When a “Plan of Care” Isn’t Really a Plan
Families and advocates navigating Massachusetts’ system for individuals with intellectual and developmental disabilities (IDD) often encounter two key documents: the Individual Support Plan (ISP) and the Plan of Care (POC). Understanding the difference between them is critical. Knowing these differences can help expose how the state is failing to meet its obligations.
📝 ISP vs. POC: What They Really Are
Individual Support Plan (ISP): This is the person‑centered plan required by Massachusetts regulation (115 CMR 6.20–6.25). It should capture the individual’s vision, goals, strategies, and outcomes. The ISP is meant to reflect dignity, self‑determination, and community integration.
Plan of Care (POC): In practice, this is the service grid, the list of services authorized to meet the goals in the ISP. It should specify the type of service, provider, frequency, and duration. The POC is also the document used to justify federal Medicaid reimbursement through the Federal Medical Assistance Percentage (FMAP).
Waiver Requirements: These documents (ISP and POC) are required under Massachusetts Home and Community-Based (HCBS) waivers. Only the ISP is required for institutional ICF/IID care. The ISP in institutional care is sometimes referred to as the individual Program Plan (IPP) and is focused on habilitation, not on waiver compliance.
⚠️ Why the Service Grid Must Be Specific
A meaningful POC must go beyond generic listings. It should spell out:
- Which supports are being provided (e.g., communication devices, behavioral supports, therapies, etc.).
- How often and by whom those supports are delivered.
- How they connect to ISP goals like independence, communication, or community participation.
When the service grid is nonspecific – reduced to “day habilitation, group home, service coordination” – it fails to meet the federal requirement for person‑centered planning. Without detail, there is no accountability, no individualized support, and no path to integration.
📄 Evidence of Failure
We obtained a redacted Plan of Care that illustrates this problem. Instead of individualized supports, it simply lists three generic services: day habilitation, residential services, and service coordination. We believe that these nonspecific Plans of Care (POC) may be common for individuals with severe and profound IDD, especially for those with severe and profound autism or co-morbid chronic medical conditions.
👉 Download the Redacted POC (PDF)
This is not a plan of care. It is a barebones service menu. By omitting specific supports, Massachusetts effectively denies individuals with severe IDD and autism the tools they need to participate in community life. This failure is more than bad practice because it raises serious civil rights concerns. Under Section 504 of the Rehabilitation Act and the Americans with Disabilities Act (ADA), individuals with disabilities are entitled to equal access and integration. A nonspecific POC that omits necessary supports to be integrated into community life is a denial of those rights.
🏥 Active Treatment: What Real Integration Looks Like
Contrast this with Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICF/IID), which are required by federal law to provide active treatment. The Wrentham Developmental Center and the Hogan Regional Center are categorized as ICF/IID facilities. Under 42 CFR §483.440, active treatment means a continuous, individualized program of training, treatment, and health services designed to help each person acquire skills for independence and community living.
Active treatment requires specificity: measurable goals, strategies, and accountability. It is far more likely to produce real integration than a boilerplate POC. Massachusetts’ reliance on nonspecific service grids falls far short of this federal standard.
📑 What Massachusetts Waiver Documents Say About Community-Based Person-Centered Planning
The Massachusetts Intensive Behavioral Supports (IBS) Waiver is one of the DDS-administered Home and Community-Based Services (HCBS) waivers, and it contains the exact assurances the Centers for Medicare and Medicaid Services (CMS) requires around person-centered planning.
Here’s what Massachusetts commits to CMS in the IBS waiver application:
- Person-Centered Service Planning
- Annual Review & Updates
- Conflict-Free Planning (Please note that Massachusetts regulation 115 CMR 6.22(4)(b) MANDATES conflict-of-interest planning, the exact opposite of what the state promised CMS on their waiver application.)
Massachusetts assures CMS that each plan includes:
- The individual’s strengths and preferences.
- Desired outcomes and goals.
- Specific services and supports to achieve those outcomes.
- Risk factors and strategies to minimize them.
- Documentation of informed choice (More below).
📑 What CMS Requires Regarding Documentation of Informed Choice
Under 42 CFR 441.301(c), every person-centered service plan must show that the individual:
- Had the chance to ask questions and receive answers in accessible formats.
- Made decisions voluntarily, without coercion.
- Could change their mind and request plan revisions.
- Was given information about all service options (including risks and benefits).
Service Options
Under 42 CFR 441.301(c) (HCBS person‑centered planning rules), the phrase “information about all service options” means the individual (or their representative) must be informed of all available Medicaid service options, not just those preferred by the state or a provider.
This includes institutional options like ICF/IID (Intermediate Care Facilities for Individuals with Intellectual Disabilities), because Medicaid law requires that individuals be free to choose between institutional and community‑based services.
The plan must document that the person was offered information about both HCBS waiver services and institutional services (ICF/IID, private congregate care facilities, etc.), even if the state strongly promotes community settings.
The plan must document this process, not just the outcome.
📝 What “Documentation of Informed Choice” Looks Like
Massachusetts assures CMS that each Plan of Care includes:
- Signatures or attestations: The individual (or guardian/representative) signs the plan to confirm they participated and understood the choices.
- Narrative notes: Case managers or service coordinators record what options were presented, what questions were asked, and what decisions were made.
- Choice statements: The plan explicitly states why certain services/supports were chosen and that alternatives were considered.
- Evidence of accessibility: Notes that information was provided in plain language, translated, or adapted for communication needs.
- Review dates: Documentation that choices were revisited during annual or interim reviews.
⚠️ The Gap in Practice
- On paper: Massachusetts tells CMS that every plan includes this documentation.
- In reality: For individuals with severe and profound IDD, “informed choice” often gets reduced to a checkbox or a provider-driven template.
- This weakens accountability. The documentation exists, but it doesn’t reflect a genuine process of informed decision-making.
👀 Oversight
- CMS reviews these assurances when approving the waiver.
- MassHealth (state Medicaid agency) is the official entity responsible for compliance.
- DDS operates the waiver under MassHealth’s authority.
⚠️ The Compliance Gap
- On Paper: Massachusetts tells CMS it complies fully with person-centered planning rules.
- In Reality: For individuals with severe IDD, plans are often boilerplate, inadequate, or not truly individualized.
- This means Massachusetts is assuring CMS of compliance it may not deliver in practice.
| Comparison of Intensive Behavioral Supports (IBS) waiver assurances and Massachusetts ISP regulations mandating provider-driven assessments | |||
|---|---|---|---|
| Topic | What Massachusetts tells CMS (IBS waiver application) | What Massachusetts regulations/practice require | Compliance risk |
| Person-centered service plan | Every participant has a person-centered plan, led by the individual and reflecting preferences, strengths, risks, and outcomes; reviewed at least annually | ISPs are governed by DDS regulations; assessments informing the ISP are performed by providers who also deliver services | Conflict-of-interest risk if assessors are also service providers, undermining conflict-free planning |
| Conflict-free planning | Plan development is separated from service delivery except where protections are demonstrated | State regulation and DDS standards mandate provider-performed evaluations that drive the ISP. | Structural conflict contradicts conflict-free assurances |
| Documentation of informed choice | Plans document choices, goals, and alternatives | Practice often relies on provider-authored evaluations and standard templates | Informed choice can be compromised if evaluations predetermine services |
When Plans of Care lack meaningful detail, they stop being tools for accountability and instead become shields for corporate providers. By keeping these documents vague, providers can claim compliance without being tied to specific service commitments. Families are left with paperwork that looks official but offers little recourse when promised supports aren’t delivered.
👀 Who Oversees This
CMS (Centers for Medicare & Medicaid Services):
- Reviews waiver applications and renewals.
- Can conduct monitoring and can impose corrective actions.
- Can hold Massachusetts accountable for the assurances it makes.
MassHealth (state Medicaid agency):
- Officially responsible for waiver compliance.
- DDS operates the IDD waivers under MassHealth’s authority.
👀 How Could a State Regulation Be in Direct Conflict with Promises on a Massachusetts Waiver Application? (115 CMR 6.22(4)(b))
The Massachusetts application for the intensive behavioral supports promises conflict of interest free service planning, yet a Massachusetts regulation mandates such conflicts of interest. How can that be?
Reliance on State Assurances:
Our United States IDD system is extremely complex with each state creating their own services and their own rules. CMS cannot independently audit every regulation in every state; it relies on what states submit in waiver applications. If Massachusetts says it has protections, CMS accepts that unless stakeholders raise red flags.
Waiver Review Process:
CMS waiver reviews are document-heavy and trust-based. Unless advocates or auditors highlight contradictions, CMS often approves based on the written assurances.
Oversight Gaps:
CMS oversight is periodic and limited. They depend on complaints, monitoring reports, and stakeholder input to uncover noncompliance.
📣 What We’re Doing About It
The Saving Wrentham and Hogan Alliance is committed to educating the public about these failures. We also are a central location to which you can bring your concerns. There is strength in numbers. By exposing inadequate Plans of Care and Individual Support Plans, highlighting civil rights violations, and contrasting them with the active treatment model, we are building awareness and pressing for accountability. Our mission is to ensure that individuals with severe and IDD and autism receive the individualized supports they need – not just a checkbox list of services, but real choices and plans that promote dignity, independence, and community integration.
👉 Key takeaway:
The ISP is the person‑centered plan. The POC is the service grid. When the grid is nonspecific, Massachusetts fails to meet person‑centered planning requirements, risks violating federal disability law, and denies individuals the supports they need to live fully in the community. By contrast, active treatment, as required in ICF/IID settings, is far more likely to produce meaningful outcomes and real community integration because it demands individualized goals, strategies, and accountability.