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Library: Policy

340:100-5-52. The Personal Support Team (Team)

Revised 9-15-2021

(a) The Team is composed of people selected by the service recipient who know and work with the service recipient or whose participation is necessary to achieve the service recipient's desired outcomes.

(1) To respect the service recipient's dignity and privacy, the Team is no larger than is necessary to plan and implement the services needed to achieve the service recipient's desired outcomes.  The Team is large enough to possess the expertise and capacity necessary to address the service recipient's needs, but not as large as to intimidate the service recipient or to stifle the service recipient's participation or that of his or her representatives.

(2) The core Team includes the service recipient, his or her case manager, the legal guardian, and advocate(s), when applicable and, who may be a parent, family member, friend, or another individual who knows the service recipient well.  The service recipient is assured of his or her opportunity to select an individual to serve as an advocate.

(3) Depending on the service recipient's needs and the issues addressed, the Team may include others.  The selection of these additional Team members reflects the service recipient's choices.

(b) The Team role is detailed in this subsection.

(1) Team members implement responsibilities identified in the Individual Plan (Plan) or in the Oklahoma Human Services (OKDHS) or Oklahoma Health Care Authority (OHCA) rules.  Implementation of the Plan may only be delegated to persons who are appropriately qualified and trained.

(2) The Team develops the Plan and reviews and approves strategies, protocols, and guidelines developed to implement services or supports.

(3) The service recipient or his or her guardian participate in the development of the Plan and provide written, informed consent for the Plan's implementation.

(4) The Team implements the Plan upon approval of the Plan of Care, and inclusion of service providers' signatures on the Plan signature sheet.

(5) A copy of the Plan is maintained, per Oklahoma Administrative Code (OAC) 340:100-3-40.  All staff implementing the Plan must be knowledgeable about its contents and have access to a copy of the Plan.

(6) Each Team member responsible for services identified in the Plan sends a quarterly summary of progress on assigned outcomes and action steps to the case manager.

(A) The quarterly summary of progress is due by the 10th of:

(i) April for services rendered in January, February, and March;

(ii) July for services rendered in April, May, and June;

(iii) October for services rendered in July, August, and September; and

(iv) January for services rendered in October, November, and December, unless an alternative schedule is specified in the Plan.

(B) The quarterly summary of progress includes:

(i) whether services were provided per the Plan, and if not why; and

(ii) if the outcomes were achieved; or

(iii) the outcome progress status, if not achieved.

(c) The case manager role is detailed in this subsection.

(1) Prior to the initial and annual Team meeting, the case manager meets with the service recipient and his or her advocate or legal guardian, when applicable, to review the individual situation, including the service recipient's vision and progress attaining the vision.  Among the questions explored are whether the service recipient is satisfied with the results of the Plan and whether outcomes need to be revised, based on the progress achieved, or on changing circumstances in the service recipient's life.  This review provides a clear agenda for the Team meeting and ensures the service recipient's input and participation.

(2) The case manager identifies available service providers for selection by the service recipient or legal guardian.

(3) The case manager ensures the size and composition of the Team support the person-centered planning process.

(A) The case manager plans for the participation of people whom the service recipient wants on the Team, people whose services are needed to achieve identified outcomes, and people who know the service recipient best.  The case manager sends Team members written or electronic notice of the meeting, at least 30-calendar days in advance of the annual Team meeting.

(B) Planning may occur in Team meetings or through individual or small group consultation according to the service recipient's wants and needs.

(C) The case manager notifies a Team member by letter when his or her services on the Team are no longer required:

(i) at the request of the service recipient or the legal guardian; or

(ii) when the Team member's performance reveals a course of action that:

(I) is not in the service recipient's best interest;

(II) is destructive toward the Team's collaborative process; or

(III) violates OKDHS or OHCA rules or accepted standards of professional practice.

(4) Unless the service recipient elects to chair his or her own meetings, the case manager serves as Team chair.

(5) The case manager empowers and supports the service recipient in setting the direction for the Team and in actively participating in Team meetings.

(6) The case manager writes or revises the Plan based on input from the Team.

(7) The case manager assists the Team in developing strategies, protocols, and guidelines to achieve the service recipient's preferred or needed outcomes.

(8) The case manager monitors all aspects of the Plan's implementation, per OAC 340:100-3-27.

(9) The case manager routinely asks the service recipient, his or her family, guardian, or advocate about their satisfaction with services and supports, and initiates appropriate action to identify and resolve barriers to consumer satisfaction.

(10) The case manager convenes Team meetings as needed.

(A) The Team evaluates if the Plan and its components are meeting the service recipient's objectives.

(B) The case manager may convene a Team meeting at the request of any Team member.

(C) Meetings are held at times and locations convenient for the service recipient.

(11) Case manager responsibilities are carried out by provider-agency program coordination staff when the service recipient receives state-funded employment, state-funded group home, or assisted living services without Waiver supports.  Each person filling this role in a provider agency must have a minimum of four years of any combination of college level education and full-time equivalent experience in serving persons with disabilities, unless this requirement is waived in writing by the DDS director or designee.

(12) The planning process must:

(A) reflect the service recipient's cultural considerations;

(B) be provided in plain language in an accessible manner; and

(C) provide needed language services or aids.

(13) In order to avoid a conflict of interest, DDS staff including the case manager, case management supervisor, and plan of care reviewer must not:

(A) be related by blood or marriage to the service recipient, or any paid service provider for the service recipient;

(B) be financially responsible for the service recipient;

(C) be empowered to make financial or health related decisions for the service recipient; or

(D) hold a financial interest in any entity paid to provide care for the service recipient. 


Revised 9-15-16

1. When a key person cannot attend the meeting, the case manager secures written or verbal input from that person prior to the meeting.

2. Since the absence of a complaint does not necessarily imply satisfaction, the case manager initiates action to resolve barriers when:

3. When applicable, the case manager coordinates the times and locations of meetings with the service recipient's legal guardian.

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