Section 52.25. Service plan

(a) A service plan must be developed for each participant that contains the following:

(1) The participant need as identified on a standardized needs assessment provided by the Department.

(2) The participant goal.

(3) The participant outcome.

(4) Service, TPR or informal community support that meets the participant need, participant goal or participant outcome.

(5) The type, scope, amount, duration and frequency of services needed by the participant.

(6) The provider of each service.

(7) The participant’s signature.

(8) Risk mitigation strategies.

(9) The participant’s back-up plan.

(b) The participant’s back-up plan must contain an individualized back-up plan and an emergency back-up plan.

(c) Each participant need must be addressed by an informal community support, TPR or service unless the participant chooses for a need to not be addressed.

(d) If a participant refuses to have a need addressed, then the SCE shall document when the participant refused to have the need addressed and why the participant chose for the need to remain unaddressed.

(e) The following services require a physician’s prescription prior to being added to a participant’s service plan:

(1) Physical therapy.

(2) Occupational therapy.

(3) Speech and language therapy.

(4) Nursing services.

(5) Telecare health status and monitoring services.

(6) Durable medical equipment.

(f) An SCE or the Department’s designee shall use a person-centered approach to develop the participant’s service plan.

(g) An SCE or the Department’s designee shall use the Department’s person-centered assessment and risk assessment to develop the participant’s service plan.

(h) An SCE or the Department’s designee shall complete the participant’s service plan on a format prescribed by the Department and enter the service plan into the Department’s designated information system.

(i) The Department will approve the participant’s service plan prior to service provision.

(j) An SCE or the Department’s designee shall review the participant need, participant goal and participant outcome documented on the service plan at least annually with the participant.

(k) An SCE or the Department’s designee shall review and modify, if necessary, the participant need, participant goal and participant outcome each time a participant has a significant change in medical or social condition.

(l) If there has been a significant change in the medical or social condition of a participant, an SCE or the Department’s designee shall use the Department’s person-centered assessment and risk assessment to determine if changes are needed in the participant’s service plan.

Notation

Cross References

This section cited in 55 Pa. Code § 52.15 (relating to provider records).