New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 314 - LONG TERM CARE SERVICES - WAIVERS › Part 3 - MEDICALLY FRAGILE HOME AND COMMUNITY-BASED SERVICES WAIVER SERVICES › Section 8.314.3.15 - INDIVIDUALIZED SERVICE PLAN

Current through Register Vol. 35, No. 13, July 16, 2024
The CMS requires a person-centered individualized service
				  plan (ISP) for each individual receiving services through a HCBS waiver
				  program. The ISP is developed annually through an ongoing person-centered
				  planning process.
A. The case manager
				assists the recipient in identifying his/her dreams, goals, preferences and
				outcomes for service. The case manager obtains information about the
				recipient's strengths, capacities, needs, preferences, desired outcomes, health
				status, and risk factors. This information is gained through a review of the
				LOC assessment; interviews between the case manager and recipient; and the
				person-centered planning process that takes place between the case manager and
				recipient to develop the ISP.
B.
				The ISP addresses: activities of daily living assistance needs, health care
				needs, equipment needs, relationships in the home and community, personal
				safety and provider responsibilities.
C. During the pre-planning process, the case
				manager provides the recipient with information about the MFW program. The case
				manager provides information about the range and scope of service choices and
				options, as well as the rights, risks, and responsibilities associated with the
				MFW program. The case manager is responsible for completing the CIA and
				obtaining other medical assessments needed for the ISP; completing the annual
				LOC redetermination process; and referring the recipient to the New Mexico
				human services department (HSD) income support division (ISD) for financial
				eligibility determination annually and as needed.
D. The case manager works with the recipient
				to identify service providers to participate in the IDT meeting. State approved
				providers are selected from a list provided by the case manager. The recipient
				sets the date and time of the IDT meeting. The case manager works with the
				recipient to plan the IDT meeting and encourages him/her to lead the IDT
				meeting to the extent possible.
E.
				The case manager assists the recipient in ensuring that the ISP addresses the
				recipient's goals, health, safety and risks along with addressing the
				information or concerns identified through the assessment process. The case
				manager writes up the ISP as identified in the IDT meeting. Each provider
				develops care activities and strategies for each outcome, goal, and objective
				identified at the IDT meeting. The case manager assures the ISP budget is
				within the capped dollar amount (CDA). To ensure continuity of care, additional
				funding is available for an eligible recipient's ISP budget that exceeds the
				CDA due to the impact of provider rate increases. Requests for additional
				funding are submitted by the case manager to the TPA contractor for review.
				Implementation of the ISP begins when provider service plans have been received
				by the case manager and recipient, and the plan and budget have been approved
				by the TPA contractor.
F. The case
				manager ensures for each recipient that:
(1)
				the plan addresses the recipient's needs and personal goals in medical supports
				needed at home for health and wellness;
(2) services selected address the recipient's
				needs as identified during the assessment process; needs not addressed in the
				ISP are addressed through resources outside the MF waiver program;
(3) the outcomes of the assessment process
				for assuring health and safety are considered in the plan;
(4) services do not duplicate or supplant
				those available to the recipient through the medicaid state plan or other
				public programs;
(5) services are
				not duplicated in more than one service code;
(6) the parties responsible for implementing
				the plan are identified and listed within the document;
(7) the back-up plans are complete;
				and
(8) the ISP is submitted to and
				reviewed by the TPA contractor in compliance with the MF waiver service
				standards.