37.90.412 HOME AND COMMUNITY-BASED SERVICES FOR ADULTS WITH SEVERE AND DISABLING MENTAL ILLNESS: PERSON-CENTERED RECOVERY PLAN
(1) A Person-Centered Recovery Plan (PCRP) is a written plan that identifies the supports and services that are necessary for the member to remain out of institutional level of care, allow the member to function at the member's maximum capacity, and achieve personal goals towards recovery.
(2) All services must be specifically authorized in writing in the member's PCRP.
(3) Each PCRP must be developed, reviewed, and revised by the case management team. The case management team must:
(a) initiate the development of the PCRP upon the member's enrollment into the SDMI HCBS waiver program;
(b) have monthly telephone contact with the member;
(c) review the PCRP quarterly with the member in the member's residence, place of service, or other appropriate setting, and update the PCRP if there are any changes to the information listed in (5)(a) through (j); and
(d) complete an annual review of the PCRP with the member and update the PCRP if there are any changes to the information listed in (5)(a) through (j).
(4) The case management team must develop the PCRP in consultation with:
(a) the member or the member's legal representative;
(b) the member's treating and other appropriate health care professionals; and
(c) others who have knowledge of the member's needs.
(5) The PCRP must include:
(a) the primary SDMI diagnosis and any other diagnosis of the member that are relevant to the services provided;
(b) the member's symptoms, complaints, and complications indicating the need for services;
(c) the member's strengths, areas of concern, goals, objectives, and required interventions;
(d) the SMDI HCSB waiver program services that will be provided;
(e) all other services the member requires including Montana Medicaid state plan services and community-based services and supports; however, including non-program services in the PCRP does not obligate the department to pay for the non-program services or ensure their delivery or quality;
(f) a description of how each service addresses each of the member's functional needs outlined in the Severe and Disabling Mental Illness, Home and Community Based Services, Evaluation and Level of Impairment form;
(g) a crisis plan;
(h) physicians' orders;
(i) a discharge plan;
(j) the projected annual cost of SDMI Home and Community-Based Services (HCBS) waiver program services provided;
(k) the signature of the member or the member's legal representative which signifies the participation in and agreement of the PCRP; and
(l) the names and signatures of all individuals who participated in the development of the PCRP which signifies the participation in and agreement of the PCRP.
(6) The case management team must provide a copy of the plan to the recipient.
(7) The case management team must retain all of the member's records in accordance with ARM 37.85.414.