104 CMR, § 29.07

Current through Register 1533, October 25, 2024

Section 29.07 - Individual Service Plans

(1) Each client who receives Case Management shall have a written individual service plan based on a comprehensive assessment of service needs conducted in accordance with 104 CMR 29.07(2) and developed in accordance with 104 CMR 29.07; provided however, for individuals who receive critical need case management or transition case management, the content and time frame for conducting the assessment of service needs and development of an individual service plan may be modified consistent with the reasons for which critical need case management or transition case management was approved pursuant to 104 CMR 29.05(3).

(2)Comprehensive Assessment of Service Needs. The individual service plan shall be based on a comprehensive assessment of the client's strengths, preferences, service needs and goals.

(a) The case manager shall arrange for and complete a comprehensive assessment of the client's service needs within 20 business days of assignment, unless an extension is granted by the Area Director or designee.

(b) The comprehensive assessment of service needs shall include review of the documents submitted with the client's application and other records, as needed; a personal interview with the client that will include, but not be limited to, identification of the client's service preferences and recovery goals; an interview with the client's legally authorized representative; and interviews with other persons as agreed upon by the case manager and the client or the client's legally authorized representative, and shall be documented using a Department approved report form.

(c) The comprehensive assessment of service needs shall be updated at least once each year before the completion of the annual individual service plan review provided in 104 CMR 29.09.

(3)Development of Individual Service Plans.

(a)General Provisions.

1. The individual service plan shall identify the strengths, preferences, service needs and goals of the client and family, as appropriate; and the treatment, services and programs which address the identified strengths, service needs and goals, including DMH services and those available from other public and private entities. The plan shall be developed together with the client, and such others, including family members as authorized by the client or legally authorized representative, and in collaboration with other services providers as applicable.

2. Services included on an individual service plan shall be, to the maximum extent possible, consistent with the client's strengths, preferences, service needs and goals, and shall be provided in the least restrictive setting.

3. The individual service plan shall be developed with the fullest possible coordination with the client's other services and treatment, including educational services and special education services, where applicable.

4. The individual service plan shall include specified treatment, services, programs, service providers and goals. If specified services are not available, the individual service plan shall detail other available services which are, to the maximum extent possible, consistent with the client's identified strengths, preferences, service needs and goals, and provided in the least restrictive setting.

5. In developing the individual service plan, the case manager shall try to informally resolve any differences that may occur between service providers. If the case manager is unable to informally resolve any such differences, within five business days after identification of the dispute, the Area Director or designee shall be notified of the need for intervention.

(b)Preparation of the Individual Service Plan.

1. Within ten business days of the completion of the comprehensive assessment of service needs, the case manager, together with the client, shall convene a meeting to prepare the individual service plan. In addition to the case manager and the client, persons invited to attend the meeting shall include the client's legally authorized representative, and may include:

a. current and potential service providers;

b. other Department staff;

c. any other person, including family members, whose participation is requested or consented to by the client or the client's legally authorized representative.

2. Preparation of the individual service plan shall include a discussion of the following:

a. the client's goals;

b. the preferences of the client and the client's legally authorized representative regarding services;

c. the client's service needs in the context of the client's assessed strengths;

d. recommended services for the client;

e. currently available treatment and services, including those provided through commercial and publicly funded health plans and programs or available from other agencies or entities, and including, where appropriate, services available to support the client's family in assisting the client to meet the client's goals;

f. potential and present service providers;

g. dates, actual or anticipated, for commencement of each service;

h. the steps necessary to complete and implement the individual service plan, and to achieve the client's goals;

i. criteria for completion of services and plan for transition;

j. a description of the financial assistance and services from federal, state and local agencies available to the client, including any benefits to which the client may be entitled but is not currently receiving;

k. the client's need for a guardian or a financial fiduciary.

(c) A request for authorization for DMH services recommended in the individual service plan that have not been previously authorized shall be made to, and acted upon, by the Area Director or designee within five business days of the individual service plan meeting, after which time the individual service plan will be finalized and given to the client and the client's legally authorized representative for acceptance or rejection, in accordance with 104 CMR 29.08.