Person-Centered Planning Rules for HCBS: What DSPs Need to Know

If you support someone through a Medicaid home and community-based services (HCBS) waiver, there is a written plan behind almost everything you do with them: where they live, what services they get, who provides them, and any limits on their daily routine. Federal rules call it the person-centered service plan, and they're specific about how it's built, what it has to say and how often it's reviewed.

This guide walks through those federal rules in plain language. It's written for direct support professionals (DSPs) who carry out plans every shift, and for the supervisors and managers who make sure the agency's day-to-day practice matches the plan.

Where the rules come from

The main rule is 42 CFR 441.301(c), which sets what a state's 1915(c) HCBS waiver must include. Paragraph (c)(1) covers the planning process, (c)(2) covers what the written plan must contain, (c)(3) covers reviews, and (c)(4) covers the qualities every HCBS setting must have. States that offer HCBS through the 1915(i) state plan option follow parallel planning rules at 42 CFR 441.725.

CMS added new review and reporting requirements in its 2024 Ensuring Access to Medicaid Services final rule (89 FR 40542), published May 10, 2024 and effective July 9, 2024. More on that below.

Your state's waiver, licensing rules and case management agency add their own forms and timelines on top of the federal floor, so the details of "your" plan will look different from state to state.

The person leads the planning process

The rule starts with who's in charge. The individual, or the individual together with their authorized representative, leads the person-centered planning process. Under 441.301(c)(1), the process must:

• Include people the individual chooses.
• Give the person the information and support they need to direct the process as much as possible and make informed choices.
• Happen at times and places that are convenient for the person.
• Reflect the person's cultural considerations and use plain language that's accessible to people with disabilities and people with limited English proficiency.
• Include ways to resolve conflict or disagreement, with clear conflict-of-interest guidelines for everyone involved.
• Offer informed choices about which services and supports the person receives, and from whom.
• Include a way for the person to ask for updates to the plan.
• Record the alternative home and community-based settings the person considered.

One provision matters a lot to provider agencies. Providers of HCBS for the person, and anyone who has an interest in or works for that provider, must not provide case management or develop the person-centered service plan. The only exception is when the state shows that the only willing and qualified entity in an area also provides HCBS, and then CMS has to approve the state's conflict-of-interest protections.

In practice, that means your agency usually isn't the one writing the plan. Your job is to bring what you know about the person to the planning meeting, when the person wants you there, and then carry the plan out faithfully.

What the written plan has to include

Under 441.301(c)(2), the plan has to reflect both what the person needs, based on an assessment of functional need, and what matters to them about how services are delivered. Among other things, the written plan must:

• Show that the person chose the setting where they live.
• Reflect the person's strengths and preferences.
• Reflect clinical and support needs identified in the functional assessment.
• Include goals and desired outcomes the person identified.
• List the paid and unpaid supports that will help them reach those goals, and who provides them, including natural supports like family and friends.
• Name risk factors and the steps in place to reduce them, including individualized backup plans.
• Be understandable to the person and the people who support them, written in plain language.
• Name who is responsible for monitoring the plan.
• Be finalized with the person's written informed consent and signed by all individuals and providers responsible for carrying it out.
• Be distributed to the person and the others involved in the plan.
• Include any services the person chooses to self-direct.
• Prevent unnecessary or inappropriate services.

For DSPs, the most practical items on that list are the goals, the risk factors and backup plans, and the person's preferences. Those are the parts that should shape an ordinary shift.

Rules about restrictions

The settings part of the rule, 441.301(c)(4), says every HCBS setting must support full access to the wider community, protect privacy, dignity, respect and freedom from coercion and restraint, and optimize, but not regiment, the person's independence in daily choices.

Provider-owned or controlled residential settings, such as many group homes, have extra conditions. People must have a lease or comparable written agreement with eviction protections, privacy in their unit with a door they can lock (only appropriate staff have keys), a choice of roommates, freedom to furnish and decorate, control of their own schedules and activities, access to food at any time, visitors of their choosing at any time, and a physically accessible setting.

Those conditions can only be modified for a specific person, and only through the plan. The rule requires the plan to document all of the following:

1. A specific, individualized assessed need.
2. The positive interventions and supports used before the modification.
3. Less intrusive methods that were tried and didn't work.
4. A clear description of the condition, directly proportionate to the need.
5. Regular collection and review of data on whether the modification is working.
6. Time limits for periodic reviews of whether it's still needed.
7. The person's informed consent.
8. An assurance that the interventions and supports will cause no harm.

This is where frontline practice and compliance meet. A locked kitchen, a set bedtime or a limit on visitors that isn't written into that person's plan, with all eight items, isn't allowed under the federal rule. If a DSP is told to enforce a restriction they can't find in the plan, the right move is to ask a supervisor where it's documented.

How often the plan is reviewed

Under 441.301(c)(3), the state must make sure each person's plan is reviewed, and revised as appropriate based on a reassessment of functional need, at least every 12 months, when the person's circumstances or needs change significantly, or when the person asks.

The 2024 Access rule added a minimum performance level. States must show, through reporting under 42 CFR 441.311(b)(3), that for at least 90 percent of people continuously enrolled in the waiver for at least 365 days, the functional reassessment is completed at least every 12 months and the plan is reviewed, and revised as appropriate, at least every 12 months. States must meet those levels beginning three years after July 9, 2024. For HCBS delivered through managed care contracts, the clock starts with the first rating period beginning on or after that date.

Providers don't run these reviews, but they feed them. A significant change you notice, such as a hospitalization, a new diagnosis, a move or a big shift in what the person wants, is exactly the kind of thing that can trigger a plan review before the annual date. Agencies should have a clear way for DSPs to report those changes up the chain.

What this means on a DSP's shift

The rule is written for states, but it shows up in a DSP's day in concrete ways:

• Know the plan. Read the goals, preferences, risk factors and backup plans for each person you support, and ask when something isn't clear.
• Support choice. The person directs daily activities, schedule and who they spend time with, unless the plan documents a specific modification.
• Respect privacy. Knock, use keys only as appropriate, and protect the person's space.
• Watch for change. Report significant changes in health, behavior or preferences so the plan can be updated.
• Document what you see. Data on goals and on any modification is what reviewers use to decide whether the plan is working.

What this means for managers

• Make sure each staff member who carries out a plan knows what's in it, and keep a record of that training.
• Sign the plan as a provider responsible for implementation, and make sure it reaches the staff who use it.
• Audit house rules against the settings conditions. Anything that limits a lease protection, privacy, roommates, decorating, schedules, food access or visitors needs to be in that person's plan with all eight required elements.
• Build a simple route for DSPs to flag changes in a person's needs to the case manager.
• Keep your agency's own staff out of plan development or case management for people you serve, unless your state's CMS-approved conflict-of-interest protections apply.

How TES helps

Our catalog includes Person Centered Planning for Direct Support Professionals, along with Supporting Individuals and Families in Making Choices for Direct Support Professionals, Promoting Community Integration and Inclusion for Direct Support Professionals and Fundamental Rights for Direct Support Professionals. Together they cover the values behind the federal rules. Staff still need training on each person's own plan, which no general course can replace. Our guide to tracking employee training in a care agency covers how to keep those records audit-ready.

Training & eTracking Solutions has trained more than 200,000 professionals since 2010, and our catalog includes 400+ courses and programs. As an NADSP Accredited Education provider, our courses count toward the DSP-I and DSP-II credentials. Contact us to set up person-centered practice training for your team.

This article summarizes federal Medicaid rules at 42 CFR 441.301 and 441.725, as published in the Electronic Code of Federal Regulations, and the 2024 Ensuring Access to Medicaid Services final rule. It is not legal advice. State waivers, licensing rules and managed care contracts add their own requirements, so check the current text and your state's guidance before making compliance decisions.