Overview
Provider organizations are accountable for providing services and supports that will assist the person to pursue the outcomes outlined in the Personal Plan. The Implementation Strategy describes how the provider organization will support the person to achieve his/her desired outcomes. This Strategy must use the DHS approved template as of October 1, 2022, It will be evaluated to assure consistency between the persons stated outcomes and provider-directed services and support, measure progress over time toward outcomes, assure that known risk factors are addressed and demonstrate compliance with Medicaid Waiver requirements.
The priorities, strengths, support needs and risk factors identified in the Personal Plan must be addressed and accounted for in the Implementation Strategy. The more comprehensive the nature of paid services being provided (e.g. 24-hour CILA vs. employment services), the more detailed and accountable the Implementation Strategy will be. Provider organizations can design their own tool for demonstrating compliance in this area and providing direction to staff. Requirements the tool must meet are detailed below.
Individual's Demographic and Descriptive Information
- Name and contact information
- Legal status and contact information for legal representative if applicable
- Introductory summary (e.g. preferred name, education/work background, current/ previous living arrangement(s), etc.)Summary of important known personal preferences that anyone working with the person should be aware of and respect; refer to the Important Things to Know About the Person section of the Personal Plan. Depending on the nature of services being provided, this may include information in the following areas:
- Food and meals
- Daily routine/rituals
- Hobbies and preferred activities
Critical Life Areas
For those life areas reflected in the Personal Plan that the provider organization is paid to support the person in, the following items must be reflected in the Implementation Strategy (Home, Important Relationships, Career and Income, Health and Wellbeing, Life in the Community, Communication, Recreation/Interest/Hobbies, Choice and Decision Making, and Future Plans):
- The outcome contained in the Personal Plan; detail on how the provider organization will assist the person to pursue their personal outcomes and how progress will be measured
- Other personal priorities/strengths the person has in this area
- On-going support needs in the area and designation of how these will be met (e.g. provider responsibility, natural support, etc.)
- Risk factors and the plan for mitigating risk
Assurances
- The Implementation Strategy must be understandable and provided to the person and other non-professionals chosen by the person;
- Identify the person responsible for monitoring the Strategy
- Demonstrate in writing the informed consent of the person
- Be signed by all those responsible for Strategy implementation
- Demonstrate review and update at least every 12 months, or when the person's needs/circumstances change significantly, and/or at the request of the person.
The Implementation Strategy must:
- Use DHS approved template
- Reflect the outcomes identified in the Personal Plan
- Describe how supports and services assist the individual to engage in community life and maintain control over personal resources
- Provide opportunities to seek employment and work in competitive integrated employment if desired
- Include functional goals/training areas and methods to measure progress
- Demonstrate that services and supports are linked to individual strengths, preferences and assessed clinical and support needs
- Describe individualized back-up plans and strategies for service delivery
- Identify risks included in the Personal Plan and any others subsequently identified; strategies that will be used to mitigate risk and who is responsible for implementing these strategies
- Identify all services and supports to be provided regardless of provider of funding source, including type, methods if applicable, frequency, duration and staff assigned if applicable
- Include justification for any restriction(s) or modifications that limit the person's choice, access or otherwise conflict with HCBS standards
- Include basic descriptive, diagnostic, demographic and medical information
- Document the items below in any situations where a person lives in a residential setting owned or controlled by a service provider and modifications are requested to the expectations of community settings laid out in section 441.301C4vi A-D (e.g. legally enforceable lease, privacy, choice of roommates, control over schedule, visitor access),
- The specific and assessed need of the person
- An attempt to use positive interventions and support
- Documentation that less intrusive methods were attempted
- Includes a clear description of the condition that is directly proportionate to the specific assessed need
- Description of data collection methods
- Timeframes for periodic review to determine if modifications remain necessary
- Informed consent of the person
- Assurance that intervention will not harm the person
- Reflects ongoing review, monitoring and updating if necessary by the Provider agency
- Is updated to reflect changes in the Personal Plan at least annually and more often if warranted by circumstances, a change in functional status or at the request of the individual
