A. The following words and terms when used in this chapter shall have the meanings ascribed in 12VAC35-270-20:

"Abuse"

"Admission"

"Authorized representative"

"Case management service" or "support coordination service"

"Commissioner"

"Contractor"

"Crisis"

"Department"

"Developmental disability"

"Discharge"

"Discharge plan"

"Individual" or "individual receiving services"

"Informed choice"

"Initial assessment"

"Legal guardian"

"Location"

"Medication"

"Mental illness"

"Neglect"

"Person-centered"

"Provider"

"Referral"

"Restriction"

"Screening"

"Service"

"Substance abuse (substance use disorders)"

B. The following words and terms when used in this chapter shall have the following meanings unless the context clearly indicates otherwise:

"Care" or "treatment" means the individually planned therapeutic interventions that conform to current acceptable professional practice and that are intended to improve or maintain functioning of an individual receiving services delivered by a provider.

"Comprehensive assessment" means a comprehensive and written assessment that updates and finalizes the initial assessment. The comprehensive assessment shall consider the individual's needs, strengths, goals, preferences, and abilities within the individual's cultural context and shall be completed in a time period appropriate to the nature and scope of the service provided. The comprehensive assessment includes all relevant social, psychological, medical, and level of care information as the basis for the development of the person-centered comprehensive ISP. The comprehensive assessment may be completed at the time of initial assessment if it includes all elements of the comprehensive assessment. In the event a comprehensive assessment is completed at the time of an initial assessment the provider is not required to update the assessment.

"Co-occurring disorders" means the presence of more than one and often several of the following disorders that are identified independently of one another and are not simply a cluster of symptoms resulting from a single disorder: mental illness, a developmental disability, substance abuse (substance use disorders), or brain injury.

"Developmental services" means planned, individualized, and person-centered services and supports provided to individuals with developmental disabilities for the purpose of enabling these individuals to increase self-determination and independence, obtain employment, participate fully in all aspects of community life, self-advocate, and achieve the fullest potential to the greatest extent possible.

"Face-to-face" means encounters that occur in person, unless explicitly indicated by a specific provision of this chapter.

"Family" means an individual's biological family or the family in which an individual is raised. For the purposes of this chapter, it also means family of choice or the group of people in an individual's life that satisfies the typical role of family as a support system.

"Individualized services plan" or "ISP" shall have the meaning ascribed in 12VAC35-270-20. For the purposes of this chapter, it also means an individualized supports plan for individuals with a primary diagnosis of developmental disability. An individualized supports plan includes the plan for supports, or "Part 5," that incorporates the activities and instructions that are tailored specifically to the preferences of the individual with a developmental disability to support the accomplishment of the individual's desired outcomes.

"Planning team" means the team that is consulted to plan the individual's plan for supports. The planning team shall, at a minimum, consist of the individual receiving services, the case manager, and any legally required authorized representative, including legal guardians. The planning team may include the individual's family or family of choice or other identified persons as desired by the individual.

"Recovery" means a journey of healing and transformation enabling an individual with a mental illness to live a meaningful life in a community of his choice while striving to achieve his full potential. For individuals with substance abuse (substance use disorders), recovery is an incremental process leading to positive social change and a full return to biological, psychological, and social functioning. For individuals with a developmental disability, the concept of recovery does not apply in the sense that an individual with a developmental disability will need support throughout the individual's entire life, although these may change over time. With supports, individuals with a developmental disability are capable of living lives that are fulfilling and satisfying and that bring meaning to the individual and those they know.

"Skills training" means systematic skill building through curriculum-based psychoeducational and cognitive-behavioral interventions. These interventions break down complex objectives for role performance into simpler components, including basic cognitive skills, such as attention, to facilitate learning and competency.

Providers shall be licensed to provide specific services as defined in 12VAC35-270, in this chapter, or as determined by the commissioner. The case management service, as defined in 12VAC35-270-20, shall require a case management license.

Case management includes assisting the individual and the individual's family, family of choice, and other identified persons as desired by the individual, in accessing medical, psychological, psychiatric, social, educational, vocational, residential, or other services that are responsive to the individual's needs and preferences. This service is offered to provide the individual with essential support for living in the community and developing his desired lifestyle. Activities include identifying and contacting potential service users; conducting needs assessments and community integration enhancement; service planning, coordination, and monitoring; and discharge planning and advocating for individuals in response to changing needs. The service does not include assistance in which the only function is maintaining service waiting lists or periodically contacting or tracking individuals to determine potential service needs. The terms "support coordination" and "care coordination" are used in certain communities to identify providers of targeted case management services.

Providers shall document that the following services are performed consistent with the individual's assessment and ISP.

1. Enhancing community integration through increased opportunities for community access and involvement, and creating opportunities to enhance community living skills to promote community adjustment, including, to the maximum extent possible, the use of local community resources available to the general public;

2. Making collateral contacts with family members, family of choice, and other persons as desired by the individual with properly authorized releases to promote implementation of the individual's ISP;

3. Assessing needs and planning services, to include developing an ISP;

4. Linking the individual to those community supports that are most likely to promote the personal habilitative or rehabilitative and life goals of the individual as identified in the ISP;

5. Assisting the individual directly to locate, develop, or obtain needed services, resources, and appropriate public benefits;

6. Ensuring the coordination of services and service planning within a provider agency, with other providers, and with other human service agencies and systems, such as local health and social services departments;

7. Monitoring service delivery through contacts with the individual receiving services; family members, family of choice, or other persons as desired by the individual; service providers; and periodic site and home visits, as appropriate, to assess the quality of care and satisfaction of the individual;

8. Providing follow up instruction, education, and guidance to support the individual and develop relationships that promote the goals in the ISP;

9. Advocating for the individual with others, such as other providers and human service agencies and systems, in response to changing needs and preferences, which shall be reflected in the ISP;

10. Planning for transitions in the individual's life;

11. Monitoring the individual's health status, including any medical conditions, and the individual's medications and potential side effects, and assisting the individual in accessing primary care and other medical and dental services, as needed; and

12. Understanding the capabilities of services to meet the individual's identified needs and preferences without placing the individual, other participants, or staff at risk of serious harm.

A. Providers shall implement screening policies and procedures that include:

1. Identification, qualification, training, and duties of employees responsible for screening;

2. The following minimum required elements of screening for case management services:

a. Date of contact;

b. Legal name, preferred name, date of birth, sex, and gender of the individual;

c. Contact information, including address, telephone number, and email address of the individual, if applicable;

d. Reasons why the individual is requesting services;

e. Current reported diagnoses and medical conditions;

f. Medical symptoms;

g. Psychoactive or other medications currently being used, including recent increases, decreases, discontinuation, misuse, or overdose of prescription medication;

h. Recent or current substance use or dependence, including risk for intoxication or substance withdrawal; and

i. Status of the individual, including referral to other services for further assessment, placement on a waiting list for services, or admission to the service; and

3. Methods to identify other appropriate services for referral to assist individuals who are not admitted to the service after screening.

B. The provider shall retain documentation of the individual's screening for six months. For individuals who are admitted to the service, documentation shall be included in the individual's record in accordance with 12VAC35-270-580.

C. The provider shall review all elements of the screening at the time of initial assessment and update as necessary.

A. The provider shall implement a written assessment policy. The policy shall define how assessments will be conducted and documented.

B. The provider shall actively involve the individual and the individual's authorized representative, if applicable, and any family, family of choice, or other identified persons as desired by the individual, in the preparation of initial and comprehensive assessments. In these assessments, the provider shall consider the individual's needs, strengths, goals, preferences, and abilities within the individual's cultural context.

C. The assessment policy shall designate appropriately qualified employees or contractors who are responsible for conducting, obtaining, or updating assessments and coordinating medical screenings. These employees or contractors shall have experience in working with the needs of individuals who are being assessed, the assessment tools being utilized, and knowledge of the array of services that the individuals may require.

D. Assessment is an ongoing activity. The provider shall make reasonable attempts to obtain previous assessments or relevant history in order to complete an individual's initial or comprehensive assessment. The provider shall use previous assessments or relevant history within the course of treatment, if applicable.

E. Providers shall utilize an assessment tool that meets the requirements in subsection F of this section for initial assessments and subsection G of this section for comprehensive assessments. Providers may utilize a standardized state-sanctioned or federally sanctioned assessment tool that does not meet the criteria in these regulations if the tool is approved by the department prior to use.

F. Providers shall conduct an individual's initial assessment prior to or at admission to the service. The provider shall complete or obtain information from other qualified providers in order to complete an initial assessment detailed enough to determine whether the individual qualifies for admission and to initiate an ISP for those individuals who are admitted to the service.

1. The initial assessment shall assess immediate service, health, and safety needs and be conducted using an assessment tool that evaluates, at a minimum, the following criteria concerning the individual:

a. Diagnosis;

b. Presenting needs, including the individual's stated needs, psychiatric needs, support needs, and the onset and duration of needs;

c. Current medical issues;

d. Current medications;

e. Current and past substance use or abuse, including co-occurring mental health and substance abuse disorders;

f. At-risk behavior to self and others; and

g. Risk factors that may impact the individual's ability to seek treatment or continue to participate in services.

2. For individuals presenting with substance use disorder, at the time of the initial assessment, the provider shall:

a. Identify individuals with a high-risk for medical complications or who may pose a danger to themselves or others; and

b. Assess substances used and time of last use.

3. The comprehensive assessment may be completed at the time of initial assessment if it includes all elements noted within subsection G of this section. In the event a comprehensive assessment is completed at the time of an initial assessment, the provider is not required to update the assessment unless a reassessment is medically or clinically indicated.

G. Providers shall conduct a comprehensive assessment for each individual who is admitted to the service. A comprehensive assessment shall update and finalize the initial assessment, unless the comprehensive assessment is completed at the time of initial assessment as provided in subdivision F 3 of this section.

1. Completion of the comprehensive assessment shall be based upon the nature and scope of the service, but shall occur no later than (i) 30 days after admission for providers of mental health and substance abuse services and (ii) 60 days after admission for providers of developmental services.

2. The comprehensive assessment may be completed at the time of initial assessment only if the assessment includes all elements enumerated in subdivision 3 of this subsection. In the event a comprehensive assessment is completed at the time of an individual's initial assessment, the provider is not required to update the assessment unless a reassessment is medically or clinically indicated.

3. The comprehensive assessment shall be conducted using an assessment tool that evaluates, at a minimum, the following criteria:

a. Onset and duration of needs;

b. Social, behavioral, developmental, and family history and supports;

c. Cognitive functioning, including strengths and weaknesses;

d. Employment, vocational, and educational background;

e. Prior interventions and outcomes, including interventions and outcomes that were unsuccessful, with the provider utilizing previous assessments and relevant history to note prior interventions as required by subsection D of this section;

f. Overall financial situation, including resources, support, and benefits, and whether the individual has the means to meet the individual's financial needs;

g. Health history and current medical care needs, to include:

(1) Allergies, including allergies to food and medications;

(2) Recent physical complaints and medical conditions;

(3) Nutritional needs;

(4) Chronic conditions;

(5) Communicable diseases;

(6) Restrictions on physical activities, if any;

(7) Restrictive protocols or special supervision requirements;

(8) Past serious illnesses, serious injuries, and hospitalizations;

(9) Serious illnesses and chronic conditions of the individual's parents, siblings, and significant others in the same household; and

(10) Current and past substance use, including alcohol, prescription and nonprescription medications, and illicit drugs.

h. Psychiatric and substance use issues, including current mental health or substance use needs, presence of co-occurring disorders, history of substance use or dependence, and circumstances that increase the individual's risk for mental illness or substance use issues;

i. History of abuse, neglect, sexual or domestic violence, or other trauma, including psychological trauma;

j. Legal competency, including authorized representative, commitment, and representative payee status;

k. Relevant criminal charges or convictions and probation or parole status;

l. Daily living skills;

m. Housing arrangements;

n. Ability to access services, including transportation needs;

o. As applicable, fall risk, communication needs, and mobility and adaptive equipment needs;

p. Leisure and recreation information; and

q. Individual empowerment, self-advocacy, and volunteerism information.

H. Case managers shall meet with each individual face-to-face as dictated by the individual's needs. At face-to-face meetings, the case manager shall (i) observe and assess for any previously unidentified risks, injuries, needs, or other changes in status; (ii) assess the status of previously identified risks, injuries, needs, or other changes in status; (iii) assess whether the individual's service plan is being implemented appropriately and remains appropriate for the individual; and (iv) assess whether supports and services are being implemented consistent with the individual's strengths and preferences and in the most integrated setting appropriate to the individual's needs.

I. The provider shall retain documentation of the individual's assessments in accordance with its written records management policy and 12VAC35-270-580.

A. The provider shall actively involve, through face-to-face contacts, the individual and the individual's authorized representative, as appropriate, in the development, review, and revision of a person-centered ISP. For substance use and mental health case management services, face-to-face contacts may be fulfilled through telemedicine if clinically appropriate and utilized for the convenience of the individual. The individualized services planning process shall be consistent with laws protecting confidentiality, privacy, human rights of individuals receiving services, and the rights of minors.

1. Providers of developmental services shall collaborate with the individual's planning team to develop and implement the initial plan for supports, which is a component of the comprehensive ISP, no later than 24 hours after admission. The initial plan for supports shall address the individual's immediate health and safety needs for the first 60 days, may include assessment activities, and shall continue in effect until the ongoing comprehensive plan for supports is developed or the individual is discharged, whichever occurs first. An ongoing comprehensive plan for supports shall be completed within 60 days of admission.

2. Providers of mental health or substance abuse services shall develop and implement an initial person-centered ISP no later than 24 hours after admission. The initial ISP shall address the individual's immediate service, health, and safety needs for the first 30 days and shall continue in effect until the comprehensive ISP is developed or the individual is discharged, whichever occurs first. An ongoing comprehensive ISP based upon the nature and scope of services shall be completed as soon as possible, but no later than (i) 48 hours after admission by providers of short-term intensive services typically provided for less than 30 days or (ii) 30 days after admission.

B. The initial ISP and the comprehensive ISP shall be developed based on the respective assessment with the participation and informed choice of the individual receiving services.

1. To ensure the individual's participation and informed choice, the following shall be explained to the individual or the individual's authorized representative, as applicable, in a reasonable and comprehensible manner:

a. The proposed services to be delivered;

b. Any alternative services that might be advantageous for the individual; and

c. Any accompanying risks or benefits of the proposed alternative services.

2. If no alternative services are available to the individual, it shall be clearly documented within the ISP or within documentation attached to the ISP, that alternative services were not available as well as the steps taken to identify alternative services.

3. Whenever there is a change to an individual's ISP, it shall be clearly documented within the ISP or within documentation attached to the ISP that:

a. The individual participated in the development of or revision to the ISP;

b. The proposed and alternative services and the respective risks and benefits were explained to the individual or the individual's authorized representative; and

c. The reasons the individual or the individual's authorized representative chose the option included in the ISP.

A. The case manager shall collaborate with the individual, the individual's authorized representative, the individual's other service providers, where applicable, and other persons as desired by the individual, to complete the individualized, person-centered initial ISP and comprehensive ISP.

B. The initial ISP shall be based on the individual's immediate service, health, and safety needs identified in the initial assessment. The initial ISP shall include:

1. Relevant and attainable goals, measurable objectives, and specific strategies for addressing needs and preferences documented within the individual's initial assessment;

2. Services, supports, and frequency of services planned to accomplish the individual's goals, including relevant psychological, mental health, substance abuse, behavioral, developmental, medical, rehabilitation, training, and nursing needs and supports;

3. The role of the individual and others, including the individual's family, if appropriate, in implementing the service plan;

4. Target dates for accomplishment of goals and objectives;

5. Identification of employees or contractors responsible for coordination and integration of services, including employees of other agencies; and

6. The activities, services, and supports of each provider, including the case manager.

C. The comprehensive ISP shall be based on the individual's needs, strengths, abilities, personal preferences, goals, and natural supports identified in the comprehensive assessment. The comprehensive ISP shall include the following minimum provisions:

1. Relevant and attainable goals, measurable objectives, and specific strategies for addressing each need documented within the individual's comprehensive assessment;

2. Services and supports required to accomplish the goals, including relevant psychological, mental health, substance abuse, behavioral, developmental, medical, rehabilitation, training, and nursing needs and supports;

3. The frequency at which services and supports must be provided to accomplish the individual's goals;

4. The role of the individual and others, including the individual's family, if appropriate, in implementing the comprehensive ISP;

5. A communication plan for individuals with communication barriers, including language barriers;

6. A behavioral support or treatment plan, if applicable;

7. A physical safety plan that addresses identified risks to the individual or to others, including a fall risk plan if indicated by the individual's assessment;

8. A crisis or recovery plan, if applicable;

9. Target dates for accomplishment of goals and objectives;

10. Identification of employees or contractors responsible for coordination and integration of services, including employees of other agencies;

11. A transportation plan, if applicable;

12. Services the individual elects to self-direct, if applicable;

13. Projected discharge plan and estimated length of stay within the service; and

14. The activities, services, and supports of each provider, including the case manager.

D. Both the initial ISP and the comprehensive ISP shall be signed and dated, at a minimum, by (i) the person responsible for implementing the plan and (ii) the individual receiving services or the individual's authorized representative, if applicable, in order to document agreement.

1. If the signature of the individual receiving services or the individual's authorized representative cannot be obtained, the provider shall document attempts to obtain the necessary signature and the reason the signature was unobtainable. The provider shall attempt to obtain the necessary signature on a periodic basis while each ISP is in effect. An attempt to obtain the necessary signature shall occur, at a minimum, each time the provider reviews the ISP as required by 12VAC35-280-90 E.

2. Prior to implementation, each ISP shall be distributed to the individual and others authorized to receive the ISP. The provider shall document dates of the distribution within the individual's record.

E. The case manager shall be responsible for developing, implementing, reviewing, and revising each individual's comprehensive ISP in collaboration with the individual or the individual's authorized representative, as appropriate, and other persons as desired by the individual. The case manager shall also monitor implementation of the individual's ISP by other service providers, if applicable.

F. The case manager shall maintain a working knowledge of the objectives and strategies contained in the individual's current ISP, including an individual's detailed health and safety protocols.

1. The case manager shall initiate revisions of the ISP as appropriate based on the changing needs and preferences of the individual.

2. When changes occur to an individual’s ISP, the case manager shall notify affected providers and other persons as appropriate.

G. When a case management agency provides more than one service to an individual, the agency may maintain a single case management ISP document that contains individualized objectives and strategies for each service provided.

H. Whenever possible, the identified goals in the ISP shall be written in the words of the individual receiving services.

I. The provider shall use signed and dated progress notes to document the implementation of the goals and objectives contained within the ISP.

J. A copy of the individual's most current ISP shall be readily accessible to the case manager during the provision of case management services.

A. Reassessments shall be completed at least annually and any time there is a need based on changes in the medical, psychiatric, behavioral, or other status of the individual.

B. The provider shall actively involve the individual, the individual's authorized representative, and other service providers, as applicable, in reassessments. The provider shall consider the individual's needs, strengths, goals, preferences, and abilities within the individual's cultural context.

C. Providers shall revise the ISP if the reassessment supports changes or if desired by the individual. If a reassessment does not support changes to the ISP, the provider shall document that no revisions are necessary and the reasoning.

D. If necessary as a result of a reassessment, case managers shall collaborate with other providers to ensure changes are made to medical, medical equipment, behavioral, or other corresponding protocols.

E. The provider shall complete quarterly reviews of the ISP in writing every three months from (i) the date of the implementation of the most recent comprehensive ISP or (ii) the most recent reassessment, whichever occurs later. For case management services, the quarterly ISP review shall be added to the individual's record no later than 30 calendar days from the date the review was due to be completed.

F. The quarterly ISP review shall be conducted in a person-centered manner to determine if services are being delivered as described within the ISP. The individual receiving services and the individual's authorized representative, if applicable, shall be included in the ISP review to determine if the individual’s treatment needs and preferences are being met and whether the individual is satisfied with the services provided.

1. A quarterly review of the ISP shall evaluate the individual's progress toward meeting the ISP goals, outcomes, objectives, and support activities; assess the continued relevance of the ISP objectives, strategies, and support instructions; and update the goals, outcomes, objectives, support activities, support instructions, and strategies contained in the ISP, if indicated, and implement any updates made.

2. A quarterly review of the ISP shall document evidence of progress toward or achievement of a specific targeted outcome for each goal and objective.

3. For goals and objectives that were not accomplished by the identified target date, or for which the individual did not demonstrate sufficient progress, the provider shall meet and collaborate with other service providers and support team members to review the reasons for lack of progress and provide the individual an opportunity to make an informed choice of how to proceed. The provider shall retain documentation of this meeting and the individual’s informed choice within the individual's record.

4. A quarterly review of the ISP shall note:

a. The involvement of the individual's family or other persons desired by the individual in the individual's treatment;

b. Whether the individual no longer needs the intensity of care provided by case management services;

c. The individual's progress towards discharge; and

d. The status of the individual's discharge planning.

G. The provider shall ensure after each reassessment that the individual's most current ISP is easily accessible to the case manager and direct care staff at the location where the individual receives services.

A. The documentation system implemented by the provider pursuant to subdivision E of 12VAC35-270-580 shall ensure that progress notes are (i) maintained in a consistent format that satisfies the minimum provisions of subsection B of this section and (ii) entered into the individual's record in accordance with the provider's record management policy.

B. The provider shall use signed and dated progress notes or other documentation to document the services provided to the individual. Progress notes shall, at a minimum:

1. Be legible and readable;

2. Record the individual's interaction with the staff writing the progress note, including care provided and events relevant to diagnosis and treatment or care of the individual;

3. Provide a narrative or descriptive component;

4. Describe needed follow-up care or note which objective within the ISP will receive focus the next time the individual receives services; and

5. Be signed and dated by the staff member who rendered the service.

C. Communication logs, information notes, and supervision notes shall not be considered progress notes.

A. Enhanced case management contacts shall be provided to individuals receiving developmental services who:

1. Receive services from providers holding conditional or provisional licenses;

2. Have more intensive behavioral or medical needs as defined by the supports for intensity scale (SIS) category representing the highest level of risk to individuals;

3. Experience an interruption of service greater than 30 days;

4. Encounter the crisis system for a serious crisis or for multiple less serious crises within a consecutive three-month period;

5. Have transitioned from a training center within the previous 12 months; or

6. Reside in congregate settings of five or more individuals.

B. An individual eligible for enhanced case management contacts shall meet with the individual's case manager face-to-face at least once every 30 days, with a minimum of every other visit occurring in person in the individual's place of residence.

A. The provider shall implement a policy that addresses the facilitation and coordination of adequate and appropriate medical care. This policy shall describe to what extent and how:

1. A case manager will ensure that an individual's medical care needs will be assessed and the circumstances that will prompt the case manager to facilitate a medical assessment.

2. The ISP will address any medical care needs appropriate to the scope and level of service.

3. The provider will arrange for or support the individual with the arrangement of the provision of medical and dental care needs identified at admission.

4. The provider will arrange for or support the individual with the arrangement of routine, ongoing, and follow-up medical and dental care services after admission.

5. The case manager will facilitate communicating the results of physical examinations, medical assessments, diagnostic tests, treatments, or examinations conducted by the individual's providers to the individual and the individual's authorized representative, as appropriate.

6. The case manager will ensure the provider keeps on file and up to date the names, addresses, and telephone numbers of the individual's medical and dental providers.

7. The provider will ensure a means for facilitating and arranging, as appropriate, transportation to medical and dental appointments and medical tests.

8. The provider will ensure the provision of emergency medical services for each individual.

B. The case management agency shall implement written policies to identify any individuals who are at risk for falls. If an individual is identified as at risk for falls by a department-licensed provider or health care professional, the case manager shall obtain the at-risk individual's assessment and ensure that a fall prevention and management plan and program for the individual is implemented across providers appropriately.

C. The provider shall report outbreaks of infectious diseases to the Department of Health pursuant to § 32.1-37 of the Code of Virginia.

A. Employees or contractors providing case management services shall provide documentation of education, training, supervision, or verified work experience that demonstrates knowledge of:

1. Services and systems available in the community, including primary health care, support services, eligibility criteria and intake processes, and generic community resources;

2. The nature of serious mental illness, developmental disability, substance use disorders, or co-occurring disorders depending on individuals receiving services, including clinical and developmental issues;

3. Different types of assessments, including functional assessment, and use of those assessments in service planning;

4. Treatment modalities and intervention techniques, such as behavior management, independent living skills training, supportive counseling, family education, crisis intervention, discharge planning, and service coordination;

5. Types of mental health, developmental, and substance use disorder programs available in the locality;

6. The service planning process and major components of a service plan;

7. The use of medications in the care or treatment of the population served; and

8. All applicable federal and state laws and regulations.

B. Employees or contractors providing case management services shall provide documentation of supervision or experience that demonstrates the following skills and abilities:

1. Identifying and documenting an individual's need for resources, services, and other supports;

2. Using information from assessments, evaluations, observation, and interviews to develop service plans or supports plans;

3. Identifying and documenting how resources, services, and natural supports, such as family or other persons as desired by the individual, can be utilized to promote achievement of an individual's personal habilitative or rehabilitative and life goals;

4. Coordinating the provision of services by diverse public and private providers;

5. Working as team members to maintain effective interagency and intraagency relationships;

6. Working independently and performing position duties under general supervision; and

7. Engaging in and sustaining ongoing relationships with individuals receiving services.

C. Case managers serving individuals with developmental disability shall complete the department's core competency-based curriculum within 30 days of hire.

The provider shall implement a written policy explaining how case managers are assigned and outlining the process by which an individual or the individual's representative, as appropriate, may request a change of an assigned case manager.