(1) Intensive support coordination services are services for the support and coordination of medicaid home and community services provided to individual recipients in the intensive family support program.

(2) Intensive support coordination services include:

(a) providing ongoing monitoring of the recipient's services;

(b) intervening when necessary to ensure that the recipient's living situation continues to be healthy and safe, and that needs continue to be met;

(c) conducting periodic assessments of risk in order to ensure that the intensive family support arrangement is appropriate and safe given the recipient's unique abilities and needs;

(d) assessing the recipient to determine the resources and services needed to carry out the individual plan;

(e) developing, monitoring, and recording written plans of care in a way the recipient, caregivers, and others understand;

(f) meeting frequently with the recipient, and others, regarding the adequacy of the plan of care, how well the plan is being implemented, and changes which may be necessary in the plan;

(g) teaching the recipient and caregivers to independently locate and establish contact with agencies who can assist them in securing the services they require in order to reduce reliance on the service system, generally, and on intensive support coordination, specifically;

(h) facilitating interaction between people working in resource systems;

(i) mobilizing and using natural helping networks such as family members, neighbors and friends;

(j) providing inservice training to people providing habilitation, personal care, or other services to the recipient. Training includes general orientation and training on the specific needs of the recipient and how best to meet those needs;

(k) managing personal as well as cost plan dollars to ensure that personal and service needs are met and that funds are efficiently utilized and accurately reported;

(l) locating and arranging for suitable high quality housing, when necessary;

(m) providing for adequate supervision of the recipient during the day, evening, and weekend;

(n) hiring and supervising qualified staff to provide necessary services, with input from the recipient and caregivers;

(o) subcontracting for services required by the plan of care;

(p) ensuring that the recipient is free to choose a provider from among available qualified providers; and

(q) requiring documentation of the service provided and for approving payment to direct service providers.