Section 51.28. SCO requirements for Consolidated and P/FDS Waiver

(a) Payment for supports coordination services is limited to waiver supports coordination, provision of TSM supports coordination and base-funded supports coordination.

(b) An SCO provider shall ensure the following information is included in the ISP:

(1) The assessed need and outcome of the participant that each HCBS addresses.

(2) The type, amount, duration and frequency of each HCBS.

(3) Risk factors and risk mitigation strategies the ISP team determined will mitigate risk factors.

(4) Participant preferences.

(5) Medical history.

(6) Health information.

(7) Functional ability information.

(8) Communication abilities and needs.

(9) Financial information.

(10) HCBS and supports.

(c) An SCO shall ensure the SC completes the following when developing an initial ISP and annual review ISP:

(1) Collaboration with the participant, family, provider and other ISP team members to coordinate a date, time and location for the annual review ISP meeting at least 90 days prior to the end date of the ISP.

(2) Coordination of information gathering and assessment activity, which includes the results from the Statewide needs assessment for the annual review ISP meeting at least 90 days prior to the end date of the ISP.

(3) Distribution of invitations to ISP team members at least 30 days before the ISP meeting is held.

(4) Facilitation of the ISP meeting with team members invited at least 60 days prior to the end date of the ISP.

(5) Submission of the annual review ISP to the Department’s designee for approval and authorization at least 30 days prior to the end date of the ISP.

(6) Resubmission of the ISP for approval and authorization within 7 days of the date it was returned to the SCO for revision.

(7) Distribution of the ISP to the participant, family and ISP team members who do not have access to HCSIS within 14 days of its approval and authorization.

(8) Revision of the ISP when there is a change in an assessed need for a participant during an ISP year.

(d) An SCO shall review the Department’s residential habilitation service criteria in subsection (e) with the participant and ISP team during the initial ISP, annual review ISP, any other ISP team meeting when a residential habilitation service is being considered for a participant who is currently not authorized for a residential habilitation service and during the 6-month review of the residential habilitation service.

(e) The following residential habilitation service criteria shall be utilized to assist the ISP team in determining if a residential habilitation service is needed or continues to be recommended by the ISP team at the 6-month review:

(1) A person is not willing or able to provide the needed natural supports or paid supports for the participant in a private home.

(2) The participant health, safety and welfare would not be met with a nonresidential habilitation service or natural supports in a private home.

(3) Others would be at risk of harm if a residential habilitation service was not provided for the participant.

(4) Assessments indicate the participant’s needs can only be met through the provision of a residential habilitation service.

(5) The residential habilitation setting is the least restrictive and most appropriate size to ensure the participant’s health and welfare while continuing to meet the assessed need.

(f) If a residential habilitation service is determined to be needed by the ISP team during the initial ISP, annual review ISP or other ISP team meeting when a residential habilitation service is being considered for a participant who is currently not authorized for a residential habilitation service based on the residential habilitation criteria in subsection (e), the family living residential habilitation service shall be considered first by the ISP team.

(g) When the ISP team proposes a residential habilitation service other than family living residential habilitation services, the proposal must be in accordance with the ISP manual developed by the Department and found on the Department’s web site.

(h) For a participant authorized for a residential habilitation service, the SCO shall conduct a monitoring visit and review the residential habilitation service criteria in subsection (e) at least once every 6 months to determine if the participant continues to need the authorized residential habilitation HCBS.

(i) If the 6-month review during a monitoring visit identifies a change in need, an ISP meeting will be convened to discuss potential changes to the ISP.

(j) When an SCO receives a request for enhanced staffing to the residential habilitation service, the SCO shall ensure the SC documents the following in the ISP:

(1) The change in the participant need, including how this change affects the participant’s health and welfare.

(2) The assessments used to support the need for residential habilitation enhanced staffing.

(3) What the enhanced staffing support will specifically provide to address the participant’s needs.

(4) The plan to reduce the residential habilitation enhanced staffing based on specific outcomes of the participant.

(5) The time frames and the person responsible for monitoring the progression of the plan to reduce the residential habilitation enhanced staffing.

(6) The results of meetings held to re-evaluate the need for continuation of the residential habilitation enhanced staffing.

(7) Adjustments to the participant’s ISP.

(k) An SCO shall monitor risk factors and the implementation and impact of risk mitigation strategies during participant monitoring activities.

(l) An SCO shall ensure the SC documents the results of discussions regarding services that require a review more frequently than annually as determined in the approved applicable waiver, including approved waiver amendments.

(m) An SCO shall ensure the SC documents contacts and actions regarding a participant in a service note in HCSIS.

(n) An SCO shall ensure the SC completes the monitoring documents in HCSIS to document findings and concerns of monitoring, as well as resolution of those findings and concerns.

(o) An SCO shall ensure the SC includes in the ISP the participant and ISP team’s decision regarding how the participant chooses to use personal funds in the ISP.

(p) This section does not apply to an SCA provider in the Adult Autism Waiver.

The provisions of this § 51.28(d)—(h) effective July 1, 2012, 43 Pa.B. 588. Immediately preceding text appears at serial pages (361291) to (361294).

Notation

Cross References

This section cited in 55 Pa. Code § 51.14 (relating to residential habilitation service providers); and 55 Pa. Code § 51.16 (relating to progress notes).