IV. Individual Service Plan

The development of a good comprehensive individual service plan is key to identifying the supports and services the individual needs and wants, assisting the individual to live successfully in the community, ensuring providers understand and fulfill their roles and responsibilities and ensuring funds are used in the best interest of the individual. The process must be as simple as possible so that all participants can understand their roles.

All three Waivers use a participant-centered planning approach directly involving the participant and the participant's guardian, if one has been appointed, as members of the service planning team along with the responsible case manager (also known as the Qualified Intellectual Disability Professional [QIDP] or Service Facilitator), direct service providers, Individual Service and Support Advocate (ISSA) and any other persons important to the participant, including family members where chosen by the participant.

The responsible case manager or Service Facilitator contacts the participant and guardian, if one has been appointed, prior to any service planning meetings to identify areas of concern, answer questions, and generally help them prepare for the meetings.

The responsible case manager or Service Facilitator convenes the service planning meetings. The case manager or Service Facilitator is responsible for ensuring that the written plan addresses the individual's needs and preferences and includes all required components.

Below is a summary of service plan requirements:

  • Is a single, comprehensive document that prioritizes and structures the delivery of all services and supports across environments.
  • Provides for supports and coordination for the participant to access school-based services (if applicable), generic resources and Medicaid State Plan services.
  • Includes relevant and timely assessment information, including individual preferences, abilities and needs.
  • Contributes to the continuous movement of the participant toward the achievement of the participant, family or guardian's preferences.
  • Describes how opportunities of choice will be provided, including specifying means for:
    • Supporting the participant, family or guardian, if one has been appointed, to indicate preferences among options presented, by whatever communication methods necessary.
    • Providing the necessary support and training for the participant and family to be able to indicate preferences, including a description of any training and support needed to fully participate in the planning process and other choice making.
    • Assisting the participant, family or guardian to understand the negative consequences of choices that may involve risk.
    • Is based on assessed needs and individual preferences, including an annual ICAP or other children's functional assessment tool.
  • Is based on principles of community inclusion and self-determination. 
  • Is designed to promote needed individual and family supports for individuals who live in a family home.
  • Includes functional goals and methods to measure progress toward those goals.
  • Identifies all services and supports to be provided, regardless of provider or funding source, including type, training methods if applicable, frequency, duration and staff assigned.
  • Addresses such areas as communications, maladaptive or inappropriate behaviors, mobility/ambulation issues, basic self-care skills and vocational/self-sufficiency skills.
  • Documents health needs and supports needed and/or provided, including doctor and dentist visits, medications, medication administration, self-medication training and oversight.
  • Documents efforts to reduce reliance on psychoactive medications used for behavior management, unless contraindicated by clinical evidence.
  • Identifies any specific circumstances when the individual may stay alone or access the community independently, if applicable.
  • Includes activities to address any poor choices by the individual, either by minimizing the potential harm or explaining why choices cannot be honored safely.
  • Includes name, title, credentials, agency affiliation and relationship to individual for all participants in service plan development.
  • Is signed by the individual and guardian, the responsible case manager or Service Facilitator, all service providers and the Independent Service and Support Advocate (ISSA) to show their participation in the development of the plan.
  • Is completed within 30 days of service initiation and is updated at least annually by the service planning team and is reviewed and revised as needed by the responsible case manager or Service Facilitator.
  • May be produced in other formats, such as pictures, DVD, etc., to accommodate specific needs of the participant, team, or provider; however, the plan must exist in written format.

The responsible case manager or Service Facilitator must: 

  • Monitor the implementation of each service plan at least monthly for participants in residental services:
    • at least monthly for participants in residential services
    • at least one every two months for participants in self-directed options and the Children's Support Waiver.
  • Revise the plan by following the same process as set out above, whenever necessary, to reflect changes in the participant's needs and preferences, achievement of goals or skills outlined within the plan or any determination made that any service being provided is unresponsive.
  • Involve the ISSA in service plan development and problem resolution.
  • Refer issues that cannot be resolved to the Division of Developmental Disabilities for technical assistance.  Please see Information Bulletin DD.011.010, ISSA Guidelines: Problem and Conflict Resolution for more information. As part of the guidelines for Individual Service and Support Advocacy (ISSA) providers, the Department developed a section entitled Problem and Conflict Resolution: Addressing Issues, Solving Problems, Trouble-Shooting. This section has been revised to comply with expectations from the Centers for Medicare and Medicaid Services regarding time frames for addressing complaints.  The revised section is attached, along with the Referral for Monitoring and/or Technical Assistance Tool and the Instructions for Completing the Tool.

The responsible ISSA must:

  • Actively participate in the development of the participant's service plan.
  • Assist the participant and guardian in actively participating in service plan development.
  • Indicate concurrence with the service plan through signature, work locally to resolve issues or, if all attempts at problem solution fail, refer issues to the Division of Developmental Disabilities for technical assistance.
  • Monitor the implementation of each participant's service plan at least quarterly, and undertake follow-up activities as appropriate and necessary.