- Satisfaction with the performance of providers and informal supports;
- Satisfaction with living situation;
- Adequacy of supports and services;
- Provision of the waiver services per the Approved Service Plan ensuring that at a minimum one waiver service is provided per month;
- Sufficient opportunities to participant in community activities;
- Achievement of goals related to waiver services;
- Changes in function and behavior; and
- Changes in priorities or goals.
Any issues identified must be addressed by the SC with the provider, other necessary parties and/or RRDS, as appropriate.
Other events that may trigger a Service Plan review include:
- The participant requests a change in services or service providers;
- There are significant changes (improvement or decline) in the participant's physical, cognitive, or behavioral status;
- A new provider is approved for the NHTD waiver and the participant is interested in either changing to that provider or adding a newly available service;
- The expected outcomes of the services are either realized or need to be altered; or
- Notification from a non-waiver provider of the need to change amount, frequency and/or duration of services.
In addition, review of the Service Plan is conducted through Team Meetings held with the participant and others involved in the Service Plan (refer to Submission of Revised Service Plans/Team Meeting below).
For plans that include one or more non-waiver services, the review of the plan must include timely outreach to and coordination with all involved parties (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).