dp 1050 (isp review checklist)
TRANSCRIPT
ISP Review Checklist
DP 1050 9/13Page i
InstructionsThis checklist is to be used by providers, supports coordinators (SCs), and administrative entities (AEs) in the preparation, completion and review of Individual Support Plans (ISPs) for waiver participants that include any of the following services.
• Licensedandunlicensedresidentialhabilitation• Licensed6400one-personhomes
* Pleasenote:55PACode,Chapter6400settingwithanapprovedprogramcapacityofone-personwillbehereinafterreferredtoas“licensed6400one-personhomes”.
• Intensivestaffing- Licensed(2380and2390)dayprogramservicewith1:1orhigherstaffingratio- Unlicensedhome&communityhabilitationwithanaverageof16hours(64units)ormoredaily- Supplementalhabilitation/additionalindividualizedstaffing(SH/AIS)
* ThischecklistreplacesDP1035.PleasereferencetheSH/AISuserguide.• Pre-vocationalservices• Supportedemployment–jobfindingservices
Use of the ISP Review Checklist for individuals who are base-funded is encouraged. Please consult with the county program if you have questions regarding the use of this checklist for the ISPs of base funded individuals.
When to complete sections of the checklist for:
Annual Review ISPs • SectionA:GeneralISPrequirements• SectionB:Licensedandunlicensedresidentialhabilitation• SectionC:Licensed6400one-personhomeguidelines• SectionD:Intensivestaffing
- Licenseddayprogramwith1:1orhigherstaffingratio- Unlicensedhome&communityhabilitation16hours(64units)ormoredaily
Critical Revision ISPs• SectionB:Licensedandunlicensedresidentialhabilitation• SectionC:Licensed6400one-personhomeguidelines• SectionD:Intensivestaffing
- Licensedpayprogramwith1:1orhigherstaffingratio- Unlicensedhome&communityhabilitation16hours(64units)ormoredaily- SH/AIS
Biannual ISPs also referred to Six-month reviews• SectionB:Licensedandunlicensedresidentialhabilitation• SectionC:Licensed6400one-personhomeguidelines• SectionE:Pre-vocational• SectionF:Supportedemployment–jobfinding
Items with asterisks (*) throughout the checklist mean:
* Itemmustmeetthestandard/bedocumentedintheISPinorderfortheISPtobeapproved.
**If“no”isselectedforthisitem,theAEandSCOmustcollaboratetoensuretheISPisrevisedtoincludethisinformationuponsubmission of the next annual review ISP or critical revision.
Definition of terms:• Itemtodiscuss/documentinISP–Theteamshouldusetheseitemstodirecttheirdiscussionsrelatedtoservices.• Recommended ISP section–“Itemstodiscuss/documentintheISP”shouldbeincludedinthesesectionsoftheISP.• Item documented?–TheAEshallvalidatethatinformationwasdocumentedtosupporttheneedfortheservice(s).• Criteria met–ThissectionisforODPtocompleteduringSH/AISreviewsinordertomakeanauthorizationdecision.
Providers:1. InitiateandcompletetheprovidersectionoftheISPReviewChecklistandprovidesupportingdocumentationforthefollowing
reasons:• Six-monthreviewofservicesinsectionsB,C,Eand/orF.• AllSH/AISrequests-sectionD.
2. SaveForm->(namingconvention:MCI#_ISPChecklist).3. SubmitsupportingdocumentationalongwithISPreviewchecklisttoSCandmaintaincopyofchecklistaswellas
documentation that information was forwarded to SC.
ISP Review Checklist
DP 1050 9/13Page ii
Supports Coordinators: 1. InitiateandcompletetheChecklistforthefollowingreasons: • AnnualreviewISPsthatincludetheidentifiedservicesinsectionsA,B,C,andD(excludingSH/AIS) • CriticalrevisionISPsthatincludetheidentifiedservicesinsectionsB,CandD(excludingSH/AIS)2. CompileinformationformultipleprovidersintotheProvidersectionoftheISPChecklistwhenapplicable.3. Conveneadiscussionwithteammembersregardingtheneedfortheservice.4. Documentthedateandsummaryoftheteamdiscussionintheoutcomeaction“Howwillyouknowthatprogressisbeingmade
towardtheoutcome?”sectionoftheindividual’sIPS.5. Reviewsectionofthechecklistthatappliestoservice.SectionAmustbecompletedforallISPswithidentifiedservicesduring
Annual review ISPs. 6. Complete“RecommendedISPSection”column.CheckofsectionsonthechecklisttoindicateinwhatareaoftheISPthat
information is documented.7. SaveForm->(namingconvention:MCI#_ISPChecklist).8. ForwardchecklisttotheAEatthetimeofsubmissionoftheISP.
• AnnualreviewandcriticalrevisionISPsforidentifiedservices–submitchecklisttoAE.• BiannualreviewISPforsix-monthreviewsofresidentialhabilitation,licensed6400one-personhomes,pre-vocational,and job-findingwhentheindividualdoesnotmeetcriteria.
Administrative Entities: 1. UponreceiptoftheChecklist,ensuretherequiredSectionsarecompletedduringthefollowingtimes:
Annual Review ISPs:• SectionA:GeneralISPrequirements• SectionB:Licensedandunlicensedresidentialhabilitation• SectionC:Licensed6400one-personhomeguidelines• SectionD:Intensivestaffing- Licenseddayprogramwith1:1orhigherstaffingratio- Unlicensedhome&communityhabilitation16hours(64units)ormoredaily
Critical Revision ISPs:• SectionB:Licensedandunlicensedresidentialhabilitation• SectionC:Licensed6400one-personhomeguidelines• SectionD:Intensivestaffing- Licensedpayprogramwith1:1orhigherstaffingratio- Unlicensedhome&communityhabilitation16hours(64units)ormoredaily- SH/AIS
Biannual ISPs also referred to six-month reviews ONLY if criteria is not met:• SectionB:Licensedandunlicensedresidentialhabilitation• SectionC:Licensed6400one-personhomeguidelines• SectionE:Pre-vocational• SectionF:Supportedemployment–jobfinding
2. ReviewISPstoensureinformationinthechecklistisdocumentedandsupportstheneedforservice/servicerequestinordertomakeanauthorizationdetermination.• SectionA–foreveryannualreviewISPthatincludesanewrequestforanyoftheidentifiedservices.• SectionD–forwardauthorizationrecommendationtoODP.• SectionsB,C,F.- Criticalrevisionsthatincludeaninitialrequestforanidentifiedservice.- Six-monthreviewindicatesindividualnolongermeetscriteria.
3. AEshallrequestclarificationfromSCOiftheAEfeelsthatadditionalinformationisneededtomakeauthorizationdeterminationforservice.Ifadditionalinformationcannotbeobtainedwithinthesevencalendardaytime-frameortheinformationprovideddoesnotfullysubstantiatetheneed,theAEshallauthorizetheservices,inpart,foralimitedtime,ordenyandcommunicatethedecisiontotheSCO&provider.
4. Notifytheindividualofthedecision,basisforthedecisionandissuefairhearingandappealrights.5. Complete“ItemDocumented?”column.6. AEshallmaintainchecklistforindividual’sfile.
Office of Developmental Programs: 1. ReviewISPswithSH/AISrequestsinordertomakeanauthorizationdetermination.
• PleasereferencetheSH/AISproceduresuserguideformoredetailsrelatedtoSH/AIS.
ISP Review Checklist
DP 1050 9/13Page 1
DATE INITIATED:
Individual’s name: MCI:
Initiator of checklist: Provider
Supports Coordinator
Activity: Six-month review Annual review
(Complete first.) SH/AIS Critical revision
Type of service: Unlicensed & licensed residential habilitation Intensive Staffing - SH/AIS
(Check all that apply.) Licensed 6400 one-person home Pre-vocational
(Complete second.) Intensive staffing - day program 1:1 or higher Supported employment - job-finding
Intensive staffing - HCH 16 hours or more
SCO:
SC name: SC e-mail:
AE:
AE contact name: AE e-mail:
Provider Information
Provider name: MPI: SLC:
SLC address:
Provider contact name: Contact e-mail:
Provider Information *
Provider name: MPI: SLC:
SLC address:
Provider contact name: Contact e-mail:
Provider Information *
Provider name: MPI: SLC:
SLC address:
Provider contact name: Contact e-mail:
* If multiple providers, SC should compile information into one individual checklist.
ISP Review Checklist
DP 1050 9/13Page 2
Provider to Complete (SH/AIS ONLY)
Current staffing pattern: Date service requested: Service Requested: Units Days
Type of service: Category of need:
Administrative Entity to Complete
AE reviewer name: Authorization recommendation:
Date returned to SCO when more information is needed:
Reason/information requested:
Date forwarded to ODP (SH/AIS only):
ODP to Complete (SH/AIS Only)
ODP reviewer: Requested prior authorization dates:
Prior authorization decision:
Reviewer comments:
Approver name:
Provider to Complete/SC to CompileReason for service need/justification of on-going service need:
Explanation of what type of support the staff will be providing:
ISP Review Checklist
DP 1050 9/13Page 3
Section A: General ISP RequirementsNote:thissectionisonlyrequiredforannualreviews.
Item to Discuss/Document in ISPTeam to Review
Recommended ISP SectionSC to Complete
Item Documented?AE to Complete
1. Theoutcomeactionsaremeasurableandobservable.*
Outcomeactions:howwillyouknowprogressis being made? Yes No*
2. TheoutcomesincludedintheISPrelatetoanidentifiedpreference;eachoutcomedescribeshowitwillmakeadifferenceintheindividual’slife.*
Individual preferences
Outcomesummary:reasonforoutcome
Outcomeactions
Other___________________________________
Yes No*
3. Useofnatural/non-paidsupports**
•Outcomeactionsexplaintherole/useofnaturalsupportsand/ornon-paidsupports.
• Documentationisavailableregardingeffortstoexplorenaturaland/ornon-paidsupports.
Know&do
Outcomeactions:whatactionsareneeded?
Other___________________________________ Yes No**
4. TheISPindicateshowprogress/successwillbe determined and documented and how the service supports the outcome.*
Outcomeactions:howwillyouknowprogressis being made?
Other___________________________________ Yes No*
5. Progress has been made toward each identifiedoutcome.Ifnoprogresshasbeenmade, an explanation is provided.**
Outcomeactions:whatarethecurrentneeds?
Other___________________________________ Yes No** NA
FornewISPs,selectN/A
6.WaiverservicesincludedintheISParebasedon assessed needs.*
OutcomeSummary:relevantassessments
Other___________________________________ Yes No*
7. Specifictrainingand/orspecificskillsneededby staff providing services (beyond general staff orientation) are described in the ISP.*
Know&do
Behavioralsupportplan
Outcomeactions:whatactionsareneeded?
Other___________________________________
Yes No*
8. TheISPincludesthetypeofservicestobeprovidedincludingthefrequencyofeachwaiver-eligibleservice.*
Outcomeactions:frequencyandduration
Service details
Other___________________________________
Yes No*
9. TheinformationintheISPisconsistentandnoobviouscontradictionswerefound.(Forexample, the ISP documents that the individual hasdifficultyambulatingwithoutassistance,but is able to evacuate independently.)*
Yes No*
10.TheISPincludesdocumentationthatthereare opportunities for the person to have an “everydaylife”.Thisshouldinclude:**
•Opportunitiestoexercisechoiceandcontrol;
• Specificactionstosupportandpromotetheperson’sconnectiontothecommunity;
• Actionstosupporttheperson’sindividuality,freedom and rights.
Know&do
Important to
Desired activities
What makes sense
Like&admire
Employment/volunteer
Understandingcommunication
Outcomesummary:outcomestatement
Outcomeactions
Other___________________________________
Yes No**
11.Themedicalappointments/healthevaluationslisted in the ISP include all known visits to any healthcarepractitionerinthepast12months.*
Medical:healthevaluations
Other___________________________________ Yes No*
12.Fortransition-agestudents(beginningatage14):TheISPdocumentsthatcollaborativetransition planning activities are occurring to preparetheyouth/youngadultforadultlife.
Educational/vocational
Outcomesummary
Outcomeactions
Other___________________________________
Yes No NA
ISP Review Checklist
DP 1050 9/13Page 4
Section A: General ISP RequirementsNote:thissectionisonlyrequiredforannualreviews.
Item to Discuss/Document in ISPTeam to Review
Recommended ISP SectionSC to Complete
Item Documented?AE to Complete
13.Thereisdemonstrationthatopportunitiestowork have been explored. The functional level employment screen should be completed for the following:
• Anindividualage16to26;and/or
• Anindividualwithvocationalservicesandoutcomesregardlessofageandsetting; and/or
• Anindividualleavingastatecenter.*
Know&do
Employment/volunteer
Outcomesummary
Outcomeactions
Other___________________________________
Yes No* NA
SelectN/Aifthefunctionallevelemploymentrequirementdoes not apply.
14.Ifthereareunmetneed(s)identifiedintheplanning process then unmet need(s) are documentedthroughPUNS.*
Outcomesummary
Outcomeactions
PUNS(supportingdocumentation)
Other___________________________________
Yes No* NA
If an individual in the waiver is also on the Emergency PUNS,documentationmustincludewhatisbeingdonetomeettheindividual’sneedandassurehealthandsafety.ChooseN/AiftherearenounmetneedsorifthePUNScategory of need is critical or planning.
15.Servicesfromotherservicesystemsarepursuedandincorporatedwhereappropriate(EPSDT,C&Y,MH,IDEA,etc.).
Note:iftheindividualisentitledtoanotherservice,waiver must be the payer of last resort.
Outcomeactions:whatactionsareneeded?
Other___________________________________ Yes No NA
If waiver is the payer for other services to which the individual is entitled and limitations have not been reached, the ISP may not be approved.
16.ThereisdocumentationofdenialforallserviceseligibleforpaymentthroughMAstateplanorprivate insurance.*
Outcomesummary:concernsrelatedtooutcome
Other___________________________________
Denial documentation (supporting documentation)
Yes No* NA
ChooseN/AiftherearenoserviceseligibleforMAstateplan or private insurance.
17.ThereisawrittenOVRdeterminationthattheserviceisnotavailablethroughOVR(RehabilitationActof1973).*
Ifwaiverfundingisrequestedforemploymentorpre-vocationalservices,adeterminationmustbeevaluated.
Outcomesummary:concernsrelatedtooutcome
Other___________________________________ Yes No* NA
ChooseN/Aiftheseservicesarenotbeingrequested.
Comments:
ISP Review Checklist
DP 1050 9/13Page 5
Section B: Residential Habilitation CriteriaInitial Request, Annual Review & Six-Month Review
Item to Discuss/Document in ISPTeam to Review
Recommended ISP SectionSC to Complete
Item Documented?AE to Complete
1. No person is willing or able to provide the needed natural supports or paid supports for the participant in a private home.
Know & do
Outcome actions: what are current needs?
Other ___________________________________
Yes No
2. The participant health, safety and welfare would not be met with a non-residential habilitation service or natural supports in a private home.
Know & do
Health & safety: focus areas
Outcome actions: what are current needs?
Other ___________________________________
Yes No
3. Others would be at risk of harm if a residential habilitation service was not provided for the participant.
Know & do
Behavioral support plan
Outcome summary: reason for outcome
Outcome actions: what are current needs?
Other ___________________________________
Yes No NA
NA - If others would not be at risk of harm. If NA, explanation should be documented in comments.
4. Assessments indicate the participant’s needs can only be met through the provision of a residential habilitation service.
Know & do
Non-medical evaluations
Outcome summary: relevant assessments
Outcome actions: what actions are needed?
Other ___________________________________
Yes No
5. The residential habilitation setting is the least restrictive and most appropriate size to ensure the participant’s health and welfare while continuing to meet the assessed need.
Know & do
Outcome summary: reason for outcome
Outcome actions: what are current needs?
Other _____________________________________
Yes No
If no, a transition plan must be present and documented in the ISP.
Family Living/LifesharingIf criteria 1-5 is met, family living/lifesharing should be discussed before a new residential service is included in the ISP. Family living/lifesharing options should be renewed annually.
6. The ISP indicates that family living/lifesharing options were discussed before a new residential service is included and that this option was reviewed annually.
Know & do
Outcome summary: relevant assessments
Outcome actions: what are current needs?
Other _____________________________________
Yes No NA
NA - Individual is already in family living/lifesharing.
Comments:
ISP Review Checklist
DP 1050 9/13Page 6
Section C: Licensed 6400 One-Person Home GuidelinesInitial Request, Annual Review & Six-Month Review
Item to Discuss/Document in ISPTeam to Review
Recommended ISP SectionSC to Complete
Item Documented?AE to Complete
One-PersonHome-mustmeetall guidelines.
1. Medicalandbehavioraldataforaperiodnot less than two months should be used to supporttheresidentialsettingsizeselected.If there are not two months of data available, there should be clinical documentation that the individual’sbehaviorisdangerousdespitealltreatment attempts.
Know&do
Psychosocial information
Health&safety:focusarea(asappropriate)
Behavioralsupportplan
Other___________________________________
Yes No
2. Theperson’sbehaviorisnotimprovedby current behavioral or mental health interventions.
Know&do
Psychosocial information
Behavioralsupportplan
Other___________________________________
Yes No
3. Thepersonpresentsanon-goingdangertoselforothers.
Know&do
Psychosocial information
Health&safety:focusarea(asappropriate)
Behavioralsupportplan
Other___________________________________
Yes No
4. Thepersonregularlyengagesorattemptstoengage in aggressive or assaultive behavior to self and others.
Know&do
Psychosocial information
Health&safety:focusarea(asappropriate)
Behavioralsupportplan
Other___________________________________
Yes No
5. Additionalstaffingand/orenvironmentaladjustmentsinalargersettinghavefailedtoensure the health and safety of the person and others.
Know&do
Psychosocial information
Health&safety:focusarea(asappropriate)
Supervision care needs: reasons for intensive staffing
Behavioralsupportplan
Other___________________________________
Yes No NA
ChooseN/Aifthisisanewresidentialhabilitationrequest.
6. Thepersonhasabehaviorsupportplanwhichpriortoorwithin30daysofmovingintoaone-personhomemustbeupdatedtoincludea fading plan to eliminate the need for a segregatedone-personhome.
Supervision care needs: reasons for intensive staffing
Behavioralsupportplan Outcomeaction:howwillyouknowthat
progress is being made toward this outcome?
Other___________________________________
Yes No
7. What are the staff responsibilities in supporting the individual?*
Know&do
Health&safety:focusarea(asappropriate)
Outcomeactions:whatactionsareneeded
Other___________________________________
Yes No*
Comments:
ISP Review Checklist
DP 1050 9/13Page 7
Section D: Intensive StaffingDayprogram1:1orhigher HomeandCommunityHabilitation-unlicensed16hours(64units)ormore SH/AIS
Item to Discuss/Document in ISPTeam to Review
Recommended ISP SectionSC to Complete
Item Documented?AE to Complete
Criteria Met? ODP to Complete
SH/AIS Only
1. Thechangeinneedisdescribed,includinghowthischangeaffectstheperson’shealthandwelfare.*
Know&do
Current health status
Health&safety:focusareas
Functionalinformation
Supervision care needs: reasons for intensive staffing
Other___________________________________
Yes
No*
NA
Yes
No
NA
2. Theformalorinformalneedsassessmentsusedtosupporttheintensivestaffing/supportneedsareidentified:*
• Formalassessmenttypesinclude,butarenotlimited to: the SISTMandPAPlus,Vineland,AdaptiveBehaviorScale(ABS),Alpern-BollDevelopmentalProfile(LPRNBOAL),andtherapy and medical evaluations.
• Informalassessmentsinclude,butarenotlimitedto:aprovider’sannualassessment,andfamilyandfriends’observationsandunderstandingoftheindividualandhis/herneeds.
Health&safety
Medical:healthevaluations Medicalhistory:currenthealthstatus,
psychosocial, and physical assessment
Health&safety:focusareas
Behavioralsupportplan
Healthpromotion
Functionalinformation:non-medicalevaluations
Outcomesummary:relevantassessments
Other___________________________________
Yes
No*
Yes
No
3. Whyisthissupportneeded?* Know&do
Current health status
Supervision care needs: reasons for intensive staffing
Behavioralsupportplan
Functionalinformation:social/emotional
Outcomesummary:reasonforoutcome
Outcomeactions:whatarecurrentneeds?
Other___________________________________
Yes
No*
Yes
No
4. Whatriskdoesthispersonpresenttothemselves or others?*
Know&do
Psychosocial information
Supervision care needs: reasons for intensive staffing
Behavioralsupportplan
Other___________________________________
Yes
No*
Yes
No
5. What are the health and safety reasons for the level of supervision?
Know&do
Health&safety:focusarea(asappropriate)
Supervision care needs: reasons for intensive staffing
Outcomesummary:reasonsforoutcome
Other___________________________________
Yes
No*
Yes
No
6.Whatarethestaffresponsibilitiesinsupporting the individual?*
Know&do
Health&safety:focusarea(asappropriate)
Outcomesummary:whatactionsareneeded?
Other___________________________________
Yes
No*
Yes
No
7. What are the expanded interactions, activities, programsand/ortrainingthatwillbeprovided?*
Individual preferences
Outcomeactions:whatactionsareneeded?
Other___________________________________
Yes
No*
Yes
No
ISP Review Checklist
DP 1050 9/13Page 8
Section D: Intensive StaffingDayprogram1:1orhigher HomeandCommunityHabilitation-unlicensed16hours(64units)ormore SH/AIS
Item to Discuss/Document in ISPTeam to Review
Recommended ISP SectionSC to Complete
Item Documented?AE to Complete
Criteria Met?ODP to Complete
SH/AIS Only
8. Whatothermeasureshavebeenattempted,i.e. communication, less restrictive supports, medical evaluation, etc.?*
Know&do
Psychosocial information
Behavioralsupportplan
Functionallevel:communication
Othernon-medicalevaluations
Other___________________________________
Yes
No*
Yes
No
9. Documentationfortheintensivestaffing/supportincludes when, where and how the enhanced supportwilloccur.(Hours/days,location,etc.).*
Know&do
Supervisioncareneeds:staffingratiohome
Outcomeactions:frequency&duration
Other___________________________________
Yes
No*
Yes
No
10.TheISPincludestheplanfortheeventualdiscontinuance or reduction of the intensive staffingthatincludestheinformationtobecollected and used to determine the effectiveness ofintensivestaffingandtheprogressbeingmadetoward the reduction criteria.*
Supervision care needs: reasons for intensive staffing Outcomeaction:howwillyouknowthat
progress is being made toward this outcome?
Other___________________________________
Yes
No*
NA
Check“N/A”ifthetargetservice is not expected to be reduced and the circumstances are documented in the ISP.
Yes
No
NA
Check“N/A”ifthetargetservice is not expected to be reduced and the circumstances are documented in the ISP.
11.Whenrequestforcontinuationofintensivestaffinghasbeenreducedeitherintheproximity or intensity of the staff support. Ifnot,thereisjustificationforcontinuedintensivestaffing.(Note:thisitemdoesnotapplytonewrequests.)
Outcomesummary:reasonsforoutcome Outcomeaction:howwillyouknowthat
progress is being made toward this outcome?
Other___________________________________
Yes
No*
NA
Check“N/A”ifthisisanewrequest.
Yes
No
NA
Check“N/A”ifthisisanewrequest.
Comments:
ISP Review Checklist
DP 1050 9/13Page 9
Section E: Pre-VocationalSix-Month Review
Item to Discuss/Document in ISPTeam to Review
Recommended ISP SectionSC to Complete
Item Documented?AE to Complete
Is this individual currently successful (meeting orexceedingoutcomesandgoals)inapre-vocational or transitional work environment?
Outcomesummary:outcomestatement
Outcomesummary:whatarecurrentneeds? Outcomeaction:howwillyouknowthat
progress is being made toward this outcome?
Other___________________________________
Yes No
Comments:
Section F: Supported Employment - Job FindingSix-Month Review
Item to Discuss/Document in ISPTeam to Review
Recommended ISP SectionSC to Complete
Item Documented?AE to Complete
1. Doestheindividualcontinuetorequirethecurrentlevelofauthorizedservices?
Outcomesummary:outcomestatement
Outcomeactions:whatarecurrentneeds? Outcomeactions:howwillyouknowthat
progress is being made toward this outcome?
Other___________________________________
Yes No
Comments: