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1 DEVELOPMENT OF THE ISP

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DEVELOPMENT OF THE ISP

>www.dpw.state.pa.us >www.dhs.pa.gov 2

Utilizing the Charting the LifeCourse Tools

Charting the LIFECOURSE NEXUS. (n.d.). Retrieved December 29, 2020, from https://www.lifecoursetools.com/lifecourse-library/foundational-tools/person-centered/

>www.dpw.state.pa.us >www.dhs.pa.gov 3

To begin the ISP process

Experience and Questions Booklet

4

Individual Support Plan (ISP) in HCSIS

5Dem

ogra

phic

s In

fo

>www.dpw.state.pa.us >www.dhs.pa.gov 6

Demographics• Make sure all known information is completed

• Select “Primary Language [of Individual]”(making sure it aligns with Communication and Understanding Communications screens in the Functional Information section)

• Select “Primary Language in the Home”

ISP Components: Demographics

7

Con

tact

s In

fo

>www.dpw.state.pa.us >www.dhs.pa.gov 8

Contacts• Make sure all known information is completed

• If the Demo screen indicates that the individual’s contact does not use English to communicate, a note should be made in the “Contact Notes” section

ISP Components: Demographics

9

Dia

gnos

is

>www.dpw.state.pa.us >www.dhs.pa.gov 10

Diagnosis• Make sure all known information is completed

• If information is already listed, do not delete it

• If you are familiar with an additional diagnosis not listed, add it

ISP Components: Demographics

11

ISP

Dev

elop

men

t

>www.dpw.state.pa.us >www.dhs.pa.gov

ISP ComponentsIndividual Preferences

12

>www.dpw.state.pa.us >www.dhs.pa.gov 13

Like and Admire• “What do people like and admire about the individual?”

• Capture multiple perspectives

• Include positive attributes, traits, characteristics, accomplishments and strengths

• Present only positive information

ISP Components: Individual Preferences

>www.dpw.state.pa.us >www.dhs.pa.gov 14

Know and Do

• Include key information that everyone should know including preferences for interaction and communication

• Identify legal guardian, power of attorney or representative payee as applicable

• Identify any concerns with natural supports

• If there are concerning behaviors and BSS is not being provided, include strategies for support

• Specific assessment information (*as listed in Clinical Checklist)

ISP Components: Individual Preferences

>www.dpw.state.pa.us >www.dhs.pa.gov 15

Like and Admire

Know and Do

Integrated Support Star

>www.dpw.state.pa.us >www.dhs.pa.gov 16

Desired Activities• Identifies activities that the participant would like to continue,

to begin, or to explore further • Written from a person-centered perspective• Describes what activities are important to the individual• Ensures activities align with goals and objectives

Important To• Describes what the individual needs and values• Captures access to or use of assistive technology• Capture only what is important to the individual, not what

others think should be important

ISP Components: Individual Preferences

>www.dpw.state.pa.us >www.dhs.pa.gov 17

• Track two levels of priority

Essential: Those things listed which must or must not be present in the individual’s life

Strongly desired: Those things listed which would strongly contribute to the individual’s happiness but would not be detrimental to his or her well-being if not present

ISP Components: Individual Preferences

>www.dpw.state.pa.us >www.dhs.pa.gov 19

What Makes Sense• Things that make the individual’s life more

meaningful or enjoyable

• If they have specific communication needs, you would want to include that here

• Describe what does not make sense (what is problematic about the previous statement that can keep the individual from completing “what makes sense”?)

• Based on multiple perspectives

ISP Components: Individual Preferences

>www.dpw.state.pa.us >www.dhs.pa.gov 20

Sally

Sally

Sally

Sally

Sally

SallySally

Sally

Sally’s mother

Sally’s mother

Identify whose view this is.

Include name and

relationship to the individual.

Avoid using “the team” in this section.

Identify whose view this is. Include name and relationship to the individual. Avoid using “the team” in this section.

What doesn’t work? What needs to change? What must be different? “What makes the individual’s life less meaningful, more difficult, or undesirable?”

ISP Components: Individual Preferences

>www.dpw.state.pa.us >www.dhs.pa.gov

ISP ComponentsMedical Information

21

>www.dpw.state.pa.us >www.dhs.pa.gov 22

Medications/ Supplements• Medication names, dosages and frequency, route, self

medication status, and necessary bloodwork

• Prescribing doctor (make sure this person is listed in the current medical contacts screen)

• Diagnosis: each medication should identify the symptom for which it is prescribed (i.e., not “autism” as there is no medication expressly for autism)

• Specific assessment information (*as listed in Clinical Checklist)

*Please check spelling and ensure medications are not duplicated

ISP Components: Medical Information

>www.dpw.state.pa.us >www.dhs.pa.gov 23

Allergies• This screen records all known sensitivities and allergies,

including food, insect bites or stings, season, animal, latex, medication allergies, adverse reactions, or contraindications, etc.

• Type of allergic reaction and required response

• If there are no known allergies, record NKA.

ISP Components: Medical Information

>www.dpw.state.pa.us >www.dhs.pa.gov 24

Health Evaluations • Include evaluations completed in the past twelve

months (i.e., dentist, psychiatrist, OBGYN, therapist, dietician, etc.)

• Include any one-time appointments

Medical Contacts• Include all medical professionals identified in the plan.

• The Medication/ Supplements, Health Evaluations and Medical Contacts sections should list the same professionals.

ISP Components: Medical Information

>www.dpw.state.pa.us >www.dhs.pa.gov 25

Current Health Status• Includes a summary of health issues and resolutions that

occurred within the past 12 months

• Includes hospitalizations, surgeries, new diagnoses, recommendations for adaptive equipment, and physician’s recommendations.

• Includes results of testing listed under Health Evaluations

• Confirms if immunizations are up to date (if missing from Immunization section) or documents why they are not up to date

ISP Components: Medical Information

>www.dpw.state.pa.us >www.dhs.pa.gov 26

Developmental Information• Date individual was diagnosed with autism

• Include significant milestones of development

Psychosocial Information• Align behavioral information with the Know & Do,

Social/Emotional, and Understanding Communication sections

• Includes current symptoms related to mental health issues.

• Specific assessment information (*as listed in Clinical Checklist)

ISP Components: Medical Information

>www.dpw.state.pa.us >www.dhs.pa.gov 27

Physical Assessment• Captures long term health history if it continues to be information

that others may need to know in order to support the participant

• Aligns with other medical sections

• Specific assessment information (*as listed in Clinical Checklist)

Immunization/ Booster• Includes current immunizations, such as influenza or tetanus

vaccinations

• If no immunizations are listed, does the Current Health Status section reflect either (a) all immunizations are up to date OR (b) the reason why

ISP Components: Medical Information

>www.dpw.state.pa.us >www.dhs.pa.gov

ISP ComponentsHealth and Safety

28

>www.dpw.state.pa.us >www.dhs.pa.gov 29

General Health and Safety Risks• Information related to any risk about the individual’s health and

safety

• 911 skills

• Ability to self-medicate

• Include accidents and incidents that have occurred in the last 12 months and mitigation plans for these. If there were none, specifically state this.

• Specific assessment information (*as listed in Clinical Checklist)

ISP Components: Health and Safety

>www.dpw.state.pa.us >www.dhs.pa.gov 30

Fire Safety• Ability to react during a fire or fire drill

• Need for supervision and assistance needed to evacuate a building

• Includes the TYPE of Supervision (e.g., verbal prompt, line of site, etc.).

• If independent and needs no supervision, is it noted as such?

• If the participant smokes, includes his or her level of awareness of smoking safety

• If this is an area of concern, is there a goal to address need?If there is no goal, is there an explanation?

ISP Components: Health and Safety

>www.dpw.state.pa.us >www.dhs.pa.gov 31

Traffic• Includes individual’s traffic safety awareness, such as:

• how and under what circumstances he/she can safely cross streets• his/her driving skills and needs• whether the individual is at risk of “bolting” into traffic

• Need for supervision and assistance needed • Includes the TYPE of supervision (e.g., verbal prompt, line of site,

etc.).• If independent and needs no supervision, is it noted as such?

• If this is an area of concern, is there a goal to address need?

If there is no goal, is there an explanation?

ISP Components: Health and Safety

>www.dpw.state.pa.us >www.dhs.pa.gov 32

Cooking/ Appliance Use

• Includes individual’s ability to: • use cooking and kitchen appliances• and prepare basic meals

• Need for supervision and assistance needed • Includes the TYPE of Supervision (e.g., verbal prompt, line of

site, etc.). • If independent and needs no supervision, is it noted as such?

ISP Components: Health and Safety

>www.dpw.state.pa.us >www.dhs.pa.gov 33

Outdoor Appliance• Includes individual’s ability to:

• outdoor appliances, such as lawn mower, weed whacker, gas grill, etc.

• If there are conditions that would or could impact abilities in this area, please include (e.g., asthma).

• Need for supervision and assistance needed • Includes the TYPE of supervision (e.g., verbal prompt, line of site,

etc.).• If independent and needs no supervision, is it noted as such?

ISP Components: Health and Safety

>www.dpw.state.pa.us >www.dhs.pa.gov 34

Water Safety• Includes individual’s ability to:

• understand water safety (including swimming) and temperature safety

• Need for supervision and assistance needed • Includes the TYPE of supervision (e.g., verbal prompt, line of

site, etc.).• If independent and needs no supervision, is it noted as such?

• Does the participant have a seizure disorder? If yes, are there additional precautions or supervision needs during bathing (including regulating water temperature) and swimming?

ISP Components: Health and Safety

>www.dpw.state.pa.us >www.dhs.pa.gov 35

Safety Precautions• Includes individual’s ability to:

• understand safety precautions including handling or storage of poisonous substances, danger signs, or warning labels

• Need for supervision and assistance needed • Includes the TYPE of Supervision (e.g., verbal prompt, line of site,

etc.). • If independent and needs no supervision, is it noted as such?

• If there is a need or a lack of skills, please comment.

• Is the person at risk for ingesting poisonous substances? Does the person know to take precautions in the handling or storage of poisonous substances?

•••

ISP Components: Health and Safety

>www.dpw.state.pa.us >www.dhs.pa.gov 36

Knowledge of Self Identifying Information• Includes individual’s ability to:

• give self-identifying information, such as name, address, and phone number

• whether the participant can request assistance if lost

• If the participant is not able to verbally give this information, does the plan identify alternative ways (e.g., carry ID) in which this information can be communicated?

• Or, does the participant carry a cell phone that he/she knows how to use to summon help?

ISP Components: Health and Safety

>www.dpw.state.pa.us >www.dhs.pa.gov 37

Stranger Awareness• Addresses the individual’s ability to:

• interact with strangers • whether or not he/she is vulnerable to victimization• whether he/she would wander off with a stranger• giving away possessions or money to strangers

• letting strangers in the house

• Addresses the individual’s ability for stranger safety awareness with regard to communicating with others via social media

• Do they understand the risk involved with sharing personal, self-identifying information with others they do not know or have not met in person?

ISP Components: Health and Safety

>www.dpw.state.pa.us >www.dhs.pa.gov 38

(Stranger Awareness continued)

• Need for supervision and assistance

• Includes the TYPE of supervision (e.g., verbal prompt, line of site, etc.).

• If independent and needs no supervision, is it noted as such?

• If this is an area of concern, is there a goal to address need?

If no goal, is there an explanation?

ISP Components: Health and Safety

>www.dpw.state.pa.us >www.dhs.pa.gov 39

Sensory Concerns• Address any hyper or hypo-sensitivities

• Are there any sensory needs that may impact behavior?

Consider: Environmental sounds, lighting, odors/ scents, crowds, clutter, distance, temperature, visual stimulation

• Are strategies identified to help meet those sensory needs? If not, consider adding a goal.

ISP Components: Health and Safety

>www.dpw.state.pa.us >www.dhs.pa.gov 40

Meals/ Eating• Includes the individual’s:

• eating skills• any dietary needs• food sensitivities• choking risks• adaptive equipment needs, etc.

ISP Components: Health and Safety

>www.dpw.state.pa.us >www.dhs.pa.gov 41

Supervision Care Needs• Addresses the current supports needs in Day, Home and

Community settings (NOT the number of service hours they will be receiving)

• Home: based on a 24 hour period• Community: based on a 24 hour period• Day: typical hours engaged in activities

• Type of supervision (line of sight, within arm’s reach, etc.) that is required to ensure the health and safety of the individual

>www.dpw.state.pa.us >www.dhs.pa.gov 42

Staffing Ratio

NOTE: This section is only completed if the individual is receiving residential services beyond the scope of AAW

For example, if an individual is in a group home through private pay, indicate the staffing ratio and information in the “Home” option

ISP Components: Health and Safety

>www.dpw.state.pa.us >www.dhs.pa.gov 43

Health Care

NOTE: Complete this section even if the individual makes his or her own health care decisions

• Identifies the specific health care support person who is designated to assist the participant in making health care decisions

• Has SC checked yes or no to “advance directive in place”?

• If no- SC please comment why not; or, make note that it will continue to be explored with the participant and family.

ISP Components: Health and Safety

>www.dpw.state.pa.us >www.dhs.pa.gov 44

Health Promotion• Identifies any health conditions or issues that the

participant currently practices, would like to work on or practice, or health issues for which there currently is a recommendation that it be addressed. Examples are weight reduction, increased exercise, smoking cessation, etc.

• If a health promotion condition or issue is identified, all sections must be completed

• Is it appropriate to link the desired outcome to an ISP goal?• If yes, does the participant want/ need to have a goal to

address this?

ISP Components: Health and Safety

>www.dpw.state.pa.us >www.dhs.pa.gov

ISP ComponentsFunctional Information

45

>www.dpw.state.pa.us >www.dhs.pa.gov 46

Physical Development• Describes current skills and needs including:

• gross and fine motor skills• vision and hearing• use of assistive technology• ability to perform simple exercises• Mobility• ability to negotiate stairs and ambulation

• Specific assessment information (*as listed in Clinical Checklist)

ISP Components: Functional Information

>www.dpw.state.pa.us >www.dhs.pa.gov 47

Adaptive/ Self Help• Information related to self-help or hygiene

• Including the participant’s ability to perform specific functions, assistance needs, and adaptation needs

Examples: bathing/showering, dressing, eating, drinking and toileting. Strengths and needs for completing household chores should be included as well.

• Specific assessment information (*as listed in Clinical Checklist)

ISP Components: Functional Information

>www.dpw.state.pa.us >www.dhs.pa.gov 48

Learning/ Cognition• Skills and needs about how the participant:

• learns and processes information• thinks• remembers• reasons• problem solves• makes decisions• manages money, etc.

ISP Components: Functional Information

>www.dpw.state.pa.us >www.dhs.pa.gov 49

(Learning/ Cognition continued)

• If the participant has behavioral needs, is there any information contained in this section that is important to consider for behavioral supports?

• Specific assessment information (*as listed in Clinical Checklist)

ISP Components: Functional Information

>www.dpw.state.pa.us >www.dhs.pa.gov 50

Communication• Includes the participant’s primary mode of

communication (dropdown value) and current skills and needs related to expressive/receptive language and assistive technology needs if appropriate

• Select a value from the drop-down list to indicate what language the individual uses

• If the individual is non-verbal, indicate the language used by those who support the individual

• The option 'Other Language' does NOT describe someone who is non-verbal. Use 'Other Language' to indicate a language not on the list.

ISP Components: Functional Information

>www.dpw.state.pa.us >www.dhs.pa.gov 51

(communication continued)

• Should connect to what is selected and written

• If no primary mode of communication is identified, is there a goal to develop a functional means of communication?

• If the participant has behavioral needs, is there any information contained in this section that is important to consider for behavioral supports?

• Specific assessment information (*as listed in Clinical Checklist)

ISP Components: Functional Information

>www.dpw.state.pa.us >www.dhs.pa.gov 52

Communication: Modes

>www.dpw.state.pa.us >www.dhs.pa.gov 53

Communication: Modes

>www.dpw.state.pa.us >www.dhs.pa.gov 54

Communication: Modes

>www.dpw.state.pa.us >www.dhs.pa.gov 55

Social/Emotional Information • Describes the skills and needs related to:

• controlling his/her emotions• having empathy and respect for others• and the ability to initiate and maintain social contacts

• Align with information captured in the Know and Do, Psychosocial, and Understanding Communication sections

• Specific assessment information (*as listed in Clinical Checklist)

ISP Components: Functional Information

>www.dpw.state.pa.us >www.dhs.pa.gov 56

Educational/Vocational Information• Captures information related to current educational

enrollment or vocational status.

• Educational status may include college or other post-secondary options.

• List Educational or vocational goals in the training goals section

• If the individual has worked with OVR, include the most recent OVR contact information and notes regarding the outcome of OVR contact

ISP Components: Functional Information

>www.dpw.state.pa.us >www.dhs.pa.gov 57

Employment/Volunteer InformationComplete this section even if the individual is not currently employed or volunteering

• Captures information related to: • the participant’s work or volunteer status• their current employer • and specifics about employment and/or volunteer goals

• This section refers to supported/competitive employment or volunteer issues

ISP Components: Functional Information

>www.dpw.state.pa.us >www.dhs.pa.gov 58

(employment/ volunteer information continued)

• If OVR is assisting with any employment services, please include that information within the Comments box

• Within the Goal Box, list the employment/ volunteer goal

• If no goal listed or it is indicated that individual not interested in employment, explanation should be provided

• Align with the employment status in the demographics section

ISP Components: Functional Information

>www.dpw.state.pa.us >www.dhs.pa.gov 59

Understanding Communication• Captures information about the individual’s verbal

or nonverbal, overt or subtle behaviors that he/she uses to communicate:

• needs• wants• likes/dislikes• what is important• when he/she is in pain, discomfort, or not feeling well

• Consider both receptive and expressive communication

ISP Components: Functional Information

>www.dpw.state.pa.us >www.dhs.pa.gov 60

(understanding communication continued)

• Behaviors and idiosyncrasies that may be misinterpreted

• Align with information captured in the Know and Do, Psychosocial, and Social/Emotional sections

• Complete for all individuals, even if they do not have any apparent communication barriers

• Specific assessment information (*as listed in Clinical Checklist)

ISP Components: Functional Information

>www.dpw.state.pa.us >www.dhs.pa.gov 61

Sally Sally Sally Sally

SallySally Sally

Sally Sally

The circumstances

around the individual, the

setting, the environment, the time of day, etc.

The observable, communicative actions in which the individual engages, including gestures, sounds, words or phrases the individual uses in those situations

The meaning of the action for the individual

The response or action expected from the people providing support

ISP Components: Functional Information

>www.dpw.state.pa.us >www.dhs.pa.gov 62

Non-Medical Evaluation• Captures detailed information about evaluations

completed that are not medical in nature

• Evaluation area is a dropdown value and includes: • fine and gross motor• adaptive skills• educational/vocational• vision or hearing• cognitive• social emotional• adaptive/self-help

ISP Components: Functional Information

>www.dpw.state.pa.us >www.dhs.pa.gov 63

(non-medical evaluation)

• adaptive/self-help• sexuality• communication• assistive technology• speech/ language• pathologist• nutritional• home modifications• vehicle modifications• Other (indicate type of evaluation)

ISP Components: Functional Information

>www.dpw.state.pa.us >www.dhs.pa.gov

ISP ComponentsGoals

64

>www.dpw.state.pa.us >www.dhs.pa.gov 65

Notes about Goals and ObjectivesRefer to the following infographics for information about Goals and Objectives:

• Goals and Objectives Cheat Sheet

• Responsibility by Service Category

ISP Components: Goals

>www.dpw.state.pa.us >www.dhs.pa.gov 66

ISP Components: Goals

67

GAS- what SC needs to know

>www.dpw.state.pa.us >www.dhs.pa.gov 68

SCs Role in Goal Attainment Scaling (GAS)

• Review the Responsibilities by Service Category to confirm which providers are responsible for completing GAS charts

• The SC is responsible for ensuring applicable providers send GAS charts to SC for entry of goals and objectives into HCSIS within 3 weeks of service start date (if objectives are required)

• The SC must follow up with the providers to check on the status of the GAS charts until completed

Although not required for SCs, visit the MyODP GAS Training section for additional trainings and resources on GAS

ISP Components: GAS

>www.dpw.state.pa.us >www.dhs.pa.gov 69

“What does the SC look for?” Ensure GAS chart has the current Plan Effective Date (PED) to make sure it's for the current year

(1) Ensure Goal and Objective info is entered into HCSIS on behalf of the provider

(2) Ensure the Goal in the ISP has only one objective (one goal, one objective)

(3) Ensure that it aligns with the Goal and Objective Cheat Sheetexpectations

(4) Document receipt and entry into Service Notes

Ensure this baseline information is entered into the “Concerns” section of the Goal/ Objective info in HCSIS as the baseline quantitative data

>www.dpw.state.pa.us >www.dhs.pa.gov

ISP ComponentsService Details

71

>www.dpw.state.pa.us >www.dhs.pa.gov 72

The Plan Effective Date (PED) is the same day and month as the eligibility date on the Plan Components screen

Plan Dates

ABC SC Agency

Home Living Inc.

The Service Start Date should be the date the individual will begin receiving that service. Falls on or after the Plan Effective Date

ISP Components: Service Details

• The Service End Date Is the day before the Projected Annual Review Date (with an exception of Career Planning and Intensive Job Coaching)

• If there is a reason why end dates are not aligned with the Projected Annual Review date, a service note is entered with the justification

>www.dpw.state.pa.us >www.dhs.pa.gov 73

“How many units are there?”

The “total units” shows you the

TOTAL amount of units requested

To see the statusof the units or the number of units

used or remaining, click “View” (see step 2)

Service frequency x units per

visit= total units requested for

service per week/ month

Service start and end dates provide

the dates of service that units are

requested for within the plan year

ISP Components: Service Details

>www.dpw.state.pa.us >www.dhs.pa.gov 74

This is where you can see how many units have been used.

“How many units are there?”

This is where you can see the authorization status of the service.

Services are divided by ODP’s fiscal year:PED-6/30 and 7/1–PED-1

This is where you can see the total units in the fiscal year.

ISP Components: Service Details

>www.dpw.state.pa.us >www.dhs.pa.gov 75

Contingency Contacts

The contingency contact is an alternative person to contact if the assigned staff is not available.

• Complete contingency contact (at least 1) for each service, including the name, relationship to individual and phone number

• Must include at least one supervisory contact

>www.dpw.state.pa.us >www.dhs.pa.gov 76

Heather Mishka 000-000-0000

Heather Mishka

000-000-0000

>www.dpw.state.pa.us >www.dhs.pa.gov 77

Tips on Service Hours and Units

*See Provider Information Table for details for each service*

Be aware of service limits (e.g., limited number of units or a total cost per year).

Pay attention to service time limits (e.g., enter service dates for six months instead of a full year).

Some services will not be authorized until an associated action (e.g., assessment, plan, etc.) has been submitted and approved.

Ongoing services should be as closely aligned as possible with actual use.

>www.dpw.state.pa.us >www.dhs.pa.gov 78

(tips on service hours and units continued)

Information for specific services:

Some services are “one time services” and should not exceed one unit. Those are:

• SSD-BSP Development• SSD-Skill Building Plan Development• Supports Coordination-Initial Plan Development• Home Modifications• Vehicle Modifications• Assistive Technology

Note: If a one-time service spans fiscal years, the SC must open the “view” on the Service Detail Screen to assure that the service unit was added to the correct fiscal year. At times, the SC will need to complete a manual correction to assure the correct fiscal year is chosen.

>www.dpw.state.pa.us >www.dhs.pa.gov 79

(tips on service hours and units continued)

The total combined hours of any mix of the following services cannot exceed 50 hours:

• Day Habilitation• Community Support• Small Group Employment• Supported Employment Services (Intensive Job Coaching,

Direct and Extended Employment Supports, Direct)

If there is justification for providing more then the combined hours, a Request for an Exception to Established Service Limits Form needs completed and submitted to BSASP.

>www.dpw.state.pa.us >www.dhs.pa.gov 80

(tips on service hours and units continued)

Family Support:

• Cannot exceed 160 units per ISP year

Out- of –Home Respite:• 15 minute units: Cannot exceed 40 units per day

Licensed: • 15 minute unit: Cannot exceed 1200 units per ISP year• Day Unit: Cannot exceed 30 units per ISP year

Unlicensed: • 15 minute unit: Cannot exceed 1563 units per ISP year• Day unit: Cannot exceed 39 units per ISP year

>www.dpw.state.pa.us >www.dhs.pa.gov 81

(tips on service hours and units continued)

In–Home Respite:• 15 minute units: Cannot exceed 1062 units per year

In–Home and Out- of- Home Respite BOTH on plan:• Cannot exceed total expenditure equal to or less than

$6504.00 per ISP year

>www.dpw.state.pa.us >www.dhs.pa.gov 82

(tips on service hours and units continued)

SSD-Behavioral Specialist (BS)- Plan Development

• The Behavioral Specialist is expected to complete the Behavioral Support Plan (BSP) and Crisis Intervention Plan (CIP) within 60 days of the service being added to the ISP.

• BSASP reviews the plans and provides feedback.

• BS Direct and Consultation services can be added to the plan only after BSASP approves the BSP/CIP

>www.dpw.state.pa.us >www.dhs.pa.gov 83

(tips on service hours and units continued)

SSD-Systematic Skill Building (SSB)- Plan Development

• The Skill Building Specialist is expected to complete the Skill Building Plan (SBP) within 60 days of adding the service to the ISP.

• BSASP reviews the plans and provides feedback.

• SSB Direct and Consultation services can be added to the plan only after BSASP approves the SBP.

>www.dpw.state.pa.us >www.dhs.pa.gov 84

(tips on service hours and units continued)

Career Planning: Vocational Assessment and Job Finding

• Either Vocational Assessment OR Job Finding can be on the plan at once. They are NOT able to be provided at the same time.

• Confirmation and documentation of OVR ineligibility or case closure is needed, OR the individual must meet one of the exception criteria as outlined in the OVR bulletin 00—16-02.

• The service is entered for 90 days.

>www.dpw.state.pa.us >www.dhs.pa.gov 85

(tips on service hours and units continued)

Supported Employment: Intensive Job Coaching and Extended Employment Supports

• Intensive Job Coaching and Extended Employment supports CANNOT be provided at the same time.

• If a participant is switching from one of these services to another, the end date and start dates of the services cannot overlap.

• Confirmation and documentation of OVR ineligibility or case closure is needed, OR the individual must meet one of the exception criteria as outlined in the OVR bulletin 00—16-02.

>www.dpw.state.pa.us >www.dhs.pa.gov 86

(tips on service hours and units continued)

Intensive Job Coaching- Direct and Indirect

• Supports must be needed for MORE THAN 20% of the individual’s work week (The Employment/Volunteer screen should be updated to include the number of hours worked, on average, each week).

• The service need to be end-dates for 6 months from the service start date.

• If the individual has received the service for the same position for 18 consecutive months and continues to need the service, a Request for an Exception to Established Service Limits form must be submitted and approved.

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(tips on service hours and units continued)

Extended Employment Supports- Direct and Indirect

• Supports must be needed for equal to or LESS THAN 20% of the individual’s work week (The Employment/Volunteer screen should be updated to include the number of hours worked, on average, each week).

• Cannot exceed 416 hours (1,664 units) per ISP year.

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(tips on service hours and units continued)

Therapies

• Medical Assistance (Health Choices) must be accessed and exhausted prior to requesting Speech/ Language therapy (SC documents in the “Comments” section of the Service Details Screen and label the item “Exhausted State Plan (MA Services),” that State Plan (MA Services) services for Speech Therapy have been exhausted).

• Counseling cannot exceed 12 initial units for the Counseling assessment to be completed.

Nutritional Consult

• Cannot exceed 12 initial units for the Nutritional Consult assessment to be completed.

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(tips on service hours and units continued)

Residential Habilitation

• If the individual resides in a Community Home, Respite must be end-dated prior to the Residential Habilitation start date.

• If the individual resides in a one-person Community Home, has SSD-Community Support must be end-dated prior to the Residential Habilitation start date.

• The level of Residential Habilitation requested must be appropriate and consistent with what was discussed and approved by ODP.

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(tips on service hours and units continued)

(residential habilitation continued)

• Both Residential Habilitation and Residential Habilitation Ineligible service lines must be added to the plan.

• The total number of units listed on both the Residential Habilitation and Residential Habilitation Ineligible service lines equal the number of days the participant needs the services and do not exceed 366 units per year.

• The service location ID on both Residential Habilitation service lines matches the address where the participant will be residing.

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Service Utilization Review

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ISP Components

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Sample Fiscal Year View on the Service Detail Screen in HCSIS

ISP Components: Service Utilization

1. GO TO: Plan > Manage Plan > View/Modify Plan Details > Service Details

2. Select the Service Name and then click on View for Fiscal Year View

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ISP Components: Service Utilization

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ISP Components: Service Utilization

3. Refer to Service Utilization Calculator (excel file) on the BAS Virtual Training Center

Service Utilization Calculator

In this example, the service provider entered the number of units authorized and utilized during the current plan year, and the number of units being submitted for the new plan year to calculate if

justification will be needed.

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• Puts AAW program at risk for decreased funds during the annual budget allocation

• Losing out on services for other individuals

Why is this so important??

ISP Components: Service Utilization

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• Review the service utilization information with the team.

• Determine how much was actually USED.

• Discuss how much is EXPECTED to be used.

• Use the service utilization calculator!

• Justification MUST be entered in service notes whenever the requested units exceed 125% of the units utilized at the time of the ISP meeting. Team agreement to the requested amounts is not adequate justification.

What can the SC DO??

ISP Components: Service Utilization

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• Change in individual or family circumstances

• Past service delivery issues

• Provider billing does not accurately reflect utilized units

• Other circumstances that suggest a higher level of utilization in the coming ISP year

Justify the hours

ISP Components: Service Utilization

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• Complete a Critical Revision.

• Enter justification in service notes.

• BSASP will review.

• Document the final decision in service notes.

Next steps (if justified)

ISP Components: Service Utilization

>www.dpw.state.pa.us >www.dhs.pa.gov

ISP ComponentsBehavior Support Plan (BSP)

and Crisis Intervention Plan (CIP)

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• The BSP/ CIP is the only part of the ISP that is entered by someone other than the SC. The Behavioral Specialist must enter the BSP and CIP in HCSIS.

• The Behavioral Specialist has 60 days to develop the BSP and CIP and put it into HCSIS.

• The BSP/CIP must be updated as BSS goals and crisis concerns change.

BSP/ CIP Tips

ISP Components: BSP & CIP

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SCs Role in BSP/ CIP

• Upon completion of the BSP, the BS provides the Desired Behavioral Outcomes (from the BSP) to the SC to enter as the BS Goals/ objectives.

• The SC must follow up with the BS if the plans are not entered or updated as needed.

ISP Components: BSP & CIP

>www.dpw.state.pa.us >www.dhs.pa.gov

ISP ComponentsSkill Building Plan (SBP)

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ISP Components: SBP

SSB Trainings SSB Resources

Recorded Virtual Office Hours (VOHs)

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• The SSB service supports another service (i.e., CS, SE, Res Hab). They should share the same goals/ objectives (each having an SBP).

• Upon completion, the Skill Building Specialist (SBS) provides the SBP(s) to the SC (1 SBP for each goal SSB is linked to).

• The SC enters the Goal and Objective information from the SBPs into HCSIS as the SSB objectives.

• The SBS has 60 days to develop the SBP.

SBP Tips

ISP Components: SBP

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• The SC should note:

• SSB should not be on a plan by itself.

• SSB can sometimes support more than one service (e.g.., CS and Res Hab)

• If there are multiple providers implementing a service, all providers are expected to be supported by SSB (e.g., if there are two providers for CS, both providers are expected to share goals with SSB).

ISP Components: SBP

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• The SC should follow up with the SSB provider :

(1) if they do not receive the SBPs by the 60-day deadline

(2) to ensure the data sheet and SBPs were provided to the individual and team

(3) to ensure the team was trained in the SBPs and data sheets

ISP Components: SBP

>www.dpw.state.pa.us >www.dhs.pa.gov

ISP ComponentsVocational Assessment

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• If Vocational Assessment is needed, no other employment services should be added (with an exception of SE).

• This service is delivered in 15-minute units; the team should determine how many hours per week or per month are needed.

• Vocational Assessment will be authorized immediately upon BSASP approval of the critical revision to add the service.

• The Vocational Assessor develops a Vocational Profile, which the SC enters in HCSIS.

Vocational Assessment TipsSee Clarification regarding AAW Employment Services BAW 17-29 specifics on all employment services

ISP Components: Functional Information

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SCs Role in Vocational Assessment

• Upon completion, the Vocational Assessor provides the Vocational Profile to the SC to enter into sections of HCSIS.

• The SC enters the Vocational Profile information into HCSIS using the Admin Notice BAW16-48 .

• The SC must follow up with the Vocational Assessor to check on the status of the plan until completed.

ISP Components: Functional Information

>www.dpw.state.pa.us >www.dhs.pa.gov

ISP ComponentsService Notes

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Go to Learning Management System (LMS) for more technical information and training on service notes

• The SC service notes are the primary documentation and serve as justification for billing.

• Enter a service note for any billable activity or contact.

• Need to be entered in HCSIS within 14 calendar days of billable activity.

Service Note Tips

ISP Components: Service Notes

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