048-45 Wyo. Code R. § 45-10

Current through April 27, 2019

Section 45-10 - Individualized Plan of Care

(a) A participant's case manager shall convene a participant's plan of care team to develop an individualized plan of care for each participant on his or her caseload and base the plan on the results of the comprehensive assessment(s) and the person-centered planning process. The team shall include persons who are knowledgeable about the participant and are qualified to assist in developing an individualized plan of care for that person, including: the participant; any legally authorized representative(s); the case manager; providers chosen by the participant; and any other advocate, family member, or entity chosen by the participant or the participant's legally authorized representative(s).

(b) The plan of care meeting shall be timely and occur at times and locations that are convenient for the participant.

(c) The Case Manager shall provide notice of the plan of care meeting to all team members at least thirty (30) calendar days prior to the meeting.

(d) The individualized plan of care shall not exceed twelve (12) months and shall be developed in accordance with state and federal rules, which includes the submission of the complete individualized plan of care to the Division at least thirty (30) days prior to the plan start date. Corrections to the individualized plan of care required by the Division shall be submitted by the case manager within seven (7) business days of being issued.

(e) The individualized plan of care shall include the provision of or describe the inability to provide:

(i) Necessary information and support to the participant to ensure that the participant directs the process to the maximum extent possible;

(ii) Services in a setting chosen by the participant from all service options available, including non-disability specific settings and alternate settings that were considered;

(iii) Opportunities for the participant to seek employment and work in competitive integrated settings;

(iv) Opportunities for the participant to engage in community life, control personal resources, and receive services in the community to the same degree of access as individuals not receiving Medicaid home and community-based services;

(v) Cultural and religious considerations;

(vi) Services based on the choices made by the participant regarding supports the participant receives and from whom;

(vii) What is important to the participant and for the participant;

(viii) Services provided in a manner reflecting personal preferences and ensuring health and welfare;

(ix) Services based on the participant's strengths and preferences;

(x) Any rights or freedoms that are restricted, including why the restriction is imposed, how the restriction is imposed, and the plan to restore the right to the fullest extent possible;

(xi) Both clinical and support needs;

(xii) Participant's desired outcomes;

(xiii) Risk factors and plans to minimize them;

(xiv) Individualized backup plans and strategies when needed;

(xv) Individuals important in supporting the participant, such as friends, family, professionals, specific staff or providers;

(xvi) Learning objectives for habilitation services that address the training activities, training methods, and the measurement used to gauge learning;

(xvii) Relevant protocols that have been updated within the past year;

(xviii) Informed consent of the participant or legally authorized representative in writing; and

(xix) Signatures of all providers listed in the individualized plan of care after the draft plan, as written, is completed by the team including participant's signature for informed consent.

(f) The individualized plan of care shall be reviewed at least semi-annually, when the participant's circumstances or needs change significantly, or at the request of any team member. The plan shall be revised upon reassessment of functional need, as needs arise, and every twelve (12) months for a new plan year.

(g) The individualized plan of care shall be written in plain language that is understandable to the participant, legally authorized representative(s), and persons serving the participant.

048-45 Wyo. Code R. § 45-10

Amended, Eff. 6/21/2017.

Amended, Eff. 7/26/2018.