4204 WRITTEN PERSON-CENTERED SERVICE PLAN REQUIRED (PCSP)

4204.1 Services under the EPD Waiver program shall be provided to eligible beneficiaries pursuant to a written Person-Centered Service Plan (PCSP) developed for each individual.4204.2 The PCSP shall be developed by the Case Manager in full consideration of the beneficiary's needs, preferences, strengths, and goals, which are key hallmarks of person-centered planning as defined in Section 4223. A PCSP shall be subject to the approval of DHCF or its designee.4204.3 Except in the circumstances outlined in Subsection 4204.7, a PCSP shall be required for the initiation and provision of any EPD Waiver service and shall be reviewed by the Case Manager at least quarterly to ensure that services are delivered to meet the established goals.4204.4 A PCSP shall be updated and revised at least annually, pursuant to the outcome of an assessment and a determination of needs or whenever a change in a beneficiary's health needs warrants updates to the plan.4204.5 A PCSP shall, at minimum, address and document the following:- (a) The beneficiary's strengths, risks, and preferences for plan development at the beginning of the written plan, including:

- (1) Consideration of the beneficiary's significant milestones and important people in the beneficiary's life; and

- (2) The beneficiary's preferences in order to tailor the plan to reflect any unique cultural or spiritual needs or be developed in a language or literacy level that the beneficiary and representative can understand;

- (b) The beneficiary's goals, including:

- (1) Consideration of the beneficiary's current employment, education, and community participation along with aspirations for changing employment, continuing education, and increasing level of community participation; and

- (2) How the goals tie to the amount, duration, and scope of services that will be provided;

1. (c) A list of other contributors selected by the beneficiary and invited to engage in planning and monitoring of the PCSP;
2. (d) An end of life plan, if one exists;
3. (e) Medicaid and non-Medicaid services and supports preferred by the beneficiary, including supports from family, friends, faith-based entities, recreation centers, or other community resources;
4. (f) The specific individuals, health care providers, or other entities currently providing services and supports;
5. (g) Potential risks faced by the beneficiary and a risk-mitigation plan to be addressed by the beneficiary and the beneficiary's interdisciplinary team;
6. (h) Approaches to be taken to prevent duplicative, unnecessary, or inappropriate services;
7. (i) Assurances regarding the health and safety of the beneficiary, and if restrictions on the beneficiary's physical environment are necessary, descriptions of the following:
8. (1) Explicit safety need(s) with explanation of related condition(s);
9. (2) Positive interventions used in the past to address the same or similar risk(s)/safety need(s) and assurances that the restriction will not cause harm to the beneficiary;
10. (3) Necessary revisions to the PCSP to address risk(s) or safety need(s), including the time needed to evaluate effectiveness of the restriction, results of routine data collection to measure effectiveness, and continuing need for the restriction; and
11. (4) Beneficiary's or representative's understanding and consent to proposed modification(s) of the restrictions; and
12. (j) Components of self-direction (if the beneficiary has chosen self-directed delivery under the Services My Way program, set forth in Chapter 101 of Title 29 DCMR).

4204.6 Upon completion of development of the PCSP, the Case Manager shall ensure the following:

(a) The PCSP receives final approval and signature from all those who

participated in its planning and development, including the Case Manager and the beneficiary or beneficiary's representative if applicable; and

(b) All contributors and others who were included in the PCSP development receive a copy of the completed plan or any specific component of the plan, as determined by the beneficiary.

4204.7 A beneficiary may temporarily access waiver services in the absence of a DHCF approved PCSP under the following circumstances:

(a) DHCF determines a delay in the receipt of services would put the beneficiary's health and safety at risk; or

(b) DHCF determines services are needed to effectuate a timely discharge from a hospital or nursing facility.

4204.8 If waiver services are provided in accordance with Subsection 4204.7, a PCSP shall be completed within thirty (30) days of the date that services were initiated.

SOURCE: Final Rulemaking published at 50 DCR 9025 (October 24, 2003); as amended by Final Rulemaking published at 64 DCR 6784 (July 21, 2017); as amended by Final Rulemaking published at 72 DCR 004996 (April 25, 2025).