What is Person-Centered Service Planning?



The Communty HealthChoices Managed Care Organization (CHC MCO) Program is built on the principle of Person-Centered Service Planning, mandating that all Long Term Services and Supports services be planned with direct participant involvement.  

Brief History of Person-Centered Service Planning of PA CHC MCO Program


 

The concept of Person-Centered Service Planning emerged during the disability rights movements of the 1970s and 1980s, which advocated for greater independence, self-determination, and community inclusion for individuals with disabilities. This approach arose in response to earlier institutional models of care that often prioritized organizational convenience over the individual needs and preferences of those receiving services.
 

In the 1990s, Person-Centered Planning gained formal recognition through the establishment of Medicaid Home and Community-Based Services (HCBS) waivers, which allowed states to develop services that support individuals living in community settings rather than institutional facilities.
 

In the 2010s, the Centers for Medicare and Medicaid Services (CMS) issued regulations—most notably the 2014 CMS Final Rule on HCBS—which required all states to implement Person-Centered Service Planning standards within Medicaid-funded long-term services and supports (LTSS) programs. These regulations mandate that service plans must be developed through a participant-directed process that reflects each individual’s strengths, preferences, needs, and desired outcomes.
 

Building upon these federal requirements, Pennsylvania incorporated Person-Centered Service Planning into its Community HealthChoices (CHC) Managed Care Program, aligning state LTSS delivery with national best practices for participant-driven care.

Key principles of Person-Centered Service Planning include:
 

• Respect for Individual Choice and Control: Participants drive the decision-making process, setting their own goals and determining the supports they need to achieve them.
  
   

• Focus on Strengths and Abilities: Plans are designed to build on each person's strengths, capabilities, and resources, rather than solely addressing deficits.
  
   

• Holistic Understanding: Services are designed to consider the whole person — including health, emotional well-being, community connections, employment, education, and leisure interests — rather than focusing only on medical or functional needs.
  
   

• Community Inclusion and Engagement: Supports are tailored to promote meaningful participation in community life, encouraging independence, employment, social relationships, and civic involvement.
  
   

• Flexibility and Individualization: Plans must be flexible enough to adjust to changing circumstances, preferences, and goals, ensuring services remain relevant and supportive over time.
  
   

• Partnership and Collaboration: Participants are equal partners with Service Coordinators, Providers, and other team members in developing and updating the Service Plan.
  
   

• Preservation of Dignity and Privacy: All planning and service delivery must protect participants' dignity, privacy, and right to confidentiality.
  
   

• Focus on the Least Restrictive Environment: Supports aim to enable individuals to live in the setting of their choice, with the maximum level of independence possible.
  
   

• Cultural Competence and Responsiveness: Plans must honor and incorporate individuals’ cultural, ethnic, linguistic, and personal identities.

Person-Centered Service Plan (PCSP) Development Procedure

Procedure

1. Initiation of Service Planning

• A comprehensive Assessment must be completed for each Participant to identify medical, behavioral, functional, and social needs, strengths, risks, and preferences.

• Service Coordinators must initiate PCSP development within 30 calendar days of completing the Assessment or Reassessment.

• The Participant must be informed of their right to participate fully and direct the service planning process.
  
   

2. Formation of the Person-Centered Planning Team (PCPT)

• Assemble a team consisting of:

  • The Participant.

  • The Participant’s representative (if applicable).

  • Service Coordinator.

  • Providers and informal supports (family/friends) identified by the Participant.

• Ensure that all team members respect the Participant’s autonomy, dignity, and preferences.
  
   

3. Conducting the Service Planning Meeting

• The Service Planning Meeting must be scheduled at a date, time, and location convenient for the Participant.

• Ensure communication methods meet the Participant's needs (e.g., language assistance, interpreters, alternative formats).

• Discuss:

  • Participant’s goals, both short-term and long-term.

  • Services and supports needed to achieve identified goals.

  • Available and willing informal supports.

  • Participant’s preferred Providers.

  • Use of technology or telehealth, if appropriate.

  • Health-related education needs.

  • Employment and educational goals, if any.

  • Risk factors and strategies to minimize risks (e.g., fall prevention).

  • Development of an individualized back-up plan for service interruptions.

  • Preferred methods and frequency of communication with the Service Coordinator.
    
     

4. Service Plan Documentation

• The Service Coordinator must document the following:

  • Scope, amount, duration, and frequency of each authorized service.

  • Measurable outcomes for each intervention.

  • Persons or Providers responsible for each service or task.

  • Anticipated timelines for goal achievement.

  • Identified barriers and strategies to overcome them.

  • Community resources, non-covered services, and reasonable accommodations to be used.

  • Emergency backup plan verified by the Participant.
    
     

5. Participant Review and Approval

• Review the completed draft PCSP with the Participant for accuracy and completeness.

• Obtain written approval and signature from the Participant (or their representative if applicable).

• Provide a copy of the finalized PCSP to the Participant.

• Document the Participant’s understanding and agreement, including their right to appeal any part of the Plan if desired.
  
   

6. Implementation and Monitoring

• Services must commence within 7 business days of service authorization unless the Participant requests a later start date.

• Service Coordinators must regularly monitor service delivery, participant satisfaction, and progress toward goals.

• Service Plans must be reviewed and updated:

  • Annually at minimum.

  • Whenever there is a significant change in the Participant’s condition or circumstances.

  • Upon Participant request.
    
     

Supporting Documents
 

• Participant Assessment Form

• PCSP Template (Department-issued)

• Participant Rights Statement

• Informed Consent Form

• Service Authorization Forms

• PCSP Checklist (as required by DHS)

Notes
 

• The Participant must never be steered toward minimal services or limited engagement.

• HIPAA and participant confidentiality must be maintained throughout the service planning and delivery process.

• Plans must be flexible and adaptable to Participant’s changing needs and preferences.

Direct Care Worker Role and Compliance in Person-Centered Service Planning


Direct Care Workers play a vital role in bringing Person-Centered Service Planning to life. Upholding the principles of respect, flexibility, communication, and professionalism ensures that services are truly person-centered. Compliance with the Person-Centered Service Planning policies is not just a regulation — it’s essential to delivering care that empowers Participants and supports their independence, dignity, and well-being.

1. Respect for Participant Choice and Autonomy

PCSP Policy: Participants must have control over their services and how they are delivered.
DCW Expectation:

• DCWs must respect the Participant’s decisions about how and when care is provided (within the authorized service plan).

• DCWs should listen carefully to Participants' preferences and adjust their approach accordingly.
  
   

2. Individualized Services Based on Participant Goals

PCSP Policy: Services must support each Participant’s individual goals and desired outcomes.
DCW Expectation:

• DCWs must understand each Participant’s goals as outlined in their PCSP (e.g., greater independence, community participation).

• DCWs should frame their daily support around helping the Participant work toward these goals, not just completing tasks.
  
   

3. Maintaining Dignity and Privacy

PCSP Policy: Participant dignity and confidentiality must be protected at all times.
DCW Expectation:

• DCWs must maintain strict confidentiality about Participant conditions, care routines, and personal information (following HIPAA standards).

• DCWs should provide support in a way that maximizes Participant dignity, such as offering choices, asking for permission before assisting, and respecting personal space.
  
   

4. Compliance with Service Specifications

PCSP Policy: Services must be provided according to the scope, frequency, and tasks outlined in the approved PCSP.
DCW Expectation:

• DCWs must follow the care tasks, schedules, and timeframes authorized in the Participant’s plan.

• DCWs must avoid performing unauthorized tasks or missing assigned tasks unless directed by the Supervisor or updated in the Service Plan.
  
   

5. Communication and Reporting

PCSP Policy: Regular follow-up and monitoring of services and Participant satisfaction are required.
DCW Expectation:

• DCWs must communicate any changes in the Participant’s needs, preferences, health status, or home environment to the agency promptly.

• DCWs must accurately document daily care notes or EVV entries to reflect the services performed.
  
   

6. Emergency Preparedness and Back-Up Plans

PCSP Policy: Each Participant must have an emergency back-up plan for service interruptions.
DCW Expectation:

• DCWs must be familiar with the Participant’s individualized back-up plan and know the procedures to follow in case of emergencies or service disruptions.

• If unable to report for duty, DCWs must follow agency call-off procedures to trigger the backup plan.
  
   

7. Health-Related Education and Fall Prevention

PCSP Policy: Participants must receive support related to health needs, including fall prevention for those at risk.
DCW Expectation:

• DCWs must implement fall prevention strategies as directed (e.g., assisting with safe mobility, ensuring clear walkways).

• DCWs should encourage and safely assist Participants with any prescribed exercises or health-related routines, as outlined in the care plan.
  
   

8. Cultural Competence and Responsiveness

PCSP Policy: Services must be culturally appropriate and sensitive to Participants' backgrounds and preferences.
DCW Expectation:

• DCWs must respect Participants' cultural, religious, and personal beliefs when providing care.

• DCWs should avoid assumptions and should ask respectfully if unsure about cultural preferences.