REVISED: 10/29/24
Name of Individual:
Sample #:
W#
Provider Agency:
Reviewer:
ISC:
Primary Program: _ CILA _ CDS _ SDA _ AHBS _ CSW _ CRW
Guardian Name:
Phone Number:
Guardian address:
Relationship: _ Parent _ OSG _ Other: _N/A - no guardian
Date/Time and initials of caller for:
Initial call:
2nd attempt:
3rd attempt:
Letter sent:
| Yes |
No |
N/A |
Item |
Comment/Note: |
| - |
- |
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If the guardian is answering the following questions substitute the individual's name. |
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| - |
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1. Are all the services and supports that (you need/"name" needs) identified and addressed in the Personal Plan and Implementation Strategy?
PMD2
|
- |
| - |
- |
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2. (Do you/Does "name") feel that all the necessary services and supports are being received to address the needs and outcomes identified in the Personal Plan and Implementation Strategy? |
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| - |
- |
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3. Do you feel (you are/"name" is) receiving services in your home or community that are allowing (you/"name") to participate in meaningful activities to help meet (your/"name's") goals/needs?
PMA4
|
- |
| - |
- |
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4. Do you feel that (you are/"name" is) supported in making decisions to remain independent to the greatest extent possible?
PMA5
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- |
| - |
- |
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5. (Are you/Is "name") treated well by direct support staff? (i.e., treated with respect, feel safe among staff, staff are respectful of individual's culture, staff communicate with individual in their preferred language, staff support individual in the way they desire.)
Direct Support Staff includes DSPs AND PSWs. This question is applicable for
CILA, CDS, CRW, and AHBS/CSW with PSW supports. If an individual receives SDA only or AHBS/CSW without PSW supports, indicate N/A.
PMG7
|
- |
| - |
- |
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If any of questions 1, 2, 3, 4, and/or 5 are answered 'No', the reviewer shall contact the ISC and request the ISC to follow the below steps.
The ISC shall:
- Follow up with the individual/guardian to determine what would lead to their satisfaction and/or ensure resolution of identified issues.
- If necessary and applicable, follow up with the provider agency until resolution is achieved.
Reviewer is to provide a summary of the discussion with the ISC in the 'Notes' section below.
|
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| - |
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Date of ISC contact: |
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| - |
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ISC contact person: |
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| - |
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ISC contact information: |
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| - |
- |
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6. Are you/Is "name") free from unauthorized restrictive interventions such as restraints or seclusion? |
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| - |
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7. (Are you/Is "name") free from abuse, neglect, or exploitation?
If questions 6 and/or 7 are answered 'No' the reviewer should determine if the Abuse, Neglect, or Exploitation:
- has been reported and investigated, and/or
- needs to be reported by reviewer.
Provide a summary below in the "Notes" section on the issue and outcome. |
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| - |
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Date follow up conducted: |
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| - |
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Follow up conducted by: |
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| - |
- |
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8. Do you believe (you are/"name" is) in the best possible health? |
- |
| - |
- |
- |
9. Competitive Integrated Employment (CIE) is work performed for wages at or above minimum wage in an integrated, non-Provider setting.
(Are you/Is "name") engaged in CIE? If 'No':
(Are you/Is "name") interested in exploring CIE? |
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| - |
- |
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10. (Are you/Is "name") happy / satisfied with the services and supports provided by the ISC? Please explain if not. |
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| - |
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11. (Are you/Is "name") happy / satisfied with the services and supports provided by the provider agency? Please explain if not.
(If no provider agency, mark N/A.) |
- |
Notes: __
File a Report of Abuse, Neglect, or Exploitation:
CILA and CDS, call Office of Inspector General (OIG) at (800) 368-1463.
Adult HBS, call Adult Protective Services (APS) Hotline at (866) 800-1409.
CRW and CSW, call Department of Children and Family Services (DCFS) at (800) 252-2873
Community Living Facility, call Department of Public Health (DPH) at (800) 252-4343 or email at DPH.CCR@illinois.gov
