Rule 24-2-44.2 - Support Coordination/Targeted Case Management ActivitiesA. Support Coordinators (SC) and Targeted Case Managers (TCM) are responsible for coordinating and monitoring all services a person receives, regardless of funding source, to ensure services are adequate, appropriate, meet individual needs, and ensure the person's health and welfare needs are met and addressed.B. SC/TCM coordinate and facilitate the development of the Plan of Services and Supports through the person-centered planning process.C. SC/TCM must revise and update each person's Plan of Services and Supports at least annually or when changes in the person's circumstances occur or when requests are made by the person/legal representative(s).D. SC/TCM inform and assist the person/legal representative(s) with access of services, both Home and Community-Based Services and non-Home and Community-Based Services, from which the person could benefit.E. SC/TCM inform the person/legal representative(s) about certified providers for the services on their approved Plan of Services and Supports initially, annually, if the person becomes dissatisfied with the current agency provider/service, when a new agency provider/service location is certified, or if an agency provider's certification status changes.F. SC/TCM assist the person/legal representative(s) with meeting/interviewing agency provider representatives and/or arranging tours of service locations until the person chooses an agency provider.G. SC/TCM are responsible for entering required information in each person's record in the Division of Medicaid's LTSS System.H. SC/TCM must notify each person/legal representative(s) in writing of: 1. Approval/denial of initial enrollment;2. Approval/denial of requests for additional services;3. Approval/denial of requests for increases in services;4. Approval for requests for recertification for services;5. Approval for requests for readmission;6. Reduction in service(s); and7. Termination of service(s).I. SC/TCM must inform and provide the person/legal representative(s) with the procedures for appealing the denial, reduction, or termination of ID/DD Waiver or IDD Community Support Program Services.J. SC/TCM must address issues related to a person's Plan of Services and Supports with their agency provider(s). If an agency provider is not responsive, the Support Coordinator/Targeted Case Manager is responsible for reporting the issue as a grievance through DMH's established grievance reporting procedures.K. SC/TCM must educate people, legal representative(s), and families on people's rights and the procedures for reporting instances of abuse, neglect, and exploitation at least annually.L. SC/TCM must perform all necessary functions for the person's annual recertification and continued eligibility to ensure each person's recertification is approved within one (1) year and services are not interrupted.M. The amount of contact a SC/TCM has with a person depends on the person's support needs. The following minimal requirements must be met:1. SC/TCM must conduct a face-to-face visit quarterly (every three [3] months) with the person, rotating observation of each service on the person's PSS. (a) Providers of all approved services not present at the quarterly visit must be contacted by telephone.(b) SC must conduct at least one (1) face-to-face visit with the person in their home annually.(c) The person's legal representative or primary caregiver (if applicable) must be contacted quarterly. Contact with the legal representative can be by phone if unable to attend the face-to-face visit.2. During months between quarterly visits, SC/TCM must contact each person on their caseload at a minimum of once a month. Contact may be made by telephone or face-to-face.3. Face-to-face visits for monthly contacts must be completed with the person if any of the following concerns are identified:(a) Person/representative is unable to communicate by phone due to an auditory or cognitive impairment;(b) Person has unmet needs that cannot be resolved by phone;(c) Person has identified risks for abuse, neglect, or exploitation; or(d) Person/representative is unable to be reached by phone after three (3) documented attempts.N. All contact with or for the person must be documented in Service Notes and should be entered in LTSS as they occur but no later than the last day of the month.O. SC/TCM must monitor service provision for compliance with HCBS Settings Rule to protect the person's rights. Any issues must be documented in Service Notes, followed up as needed, and reported to DMH Bureau of IDD if unresolved.P. Monitoring and assessment of the person's Plan of Services and Supports must include:1. Information about the person's health and welfare, including any changes in health status, needs for support, preferences, progress and accomplishments, and or changes in desired outcomes.2. Information about the person's satisfaction with current service(s) and provider(s) (IDD Services and others).3. Information addressing the need for any new services (IDD Services and others) based upon expressed needs or concerns or changing circumstances and actions taken to address the need(s).4. Review of utilization of services to determine services are rendered according to the approved Plan of Services and Supports and the amount/frequency of service(s) remains appropriate.6. Review of the Plan of Services and Supports and Activity Support Plan to determine the service(s) are addressing the person's outcomes.7. Review of all services a person receives, regardless of funding source, are coordinated to maximize the benefit and outcome for the person.8. Follow-up activities regarding issues/needs identified during monthly or quarterly contacts or those reported by providers.9. Determination of the need to update the Plan of Services and Supports.10. Information about new agency providers/service locations in the person's area.