N.Y. Comp. Codes R. & Regs. tit. 14, § 636-1.3 – Person-centered service plan.

(a) The person-centered service plan is created using the planning process described in section 636-1.2 of this Subpart. The person-centered service plan may also be known as the individualized service plan (ISP, see definition in section 635-99.1 of this Title) or Life Plan.
(b) The individual’s care manager must develop a person-centered service plan with the individual. The plan must include and document the following:
1. (1) the individual’s goals and desired outcomes;
2. (2) the individual's strengths and preferences;
3. (3) the individual’s clinical and support needs as identified through an assessment of functional and health-related needs;
4. (4) the necessary and appropriate services and supports (paid and unpaid) that are based on the individual’s preferences and needs (as identified through an assessment of functional and health-related needs) and that will assist the individual to achieve his or her identified goals;
5. (5) the services that the individual elects to self-direct;
6. (6) the providers of those services and supports specified in paragraph (4) and (5) of this subdivision;
7. (7) if an individual resides in a certified residential setting, document that the residence was chosen by the individual, and document the alternative residential settings considered by the individual, including alternative residential settings that are available to individuals without disabilities (Note: the setting chosen by the individual is integrated in, and supports full access of individuals receiving services to the broader community, including opportunities to seek employment and work in competitive integrated settings, engage in community life, control personal resources, and receive services in the community with the same degree of access as the broader community. The individual may choose service and support options that are available to individuals without disabilities for his or her residence and other areas of his or her life);
8. (8) the risk factors and measures in place to minimize risk, including individual specific back-up plans and strategies when needed; and
9. (9) the individual and/or entity responsible for monitoring the plan.
(c) The care manager must develop the person-centered service plan in a way that is understandable to the individual and parties chosen by the individual. At a minimum, for the written plan to be understandable, it must be written in plain language and in a manner that is accessible to the individual, to the extent possible, and parties chosen by the individual.
(d) The plan must be finalized and agreed to with the individual’s written informed consent and signed by the provider(s) responsible for implementing the person-centered service plan.
(e) The care manager must distribute the person-centered service plan to the individual and parties involved in the implementation of the plan.
(f) The individual, parties chosen by the individual, the service provider, and care manager must review the person-centered service plan described in subdivision (b) of this section and section 636-1.4(a)(3) and (4) of this Subpart, and the care manager must revise such plan if necessary, as follows:
1. (1) at least semi-annually;
2. (2) when the capabilities, capacities, or preferences of the individual have changed and warrant a review;
3. (3) at the request of the individual and/or parties chosen by the individual;
4. (4) when it is determined that the existing plan (or portions of the plan) is/are ineffective; and
5. (5) upon reassessment of the individual’s functional need.