Section 141.230  Service Planning

a)         When an individual is determined eligible for CMH-HCBS, they shall be assigned to a designated Care Coordination and Support Organization (CCSO) to initiate service planning.  Participants shall have free choice of CCSO providers, including the ability to switch CCSO providers at any time.

b)         Child and Family Teams. CCSOs shall convene a CFT for each participant receiving CCS.  The CFT shall include the participant, the participant's primary caregiver and family members as appropriate, the CCSO, and should seek to include additional formal and informal supports involved in the participant and family's lives.

1)         The CFT shall meet on a regular basis, consistent with the Department's provider handbook for CCSOs available on the Department's website and pursuant to the requirements of CCS services outlined in Section 141.220(a). 

2)         Participants shall have full choice in determining the members of their CFT.

3)         The CFT, utilizing a consensus based process facilitated by the CCSO, shall support participants and families in achieving their identified goals through the ongoing identification of the participant and family's strengths and needs, the development of a strengths-based service plan, and regular review of the participant and family's progress towards meeting their goals.

c)         Strengths-Based Service Plans.  The CCSO shall work with participants, their family, and CFT members, as appropriate, to develop an individualized, strengths-based service plan that is based upon the participant's assessed needs and strengths and identified service preferences.

1)         The strengths-based service plan shall include:

A)        The presentation, diagnosis, and holistic strengths and needs of the participant;

B)        A crisis prevention and safety plan;

C)        Recommended services to address the needs of the participant and family; and

D)        A clinical summary in support of recommended services.

2)         The service plan shall be finalized and agreed to with the informed consent of the participant in writing, signed by all individuals and providers responsible for its implementation, and reviewed and authorized by an LPHA.

3)         Individuals receiving CCS services shall have their strengths-based service plans reviewed and updated, as necessary, consistent with the CFT meeting frequency outlined in Section 141.220(a).  Strengths-based service plans for participants receiving CMH-HCBS but not receiving CCS services shall be reviewed and updated no less frequently than every 180 days.