Person Centered Planning Policy and Guidelines for DD Waiver Services

Updated September 2022

Table of Contents

  1. I. Federal Home and Community Based Services Regulations
  2. II. Discovery
  3. III. Personal Plan
  4. IV. Implementation Strategies
  5. V. Appendices

I.  Federal Home and Community Based Services Regulations

The Centers for Medicare and Medicaid Services (CMS) published Home and Community Based Services (HCBS) Regulations on January 16, 2014. These Regulations became effective on March 17, 2014 and impact all 1915c HCBS Waivers.  In Illinois, this is relevant to all three Developmental Disability (DD) HCBS Medicaid Waivers: Children's In Home Support Waiver, Children's Residential Waiver, and the Adult Waiver. The Regulations include Conflict of Interest Free Case Management and Person Centered Planning. These regulations, as outlined below, apply to people who are in any of the Medicaid Waivers programs listed above.

A.  Conflict of Interest Free Case Management

Conflict of Interest Free Case Management is a CMS HCBS Regulation that specifies States are required to separate case management functions (including the person centered plan development) from service delivery functions. Case management includes: determination of eligibility, provider identification, service plan development, and monitoring of Plan. "Conflict free" means that Case Management must be performed by someone other than a relative of the person served, someone other than a direct provider of service, someone who does not have a financial interest in a provider, or someone who is not employed by a provider.

In Illinois, the Independent Service Coordination (ISC) agencies are identified as the Conflict of Interest Free Case Management entity. As the case management entity, the ISC will:

  • Assist individuals in application for Waiver services.
  • Maintain the waiting list for Waiver services, updating all enrollments at least annually.
  • Prior to enrollment, inform individuals of right to choose between ICF/MR and HCBS services using IL Form 1238.
  • Complete initial eligibility determination, i.e., level of care evaluation.
  • Upon enrollment and annually thereafter, inform individuals of rights under the Waiver using IL Form 1201.
  • Conduct necessary evaluations and assessments of individual service needs, including risk assessments.
  • Ensure a Personal Plan is developed upon enrollment and at least annually thereafter. Complete modifications to the plan as directed by participant needs.
  • Assist individuals with linkage and applications for any non-Waiver services.
  • Inform individuals of all willing and qualified providers.
  • Complete any necessary prior approval applications for Waiver services.
  • Ensure Personal Plan is implemented.
  • Provide any necessary coordination of services.
  • Explain and provide information to individuals about reporting allegations of abuse, neglect, and exploitation, as well as filing other complaints and grievances.
  • Explain appeal rights, using IL Form 1202, and assist in filing appeals as needed.
  • Complete clinical eligibility for annual redeterminations.
  • Conduct on-going visits and make other contacts to ensure the continued effectiveness of the service plan and the general health and well-being of the individual.
  • Conduct necessary problem solving activities as issues arise regarding implementation of the service plan, coordination of services, or general health and well-being.

B.  Person Centered Planning

Person Centered Planning is a CMS HCBS Regulation that addresses the balance between what is important to a person and what is important for a person in service planning.  The Person Centered Planning process focuses on outcomes that are identified by the person receiving services in collaboration with their guardian and family. The ISC will document those desired outcomes, assist in identifying the barriers that currently prevent the outcomes, and assist the individual/family to locate and select agencies that are willing and qualified to provide the needed supports.

Person Centered Planning:

  • Must be driven by the person
  • Ensure services are delivered in a manner that reflects personal preferences and choices
  • Must include evidence that setting is chosen by the individual
  • Assist to achieve personally defined outcomes in the most integrated setting
  • Contributes to the assurance of health and welfare of the person receiving services
  • Must include opportunities to seek employment and work in competitive integrated settings
  • Must include opportunities to engage in community life, control personal resources, and receive services in the community to same degree of access as those not receiving Medicaid Home and Community Based Services
  • Includes risk factors and measures to minimize risk
  • Should be written in plain language that can be understood by the person who receives services and their guardian
  • Reflects cultural considerations
  • Include strategies for solving disagreements

Person Centered Planning within the DD Waivers includes three main components: the Discovery Tool, the Personal Plan and Implementation Strategies; below, each of these are described in detail. Person Centered Planning is required for individuals funded through DD Waiver services only. Person Centered Planning does not mandate goals in independence in daily living, economic self-sufficiency, community integration or self-administration of medication.

II.  Discovery

Discovery is the first component of Person Centered Planning. The Discovery process is designed to gather information about a person's preferences, interests, abilities, preferred environments, activities, and supports needed. The ISC agencies will be responsible for facilitating the Discovery process and documenting what they gather in the Discovery Tool. The Discovery process is not a one-time event, but a series of information gathering activities. The ISC will gather information through discussions (face to face, phone, and electronic), observations, and record reviews (evaluations, assessments, case notes). This process should begin with the individual and then include the guardian, advocate or family, and others chosen by the individual. It must also include current providers. The information captured during this process is used to develop the Personal Plan which summarizes key and critical areas of the person's life.

A.  Independent Service Coordinator (ISC) Responsibilities

  • The ISC is responsible for the completion of the Discovery process and Tool. This must be done in conjunction with the person and his/her guardian.
  • The ISC must complete the Discovery process for:
    • Children and adults currently enrolled in a DD Waiver. This should be done as a part of Individual Service and Support Advocacy (ISSA).
    • Children and adults newly transitioning to a DD Waivers, including Ligas Class members.  This does not include individuals in Crisis.
  • The ISC must continue to complete and submit the Crisis Transition Plan and Funding Request form for individuals who are considered to be in Crisis (homeless, abuse or neglect). The ISC then has 30 calendar days after the date the person begins DD Waiver services to complete the Discovery process and develop the Personal Plan.
  • The ISC should not complete the Discovery Tool/process for:
    • Individuals who are Bogard class members living in an Intermediate Care Facility for individuals with Developmental Disabilities (ICF/DD). These individuals are not involved in the Person Centered Planning process and will continue to have an Individual Service Plan developed by the ICF/DD provider.
    • Individuals who are 100% State funded.

B.  The Process

  • In preparing for the Discovery process, consider the individual's desired preference for the manner, location(s) and time(s) to gather this information.
  • The ISC must facilitate the discovery process and complete the Discovery Tool.
  • The ISC should ask the individual who they want to participate in the initial discussions. They should consider inviting people that know, support, and respect them.
  • If possible, the discovery process should include a face to face discussion with the individual/guardian (if applicable). In situations where the guardian is unable to be present, the ISC must document how information was received from the guardian.
  • The ISC must obtain information from provider agencies currently serving the individual.
  • The ISC can also obtain information from family members, Personal Support Workers, teachers, therapists, friends, child care providers, and others who know the person well.
  • The Discovery process is fluid and should be conducted over a period of time instead of in a single meeting. 
  • The completion date of the Discovery Tool cannot be more than six (6) months from the date of the Personal Plan.
  • The Discovery Tool should be updated within 365 days of the previous Tool, but can be updated more often if the individual/guardian request changes.

C.  Sources of Information

  • The questions in the Discovery Tool are meant to guide conversations. It is not necessary to ask every question in each section, but it is necessary to address each section of the Tool.
  • Prior to talking to the individual, the ISC should consider what supports may be needed to promote the person's full participation (visual aids such as graphics/pictures to understand concepts, pen, paper, sign language interpreter, etc.).
  • ISC can obtain information in various ways: conversations (face to face, phone, e-mails), record reviews, assessments/evaluations, provider agency notes and summaries.
  • If the individual is currently enrolled in a DD Waiver service, the ISC agency must obtain information from the current provider agency(s).
    • Provider agencies must send the ISC requested information/documents within 14 calendar days of receiving a request.
    • If information will be obtained face to face, the ISC staff must ensure agency staff has the appropriate authorization to leave their work responsibilities to participate. Agency staff should not participate in Discovery discussions without consulting with or informing the appropriate provider agency management.
  • When addressing risk, gather information from a variety of sources including the individual, guardian, family, staff, record review, and observation. Use the information gathered to document why the concern currently presents a risk or when the concern has presented significant risk in the past.
  • A separate risk assessment is not required but if an ISC chooses to use one it must include the following domains: health/medical, safety at home, in the community and in the workplace, finances and behavioral supports.

D.  Guiding Conversations

  • When gathering information:
    • Speak with the person using first person language and open ended questions, such as "What do you…"
    • Communicate with the individual/family using words that are easy to understand. Refrain from canned language and acronyms.
    • If conducting a discussion with multiple people, ask the individual for input before asking others present to respond.
    • Allow sufficient time for the individual to formulate thoughts and answer.
    • Encourage/support multiple styles of communicating thoughts and ideas (pictures, drawing, symbols and words).
  • The ISC should consider having a separate discussion with the individual prior to gathering information from other sources.
  • If the individual is unable to communicate in a way for the ISC to understand, ISCs will have to rely on caregivers/those who know the person best to complete the discovery process. You may also rely upon caregivers when conducting the Discovery process with young children.

E.  Documenting the Information

  • The Discovery Tool should be typed using the form provided.  Using bullet points is preferred.
  • The Tool must be completed by the ISC staff and therefore will not be written in first person.
  • The ISC should provide a copy of the Discovery Tool to the individual/guardian once the Tool is considered complete (each section addressed and with the ISC signature).
  • The most recent copy of the Discovery Tool should be kept on file with the ISC.
  • The ISC should provide a copy of the Discovery Tool, as a part of the complete referral packet, to the provider agency selected by the individual/guardian. This should occur after the person has selected the provider(s) and given consent to make a detailed referral for services. If the individual is remaining with a current provider, a copy should also be given to this provider.
  • The ISC must update the Discovery Tool within 365 days from the previous date but can do so more often if the preferences, abilities or needs of the person changes.
  • The completed Discovery Tool will not require a review/approval from the Division of Developmental Disabilities.

III.  Personal Plan

The Personal Plan is the single, comprehensive personal vision for a person's life. This document focuses on the individual's strengths, preferences, needs and desires. The ISC agencies will be responsible for developing the Personal Plan in conjunction with the individual, guardian, family, and providers. The Personal Plan will not only contain the outcomes that the person requires in their life, but also documents choices of qualified providers, reflect what is important to the person regarding delivery of services in a manner which ensures personal preferences, health and welfare. It must also include risk factors and plans to minimize them. This document is developed through a person centered process and serves as a mechanism for sharing this information with others who are or will be involved in supporting the person to achieve his/her desired life. The Personal Plan provides the basis for receiving services, service monitoring and quality evaluation.

The Personal Plan should be developed only after the Discovery process (initial or updated) is complete, except situations when a Ligas Transition Service Plan (LTSP) is required. In these cases, the personal Plan should be completed based on the LTSP instead of the Discovery Tool. Prior to the initiation of services or the expiration of the current Plan, the ISC should complete Personal Plan form based on what was learned during the Discovery or LTSP process.

A.  Developing the Plan

  • The ISC is responsible for developing the outcomes with the individual and ensuring the completion of the Plan.
  • The Personal Plan is based on information gathered during the Discovery process.
  • The ISC must develop the Personal Plan for:
    • Children and adults currently funded in a DD Waiver. This should be done as a part of Individual Service and Support Advocacy (ISSA).
    • Children and adults newly transitioning to a DD Waiver. This must be completed prior to initiating DD Waiver services, with the exception of Crisis cases.
  • For individuals who are considered to be in Crisis (homeless, abuse, or neglect), the ISC must complete the Crisis Transition Plan and Funding Request form. The ISC then has 30 calendar days after the date the person begins DD Waiver services to conduct the Discovery process and develop the Personal Plan.
  • The ISC will use the Personal Plan form as the official Plan. Alternative formats of the Plan may be generated and distributed to the individual/guardian as needed.
  • The contents of the Plan must reflect the key aspects of a person's life as outlined on the form. If there is no outcome listed in a section, the ISC should still complete the remaining statements/questions of that particular section as appropriate.
  • It should be recognized that some individuals will have multiple desired outcomes, all of which may not be addressed at this time. In such cases, the ISC should assist the person to prioritize outcomes and select providers that meet the "top" priorities. The ISC should document the outcome(s) that are currently on hold and the reason why.
  • The ISC must ensure the Plan accurately reflects the outcomes, preferences, strengths and support needs of the individual.
  • The Plan must also discuss risk and strategies to minimize these risks.
  • The current Plan must be completed within 365 days of the previous Plan.
  • The Personal Plan is considered complete when the individual and guardian approve the services, identified outcomes and supporting information in the Plan. The individual, guardian (if applicable) and ISC must sign the Personal Plan. The last signature date of these three parties becomes the annual renewal date for the Personal Plan.
  • If the individual is unable or unwilling to sign the Personal Plan, the ISC must document the reason why and the date the ISC reviewed the Plan with the person.
  • If the guardian:
    • Is unable to sign the Plan, the ISC must obtain verbal approval from the guardian and document the method and date the approval was received.
    • Is unwilling to approve and sign the Plan, the ISC must first work to resolve any disagreement(s) and document in the Plan how the disagreement(s) was addressed. If the guardian is still unwilling to approve and sign the Plan, the ISC must document the reasonable measures taken to obtain their approval/signature.
    • Is unresponsive to requests for their approval and signature, the ISC must document the reasonable measures taken to obtain this information and that the individual's guardian has failed to respond.
    • Does not sign and date the Personal Plan, the last signature date of the individual or ISC becomes the annual renewal date for the Personal Plan.
  • The completed Plan shall become a part of the individual's record.
  • The ISC will update the Plan at least annually to ensure it continues to reflect the person's preferences.
  • Individuals, guardians, families or service providers who are aware of the revise or edit a Plan should notify the ISC.
  • The Plan can be revised or edited more often if the person's desires or needs change.  Revisions and edits to the Plan must be done using the following guidelines:
    • Revising the Personal Plan: 
  • If there is a significant change in the individual's wellbeing (medical or behavioral), the ISC must review and revise the Discovery Tool and Personal Plan to ensure that these documents accurately reflect the current preferences, desires, abilities and support needs of the individual.
  • On page 1 of the Personal Plan, under Check type of Plan, the ISC must select Revision.
  • A Revision requires new signatures (and dates) from the individual, guardian(s) and ISC.
  • The last signature date of the individual, guardian(s) and ISC becomes the annual renewal date for the Personal Plan.
  • A new Provider Signature Page(s) should be completed along with a new Implementation Strategy

Edits to the Personal Plan:

  • When the ISC becomes aware of the need to add or subtract an outcome or service the Plan can be edited.
  • The Discovery Tool should be reviewed and updated as needed (if discrepancies are identified).
  • It is not necessary to obtain new signatures from the individual, guardian(s) or ISC when the Plan is edited.
  • An edit to the Plan does not reset the annual renewal date.

B.  Dissemination of the Plan and Provider Selection

  • The individual/guardian directs the ISC to disseminate the Personal Plan to provider organizations that he/she is considering as a possible service provider for the purpose of determining organizations' ability to meet the desired outcomes and/or provide services identified in the Plan.
  • Organizations that believe they can meet outcomes and/or provide services identified in the Plan can request additional information from the ISC (i.e. Discovery Tool, medical and social histories, psychological evaluation(s), etc.) and work with the ISC who will facilitate the provider selection process.
  • In cases where a current provider is unable or unwilling to assist the person to work towards any desired outcome or provide services:
    • This provider should not sign a Provider Signature Page.
    • The ISC should assist the individual to locate other qualified and willing providers. Until a qualified and willing provider(s) is located, the ISC should:
      • Document its progress toward finding an appropriate service provider.
      • Document the outcome(s) that is currently on hold and the reason(s) why.
  • It is crucial for all stakeholders to understand that the outcomes listed in the personal plan are those expressed by the individual through the discovery process. Service providers who are aware of the need to change the Plan should notify the ISC of the person's need or desire to change their plan.

C.  Outcomes

It is expected that each individual in DD Waiver services has at least 1 outcome. This may reflect something the individual desires that is not currently present or it may reflect something that is already present and they want to maintain. When developing outcomes in the Personal Plan, remember that outcomes:

  • Can only be developed after identifying what is important to the person.
  • Should include what is important for the person. The outcome statement should reflect "in order to" or "so that". See examples below.
  • May have to be prioritized.
  • Are not services and supports; see examples below.
  • Should make sense for a person without an intellectual/developmental disability.
  • Must be written in present tense and plain language.
  • Should not be written in first person.
  • Do not have to be present in each section of the Plan. Outcomes should only be identified for sections that the individual expressed a desire or preference.

  • Examples of Outcomes Statements:

  • Mary volunteers at a day care center so that she gets to spend time with children and knows that she is needed.
  • Bernice sings with the choir on Sundays so that she stays active.
  • Ron enjoys rock music while bathing so that he can relax and feel refreshed.
  • Bree watches Animal Planet when she is assisted to stretch so that she feels safe and relaxed during her exercise time.
  • John delivers mail at the hospital in order to gain job skills.

D.  Risk

  • When documenting risk in the Personal Plan:
  • Provide narrative information (including brief overview of current skills as well as potential and known risks) sufficient to guide a provider.
  • Consideration should be given to both the risks associated with current activities of the individual as well as potential risks which inhibit the individual from pursuing his/her goals and fully participating in integrated settings.
  • All safeguards, supports, education and training necessary to mitigate identified risks should be included.
  • Discuss with the individual/guardian, if applicable, if they are willing to accept some situations with risks to facilitate choice, independence, and community integration.
  • Identify safeguards that are already in place to minimize identified risks and outline additional needed actions to reduce other risks which pose a real or potential threat to the individual's health, safety and/or welfare.
  • Identify who will be responsible for each of the needed safeguards and actions.

E.  Conflict

If conflict arises during Personal Plan development, the ISC should:

  • Determine what needs to change, what needs to remain the same for the person.
  • Consider what makes sense or what is working in the individual's life?
  • Consider what doesn't make sense or what is not working in the individual's life?
  • Allow each person to contribute his/her perspective.
  • Use the information gathered as the basis of thought for the development of an outcome.

F.  Summary of Services & Supports Page

The Summary of Services & Supports page of the Personal Plan is to be completed by the ISC agency. The ISC must document all services, as applicable to each individual, on this page Plan under the column titled Service/Support.  ISC agencies must ensure that all Medicaid Waiver services to be provided to an individual (including the services' scope, amount, frequency and duration) must be listed in the individual's Personal Plan. This should include Individual Service & Support Advocacy. Billings and claims for any Medicaid Waiver service found during an audit not to be included in the Plan will be voided. It is not necessary for ISCs agencies to document the details of these services (i.e. provide assistance with meal preparation) on this page. Provider agencies who are aware of the need to change services (i.e. add Supported Employment), should notify the ISC to ensure that this service is requested by the individual/guardian and included in the Personal Plan.

G. Provider Signature Page

The Provider Signature Page of the Personal Plan should only be completed and signed by provider agencies that will render services or work toward outcomes listed on Summary of Services and Supports page of the Personal Plan.  Prior to delivering any services through the Medicaid Waivers, providers should ensure they have a copy of the final and completed Plan.  The Summary of Services & Supports page of the Plan must contain the service(s) the provider will deliver. All paid services that are applicable to the individual must be identified on this page. Billings and claims for any Medicaid Waiver service found during an audit not to be included in the Plan will be voided.

  • After receipt of a Personal Plan, provider agencies that will support any of the services or outcomes listed on the Plan should document the particular service(s) and outcomes they will address on the Provider Signature Page of the Personal Plan. It is not necessary for provider agencies to document the details of these services (i.e. providing assistance with hygiene) on this page. The details of how the service will be provided should be outlined in a provider's Implementation Strategy.
  • A provider agency must not change the services or outcomes contained in the Plan.  Provider agencies who are aware of the need to revise or edit the Plan, should notify the ISC.
  • Provider agencies have 10 calendar days to complete, sign and return the Provider Signature Page.  The completed and signed page becomes a part of the individual's Personal Plan.

IV.  Implementation Strategies

The information identified in the Personal Plan must be addressed and accounted for in the Implementation Strategy. An Implementation Strategy must detail the supports and services that will be provided on a day-to-day basis. Implementation Strategies are developed by provider agencies that have agreed to provide services.  Implementation Strategies will be completed using the DHS approved template to assure consistency between the stated desires and provider-directed activities/support.

  1. Strategies developed by Provider Agencies

After the provider agency's signature on the Provider Signature Page of the Personal Plan, the provider agency will complete an Implementation Strategy using the form provided that includes the details of how the service(s) will be provided.  Prior to delivering any services through the Medicaid Waivers, providers should ensure they have a copy of the final and completed Plan. Billings and claims for any Medicaid Waiver service found during an audit not to be included in the Plan will be voided.

  • Provider agencies must use the Implementation Strategy form. It must contain the following:
    • Basic descriptive, diagnostic, demographic and medical information
    • Outcomes identified in the Personal Plan that the provider has agreed to work toward.
    • A description of how supports and services assist the individual to engage in community life and maintain control over personal resources.
    • Opportunities to seek employment and work in competitive integrated employment if desired.
    • Functional goals/training areas and methods to measure progress.
    • Documentation that services and supports are linked to individual strengths, preferences and assessed clinical and support needs.
    • Risks included in the Personal Plan and any others subsequently identified; strategies that will be used to mitigate risk and identify who is responsible for implementing these strategies.
    • All services and supports to be provided regardless of provider or funding source, including type, methods if applicable, frequency, duration and staff assigned if applicable.
    • Justification for any restriction(s) or modifications that limit the person's choice, access or otherwise conflict with HCBS standards.
    • Documentation for any situation where a person lives in a residential setting owned or controlled by a service provider and modifications to the community settings are requested.
  • When an individual is using the same provider agency for both CILA and DT services, a provider agency is not required to develop 2 different Strategies. However, if the strategies for CILA and DT are significantly different and the provider determines that separate Implementation Strategy documents would be more "user friendly" for the staff, the use of separate documents is acceptable. Regardless of whether the provider opts to use separate or combined strategies, each the Implementation Strategy document must contain all the necessary components described above. The provider should keep a copy in both locations so that staffs are aware of the supports and services they are to provide.
  • Provider Agencies have 20 calendar days to develop their Implementation Strategy.  The 20 calendar days begins with the provider's signature date on the Provider Signature Page of the Personal Plan.
  • Provider agencies must provide the Individual/guardian and the ISC a copy of the Implementation Strategy.
  • Individual/guardians must review the proposed strategies. If approved, the individual/guardian is required to sign the provider's Implementation Strategy. The ISC will not sign or approve Implementation Strategies.
  • Provider agencies must ensure that all services being billed are identified in the Personal Plan. Provider agencies who are aware of the need to change services (i.e. add Supported Employment), should notify the ISC to ensure that this service is requested by the individual/guardian and included in the Personal Plan.
  • Implementation Strategies must reflect ongoing review, monitoring and updating when necessary. Implementation Strategies must also be updated to reflect changes in the Personal Plan at least annually and more often if warranted by circumstances, a change in functional status or at the request of the individual.
  • Provider types listed below, who have agreed to render services and/or work toward outcomes, should develop Implementation Strategies as outlined below:

The following provider types are required to develop Implementation Strategies:

  • Adult Day Care
  • Agency-based Personal Support Worker (HBS only)
  • Child Group Home
  • Community Integrated Living Arrangement
  • Community Day Services (formerly known as Developmental Training)
  • Community Living Facility
  • Supported Employment Program

The following provider types can develop Implementation Strategies OR use current Assessment/Treatment Documents:

  • Behavior Counseling
  • Nursing (HBS only)
  • Occupational Therapy
  • Physical Therapy
  • Psychotherapist
  • Speech Therapy

The following provider types are not required to develop an Implementation Strategy

  • Adaptive Equipment
  • Assistive Technology
  • Home Modifications
  • Non-Medical Transportation (HBS only)
  • Self Direction Assistant (HBS only)
  • Vehicle Modifications

V.  Appendices