Section He-M 503.09 - Service Planning(a) Preliminary planning for services shall be done in accordance with He-M 503.05(l).(b) Within 15 days of an individual's eligibility or conditional eligibility pursuant to He-M 503.05(d) or level of care approval pursuant to He-M 503.05(o), for those for whom an application for home and community-based waiver services has been submitted pursuant to He-M 503.05(n), the area agency shall assist the individual, guardian, or representative with resources to select a service coordinator.(c) In instances when an individual has been determined eligible pursuant to He-M 503.05(d), and declines services available pursuant to He-M 503.05(l) and (m), the area agency shall assign a service coordinator within 30 days.(d) In instances when a service coordinator has been assigned pursuant to (c) above, the service coordinator shall, at minimum, contact the individual annually to discuss ongoing needs and determine if service planning is desired.(e) The service coordinator shall hold an initial person-centered service planning meeting to determine the individual's goals and service needs in meeting those goals with the individual, the individual's guardian or representative, and any other person chosen by the individual within 15 business days of the selection of and acceptance by, a service coordination agency.(f) The service coordinator shall document that they have maximized the extent to which an individual participates in and directs their person-centered service planning process by: (1) Explaining to the individual the person-centered service planning process and providing the information and support necessary to ensure that the individual directs the process to the maximum extent possible;(2) Explaining to the individual their rights and responsibilities pursuant to He-M 310;(3) Eliciting information from the individual regarding their goals, personal preferences, and service needs, including any health concerns, that shall be a focus of person-centered service planning meetings;(4) Determining with the individual issues to be discussed during all person-centered service planning meetings; and(5) Explaining to the individual the limits of the decision-making authority of the guardian, if applicable, and the individual's right to make all other decisions related to services.(g) The person-centered service planning process shall include a discussion regarding whether or not there is a need for a limited or full guardianship, conservatorship, representative payee for social security benefits, durable power of attorney, durable power of attorney for healthcare, supported-decision making, or other less restrictive alternatives to guardianship. The discussion and any recommendations from the team shall be incorporated into the service agreement.(h) Service coordinators shall facilitate service planning to develop service agreements in accordance with He-M 503.10. Service agreements shall be prepared initially according to the timeframe specified in He-M 503.10(c) and annually thereafter, as required by He-M 503.08(b)(10).(i) The individual, guardian, or representative may determine the following elements of the person-centered service planning process: (1) The number and length of meetings;(2) The location, date, and time of meetings;(3) The meeting participants; and(4) Topics to be discussed.(j) Copies of relevant evaluations and reports shall be sent to the individual and guardian at least 5 business days before person-centered service planning meetings.(k) If people who provide services to the individual are not selected by the individual to participate in a person-centered service planning meeting, and the individual determines that the provider would have information beneficial to service planning, the service coordinator shall contact such persons prior to the meeting so that their input can be considered.(l) The service coordinator shall contact all persons who have been identified to provide a service to the individual and confirm arrangements for providing such services.(m) All service planning shall occur through a person-centered service planning process that: (1) Maximizes the decision-making of the individual;(2) Is directed by the individual or the individual's guardian or representative, if applicable;(3) Facilitates personal choice by providing information and support to assist the individual to direct the process, including information describing: a. The array of services and provider agencies available; andb. Options regarding self-direction of services;(4) Includes participants freely chosen by the individual;(5) Reflects cultural considerations of the individual and is conducted in clearly understandable language and form;(6) Occurs at times and a location of convenience to the individual, guardian, or representative;(7) Includes strategies for solving conflict or disagreement within the process, including clear conflict of interest guidelines for all planning participants;(8) Is consistent with an individual's rights to privacy, dignity, respect, and freedom from coercion and restraint;(9) Includes the process for the individual, guardian, or representative to request amendments to the service agreement;(10) Records the alternative home- and community-based settings that were considered by the individual, guardian, or representative;(11) Includes information related to risk by: a. Incorporating information obtained through a comprehensive risk assessment, which shall be administered: 1. Initially, at the beginning of service planning, or as needed to each individual with a history of, or exhibiting signs of, behaviors that pose a potentially serious likelihood of danger to self or others, or a serious threat of substantial damage to real property, such as, but not limited to, the following: (i) Problematic sexual behavior;(iii) Fire-setting behaviors; or(iv) Other similar violent or dangerous behaviors or events;2. Prior to any significant change in the level of the individual's treatment or supervision;3. At any time an individual who previously has not had a comprehensive risk assessment begins to engage in behaviors referenced in 1. above; and4. By an evaluator with specialized experience, training, and expertise in the treatment of the types of behaviors referenced in 1. above;b. Ensuring that plans created pursuant to He-M 505 are reviewed with evaluators to consider ongoing appropriateness and opportunities for modification of restrictions following initiation of risk management related strategies. Such considerations may be made through reassessment or through a consultative review of other documentation and updated data related to the individual's progress;c. Ensuring documentation of activities and progress in treatment relative to management of risk for an individual to help inform development of person-centered service plans;d. Making referrals for individuals associated with high-risk incidents to participate in evaluations or planning activities initially and ongoing;e. Processing and analyzing incidents related to violent aggression, problematic sexual behavior, or fire-setting behaviors; andf. Making referrals for individuals associated with high-risk incidents to evaluations or planning activities initially and ongoing;(12) Includes information from specialty medical and health assessments and clinical assessments as needed, including, at a minimum, communication, assistive technology, and functional behavior assessments, as applicable;(13) Includes strategies to address co-occurring severe mental illness or behavioral challenges which are interfering with the person's functioning, including positive behavior plans or other strategies based on functional behavior or other evaluations or referrals to behavioral health services;(14) Provides the individual with information regarding the services and provider agencies available to enable the individual to make informed decisions as to whom they would like to provide services;(15) Includes individualized backup plans and strategies;(16) Includes strategies for solving disagreements;(17) Uses a strengths-based approach to identify the positive attributes of the individual;(18) Includes the provision of auxiliary aids and services when needed for effective communication, including low literacy materials and interpreters;(19) Addresses the individual's concerns about current or contemplated guardianship or other legal assignment of rights; (20) Explores housing and employment in integrated settings, and develops plans consistent with the individual's goals and preferences;(21) Includes a review of the past year that: a. Includes the individual's: 1. Personal achievements;3. Degree of community involvement;4. Challenging issues or behavior;5. Health status and any changes in health; and6. Safety considerations during the year;b. Addresses the previous year's goals with level of success and, if applicable, identifies any obstacles encountered;c. Identifies the individual's personal goals and the supports that will aid in achieving their goals;d. Identifies the type and amount of services the individual receives and the support services provided under each service category;e. Identifies the individual's health needs;f. Identifies the individual's safety needs;g. Identifies any follow-up action needed on concerns and the persons responsible for the follow-up; andh. Includes a statement of the individual's and guardian's satisfaction with services;(22) Includes the individual's paid employment and volunteer positions, as applicable;(23) Considers historical information about the individual's experiences; and(24) Includes a discussion of the need for assistive technology that could be utilized to support all services and activities identified in the proposed service agreement without regard to the individual's current use of assistive technology.(n) The information outlined in (m)(1)-(24) above shall be entered into the service agreement outlined in He-M 503.10 when the individual, guardian, or planning team determine that such information is necessary for successful participation in the services and supports outlined in the service agreement.(o) All planning for home and community-based waiver services shall include information from the following assessments: (1) The American Association on Intellectual and Developmental Disabilities', "SIS-A ®", (2023 edition), available as noted in Appendix A, for individuals aged 16 or older, which shall be administered:a. Initially, within 60 days of the determination of eligibility for waiver services pursuant to He-M 503.05(o) for each individual;b. For individual's receiving In Home Supports home and community-based waiver services within 60 days of when the individual reaches age 16;c. Upon a significant change as defined under SIS-A ® protocols;d. Five years following each prior administration; ande. To individuals who have moved to New Hampshire and are requesting home and community-based waiver services in the next 12 months. If the individual has previously had a SIS-A ® completed in another state within the last 5 years, however, then they may provide the out-of-state SIS-A ® results in place of taking a new SIS-A ®; and(2) Information obtained through the HRST (2015 edition), available as noted in Appendix A, which shall be administered: a. Initially, upon determination of eligibility for waiver services pursuant to He-M 503.05(o) or He-M 524 for each individual; andb. Annually or upon significant change in an individual's status; and(3) For residential services, includes information from personal safety assessments pursuant to He-M 1001.(p) In order to develop or revise a service agreement to the satisfaction of the individual, guardian, or representative, the person-centered service planning process shall consist of periodic and ongoing discussions regarding elements identified in He-M 503.07(b) that: (1) Include the individual and other persons involved in their life;(2) Are facilitated by a service coordinator; and(3) Are focused on the individual's abilities, health, interests, and achievements.(q) Service agreements shall be reviewed by the service coordinator with the individual, guardian, or representative at least once during the first 6 months of service and as needed. The annual review required by He-M 503.08(b)(10) shall include a service planning meeting.(r) Pursuant to RSA 171-A:11, the reviews required in (q) above shall include, at a minimum, the following: (1) A thorough clinical examination including an annual health assessment;(2) An assessment of the individual's capacity to make informed decisions; and(3) Consideration of less restrictive alternatives for service.(s) The individual, guardian, or representative may request, in writing, a delay in an initial or annual service agreement planning meeting. The area agency and provider agencies shall honor this request.(t) In the event an individual, guardian, or representative requests an extension of the service agreement meeting, the extension shall be documented and not exceed 60 days after the expiration of the current service agreement.(u) The service coordinator shall be responsible for monitoring services identified in the service agreement pursuant to He-M 503.10(1) and for assessing individual, family, or guardian satisfaction at least annually for non-waiver services and quarterly for waiver services.(v) If an individual has a residency agreement and there is notification of intended termination, the service coordinator shall convene a person-centered service planning meeting as follows:(1) Within 10 days of receipt of notification of the intended termination; or(2) Within 24 hours of receipt of the notification if the intended termination is within 72 hours due to the threat of serious bodily injury by or to the resident.(w) An area agency, service coordinator, provider agency, provider, individual, guardian, or representative shall have the authority to request a person-centered service planning meeting at any time.(x) Service agreement amendments may be proposed at any time.(y) If the individual, guardian, or provider agency disapproves of the service agreement, or a service agreement amendment, the dispute shall be resolved:(1) Through informal discussions between the individual, guardian, or representative and service coordinator;(2) By reconvening a person-centered service planning meeting; or(3) By the individual, guardian, or representative filing an appeal to the bureau pursuant to He-C 200.N.H. Admin. Code § He-M 503.09
#1969, eff 2-25-82; ss by #2615, eff 2-6-84; ss by #2962, eff 1-22-85; ss by #5211, eff 8-28-91; EXPIRED: 8-28-97
New. #6581, INTERIM, eff 9-19-97, EXPIRED: 1-17-98
New. #6932, eff 1-27-99; ss by #8805, eff 1-27-07
Amended byVolume XXXV Number 06, Filed February 12, 2015, Proposed by #10774, Effective 1/27/2015, Expires7/27/2015.Amended by Volume XXXV Number 32, Filed August 13, 2015, Proposed by #10900, Effective 7/25/2015, Expires7/25/2025.Amended by Number 2, Filed January 11, 2024, Proposed by #13841, Effective 12/29/2023, Expires 12/29/2033.