DRAFT - Hamilton County Developmental Disabilities · , removing oral or topical medication from the container and assisting the individual take or apply the medication. If the individual

Name:

My Plan | Assessment

Span: -

Annual Completion Date:

Effective Date:

Participants (for this current assessment):

Details of Change:

SSA:

Mid-Span Change

DRAFT

Things I Want You To Know About Me

Changes that have occurred over the past year or are expected in the future:

If I want to learn something new, I learn best by:

Unique things that I may say or do that may not be understood by others:

This is what I want people to know when they support me:

This is how I best communicate with others:

When helping me plan for my future, the most important thing I want my team to know is:

Outcome(s):

2

Medical CareProfessional Name Practice Name Frequency

Primary Physician Per Year

Dentist Per Year

Optometrist/Eye Doctor Per Year

Psychiatrist Per Year

Psychologist Per Year

Counselor Per Year

OB/GYN Per Year

Other: Per Year

Other: Per Year

Other: Per Year

Other: Per Year

I Participate In My Medical Care By:

My Pharmacy Location Phone Number

My Rx Are Picked Up By:My Rx Are Delivered

Detailed Support I Require With My Medical Care:

Important Things to Know:

YesI Require Support with My Medical Care: No

What you should know about my diet: What you should know about my medical equipment/needed equipment:

I have a diagnosis that is expected to lead to hospitalizations (document as a UI):

Who Assists:Who Assists:

Freq.:Freq.:

Funding:Funding:

Provider Type:Provider Type:

Outcome(s):

3

Planning for Medication AdministrationChoose One Option:

1. I take routine medications. My team agrees that I do not need support for medication administration. "Self-Administration Assessment-Oral & Topical Medications" not Needed

2. I do not take routine medications. It is expected that I will not require support if I start taking routine medications. If my needs change or concerns arise, my SSA will be contacted by my provider. "Self-Administration Assessment-Oral & Topical Medications" not Needed

3. I do not take routine medications. It is expected that I will require support if I start taking routine medications. If I start a routine medication, my provider will contact my SSA to have a medication assessment completed. My provider will support me in the interim. "Self-Administration Assessment-Oral & Topical Medications" not Needed

Expected Support:

4. I take routine medications and/or have health related activities. The following assessments have been conducted:

Self-Administration Assessment - Oral and Topical Medication

Self-Administration Assessment - Performance of Health‐Related Activities (stockings, blood pressure, pulse, etc.)

Self-Administration Assessment - Insulin/Metabolic Glycemic Disorder Medications (completed by licensed nurse ONLY)

Self-Administration Assessment for Administration of Medications, Nutrition, Fluids per G/J Tube (completed by licensed nurse ONLY)

Outcome(s):

4

Self-Administration Assessment - Inhaled Medications

Self-Administration Assessment - Oxygen Administration

Self-Administration Assessment - Using a Glucometer

Self-Administration Assessment-Oral & Topical Medications

YES NO Unable to self-administer with or without assistance.

I can recognize my medication by color, size, shape and/or by reading the label (i.e., can read label, has memorized, will ask for help or will confirm with someone else).

1.

I know what my medication is for (i.e. pain, nerves, breathing, rash, itch).2.

I know and recognize how much medication to take (i.e., 1/2 pill, the cup filled to this line, thin coating).

I will recognize when I am not felling well; knows who to tell and will tell them; it may be a side effect of medication (i.e., pain, nausea, dizziness).

I know when a refill is needed so medication never runs out (i.e., 4-7 days of medication left). Will get refill; knows who to tell to get refill when needed; will seek assistance if needed for refill or if medication is not available.

I know who to ask/tell when there is a problem with my medication (i.e., doesn't look right, dose is not correct, spilled medication). Will not take incorect medication and will notify that person immediately of any problems.

YES

YES

YES

YES

NO

NO

NO

NO

NOYES

Unable to self-administer with or without assistance.

Unable to Self-Administer with or without assistance.

3.

4.Unable to Self-Administer with or without assistance.

5.

6.



7. I know when to take medication and have demonstrated my ability to take it at the right time every day by using a clock or routine (i.e., with meals, before bed).

YES NO If able to self-administer (questions 1-6 are all "Yes", outcome is "Self-Administration with Assistance"), the need for reminder assistance must be detailed on the next page.

I am able to get medication to and from storage, out of container and to my mouth without spills.8.

YES

NO

If "YES" to all 8 questions, I CAN SELF-ADMINISTER WITHOUT ASSISTANCE.If able to self-administer (questions 1-6 are all "Yes", outcome is "Self-Administration with Assistance"), the need for physical assistance regarding storage or packaging or consuming/applying medication must be detailed on the next page.

Record Assessment Outcome on Next Page

Outcome(s):

5

This assessment applies to the following setting(s): All Settings At Home At ADA/Work Other:

Name/Title of Person Performing Assessment:

Name/Title of Person of Second Observer:

Date:

Date:

This assessment is to be completed by a person who knows the individual well and, when possible, with a second observer present. Assess the individual's knowledge and skills in each environment where medication(s) is taken. Persons conducting this assessment will need to have ALL necessary information regarding current medications including medication name(s), dose(s), route(s), time(s), purpose for medication(s) and basic side effects. Complete this assessment (two pages) in its entirety regardless of answers. See Introduction-Instruction Self-Administration Assessments for more information.

ANSWER QUESTIONS 1-8 FOR EVERYONE TAKING ROUTINE MEDICATIONS

N/A

Self-Administration Assessment-Oral & Topical ResultsBased on all answers to questions 1-8, choose one of the 3 outcomes listed below.

Able to "self-administer" without assistance (Questions 1 through 8 are all "Yes").

Able to "self-administer" with assistance (Questions 1 through 6 are "Yes"; 7 and/or 8 are "No"). OAC 5123:2-6-02 specifies the three types of assistance that can be provided by uncertified personnel. Indicate below the type or types of assistance that apply. Provide specific instruction below.

The individual receives assistance with self-administration of medication through reminders of when to administer the medications and/or confirm directions on the container.

The individual receives assistance with medication by removing medication from storage area, handing the container of medication to the individual, and, if physically unable, opening the container for the individual.Upon request or with consent, and at the individual's direction, removing oral or topical medication from the container and assisting the individual take or apply the medication. If the individual is physically unable to place the dose of medication in his/her mouth or topically apply to skin, assisting the individual to do so.

Unable to self-administer with or without one of the three types of assistance (the answer is "NO" to any one or all of questions 1-6). Choose one of the following:

The individual can do some steps of medication administration and a properly licensed or certified and authorized person completes the other steps of medication administration (list details):

A properly licensed or certified and authorized person must administer medication.

Other Considerations:

Because of demonstrated and documented unsafe behaviors, the individual is unable to safely self-administer with or without assistance. If yes, according to rule (OAC 5123:2-2-06, Behavior Support Strategies that include Restrictive Measures), this must be addressed as a rights restriction in the My Plan. Brief summary:

The individual can self-administer some medications/doses/routes (certain drugs or administration times or topical vs. oral); Other medications are administered as indicated by the outcome listed above. List the medication(s) the individual can self-administer:

Name:

Who Assists:

Freq.:

Funding:

Who Assists:

Freq.:

Funding:

1.

2.

3.

6

OR

The individual has a G/J Tube or modified texture diet.

Medications are given via G/J tube.

The prescriber and team have confirmed the safe administratin or any medications given orally (or modified the administration to ensure safety.

Provider Type:

Provider Type:

Who Assists: Provider Type: Freq.: Funding:

Other Self-Administration Assessments Have Been Completed :

7

Other Self-Administration Assessment Results

INHALED MEDICATION Conducted By/On File With: Result:

When "self-administer with assistance" is the result: Choose type of assistance required

Through reminders of when to administer the medications and/or confirm directions on the container.

By removing medication from storage area.

Upon request or with consent, and at the individual's direction, provide physical assistance with any step of the process.

OXYGEN ADMINISTRATION

Through reminders of when to administer the oxygen and when to obtain oxygen saturation readings, if applicable.

By removing medication from storage area, handing the container of medication to the individual, and, if physically unable, opening the container for the individual.

Upon request or with consent, and at the individual's direction, provide physical assistance with any step of the process (i.e., application of oxygen mask/nasal cannula, turning on oxygen concentrator, opening/closing oxygen tank, cleaning equipment, etc.).

HEALTH-RELATED ACTIVITIES

GLUCOMETER

INSULIN

G/J TUBE

Through reminders of when to perform the task.

Through physical assistance with getting equipment out of storage.

Upon request or with consent, and at the individual's direction, receives physical assistance with any or all the following: getting supplies out of container; assembly of equipment.

Conducted By/On File With: Result:



Through reminders of when to administer the medications and/or confirm directions on the container.

By removing medication from storage area, handing the container of medication to the individual, and, if physically unable, opening the container for the individual.

Upon request or with consent, and at the individual's direction, removing oral or topical medication from the container and assisting the individual take or apply the medication. If the individual is physically unable to place the dose of medication in his/her mouth or topically apply to skin, assisting the individual to do so.


Through reminders of when to administer the medications/nutrition/fluids and/or confirm directions on the container/label.

By removing medications/nutrition/fluids and/or equipment from storage area, physically handing the medication/nutritional formula/fluid to the individual and returning to proper storage.

Upon request or with consent, and at the individual's direction, provide physical assistance with any step of the process (i.e., open/assist with opening the medication or nutritional formula container, preparing the medications/nutritional formula/fluid for administration, cleaning equipment, etc.).


Nurse Delegation Is Required! The agency that is responsible for nursing delegation is:

Nurse Delegation Is Required! The agency that is responsible for nursing delegation is:

N/A

Through reminders of when to administer the medications and/or confirm directions on the container/label and/or reading a sliding scale.

By removing medication from storage area, physically handing the vial, prefilled syringe/pen to the individual, returning to proper storage and assistance with disposal of needles.

Upon request or with consent, and at the individual's direction, provide physical assistance with steps identified in questions 12,13,14 of the assessment (i.e., dial pen, insert cartridge, rotate site)

Provider Administers Medications (PAM)Name:

ResidentialComplete the following questions if medications are administered by a paid residential provider. If "N/A" is selected from the two options below, no further information is needed in this section; proceed to the ADA section.

N/A - Currently does not receive ROUTINE medication administered by a paid residential provider. N/A - Medications are administered by a provider, but the family delegates medications. A Family Delegation Form is attached to the My Plan (INDEPENDENT PROVIDERS ONLY).

Provider Administers Medications

YES NO

Provider

NO

NO

NO

YES

YES

YES

Does the individual reside in a Group Home? YES NO If YES, what is the number of beds in the home?

Does the individual receive Adult Shared Living (ASL)? YES NO Is the individual related to the ASL provider? YES NO

Adult Day ArrayComplete the following questions if medications are administered by an ADA provider.

N/A - Currently does not receive medications administered by a paid ADA provider.

Provider Provider Administers Medications

YES

YES

YES

NO

NO

NO

SSA:

8

Employment

What You Should Know About My Place On The Path To Employment:

My Place On The Path To Employment (Post-Graduation):

1. My History of Work/Volunteer Work/Training/School:

Additional Information (14 years-old or older):

3. My Responsibilities at Home/School/Work:

2. My Strengths/Interests/Obstacles to Community Employment:

4. What I Can Do To Find Employment:

6. Current Status of an Opportunities For Ohioans with Disabilities Referral:

5. What I Can Do To Find Employment:

I am interested in a benefit analysis so that I know how employment or employment changes will affect me:

Details:

1. I have a job but would like support to maintain or move up at work.

2. I want a job. I want help finding one.

3. I am not sure if I want a job. I need support to identify career options.

4. I don't have a desire to work. I need support to make an informed choice.

Who Assists: Freq.: Funding:

N/A (I have not graduated)

Outcome(s):

Provider Type:

9

N/A (I"m under 14 years old)

Health, Safety and WelfareLEVEL OF SUPERVISION | Home & Community

At HomeDetailed Description of My Level of Supervision/Exceptions/Significant Risks at HOME:

Constant Visual - paid support should maintain visual contact with me. However, there isn't a specific distance required.Constant Auditory - paid support should maintain a distance where they are able to hear me. We do not need to be in the same room.Intermittent - paid support is available; does not need to be able to constantly see/hear me. Visual checks are required (described in detail below).

What is the approved level of supervision for when I go to the restroom?

What is the approved level of supervision for when my staff go to the restroom?

How much supervision is required during bathing? Can staff leave the room?

Are baths safe for me? YES NO

CommunityDetailed Description of My Level of Supervision/Exceptions/Significant Risks in the COMMUNITY:

What is the approved level of supervision for when I go to the restroom?

What is the approved level of supervision for when my staff go to the restroom?

Close Constant Visual

Constant Visual

Constant Auditory

Intermittent

N/A - No Paid Supports

The number of minutes I can safely be left alone in the bath/shower:

Close Constant Visual

Constant Visual

Constant Auditory

Intermittent


Overnight Staffing:I have overnight staff (choose):I do not have overnight staff.

HPC (awake staff) On-Site/On-Call (asleep staff) Nursing Daily Rate

I require checks throughout the night (why? how often?):

Outcome(s):

Close Constant Visual - paid support should maintain a close distance in order to maintain visual contact with me (within an arms length unless noted otherwise).

10

Remote Supports

Health, Safety and WelfareLEVEL OF SUPERVISION | Adult Day Array & Non-Medical Transportation

Adult Day Array

Level of Supervision Required: I Can Safely Be Unsupervised For:

minutes before someone should check on me (for intermittent LOS only)

Detailed Description of My Level of Supervision/Exceptions (for routine services, breaks, lunch, restroom and outside of the building):

Non-Medical Transportation


Routine ADA Services: N/A

During Breaks:

During Lunch:

When Using the Restroom:

When Outside Building:

N/A

N/A

N/A

N/A

How I get into my house (key, let in, etc.):

Who Assists:Who Assists: Freq.:

Freq.:Funding:Funding:



Outcome(s):







11

Visual (NMT provider will ensure that a responsible party is present to provide LOS after drop-off) I am always safe- supervision not requiredWhile Exiting my Non-Medical Transportation, I require the following Level of Supervision:

While Receiving Non-Medical Transportation, I Need the Following Supports From My NMT Provider:

Details:

Health, Safety and WelfareLEVEL OF SUPERVISION | Other (camp, family visits, etc.)

Other

Detailed Description of My Level of Supervision/Significant Risks


TRENDS AND PATTERNS |MUIs and UIs

DETAILS:

Who Assists:

IDENTIFICATION

Freq.: Funding:

Major Unusual Incidents: A trend or pattern has been identified during the previous 12 monthsUnusual Incidents: A trend or pattern has been identified during the previous 12 months

OAC 5123:2-1-11(F)(2)(b)(k)(v)

N/A

Describe How the Trend/Pattern Has Been (or will be) Addressed (Include historical trends or patterns of significance)

N/A

I need to get a new I.D.I have an I.D. that expires on:

Provider Type:

Back-Up PlanThe following person(s) is responsible for making arrangements if my primary staff is not able to provide supports:

Primary Back-Up Plan Coordinator:

Secondary Back-Up Plan Coordinator:

Outcome(s):


24/7 Phone #:

24/7 Phone #:

12

Weekdays Weekends

Health, Safety and WelfareALONE TIME

I Can Safely Be Without Support

Hours Per Day on Weekdays

Weekday Details Weekend Details

HOME

Hours Per Day on Weekends

COMMUNITY

Weekday Details Weekend Details Hours Per Day on Weekends Hours Per Day on Weekdays

Details of My Scheduled Alone Time:

Significant Risks For Me (include probability/frequency)

Alone Time Considerations

HOME COMMUNITY

At What Point, Beyond My Alone Time, Am I at a Significant Risk?HOME COMMUNITY

Fire Safety Getting Help/Calling 911 Medication Administration Stranger Awareness

N/A- I have no alone time *if the person disagrees with this, it is a restriction; CONTACT BEHAVIOR SUPPORT.

Routinely Scheduled Time Without Support (Alone Time)

Outcome(s):

13

I want my alone time to be routinely scheduled:I do not want my alone time to be routinely scheduled

N/A - I do not have SIGNIFICANT risks

REMOTE SUPPORTSN/A (I do not receive remote supports)

How should remote support staff respond when alerts are received? (Be sure to refer back to the level of supervision)

Name/Agency:

Back-Up Support Contact Information

Telephone Number:

Type of Back-Up Support:

Secondary Number:

Protocol to follow if I request that Remote Supports equipment be turned off during the time that I am scheduled to receive them:

Protocol to follow at the end of the Remote Supports shift (i.e., does HPC staff need to be present first, etc.?):

Does the person have a housemate that does not use Remote Supports? NO YES: Please coordinate with the housemate's SSA

Health, Safety and Welfare Outcome(s):

14

Expected time frame for back-up to arrive should the person need non-emergency assistance:

Money ManagementA payee assists a person in managing his/her SSI or SSDI benefits. A payee's main responsibility is to pay for current and future needs of the beneficiary. A payee must keep records of expenditures and submit to Social Security upon request. I have a payee that helps me manage my benefits:

N/A (I do not have a payee)

SSI: SSDI:N/A (I do not receive benefits) $$

MY PAYEE:

MY BENEFITS:

I am able to manage all of my personal funds and do not need assistance from residential or ADA providers

MY OHIO DIRECTION CARD (ODC):

NO YESI Receive Food Assistance: I Require Assistance Using My ODC: YES

NOI Participate in the Use of My ODC By: The Assistance I Require With My Ohio Direction Card (details):

Other (Who? List):My Provider

How I Participate in Managing My Personal Funds The Assistance I Require With Managing My Personal Funds (details):

$I can manage up to

Who Assists Me?:

GIFT CARDS: without support from my provider. N/A (I will aways need assistance) N/A (I use gift cards w/o support)

Freq.:

PERSONAL FUNDS: "Personal Funds" is money remaining from earned/unearned income after a person has paid bills and other obligatory payments.

How I Receive Personal Funds at Home/Respite How Receive Personal Funds at Work/ADA How I Receive Personal Funds For Community

Freq.:

Freq.:

Freq.:

Freq.:Who Assists:Who Assists:

The maximum dollar amount my provider may spend on my behalf for a single purchase without guardian/payee/team approval:

$

I require assistance from residential and/or ADA providers to manage my personal funds. I am able to independently manage up to $at one time without support from a provider.

Miscellaneous:

1. I live in a licensed setting and need an initial/annual inventory of my possessions. YES NO N/A

2. The guardian of my estate is: N/A

3. In the event of my death, is responsible for my estate.

1.

2.

N/A

N/A

3. The anticipated amount of personal spending money that should be available to me when I ask: per

Funding:Funding:Funding:

Funding:Funding:

$

Outcome(s):


Who Assists:Who Assists:Who Assists:

Provider Type:Provider Type:Provider Type:

15

Non-Medical Identified Risks & Supports - Risk of Harm No Identified Risks

Identified Potential Risks of Harm:

My Behavior Support Specialist (if applicable)?

Risk of Harm | What Works and What Doesn't?

What do I do that puts me and those around me at risk of harm?

What is my behavior telling those who support me?

What has been done to support me to make safer choices?

What has worked?

OTHER:

I have a Behavior Rate Add-On in my current planLevel of Behavior Support Involvement:

STOP HERE - TO BE COMPLETED BY BSS ONLY

Outcome(s):

16

Non-Medical Identified Risks & Supports - Risk of Harm (CONTINUED)

Risk of Harm | What Works and What Doesn't? (continued)

Is there a restriction in my plan based on these risks?

If there is a restrictive measure in my plan, how should it be used in order to keep me and those around me safe?

Risk of Harm | How Likely?What are some reasons me or those around me might be at risk of harm? How Probable is it that this will happen again (high, medium, low)? Is there a

restriction in my plan?

TO BE COMPLETED BY BSS ONLY

TO BE COMPLETED BY BSS ONLY

17

Non-Medical Identified Risks & Supports - Risk of Harm (CONTINUED)

Restrictive StrategiesRISKS

(Describe the target behaviors to increase and decrease, including baseline data for each. Include triggers for behavior and other motivating factors. Explain type of harm/legal sanction that may occur).

HISTORY (Include developmental history, history of trauma, and history of target behavior).

Interventions, Supports & Strategies

RESTRICTIVE STRATEGIES (Describe the restrictive strategy in this plan. Include when, where and how the restriction will be used. Include a statement

about how this restriction will be assessed and eventually faded).

PREVIOUS INTERVENTIONS, SUPPORTS AND NON-RESTRICTIVE STRATEGIES (Describe ALL previously tried strategies and existing strategies that are no-restrictive. Include the effectiveness of each

and if these strategies will be continued/discontinued. If a restrictive measure is needed, detail why).

FOLLOW-UP INFORMATION

Effectiveness

TO BE COMPLETED BY BSS ONLY Outcome(s):

18

Services and Supports | Home Living

Restroom/Bathing/Hygiene

Who Assists How They Assist and Type of AssistanceFrequency Funding

Provider Type:

Provider Type:

Provider Type:

Provider Type:

Provider Type:

Provider Type:

Provider Type:

Provider Type:

Provider Type:

Food: Shopping, Preparing, Eating

Housekeeping/Cleaning/Laundry

Dressing/Other

Outcome(s):How I Participate/My Strengths

19

Services and Supports | Physical/Emotional Well-Being

Responding to Emergencies/ Safety Skills


Provider Type:

Provider Type:

Provider Type:

Provider Type:

Provider Type:

Provider Type:

Provider Type:

Provider Type:

Provider Type:

State Plan Svcs., Home Mods/Equip. & Medication Administration

Medicaid Authorized Rep.

Physical Health/Diet/Exercise/Other


20

Services and Supports | Material Well-Being

Housing & Furnishings


Provider Type:

Provider Type:

Provider Type:

Provider Type:

Provider Type:

Provider Type:

Provider Type:

Provider Type:

Provider Type:

Money Management

Reporting Income/Filing Taxes

Community Resources


21

Services and Supports | My Rights & Self-Determination

Meetings (work, school, etc.)


Provider Type:

Provider Type:

Provider Type:

Provider Type:

Provider Type:

Provider Type:

Provider Type:

Provider Type:

Provider Type:

Advocating for Myself/Due Process

Making Choices & Decisions

Guardianship/Advocacy/Other


22

Services and Supports | Relationships

Intimate Relationships/Partner


Provider Type:

Provider Type:

Provider Type:

Provider Type:

Provider Type:

Provider Type:

Provider Type:

Provider Type:

Provider Type:

Making Friends

Visiting Friends and Family

Relationships/Other


23

Services and Supports | Personal Development

Using Technology


Provider Type:

Provider Type:

Provider Type:

Provider Type:

Provider Type:

Provider Type:

Provider Type:

Provider Type:

Provider Type:

Training/Classes/Courses

Satisfaction - Life/Spirituality

Independence/Other


24

Services and Supports | My Community

Travel/Camp/Respite/Other


Provider Type:

Provider Type:

Provider Type:

Provider Type:

Provider Type:

Provider Type:

Provider Type:

Provider Type:

Provider Type:

Transportation (HPC, NMT, Other)

Finding and Participating in Meaningful Activities - In My

Neighborhood, Cincinnati, and Surrounding Areas


25

Documents

DRAFT - Hamilton County Developmental Disabilities · , removing oral or topical medication from the container and assisting the individual take or apply the medication. If the individual