DHS 10.44(2)(e)1.f. f. Mental health and cognition.

DHS 10.44(2)(e)1.g. g. Presence of, and opportunities for enhancing, informal supports.

DHS 10.44(2)(e)1.h. h. Understanding and exercising rights and responsibilities.

DHS 10.44(2)(e)1.i. i. Community integration.

DHS 10.44(2)(e)1.j. j. Safety.

DHS 10.44(2)(e)1.k. k. Personal values.

DHS 10.44(2)(e)1.L. L. Education and vocational activities, including any needs for job development, job modifications, and ongoing support on the job.

DHS 10.44(2)(e)1.m. m. Economic resources.

DHS 10.44(2)(e)1.n. n. Religious affiliations, if any.

DHS 10.44(2)(e)2. 2. Long-term care outcomes that are consistent with the values and preferences of the enrollee in at least the following areas:

DHS 10.44(2)(e)2.a. a. Safety.

DHS 10.44(2)(e)2.b. b. Best possible health.

DHS 10.44(2)(e)2.c. c. Self-determination of daily routine, services, activities and living situation.

DHS 10.44(2)(e)2.d. d. Privacy.

DHS 10.44(2)(e)2.e. e. Respect.

DHS 10.44(2)(e)2.f. f. Independence.

DHS 10.44(2)(e)2.g. g. Social roles and ties to family, friends and community.

DHS 10.44(2)(e)2.h. h. Educational and vocational activities.

DHS 10.44(2)(e)2.i. i. Desired level and type of participation in community life.

DHS 10.44(2)(e)2.j. j. Spiritual needs and desired participation in religious activities.

DHS 10.44(2)(f) (f) The CMO, in partnership with the enrollee, shall develop an individual service plan for each enrollee, with the full participation of the enrollee and any family members or other representatives that the enrollee wishes to participate. The CMO shall provide support, as needed, to enable the enrollee, family members or other representatives to make informed service plan decisions, and for the enrollee to participate as a full partner in the entire assessment and individual service plan development process. The service plan shall meet all of the following conditions:

DHS 10.44(2)(f)1. 1. Reasonably and effectively addresses all of the long-term care needs and utilizes all enrollee strengths and informal supports identified in the comprehensive assessment under par. (e) 1.

DHS 10.44(2)(f)2. 2. Reasonably and effectively addresses all of the enrollee’s long-term care outcomes identified in the comprehensive assessment under par. (e) 2. and assists the enrollee to be as self-reliant and autonomous as possible and desired by the enrollee.

DHS 10.44(2)(f)3. 3. Is cost-effective compared to alternative services or supports that could meet the same needs and achieve similar outcomes.

DHS 10.44(2)(f)4. 4. Is agreed to by the enrollee, except as provided in subd. 5.

DHS 10.44(2)(f)5. 5. If the enrollee and the CMO do not agree on a service plan, provide a method for the enrollee to file a grievance under s. DHS 10.53, request department review under s. DHS 10.54, or request a fair hearing under s. DHS 10.55. Pending the outcome of the grievance, review or fair hearing, the CMO shall offer its service plan for the enrollee, continue negotiating with the enrollee and document that the service plan meets all of the following conditions:

DHS 10.44(2)(f)5.a. a. Meets the conditions specified under subds. 1. to 3.

DHS 10.44(2)(f)5.b. b. Would not have a significant, long-term negative impact on the enrollee’s long-term care outcomes identified under par. (e) 2.

DHS 10.44(2)(f)5.c. c. Balances the needs and outcomes identified by the comprehensive assessment with reasonable cost, immediate availability of services and ability of the CMO to develop alternative services and living arrangements.