DP 1050 (ISP Review Checklist)

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.


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.


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 *


SLC address:


Provider Information *


SLC address:


* If multiple providers, SC should compile information into one individual 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:

ambsnyder

Typewritten Text

(SH/AIS Only)


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


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


DP 1050 9/13Page 4

Section A: General ISP RequirementsNote:thissectionisonlyrequiredforannualreviews.




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.


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:


DP 1050 9/13Page 5

Section B: Residential Habilitation CriteriaInitial Request, Annual Review & Six-Month Review




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


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


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


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


Other _____________________________________

Yes No NA

NA - Individual is already in family living/lifesharing.

Comments:


DP 1050 9/13Page 6

Section C: Licensed 6400 One-Person Home GuidelinesInitial Request, Annual Review & Six-Month Review




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)


Other___________________________________

Yes No

2. Theperson’sbehaviorisnotimprovedby current behavioral or mental health interventions.

Know&do



Other___________________________________

Yes No

3. Thepersonpresentsanon-goingdangertoselforothers.

Know&do




Other___________________________________

Yes No

4. Thepersonregularlyengagesorattemptstoengage in aggressive or assaultive behavior to self and others.

Know&do




Other___________________________________

Yes No

5. Additionalstaffingand/orenvironmentaladjustmentsinalargersettinghavefailedtoensure the health and safety of the person and others.

Know&do



Supervision care needs: reasons for intensive staffing


Other___________________________________

Yes No NA

ChooseN/Aifthisisanewresidentialhabilitationrequest.

6. Thepersonhasabehaviorsupportplanwhichpriortoorwithin30daysofmovingintoaone-personhomemustbeupdatedtoincludea fading plan to eliminate the need for a segregatedone-personhome.


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


Outcomeactions:whatactionsareneeded

Other___________________________________

Yes No*

Comments:


DP 1050 9/13Page 7

Section D: Intensive StaffingDayprogram1:1orhigher HomeandCommunityHabilitation-unlicensed16hours(64units)ormore SH/AIS




Criteria Met? ODP to Complete

SH/AIS Only

1. Thechangeinneedisdescribed,includinghowthischangeaffectstheperson’shealthandwelfare.*

Know&do

Current health status

Health&safety:focusareas

Functionalinformation


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


Healthpromotion

Functionalinformation:non-medicalevaluations

Outcomesummary:relevantassessments

Other___________________________________

Yes

No*

Yes

No

3. Whyisthissupportneeded?* Know&do

Current health status



Functionalinformation:social/emotional

Outcomesummary:reasonforoutcome

Outcomeactions:whatarecurrentneeds?

Other___________________________________

Yes

No*

Yes

No

4. Whatriskdoesthispersonpresenttothemselves or others?*

Know&do




Other___________________________________

Yes

No*

Yes

No

5. What are the health and safety reasons for the level of supervision?

Know&do



Outcomesummary:reasonsforoutcome

Other___________________________________

Yes

No*

Yes

No

6.Whatarethestaffresponsibilitiesinsupporting the individual?*

Know&do


Outcomesummary:whatactionsareneeded?

Other___________________________________

Yes

No*

Yes

No

7. What are the expanded interactions, activities, programsand/ortrainingthatwillbeprovided?*

Individual preferences


Other___________________________________

Yes

No*

Yes

No


DP 1050 9/13Page 8

Section D: Intensive StaffingDayprogram1:1orhigher HomeandCommunityHabilitation-unlicensed16hours(64units)ormore SH/AIS




Criteria Met?ODP to Complete

SH/AIS Only

8. Whatothermeasureshavebeenattempted,i.e. communication, less restrictive supports, medical evaluation, etc.?*

Know&do



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


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


Other___________________________________

Yes

No*

NA

Check“N/A”ifthisisanewrequest.

Yes

No

NA

Check“N/A”ifthisisanewrequest.

Comments:


DP 1050 9/13Page 9

Section E: Pre-VocationalSix-Month Review




Is this individual currently successful (meeting orexceedingoutcomesandgoals)inapre-vocational or transitional work environment?


Outcomesummary:whatarecurrentneeds? Outcomeaction:howwillyouknowthat


Other___________________________________

Yes No

Comments:

Section F: Supported Employment - Job FindingSix-Month Review




1. Doestheindividualcontinuetorequirethecurrentlevelofauthorizedservices?


Outcomeactions:whatarecurrentneeds? Outcomeactions:howwillyouknowthat


Other___________________________________

Yes No

Comments:

Documents

DP 1050 (ISP Review Checklist)