.06 Covered Services.

A. Only core services shall be authorized for payment by DDA as covered coordination of community services.

B. The coordinator of community services shall provide the core services listed in this regulation to every participant assigned to the coordinator.

C. Comprehensive Assessment. Coordination of community services shall include a comprehensive assessment of the participant’s needs and supports to determine eligibility, in accordance with COMAR 10.22.12. The assessment shall be completed within 45 days after referral by the DDA and include:

(1) A review of relevant medical and other records with the applicant or legal representative’s written consent;

(2) A review of current providers of medical, social, or other support services, as appropriate;

(3) Unless otherwise authorized by the DDA, a face-to-face assessment of the participant, preferably at the participant’s residence, to review:

(a) Medical, developmental, and mental history, including current medications;

(b) Nutritional status;

(c) Emotional and behavioral status;

(d) Health care coverage;

(e) Living situation;

(f) Personal support systems;

(g) Participant goals and preferences;

(h) Environmental, social, and functional status;

(i) Educational history;

(j) Employment and income status;

(k) Health education;

(l) Social support;

(m) The most integrated setting appropriate to meet the participant’s needs; and

(n) Any additional service needs;

(4) Assistance with information-gathering such as obtaining professional evaluations and assessments necessary to document and recommend eligibility and priority for services; and

(5) A completed assessment form as required by the DDA.

D. Person-Centered Plan.

(1) The coordinator of community services shall facilitate the person-centered plan that is designed to meet the participant’s needs, preferences, goals, and outcomes in the most integrated setting and in the most cost effective manner.

(2) The person-centered plan shall:

(a) Be participant-centered, outcome-oriented, and person directed, as selected by participant;

(b) Comply with the requirements set forth in COMAR 10.22.05;

(c) Establish a plan for emergencies;

(d) Be completed within 30 business days after initial contact with the participant, and, if necessary, updated or modified within 30 business days after service initiation;

(e) Be developed and written in collaboration with the participant and his or her identified representatives as appropriate;

(f) Provide services in the most integrated setting;

(g) Identify services needed to accomplish intended outcomes and preferences;

(h) Address risks and needs identified in the comprehensive assessment; and

(i) Be updated or revised:

(i) As the conditions or circumstances of the participant change or as requested by the participant; and

(ii) Within 365 days of the initial person-centered plan or annually.

(3) Specific requirements for the person-centered plan developed for participants receiving transition coordination services are that the person-centered plan shall:

(a) Address challenges related to transitioning;

(b) Focus on transition from the institutional setting to the community;

(c) Identify services and supports that may be available;

(d) Be outcome-oriented; and

(e) Include the provision of services and supports.

E. Referral and Related Activities.

(1) At the time of the initial meeting and any follow-up contacts, coordinators of community services shall provide information, make referrals, and assist participants with applications for services provided by:

(a) Community organizations;

(b) State programs; and

(c) Federal programs.

(2) Referral and related activities may include:

(a) Assisting the participant with the completion of applications for services and programs;

(b) Providing the participant with contact or other information for services provided by self-advocacy groups, recreation organizations, or social groups;

(c) Assisting the participant with transitioning to new services, providers, or supports;

(d) Assisting the participant with referrals, as needed; and

(e) Providing education to participants and their families concerning:

(i) The range of most integrated setting service and support options that may be appropriate to meet the participant’s needs and preferences;

(ii) How to access services; and

(iii) How to coordinate and advocate for services.

F. Monitoring and Follow-Up.

(1) The coordinator of community services shall provide monitoring and follow-up activities, which shall include:

(a) Assessment of:

(i) Services being rendered as specified in the person-centered plan;

(ii) The participant’s current circumstances;

(iii) Progress toward goals and intended outcomes;

(iv) The participant’s referral status; and

(v) The participant’s needs and supports to maintain eligibility for Medicaid, Medicaid waiver programs, DDA services, and any other relevant benefits or services;

(b) Identification of new medical, health services, or other needs;

(c) Recommendation of new DDA priority category as the conditions or circumstances of the participant changes, or as requested by the DDA;

(d) Requests for service change and modifications of the person-centered plan as necessary to meet health and safety needs, preferences, and goals;

(e) Identification of new support or resource options;

(f) Review and, if necessary, revision of the plan for emergencies;

(g) Monitoring of any and all reportable incidents as defined in DDA’s reportable incident policy; and

(h) Application or re-application for necessary programs or services to prevent or remedy a gap in eligibility.

(2) Frequency of Monitoring and Follow-up Contact.

(a) For participants receiving waiting list coordination services, monitoring and follow-up contact activities shall meet the following requirements:

(i) For participants who meet the criteria for the crisis resolution priority category as set forth in COMAR 10.22.12.07, minimum monthly face-to-face contacts shall be made for the first 90 days, after which face-to-face contacts will be made quarterly;

(ii) For participants who meet the criteria for the crisis prevention priority category as set forth in COMAR 10.22.12.07, minimum quarterly face-to-face contacts shall be made; and

(iii) For participants who meet the criteria for the current request priority category as set forth in COMAR 10.22.12.07, minimum annual face-to-face contacts shall be made.

(b) Participants on the DDA waiting list shall be monitored in accordance with §F(2)(a) of this regulation unless:

(i) The participant’s priority category changes; or

(ii) Additional units are authorized by DDA.

(c) For participants receiving community coordination services, monitoring and follow-up activities shall be performed:

(i) On a minimum quarterly basis;

(ii) Face to face with the participant;

(iii) In different services delivery settings; and

(iv) At least one time in each service delivery setting.

(d) For participants receiving transition coordination services, monitoring and follow-up activities shall be performed face-to-face at least once a month for the first 90 calendar days, after which face-to-face contacts shall be made quarterly.

(3) Records of monitoring activities shall:

(a) Be completed in a format approved by the DDA;

(b) Include descriptions of the participant’s current circumstances, progress toward goals, intended outcomes, preferences, and referral status;

(c) Document new support and resource options for intake and referral;

(d) Be submitted using the electronic system provided by the Department; and

(e) Document all reportable events as set in the DDA’s policy on reportable incidents and investigations.