Behavioral Health Standard 2.C – Person-Centered Plan


A written person-centered plan is:

  1. Developed with:
    1. The active participation of the person served
    2. The involvement of family/legal guardian of the person served, when applicable and permitted
  2. Prepared using the information from the assessment process
  3. Based upon the person’s:
    1. Strengths
    2. Needs
    3. Abilities
    4. Preferences
  4. Focused on the integration and inclusion of the person served into:
    1. His or her community
    2. The family, when appropriate
    3. Natural support systems
    4. Other needed services
  5. Communicated to the person served in a manner that is understandable
  6. Provided to the person served, when applicable
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The person-centered plan includes the following components:

  1. The identification of the needs/desires of the person served through:
    1. Goals that are expressed in the words of the person served
    2. When necessary, clinical goals that are understandable to the person served
    3. Goals that are reflective of the informed choice of the person served or parent/guardian
  2. Specific service or treatment objectives that are:
    1. Reflective of the expectations of:
      1. The person served
      2. The service/treatment team
    2. Reflective of the person’s:
      1.  Age
      2.  Development
      3. Culture and ethnicity
    3. Responsive to the person’s disabilities/disorders or concerns
    4. Understandable to the person served
    5. Measurable
    6. Achievable
    7. Time specific
    8. Appropriate to the service/treatment setting
  3. Identification of specific interventions, modalities, and/or services to be used
  4. Frequency of specific interventions, modalities, or services
  5. When applicable, information on, or conditions for:
    1. Any needs beyond the scope of the program
    2. Referrals for additional services
    3. Transition to other community services
    4. Community-based service options available to persons in long-term residential support programs
    5. Available aftercare options, when needed
  6. When applicable, identification of:
    1. Legal requirements
    2. Legally imposed fees
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The program implements written procedures identifying timeframes for reviewing and modifying person-centered plans to ensure that the plan for each person served:

  1. Reflects current issues
  2. Maintains relevance
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When assessment identifies a potential risk for suicide, violence, or other risky behaviors, a safety plan:

  1. Is completed:
    1. With the person served
    2. As soon as possible
  2. Includes:
    1. Triggers
    2. Current coping skills
    3. Warning signs
    4. Actions to be taken to:
      1. Respond to periods of increased emotional pain
      2.  Restrict access to lethal means
    5. Preferred interventions necessary for:
      1. Personal safety
      2. Public safety
  3. Advance directives, when available
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When the person served has concurrent disorders or disabilities and/or comorbidities:

  1. The person-centered plan specifically addresses these conditions in an integrated manner
  2. Services are provided by personnel, either within the organization or by referral, who are qualified to provide services for persons with concurrent disabilities and/or disorders
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Progress notes:

  1. Document:
    1. Progress toward achievement of identified:
      1. Objectives
      2. Goals
    2. Significant events or changes in the life of the person served
    3. The delivery and outcomes of specific interventions, modalities, and/or services that support the person-centered plan
    4. Changes in:
      1. Frequency of services
      2. Levels of care
  2. Are:
    1. Signed
    2. Dated
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