Address issues related to a person's Plan of Services and Supports with the applicable agency provider(s) and, when a provider is unresponsive, report the issue as a grievance through DMH's established grievance reporting procedures (Rule 44.2.J).Educate people, legal representatives, and families at least annually on rights and procedures for reporting abuse, neglect, and exploitation (Rule 44.2.K).Perform all functions necessary for each person's annual recertification and continued eligibility to ensure recertification is approved within one (1) year without interruption of services (Rule 44.2.L).Actively coordinate with other individuals and entities essential to the person's physical and behavioral care, including other care coordinators, to ensure seamless coordination between physical, behavioral, and support services (Rule 44.2.P.7).Conducts monitoring and assessment of the Plan of Services and Supports covering every element of Rule 44.2.P, including changes in health status and support needs, satisfaction with current services and providers, the need for new services and actions taken, utilization review against the approved plan, review of the plan and Activity Support Plan against the person's outcomes, coordination of all services regardless of funding source, follow-up on issues identified during monthly or quarterly contacts or reported by providers, determination of the need to update the plan, and information about new providers and service locations in the person's area (Rule 44.2.P).Conducts a face-to-face visit quarterly, rotating observation of each service on the person's Plan of Services and Supports; contacts by telephone any provider of an approved service not present at the quarterly visit; conducts at least one (1) face-to-face visit annually with the person in their home; and contacts the legal representative or primary caregiver quarterly (Rule 44.2.M.1).Contacts each person on the caseload at least once monthly during months between quarterly visits, by telephone or face-to-face (Rule 44.2.M.2).Conduct additional face-to-face monthly visits when a person cannot communicate by phone due to auditory or cognitive impairment, has unmet needs unresolved by phone, has identified risk of abuse, neglect, or exploitation, or cannot be reached by phone after three (3) documented attempts (Rule 44.2.M.3).Monitor service provision for compliance with the HCBS Settings Rule, documenting and following up on any issues, and reporting unresolved issues to the DMH Bureau of IDD (Rule 44.2.O).Develop and maintain a professional working relationship with people receiving services and their families and caregivers. Coordinate and facilitate development of each person's Plan of Services and Supports (PSS) through the person-centered planning process, and revise/update the plan at least annually or upon a change in circumstances or person/legal representative request (Rules 44.2.B–C).Inform and assist the person/legal representative(s) with access to Home and Community-Based Services and non-Home and Community-Based Services from which the person could benefit and ensure the person's choice of providers by supplying information needed to make a fully informed decision (Rule 44.2.D).Inform the person/legal representative(s) about certified providers for services on the approved Plan of Services and Supports initially, annually, upon dissatisfaction, or upon a change in provider certification status, and assist with meeting or interviewing providers and arranging tours until the person chooses an agency provider (Rules 44.2.E–F).Ensure the Behavior Support Plan, any support plan from a medical professional, and any Crisis Plan are consistent with the Plan of Services and Supports.