Chap II, page 18 says the following:  Person centered plans should document the individual’s goals in the short-term (within the next few weeks to months), medium-term (within the next year or two), and long-term (greater than two years).  Further, the individual should identify backup plans and supports that address needs that may go on for the short-term (hours to a day); medium-term (a week); and long-term (a month or more).  

 

    Where is this supposed to be documented, as the only POC that we have is a DMAS-97 and there is no place on this to document the above.  Will new forms be developed that service facilitators will be trained on?