PDFWAC 388-107-0130
Ongoing comprehensive person-centered service plan.
(1) The enhanced services facility must ensure the person-centered service planning team reviews and updates each resident's comprehensive person-centered service plan as follows:
(a) Within a reasonable time consistent with the resident's needs following any significant change in the resident's physical, mental, emotional, or behavioral functioning;
(b) Upon request by the resident;
(c) Whenever the comprehensive person-centered service plan no longer adequately addresses the resident's current assessed needs and preferences;
(d) Following every full comprehensive assessment and medicaid client's full comprehensive assessment reporting evaluation (CARE) assessment; and
(e) At least once every one hundred eighty days.
(2) The enhanced services facility must ensure that when developing the resident's comprehensive person-centered services plan the person-centered service planning team will:
(a) Discuss the resident's assessed needs, capabilities, and preferences;
(b) Negotiate an agreed comprehensive person-centered service plan that supports the resident;
(c) Prevent the provision of unnecessary or inappropriate services and supports; and
(d) Document the agreed comprehensive person-centered service plan in the resident's record.