The enhanced services facility must develop the initial person-centered service plan prior to the resident's admission to the ESF, using information from the resident, the resident's representative if the resident has one, the comprehensive assessment reporting evaluation (CARE) assessment for medicaid clients, and the preadmission assessment. The ESF must ensure that each resident has an initial person-centered service plan that describes:

(1) The resident's immediate specific support needs (physical, mental, and behavioral) identified in the preassessment;

(2) Direction to staff and caregivers relating to the resident's immediate needs, capabilities, and preferences;

(3) The means by which the resident may choose not to accept care or services;

(4) The resident's informed consent to the person-centered service plan;

(5) What the facility will do to ensure the resident's health and safety related to the refusal of any care or service;

(6) Resident defined goals and preferences;

(7) How the facility will provide behavioral support to prevent a crisis and maintain placement in the facility while respecting the resident's rights;

(8) What the facility will do to ensure resident and community safety when the resident is in the community;

(9) Factors that prevent the resident from accessing less restrictive community based services; and

(10) When and how the resident may transfer or transition from the enhanced services facility to a more independent living situation in the community.