TITLE 8 SOCIAL SERVICES
CHAPTER 371 DEVELOPMENTAL DISABILITIES
PART 5 SERVICE PLANS FOR INDIVIDUALS
WITH DEVELOPMENTAL DISABILITIES LIVING IN THE COMMUNITY
8.371.5.1 ISSUING AGENCY: New Mexico Health
Care Authority, Developmental Disabilities Supports Division.
[8.371.5.1 NMAC - N, 7/1/2024]
8.371.5.2 SCOPE:
A. For
each individual with developmental disabilities receiving services in the
community, either through state general funds or federal funding through the
developmental disabilities medicaid waiver, there shall exist a single, unified
individual service plan, or ISP. This ISP shall be developed by a single
interdisciplinary team, or IDT, consisting of the individual, the guardian,
parents, family, and representatives from all key community service provider
agencies servicing to the individual, regardless of their source of funding, as
well as advocates and others invited to participate by the individual.
B. These
regulations shall apply to all individuals with developmental disabilities
living in the community, regardless of whether their services are funded
through the developmental disabilities medicaid waiver or through state general
fund contracts with community providers.
The following groups are excluded
from these regulations, as their services and service delivery are addressed in
other regulations:
(1) children, aged birth to three, who are recipients of
services covered by the federal Individuals with Disabilities Education Act
(IDEA), Part C as administered under the New Mexico family, infant and toddler
program;
(2) early periodic screening, diagnosis and treatment (EPSDT)
case management recipients, unless allocated to the DD waiver;
(3) medically fragile waiver recipients;
(4) state general funded recipients of only ancillary services
(non-residential and non-day program services), such as respite and the various
therapies;
(5) community ICF/MR group home residents, covered by federal
ICF regulations, except Jackson class members.
[8.371.5.2 NMAC - N, 7/1/2024]
8.371.5.3 STATUTORY AUTHORITY: Subsection E Section
9-7-6 NMSA 1978. Section 9-8-1 et seq.
NMSA 1978 establishes the health care authority (authority) as a single,
unified department to administer laws and exercise functions relating to health
care facility licensure and health care purchasing and regulation.
[8.371.5.3 NMAC - N, 7/1/2024]
8.371.5.4 DURATION: Permanent.
[8.371.5.4 NMAC - N, 7/1/2024]
8.371.5.5 EFFECTIVE DATE: July 1, 2024,
unless a later date is cited at the end of a section.
[8.371.5.5 NMAC - N, 7/1/2024]
8.371.5.6 OBJECTIVE:
A. These
regulations contain a process for development of an individual service plan for
persons with a developmental disability. The requirements set out in these regulations
apply, with some exceptions, to providers of services to persons with
developmental disabilities living in the community.
B. These
regulations are promulgated, in part, to satisfy requirements arising from the
implementation of the decision in Jackson, et al. v. Fort Stanton, et al.,
N.M. Dist. Ct. No. Civ. No. 87-839.
These regulations incorporate certain agreements reached by the parties,
including the authority, to the Jackson lawsuit.
C. The
purpose of this regulation is to establish a framework for planning, designing,
implementing and modifying the individual service plan for an individual with
developmental disabilities living in the community.
[8.371.5.6 NMAC - N, 7/1/2024]
8.371.5.7 DEFINITIONS:
A. The Interdisciplinary Team (IDT):
(1) The “interdisciplinary
team (IDT)” is responsible for the development of the individual service
plan (ISP) and for identifying the agencies and individuals responsible for
providing the services and supports identified in the ISP.
(2) The IDT shall consist of the following core members:
(a) “individual”: the person with a developmental disability
for whom the ISP is written;
(b) “case
manager”: the independently-funded professional responsible for service
coordination to indviduals with developmental disabilities on the developmental
disabilities medicaid waiver; the case manager must be external to, and independent
from, the community service provider agency;
(c) “guardian”: the court appointed guardian of an adult
individual or the custodial parent(s) if the individual is a minor;
(d) “helper”: the individual may choose a helper to assist
with communication; in instances where the individual is unable to make this
choice, the guardian may choose a helper, if desired; the helper may be a
friend, housemate, family member, teacher, co-worker, current or former
employee of an agency or facility with which the individual has had contact,
foster grandparent, or any other person from the individual's circle of
relatives, friends and acquaintances;
(e) “key
community service provider staff”:
“key” community service providers are providers of residential
employment, day program and behavioral services specifically designed for
persons with developmental disabilities; “key” provider staff participating in
the IDT shall include, at a minimum:
(i) “direct
service staff”: the provider staff
member(s) directly responsible for the provision of specified services to the
individual with developmental disabilities;
(ii) “service
coordinator”: the community provider
staff member, sometimes called the program manager or the internal case
manager, who supervises, implements and monitors the service plan within the
community service provider agency;
(f) “ancillary
service providers”: the service
provider agencies and staff providing non-residential and non-day services,
either specifically designed for individuals with developmental disabilities or
generic in nature, regardless of funding source; examples of ancillary services
include nutritional services, physical therapy, occupational therapy, speech
therapy, respite, nursing, etc.; as well as services provided by the
individual's physician and other medical personnel;
(g) “designated
healthcare coordinator” the team member designated to coordinate medical
supports and services which the individual requires to manage any chronic
health conditions and to access preventative healthcare services;
(h) “others”: unless the individual objects, other
participants may include family members not already mentioned, if invited by
the individual or guardian; advocates or other chosen representatives who
participate in the ISP development process on the individual's behalf;
representatives of generic services, who may participate in the IDT with the
individual's or guardian's consent; representatives of the public school
system, if the individual is of school age and attends public school; and, any
others that the individual wishes to have attend the IDT meeting.
B. Content of individual service plans:
(1) “Demographic
information”: The individual's name,
age, date of birth, important identification numbers (i.e., medicaid, medicare,
social security numbers, level of care), address, phone number, guardian
information (if applicable), physician name and address, primary care giver or
service provider(s), date of the ISP meeting (either annual, or revision),
scheduled month of next annual ISP meeting, and team members in attendance.
(2) “Long-term vision”: A written statement of the individual's
personal vision for the future.
(3) “Outcomes”: Desired outcomes generated by the individual,
guardian and the team. An outcome is a
realistic change that can occur in the individual's life, that the individual
can achieve and that leads towards the attainment of the individual's long-term
vision. For example, an outcome may
state that the individual obtain preferred employment or that the individual
learn to drive.
(4) “Individual
preference”: The individual's
preferences, capabilities, strengths and needs in each life area determined to
be relevant to the identified ISP outcomes shall be reflected in the ISP. The long term vision, age, circumstances and
interests of the individual, shall determine the life area relevance, if any,
to the individual's ISP.
(5) “Action
plans”:
(a) specific action plans designed to
assist the individual in achieving each identified desired outcome listed in
the ISP, by the team, which include criteria for measuring progress, timelines
and responsible parties on each action step.
(b) service providers shall develop
specific tasks and strategies (methods and procedures) for implementing each
specified action step within timelines established by the IDT.
(6) “Assistive
technology”: Necessary support
mechanisms, devices, and environmental modifications including the rationale
for the use of assistive technology or adaptive equipment when a need has been
identified, shall be documented in the ISP. The rationale shall include the
environments and situations in which assistive technology is used. Selection of assistive technology shall
support the individual's independence and functional capabilities in as nonintrusive
a fashion as possible.
(7) “Availability of
supports and services”:
Identification of potential supports and services for individuals by the
IDT should be undertaken without regard to the cost of the supports and
services or whether they are actually available at that time in the community.
(8) “Signature form”: A signature form, containing the name, phone
number and role on the IDT of all team members shall be included in the ISP.
All individuals attending the annual IDT meeting shall sign the signature form
to indicate their participation in the planning process. For all team members
not in attendence the alternative method of their participation shall be stated
on the signature line. (e.g. telephone, written report, premeeting consultation
or designated representative).
(9) “Budget
page”: For individuals receiving services through
the developmental disabilities medicaid waiver a proposed budget page developed
by the case manager in consultation with the various service providers shall be
included in the ISP.
[8.371.5.7 NMAC - N, 7/1/2024]
8.371.5.8 INTRODUCTION:
A. For
all recipients of the developmental disabilities medicaid waiver services, this
interdisciplinary team shall be chaired by the individual, if they so desire,
or by the independent case manager. Services called for in the ISP shall be
coordinated by the independent case manager according to the procedures
described herein.
B. For
all state general fund recipients, this interdisciplinary team shall be chaired
by the individual, if he or she desires, or by the designated service
coordinator of a community service provider agency. Services called for in the ISP shall be
coordinated by the service coordinator staff of the key community service
provider agency according to the procedures described herein.
C. The
IDT shall review and discuss information and recommendations with the
individual, with the goal of supporting the individual in attaining desired
outcomes. The IDT develops an ISP based
upon the individual's personal vision statement, strengths, needs, interests
and preferences. The ISP is a dynamic
document, revised periodically, as needed, and amended to reflect progress
towards personal goals and achievements consistent with the individual's future
vision. This regulation is consistent
with standards established for individual plan development as set forth by
accreditation entities approved and adopted by the developmental disabilities
supports division and the health care authority. It is the policy of the developmental
disabilities support division (DDSD) that to the extent permitted by funding,
each individual receive supports and services that will assist and develop
independence and productivity in the community and take affirmative action to
prevent regression or loss of current capabilities. Services and supports include specialized and
generic services, training, education or treatment as determined by the IDT and
documented in the ISP.
D. The
intent is to provide choice and obtain opportunities for individuals to live,
work and play with full participation in their communities.
[8.371.5.8 NMAC - N, 7/1/2024]
8.371.5.9 GUIDING PRINCIPLES: The following
principles shall provide direction and purpose in planning with individuals
with developmental disabilities.
A. Principle
No. 1: The individual with developmental
disabilities has choices in, and ownership of, the planning process. If the
individual is unable to independently communicate, the team shall use observed
preferences and consultation with close friends, family members, guardians,
helpers, direct service staff and advocates to guide decisions.
B. Principle
No. 2: A person-centered planning
process shall be used to maintain the self-esteem of the person with
developmental disabilities.
C. Principle
No. 3: The individual's long-term vision
statement shall guide assessments, planning, plan implementation and service
evaluation. The plan shall describe
reasonable accommodations and supports to assist the individual in the
realization of the individual's vision.
D. Principle
No. 4: Planning shall focus on outcomes
or results which the individual wishes to achieve.
E. Principle
No. 5: The plan shall address individual strengths and capabilities in
developing action plans and strategies for reaching desired outcomes.
F. Principle
No. 6: Visions shall usually reflect results which can be reached within one
(1) year. Action plans will delineate
which activities will be completed within one year and those which will be
detailed in future plans or plan modifications.
G. Principle
No. 7: The team developing the action
plan shall recognize and understand that behavior is a form of communication.
H. Principle
No. 8: Natural supports and services normally utilized by the community at
large shall be preferred over specialized services in assisting individuals to
reach desired outcomes; when specialized services are necessary they shall take
place in natural settings whenever possible.
I. Principle
No. 9: The planning process shall be tailored to each individual's culture,
communication style, physical requirements, learning style and personal
preferences.
[8.371.5.9 NMAC - N, 7/1/2024]
8.371.5.10 AVAILABILITY OF SUPPORTS, SERVICES
AND FUNDS AND DDSD APPROVALS:
A. The
case manager assures that identification of potential supports and services for
the individual by the IDT is undertaken without regard to the cost of the
supports and services or whether they are actually available at that time in
the community. If needed supports and
services are not available this shall be reported to the DDSD regional office
by the case manager.
B. For
individuals who are not Jackson class
members, in specifying the supports and services in the ISP required to be
provided, the IDT, exercising professional judgment, may take into account the
availability of supports and services. If
supports or services are identified in the ISP, but not required to be provided
in the exercise of professional judgment taking into account the availability
of services, the IDT shall promptly submit a list of these unavailable supports
and services to the DDSD. The DDSD shall
use these lists to identify appropriate community resource needs and develop
strategies to add community supports and services for persons with
developmental disabilities, subject to appropriations for this purpose.
C. For
Jackson class members, the ISP shall
include the supports and services identified by the IDT.
D. The
ISP for individuals who are on the developmental disabilities medicaid waiver,
including Jackson class members, must
be reviewed and approved by the DDSD, as to the cost of the individual's ISP,
and aggregate costs of ISPs, and as to compliance with medicaid regulations and
DDSD standards. If the DDSD does not
approve the ISP because of cost or non-compliance with DDSD standards, the ISP
will be returned to the IDT with appropriate instructions to develop an ISP
that meets requirements and is within the DDSD's budget parameters. The ISP for these individuals will not be
implemented unless and until it is approved by the DDSD.
E. Because
cost limitations are established upfront in the contracting process for persons
funded solely by state general funds, the above ISP review and approval process
(per Subsection D of 8.371.5.10 NMAC above) is not required. The DDSD reserves the right to conduct
on-site reviews for compliance with applicable policy and regulation.
[8.371.5.10 NMAC - N, 7/1/2024]
8.371.5.11 THE
INTERDISCIPLINARY TEAM:
A. The interdisciplinary team (IDT) is
responsible for the development of the individual service plan (ISP) and for
identifying the agencies and individuals responsible for providing the services
and supports identified in the ISP.
B. The
IDT shall consist of the following core members:
(1) individual: the
individual shall be actively encouraged to participate in all IDT meetings and
the ISP development process; this participation shall include, but not be
limited to, expressing a personal vision statement for the future, indicating
desired outcomes that help to realize that vision, identifying action plans
that will achieve those outcomes, and personally chairing the IDT meeting, if
desired and when able to do so;
(2) case manager: the
duties of the case manager in relation to the individual with developmental
disabilities and the IDT shall include:
(a) coordinating the development,
modification and implementation of the ISP in consultation with the IDT and the
individual;
(b) monitoring the integration and
coordination of the individual’s services;
(c) serving as the IDT chairperson, or
assisting the individual in chairing the IDT meeting if he or she is capable of
doing so and wishes to do so;
(d) scheduling IDT meetings annually, or
more often as needed, to review or modify the ISP, and encouraging optimum
participation by all IDT members;
(e) monitoring supports and services
being delivered as specified in the ISP as determined by the IDT;
(f) reviewing progress on chosen
outcomes, and action plans and through consultation with the IDT, amending the
ISP, if needed;
(g) through timely consultation with the
IDT, modifying unsuccessful service programs and developing service programs
for previously unaddressed but significant individual needs that may arise
prior to the next scheduled ISP meeting;
(h) advocating on behalf of the
individual by making recommendations and requests on behalf of the individual;
(i) ensuring objective, quantifiable
data has been systematically recorded, analyzed and used to determine
effectiveness of service provided in order to justify needed changes in
services;
(j) coordinating and monitoring any
follow-up needed as a result of reviews;
(k) serving as liaison between the IDT
and the public school system, the special education division, or any other
community service teams relevant to the individual served; and
(l) assisting the community service
providers in community placement or other services as needed and as specified
by the IDT;
(3) the case manager ensures that the IDT identified services
and supports for the individual without regard to their current availability;
at the conclusion of the IDT meeting the case manager shall document
unavailable services on the appropriate page of the ISP form, which is provided
for this purpose, and submits this list to the DDSD, regional office;
(4) guardian: the
guardian shall convey to the IDT information about the individual, historical
or otherwise, which shall be useful in the development of the ISP;
(5) helper: the helper
is someone who knows the individual’s capabilities, interests, likes, and
dislikes and who can assist the individual in communicating these with the IDT;
in turn, the helper may assist the individual in understanding the ISP
development process and the individual service plan that is developed;
(6) “key” community service provider staff: “key” community service providers are
providers of residential, employment day program and behavioral services
specifically designed for persons with developmental disabilities; “key”
provider staff participating in the IDT shall include, at a minimum:
(a) direct service staff: the participation of direct service staff in
the development of the individual service plan is crucial, as they are the
persons who work directly with the individual within their respective domains;
at least one provider staff member from each of the “key” service areas
(residential, day/work-related and behavioral), who is directly involved in the
provision of services to the individual in those areas, must be in attendance
at all IDT meetings;
(b) service coordinator: the service coordinators of the community
provider agencies shall assure that appropriate staff develop strategies
specific to their responsibilities in the ISP; the service coordinators shall assure
the action plans and strategies are implemented consistent with the provisions
of the ISP, and shall report to the case manager on ISP implementation and the
individual’s progress on action plans within their agencies; for persons funded
solely by state general funds, the service coordinator shall assume all the
duties of the independent case manager described within these regulations; if
there are two or more “key” community service provider agencies with two or
more service coordinator staff, the IDT shall designate which service coordinator
shall assume the duties of the case manager; the criteria to guide the IDTs
selection are set forth as follows:
(i) the designated service coordinator
shall have the skills necessary to carry out the duties and responsibilities of
the case manager as defined in these regulations;
(ii) the designated service coordinator
shall have the time and interest to fulfill the functions of the case manager
as defined in these regulations;
(iii) the designated service coordinator
shall be familiar with and understand community service delivery and supports;
(iv) the designated service coordinator
shall know the individual or be willing to become familiar and develop a
relationship with the individual being served;
(7) ancillary service providers: ancillary service providers
shall participate in the IDT meeting and the ISP development process through
written assessments, evaluations or reports to the IDT, or in person; the case
manager, in consultation with the individual and the IDT, shall determine the
need for personal participation at IDT meetings on the part of any ancillary
service provider;
(8) designated healthcare coordinator: the team member
designated to coordinate medical supports and services which the individual
requires to manage any chronic health conditions and to access preventative healthcare
services;
(9) others: unless the individual objects, other participants
may include family members not already mentioned, if invited by the individual
or the ISP development process on the individual’s behalf; representatives of
general services, who may participate in the IDT with the individual’s or
guardians’ consent; representatives of the public school system, if the
individual is of school age and attends public school; and, any others that the
individual wishes to have attend the IDT meeting.
[8.371.5.11 NMAC - N, 7/1/2024]
8.371.5.12 DEVELOPMENT OF THE INDIVIDUAL
SERVICE PLAN (ISP) - PARTICIPATION IN AND SCHEDULING OF INTERDISCIPLINARY TEAM
MEETINGS:
A. Prior
to the initial IDT meeting the case manager shall provide the individual and
guardian, if any, with an orientation to the person-centered planning process,
purpose of the ISP and roles and responsibilities of IDT members. After completion of the ISP, the individual
and guardian shall be offered the opportunity to meet with the case manager and
ask questions regarding the completed ISP within 30 days of the meeting, if
desired.
B. The
IDT shall be convened at least annually and may be convened as frequently as
conditions or circumstances warrant to review and modify the ISP. If an ISP
includes programs or services which restrict an individual or a behavioral
program subject to the DDSD behavior support policy, the IDT shall review the
relevant program or service at least quarterly.
In situations where an individual is at risk of significant harm, the
team shall convene within one working day, in person or by teleconference. If necessary, the ISP shall be modified
accordingly within 72 hours.
C. The
IDT meeting shall be scheduled and conducted by the case manager who will
solicit and facilitate the full participation of all team members. The
individual shall be present unless he/she chooses not to attend. If any member is unable to attend IDT
meetings, arrangements for their involvement shall be made through
teleconference, designated representatives, or in the case of ancillary
services, written reports provided to the case manager prior to the meeting.
D. The
case manager shall provide written notice of the annual IDT meeting at least 21
days prior to the meeting. Notice shall
be provided to the individual, their representative, guardian, providers and
other invited participants. The case
manager shall consult IDT members prior to scheduling the meeting in order to
determine the best dates and times. The
case manager shall attempt to accommodate team member’s scheduling needs shall
be accomodated as long as the timing does not jeopardize continued eligibility
for the DD Waiver. A request for a change of meeting date made by the
individual and guardian. Written
documentation of notice and scheduling activities will be maintained by the
case manager in the individual’s records.
E. For
state general funded services, the initial IDT meeting shall be held within 60
days of the start of services, and then annually thereafter. For all other developmental disabilities
medicaid waiver recipients, the IDT meeting shall be held annually based upon
the previous or initial ISP approval date.
F. In
the event the individual or guardian requests that others be invited to attend
the IDT meeting, the case manager shall also provide them with notification of
the meeting.
G. The
case manager will convene the IDT on an “as needed” basis to modify (revise or
amend) the ISP once it has been developed.
Participants may attend through teleconference.
H. The
IDT shall be convened to discuss and modify the ISP, as needed, to address:
(1) a significant life change, including a change in medical
condition or medication that affects the individual’s behavior or emotional
state;
(2) situations where an individual is at risk of significant
harm. In this case the team shall
convene within one working day, in person or by teleconference; if necessary,
the ISP shall be modified accordingly within 72 hours;
(3) changes in any desired outcomes, (e.g. desired outcome is
not met, a change in vocational goals or the loss of a job);
(4) the loss or death of a significant person to the
individual;
(5) a serious accident, illness, injury or hospitalization
that disrupts implementation of the ISP;
(6) individual, guardian or provider requests for a program
change or relocation, or when a termination of a service is proposed; the
DDSD’s policy no. 150 requires the IDT to meet and develop a transition plan
whenever an individual is at risk of discharge by the provider agency or
anticipates a change of provider agency to identify strategies and resources
needed; if the individual or guardian is requesting a discharge or a change of
provider agency, or there is an impending change in housemates the team must
meet to develop a transition plan;
(7) situations where it has been determined the individual is
a victim of abuse, neglect or exploitation;
(8) criminal justice involvement on the part of the individual
(e.g., arrest, incarceration, release, probation, parole);
(9) any member of the IDT may also request that the team be
convened by contacting the case manager; the case manager shall convene the
team within 10 days of receipt of any reasonable request to convene the team,
either in person or through teleconference;
(10) for any other reason that is in the best interest of the
individual, or any other reason deemed appropriate, including development,
integration or provision of services that are inconsistent or in conflict with
the desired outcomes of the ISP and the long term vision of the individual;
(11) whenever the DDSD decides not to approve implementation of
an ISP because of cost or because the DDSD believes the ISP fails to satisfy
constitutional, regulatory or statutory requirements.
[8.371.5.12 NMAC - N, 7/1/2024]
8.371.5.13 DEVELOPMENT OF THE INDIVIDUAL
SERVICE PLAN (ISP) ASSESSMENTS:
A. Assessment
information, as described in Subsection C of 8.371.5.13 NMAC, shall be utilized
to develop and revise the ISP. The
individual, helper, family members and friends shall be provided an opportunity
to present their perceptions regarding the individual’s progress and current
status. The observations and perceptions
of people who know the individual well shall be considered when decisions
regarding the ISP are made.
B. All
IDT members shall review clinical and other assessments and evaluations
completed on behalf of the individual.
These assessments must be prepared with enough time for adequate review
prior to the annual IDT meeting. Service
providers preparing written assessment reports shall be responsible for
submitting these documents to the IDT members at least two weeks prior to the
scheduled annual IDT meeting. The case
manager shall review written assessment reports with the individual and
guardian prior to the IDT meeting.
C. Relevant
IDT members, including ancillary service providers, shall prepare reports at
least two weeks in advance of the IDT meeting, based on their assessments of
the individual’s progress and current status in the domain for which they are
responsible. Reports shall include, at a
minimum, a client individual assessment (CIA) and a long term care abstract
(LOC) completed by the case manager at least annually in consultation with the
IDT; adaptive behavior scales completed by relevant IDT members; assessments
from the various disciplines providing services to the individual (such as vocational
evaluations, physical therapy evaluations, history and physical, etc.);
objective data to corroborate evaluation information; reports by progress
residential and day program providers; information, historical or otherwise,
provided by guardians or family members; direct observations, especially during
transitional periods. IDT members shall
report other relevant information depending on the individual's service
needs. Assessments shall be performed in
settings normally utilized whenever possible.
D. When
the IDT determines further independent assessment is needed, the team shall
develop action plans within the ISP that addresses the need for such an
assessment, including responsibility and timelines. Implementation of any action plan related to
independent assessment shall be monitored by the case manager.
E. At
the IDT meeting, team members shall:
(1) elicit and develop the individual's long term vision
statement;
(2) review and discuss clinical and other assessments and
evaluation reports in relation to the individual’s abilities, interests,
preferences and desired outcomes;
(3) review objectives, quantifiable data information from the
previous ISP to determine the effectiveness of services and interventions and
use this information when determining new or revised outcomes, action plans and
strategies for the ISP under development;
(4) use the comprehensive compilation of client assessment
information and the long term vision statement to perform a functional
assessment; this functional assessment identifies the supports and services
needed in assisting the individual in the attainment of the long term vision;
for example, the functional assessment may evaluate the use of an interpreter
as a support or assistive communication devices, environmental modifications,
etc.; and
(5) the functional assessment shall reflect the experience,
choices, cultural background, skills, needs and abilities of the individual;
this functional assessment precedes the development of the action plan at the
IDT meeting; functional assessments shall reflect the individual’s current
skills and abilities in relation to the individual’s environment and community;
functional assessments shall include the interpretation of clinical assessments
and evaluations in assisting the individual in meeting the long term vision.
[8.371.5.13 NMAC - N, 7/1/2024]
8.371.5.14 DEVELOPMENT OF THE INDIVIDUAL
SERVICE PLAN (ISP) - CONTENT OF INDIVIDUAL SERVICE PLANS: Each ISP shall
contain.
A. Demographic
information: The individual’s name, age,
date of birth, important identification numbers (ie., medicaid, medicare,
social security numbers), level of care address, phone number, guardian
information (if applicable), physician name and address, primary care giver or
service provider(s), date of the ISP meeting (either annual, or revision),
scheduled month of next annual ISP meeting, and team members in attendance.
B. Long
term vision: The vision statement shall
be recorded in the individual’s actual words, whenever possible. For example, in a long term vision statement,
the individual may describe him or herself living and working independently in
the community.
C. Outcomes:
(1) The IDT has the explicit responsibility of identifying
reasonable services and supports needed to assist the individual in achieving
the desired outcome and long term vision.
The IDT determines the intensity, frequency, duration, location and
method of delivery of needed services and supports. All IDT members may generate suggestions and
assist the individual in communicating and developing outcomes. Outcome statements shall also be written in
the individual's own words, whenever possible.
Outcomes shall be prioritized in the ISP.
(2) Outcomes planning shall be implemented in one or more of
the four “life areas” (work or leisure activities, health or development of
relationships) and address as appropriate home environment, vocational,
educational, communication, self-care, leisure/social, community resource use,
safety, psychological/behavioral and medical/health outcomes. The IDT shall assure that the outcomes in the
ISP relate to the individual's long term vision statement. Outcomes are required
for any life area for which the individual receives services funded by the
developmental disabilities meadicaid waiver.
D. Individual
preference: The individual’s preferences, capabilities, strengths and needs in
each life area determined to be relevant to the identified ISP outcomes shall
be reflected in the ISP. The long term
vision, age, circumstances, and interests of the individual, shall determine
the life area relevance, if any to the individual's ISP.
E. Action
plans:
(1) Specific ISP action plans that will assist the individual
in achieving each identified, desired outcome shall be developed by the IDT and
stated in the ISP. The IDT establishes
the action plan of the ISP, as well as the criteria for measuring progress on
each action step.
(2) Service providers shall develop specific action plans and
strategies (methods and procedures) for implementing each ISP desired
outcome. Timelines for meeting each
action step are established by the IDT.
Responsible parties to oversee appropriate implementation of each action
step are determined by the IDT.
(3) The action plans, strategies, timelines and criteria for
measuring progress, shall be relevant to each desired outcome established by
the IDT. The individual’s definition of success shall be the primary criterion
used in developing objective, quantifiable indicators for measuring progress.
(4) Provider agencies shall use formats to complete strategies
relating to the ISP action plans during or after the IDT meeting. Separate provider agencies working to
coordinate specific strategies to achieve the same action plans shall develop
their strategies jointly. Service
provider agencies shall develop strategies that are clearly integrated and
associated with the individual's long term vision, outcomes, action plans and
therapy recommendations identified by the IDT. Therapists shall provide input
into the development of strategies either directly or through review and
revision prior to submission to the case manager. Provider agencies shall
submit strategies for inclusion into the ISP to the case manager within two
weeks following the ISP meeting. The
case manager shall review the strategies for consistency.
(5) Supports and services, including services available to the
general public, determined by the IDT and indicated in the ISP, shall be
relevant to the individual's long term vision, desired outcomes and action
plans. Supports and services shall be
the least restrictive, not unduly intrusive and not excessive in light of the
individual’s needs.
F. Assistive
technology: Necessary support mechanisms
devices, and environmental modifications including the rationale for the use of
assistive technology or adaptive equipment when a need has been identified,
shall be documented in the ISP. The
rationale shall include the environments and situations in which assistive
technology is used. Selection of
assistive technology shall support the individual's independence and functional
capabilities in as nonintrusive a fashion as possible.
G. Availability
of supports and services:
(1) Identification of potential supports and services for
individuals by the IDT should be undertaken without regard to the cost of the
supports and services or whether they are actually available at the time in the
community.
(2) For individuals who receive services through state general
fund or developmental disabilities medicaid waiver but who are NOT Jackson class members, the IDT,
exercising professional judgment, may take into account the availability of
supports and services in specifying in the ISP the supports and services
required to be provided. If supports or
services are identified in the ISP, but not required to be provided in the
exercise of professional judgment taking into account the availability of
services, the IDT shall promptly submit a list of these unavailable supports
and services to the DDSD.
(3) For Jackson
class members, the ISP shall include the supports and services identified by
the IDT.
(4) The DDSD shall use these lists to identify appropriate
community resource needs and develop strategies to add community supports and
services, generally, for persons with developmental disabilities, subject to
appropriations for this purpose.
H. Signature
form:
(1) A signature form, containing the name, phone number and
role on the IDT of all team members shall be included in the ISP. All individuals participating in the annual
IDT meeting shall sign the signature form to indicate their participation in
the planning process.
(2) Signing this form does not affect the individual’s or
guardian’s right, if any, to dispute all or part of the ISP or to initiate a
complaint or grievance procedure. The
case manager shall explain the right to dispute or to file a grievance to the
individual and guardian at the IDT meeting.
The case manager shall inform the individual and guardian of the DDSD,
office of quality assurance, its role and function in monitoring services in
the community, as well as the role and function of any other relevant monitoring
agencies, such as the licensing and certification bureau of the division of
health improvement and adult protective services program of the aging and long
term services department. The case
manager shall give the individual and guardian their business address and phone
number, as well as the 800 number of the DDSD’s office of quality assurance and
other relevant numbers.
I. Budget
page: For individuals receiving services
through the developmental disabilities medicaid waiver, a proposed budget page
developed by the case manager in consultation with the various service
providers shall be included in the ISP.
[8.371.5.14 NMAC - N, 7/1/2024]
8.371.5.15 DEVELOPMENT OF THE INDIVIDUAL
SERVICE PLAN (ISP) - APPROVAL OF THE ISP BY THE DEVELOPMENTAL DISABILITIES
SUPPORTS DIVISION:
A. The
ISP for recipients of the medicaid developmental disabilities waiver services
(including Jackson class members)
must be reviewed by the DDSD as to the cost of the individual's ISP and
aggregate costs of ISPs and as to compliance with DDSD standards and medicaid
regulations. If the DDSD does not
approve an ISP because of cost or non-compliance, the ISP will be returned to
the IDT with appropriate instructions to develop an ISP that meets requirements
and is within the DDSD’s budget parameters.
The ISP for developmentally disabled medicaid waiver recipients
(including Jackson class members) shall
not be implemented until approval by the DDSD.
B. Because
cost limitations are established upfront in the contracting process for persons
funded solely by state general funds, the above ISP review and approval process
(per Subsection A of 8.371.5.15 NMAC above) is not required. The DDSD reserves the right to conduct
on-site review for compliance with these regulations.
[8.371.5.15 NMAC - N, 7/1/2024]
8.371.5.16 DEVELOPMENT OF THE INDIVIDUAL
SERVICE PLAN (ISP) - IMPLEMENTATION OF THE ISP: The ISP shall
be implemented according to the timelines determined by the IDT and as
specified in the ISP for each stated desired outcome and action plan.
[8.371.5.16 NMAC - N, 7/1/2024]
8.371.5.17 DEVELOPMENT OF THE INDIVIDUAL
SERVICE PLAN (ISP) - DISSEMINATION OF THE ISP, DOCUMENTATION AND COMPLIANCE:
A. The
case manager shall provide copies of the completed ISP, with all relevant
service provider strategies attached, within 14 days of ISP approval to:
(1) the individual;
(2) the guardian (if applicable);
(3) all relevant staff of the service provider agencies in
which the ISP will be implemented, as well as other key support persons;
(4) all other IDT members in attendance at the meeting to
develop the ISP;
(5) the individual's attorney, if applicable;
(6) others the IDT identifies, if they are entitled to the
information, or those the individual or guardian identifies;
(7) for all developmental disabilities mediciad waiver
recipients, including Jackson class
members, a copy of the completed ISP containing all the information specified
in 8.371.5.14 NMAC, including
strategies, shall be submitted to the local regional office of the DDSD;
(8) for Jackson
class members only, a copy of the completed ISP, with all relevant service
provider strategies attached, shall be sent to the Jackson lawsuit office of the DDSD.
B. Current
copies of the ISP shall be available at all times in the individual's records
located at the case management agency.
The case manager shall assure that all revisions or amendments to the
ISP are distributed to all IDT members, not only those affected by the
revisions.
C. Objective
quantifiable data reporting progress or lack of progress towards stated
outcomes, and action plans shall be maintained in the individual’s records at
each provider agency implementing the ISP.
Provider agencies shall use this data to evaluate the effectiveness of
services provided. Provider agencies
shall submit to the case manager data reports and individual progress summaries
quarterly, or more frequently, as decided by the IDT. These reports shall be included in the
individual’s case management record, and used by the team to determine the
ongoing effectiveness of the supports and services being provided. Determination of effectiveness shall result in
timely modification of supports and services as needed.
D. The
ISP shall be consistent with all relevant health care authority and DDSD rules,
policies, procedures operational guidelines, including, but not limited to, the
HCA operational procedures; standards and applicable accreditation standards
approved by the authority and DDSD; the behavioral support policy, the Jackson management manual (appendices A
and B); the medicaid waiver operations manual; the program standards for DD
community agencies; the case manager standards and client rights
regulations. Confidentiality and
individual rights shall be protected at all times.
E. For
Jackson class members, the request to
initiate a dispute under appendix B of the Jackson
management manual shall automatically delay implementation of the disputed
portions of the ISP until the dispute is resolved unless the health or safety
of the individual would be adversely affected.
Any dispute raised under appendix B shall be decided under the hearing
officer guidelines for decisions contained in the appendix.
F. Nothing
in this regulation shall provide an entitlement to programs, supports, services
or benefits or create any legal rights that do not otherwise exist under other
law or regulation.
G. The
health care authority’s decision regarding the allocation of resources to any
ISP is final, (within the HCA) in the authority’s sole discretion, and is not
reviewable in the dispute resolution process or other agency administrative
review process.
H. Community
service provider agencies and case management agencies shall modify or amend
their internal policies and procedures regarding ISP development to reflect the
provisions stated within the ISP regulations.
All ISPs and all modifications to ISPs shall be developed in compliance
with these regulations.
[8.371.5.17 NMAC - N, 7/1/2024]
8.371.5.18 SANCTIONS. The authority
or other governmental agency having regulatory enforcement authority for
community based services provider agencies who have entered into contracts or
medicaid provider agreements with the health care authority, developmental
disabilities supports division, may sanction in accordance with applicable law
if the service provider fails to provide services as set forth by this rule. Such sanctions may include revocation or
suspension of license, directed plan of correction, intermediate sanctions or
civil monetary penalty up to $5000 per instance, or termination or non-renewal
of any contract with the authority or other governmental agency.
[8.371.5.18 NMAC - N, 7/1/2024]
HISTORY OF 8.371.5 NMAC: RESERVED