Sh Ais Isp Checklist Form Dp 1035

DP 1035 9/10

SH/AIS ISP CHeCklISt

Page 1

SAVING tHIS FORM: You may save data entered into this form. Please use the Save function only. Do not save or rename using Save As or the file may be locked.

Individuals Name: MCI #: Ae Reviewer:

PROVIdeR INFORMAtION

Providers Name:

13-digit MPI#: Service location Code:

SlC Address:

Provider Contact: Contact e-mail:

Contact Address:

type of Service (choose):

Category of Need (choose):

Reason Service is Needed:

the specific change to the individuals circumstances requires additional support:

Current Staffing Pattern: Units Requested Per day: x days =

DP 1035 9/10


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IteM tO ReVIeW IN ISP

ISP dOCUMeNtAtION

Ae ReVIeW OdP ReVIeW

YeS, NO, N/A

COMMeNtS/lOCAtION OF dOCUMeNtAtION

YeS, NO, N/A


1. The change in need is described, including how this change affects the persons health and welfare.

Plan Comments Section describes the nature of change(s).

Supervision Care Needs: Reasons for Intensive Staffing

Ae tO COMPlete

When change of need was identified:

location of documentation that validates the need (i.e. know & do section of ISP, outcome summary & outcome actions or ISP, incident reports, etc.):

explanation of what type of support the staff will be providing:

Authorization Recommendation (choose):

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ISP dOCUMeNtAtION


YeS, NO, N/A


YeS, NO, N/A


2. The formal or informal needs assessments used to support the intensive staffing/support needs are identified. (Formal assessment types include, but are not limited to: the SISTM and PA Plus, Vineland, Adaptive Behavior Scale, or ABS, Alpern-Boll Developmental Profile, or LPRN BOAL, and therapy and medical evaluations. Informal assessments include, but are not limited to: a providers annual assessment, and family and friends observations and understanding of the individual and his/her needs.)

Summarize behavior support plan for individuals who require SH or AIS because they have behavioral needs.

Individual Outcome Summary (relevant assessments linked to outcome listed here)

Additional relevant sections include:

Medical: Health Evaluations

Non-Medical Evaluations

Medical History: Current Health Status and Psychosocial, and Physical Assessment Sections

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ISP dOCUMeNtAtION


YeS, NO, N/A


YeS, NO, N/A


2. (CONTINUED) The formal or informal needs assessments used to support the intensive staffing/support needs are identified. (Formal assessment types include, but are not limited to: the SISTM and PA Plus, Vineland, Adaptive Behavior Scale, or ABS, Alpern-Boll Developmental Profile, or LPRN BOAL, and therapy and medical evaluations. Informal assessments include, but are not limited to: a providers annual assessment, and family and friends observations and understanding of the individual and his/her needs.)

Summarize behavior support plan for individuals who require SH or AIS because they have behavioral needs.

Health and Safety Focus Areas

Behavioral Support Plan

Health Promotion

Functional Information

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ISP dOCUMeNtAtION


YeS, NO, N/A


YeS, NO, N/A


3. The purpose of the intensive staffing/support is adequately described. (Why is this support needed? What risk does the person present to themselves or others? What are the expanded interactions, activities, programs and/or training that will be provided? What are the health and safety reasons for the level of supervision? What other measures have been attempted, i.e. communication, less restrictive supports, medical evaluation, etc.?)

Supervision Care Needs:Reasons for Intensive Staffing, Plan for Reducing Staff Support

Outcome Summary: Relevant Assessments

Outcome Actions

4. The ISP includes the plan for the eventual discontinuance or reduction of the intensive staffing/support.


Outcome Actions

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ISP dOCUMeNtAtION


YeS, NO, N/A


YeS, NO, N/A


5. The plan for monitoring and determining the effectiveness of enhanced support. If relevant, the plan for assessing progress being made toward the fading/exit criteria.


Plan for Reducing Intensive Staff Support

Outcome Actions: How will you know that progress is being made towards this outcome?

6. Documentation for the intensive staffing/support includes when, where and how the enhanced support will occur. (Hours/days, location, etc.)


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OdP tO COMPlete

OdP Reviewer:

date of ISP Submitted:

Requested Prior Authorization date: ISP Service Start & end dates:

Reviewer Authorization Recommendation (choose):

Reviewer Comments:

OdP RO SH/AIS Approver: Prior Authorization decision (choose):


ISP dOCUMeNtAtION


YeS, NO, N/A


YeS, NO, N/A


7. FOR CONTINUING REQUESTS: When request for continuation of intensive staffing/support has been faded (either in the proximity or intensity of the staff support). If not, there is justification for continued staff support. (Note: this item does not apply to new requests.)

Outcome Actions: How will you know that progress is being made towards the outcome.

Indvl_Name: MCI#: AE_Reviewer: Prvdr_Name: MPI#: Svc_Loc_Code: SLC_Address: Prvdr_Contact: Contact_Email: Contact_Address: Type_of_Service: SelectCat_of_Need: SelectReasonNeeded: Spec_Change: Staff_Pattern: Units_Requested: Units_RequestedDays: Units_RequestedTotal: 0WhenChangeofNeed: Loc_of_Doc: Staff_Providing: Auth_Recommendation: Select1_AE_YNA: Select1_AE_CommA: 1_ODP_YNA: Select1_ODP_CommA: 1_AE_YNB: Select1_AE_CommB: 1_ODP_YNB: Select1_ODP_CommB: 2_AE_YNA: Select2_AE_CommA: 2_ODP_YNA: Select2_ODP_CommA: 2_AE_YNB: Select2_AE_CommB: 2_ODP_YNB: Select2_ODP_CommB: 2_AE_YNC: Select2_AE_CommC: 2_ODP_YNC: Select2_ODP_CommC: 2_AE_YND: Select2_AE_CommD: 2_ODP_YND: Select2_ODP_CommD: 2_AE_YNE: Select2_AE_CommE: 2_ODP_YNE: Select2_ODP_CommE: 2_AE_YNF: Select2_AE_CommF: 2_ODP_YNF: Select2_ODP_CommF: 2_AE_YNG: Select2_AE_CommG: 2_ODP_YNG: Select2_ODP_CommG: 2_AE_YNH: Select2_AE_CommH: 2_ODP_YNH: Select2_ODP_CommH: 3_AE_YNA: Select3_AE_CommA: 3_ODP_YNA: Select3_ODP_CommA: 3_AE_YNB: Select3_AE_CommB: 3_ODP_YNB: Select3_ODP_CommB: 3_AE_YNC: Select3_AE_CommC: 3_ODP_YNC: Select3_ODP_CommC: 4_AE_YNA: Select4_AE_CommA: 4_ODP_YNA: Select4_ODP_CommA: 4_AE_YNB: Select4_AE_CommB: 4_ODP_YNB: Select4_ODP_CommB: 5_AE_YNA: Select5_AE_CommA: 5_ODP_YNA: Select5_ODP_CommA: 5_AE_YNB: Select5_AE_CommB: 5_ODP_YNB: Select5_ODP_CommB: 5_AE_YNC: Select5_AE_CommC: 5_ODP_YNC: Select5_ODP_CommC: 6_AE_YNA: Select6_AE_CommA: 6_ODP_YNA: Select6_ODP_CommA: 7_AE_YNA: Select7_AE_CommA: 7_ODP_YNA: Select7_ODP_CommA: ODP_Reviewer: Date_ISP_Submt: PriorAuth_Date: ISP_StartEnd: ODPAuth_Recommendation: SelectODP_Rev_Comm: ODP_ROAppr: PriorAuthDec: Select

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Sh Ais Isp Checklist Form Dp 1035