(a) The Personal Support Team (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 outcomes desired by the service recipient.

• (1) To respect the dignity and privacy of the service recipient, the Team is no larger than is necessary to plan for 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 so large as to intimidate the service recipient or to stifle participation on the part of the service recipient or his or her representatives.
• (2) At its core, the Team includes the service recipient, his or her case manager, the legal guardian, and advocate(s), if there is one, who may be a parent, a family member, a friend, or another who knows the service recipient well.  The service recipient is assured the opportunity to select an individual to serve as an advocate.
• (3) Depending on the needs of the service recipient and the issues to be addressed, the Team may include others.  The selection of these additional Team members reflects the choices of the service recipient.

(b) The role of the Team is explained in this subsection.

• (1) Team members implement responsibilities identified in the Individual Plan (Plan) or in the Oklahoma Department of 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 reviews and approves strategies, plans, and guidelines developed to implement services or supports.
• (3) The Team implements the Plan upon approval of the Plan of Care.
• (4) A copy of the Plan is maintained in accordance with 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.
• (5) Each Team member responsible for services identified in the Plan sends a monthly summary of progress on assigned outcomes and action steps to the case manager by the tenth of each month, unless an alternative schedule is specified in the Plan.

(c) The role of the case manager is detailed in this paragraph.

• (1) Prior to the initial and each annual Team meeting, the case manager meets with the service recipient and the service recipient's advocate or legal guardian, if there is one, to review the individual situation, including the service recipient's desired vision and progress in 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 assures 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 that 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 desires to have on the Team, people whose services are needed to achieve identified outcomes, and people who know the service recipient best. The case manager sends written notice of the annual meeting to all Team members at least two weeks in advance.   • 1
• (B) Planning may occur in Team meetings or through individual or small group consultation according to the desires and needs of the service recipient.
• (C) The case manager notifies a Team member by letter that 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) if the performance of the Team member reveals a course of action that:
• (I) is not in the best interest of the service recipient;
• (II) is destructive towards the collaborative process of the Team; 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 chair of the Team.
• (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, plans, and guidelines to achieve the outcomes desired or needed by the service recipient.
• (8) The case manager monitors all aspects of the Plan's implementation.  Each month, contact notes reflect the case manager's review of the progress of each service recipient.
• (9) The case manager routinely asks the service recipient and 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.  • 2
• (10) The case manager convenes Team meetings as needed.
• (A) The Team, as needed, evaluates whether the Plan and its components are meeting the objectives of the service recipient.
• (B) The case manager convenes a Team meeting, when needed, at the request of any Team member.
• (11) Case manager responsibilities are carried out by service agency program coordination staff if the service recipient does not receive Developmental Disabilities Services Division (DDSD) case management services.  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 DDSD director or designee.