104 CMR, § 29.09

Current through Register 1533, October 25, 2024

Section 29.09 - Annual Review of the Individual Service Plan

(1) No later than one year from the date of the last completed or substantially modified individual service plan, the case manager, the client, and the client's legally authorized representative shall complete a review of the client's individual service plan. The purpose of this review is to:

(a) ensure that treatment and services continue to be consistent with the client's strengths, preferences, service needs and goals as identified in the comprehensive assessment of needs, as it may have been revised;

(b) determine whether there has been progress toward attainment of goals and objectives stated in the client's individual service plan;

(c) ensure services continue to be, to the maximum extent possible, consistent with the client's strengths, preferences, service needs, and goals; and where appropriate, the strengths, preferences, service needs, and goals of the client's family, and with the goals of the individual service plan and are provided in the least restrictive setting;

(d) to reassess, if appropriate, the client's need for a guardian, or other fiduciary; and

(e) ensure the client's community service plans, if any, continue to be compatible with the individual service plan and to determine if service goals have been met.

(2) Within ten business days of the completion of the annual review, the case manager, together with the client, shall convene a meeting to prepare an updated individual service plan. In addition to the case manager and the client, persons invited to attend the meeting shall include:

(a) the client's legally authorized representative;

(b) current and potential service providers;

(c) other Department staff;

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

Preparation of the updated individual service plan shall include discussion of the factors outlined in 104 CMR 29.07(3)(b)2.

(3) 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.

(4) The written individual service plan shall be given to the client, or the client's legally authorized representative, for acceptance or rejection as provided in 104 CMR 29.08.

(5) If at the time of the annual review it appears that the client may no longer meet the criteria for DMH services, the client will be referred for redetermination in accordance with the provisions of 104 CMR 29.04. Action on any such redetermination shall be subject to 104 CMR 29.04 and 104 CMR 29.13 or 29.14, as applicable, and shall be subject to appeal pursuant to 104 CMR 29.16.