The enhanced services facility must develop and maintain a person-centered service planning team for each resident. The ESF must:

(1) Ensure the person-centered service planning team includes the resident, the resident's representative when applicable, individuals chosen by the resident, a mental health professional, nursing staff, the medicaid client's department case manager, and other persons as needed;

(2) Provide the necessary information and support to ensure that the resident has an opportunity to identify team members, make informed choices and decisions regarding care and treatment, and direct the person-centered service planning process as much as possible;

(3) Ensure the person-centered service planning team has a coordinated approach to the development, implementation, and evaluation of the comprehensive person-centered service plan for the resident; and

(4) Ensure the person-centered service planning team meets at least monthly and more often as needed, at times and locations convenient to the resident, to review and modify the comprehensive person-centered service plan as needed.