ISP
What does ISP stand for, and what is its purpose?
The Individual Support Plan (ISP) is a person-centered plan that identifies an individual's strengths, preferences, goals, support needs, and the services necessary to help them achieve desired outcomes.
What documents are required if someone is on the waitlist as Priority 1 Status?
VIDES Assessment (complete in WAMS and uploaded to Credible record)
-Priority Needs Checklist
-Critical Needs Summary (CNS)
-Slot Assignment Review Form (SARF)
-Individual choice form
-BI Waiver Notice (18+)
Additional documents:
ROIs (if applicable)
Additional Info to be completed in WAMS:
Waitlist tab-last date of contact,
Last date individual choice form was signed,
Requested Waiver services
What dates must be entered into the Credible plan? and where do they go?
ISP Start Date/Target Date in goal(s) section.
What should be noted in the employment section of the ISP?
The individual's employment status, goals, support needs, and all employment services discussed should be documented, including supports needed to achieve and maintain competitive integrated employment.
How often is the Individual Choice form required for individuals on the WWL?
Yearly
What are the documents that must be submitted on time for supervisor review, feedback, and any necessary corrections before the ISP can be completed in its entirety?
ISP Plan
ISP Signature Sheet
Credible Plan
What assessment information and supporting documentation should be included in the Health section of the ISP?
The exceptional medical and behavioral needs identified through the SIS assessment, along with any applicable medical, mental health, safety, and behavioral protocols or plans.
What is the WSAC?
Waiver Slot Assignment Committee
- It is a group of impartial volunteers responsible for determining the urgency of a person's need for a Developmental Disabilities (DD) Medicaid waiver slot.
What pertinent information must be documented in F2F notes?
-Mention of completing OSVT/CAT and current status (stable, etc.)
-ECM (if change in status)
-Health status, doctors appts (in applicable)
-SCs interaction with the individual; if individual is presentable/well-groomed.
-Progress in ISP shared plan outcomes
-Satisfaction with services; plans to address/follow-up with any concerns
What additional information should be included under essential routine supports in the ISP?
-Any exceptional medical/behavioral needs from SIS
-Medical diagnoses, mental health, or behaviors that require daily monitoring/support (should also be mentioned under the health section)
What is the name of the portal individuals/families can use to update individual choice form and services needed under the waiver within 30 days of accepting a DD waiver?
DBHDS Waitlist Portal
What pertinent information must be documented in Quarterly Reviews?
-If the provider provided quarterly reviews and if not, SC requested
-Brief summary of provider quarterlies (list provider and service they provide) and if individual is making progress towards shared plan goals
-Any health/medication/appts updates; any changes to ECM status
-Satisfaction with services; current services meeting needs
-Mention of Completion of F2F/OSVT/CAT assessments during the quarter
Additionally, if an individual has a quarterly review due at discharge, mentioning the discharge information: Transfer Location? CSB? SC? Any transfer of Psych services?
What acronym is used in the Shared Plan to help develop person-centered ISP goals?
SMART goals — Specific, Measurable, Achievable, Relevant, and Time-bound. ISP goals should be person-centered, reflecting the individual's preferences, strengths, needs, and desired outcomes.
An individual on your tracking caseload who is on the WWL reports they are homeless. What actions should you take next?
Assess for immediate health and safety needs.
Determine if the individual is in immediate danger or needs emergency assistance.
If there is an emergency, direct them to call 911 or connect them with emergency services.
Gather information about the change in circumstances.
Confirm the homelessness and when it began.
Identify current living arrangements and available supports.
Document the contact in the individual's case record, including the reported homelessness and any actions taken.
Notify your supervisor
Discuss a Emergency Waiver Slot with supervisor:
Homelessness may qualify as a significant change in circumstances.
Review the criteria to determine whether an Emergency waiver form should be completed.
Complete and submit the Emergency Waiver request if appropriate, with supporting documentation.
Provide referrals and resource information, such as:
Local Department of Social Services
Community Services Board resources
Emergency shelter or housing assistance
Continue waiver waitlist tracking responsibilities, including documenting follow-up and monitoring the individual's status until the issue is resolved or the Emergency Waiver request process is complete.
What is required for individuals on your tracking caseload?
-Contact 2x a year (document contact and any attempts)
-If on the WWL, update VIDES; Priority checklist; SARF; CNS; ROIs ; updated signed Individual choice form (update Last date in WAMS, and update last date of contact in WAMS
-Update priority in Individual Ext. profile; ensure all documentation is uploaded credible (Vides, priority, ROIs, CNS). We do not upload SARFs to Credible.