Commonwealth of Pennsylvania Department of Public · PDF fileOffice of Developmental Programs Individual Support ... mental retardation service ... to empower the individual to plan

For Review and Comment Purposes Only – Not For Implementation

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Commonwealth of Pennsylvania Department of Public Welfare

Office of Developmental Programs

Individual Support Plan (ISP) Manual


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Table of Contents

Page Preface 3 Introduction/Background 4 Section 1 5

General ISP Requirements 6 ISP Preparation 7 ISP Meeting 7 Creating and Updating ISPs in HCSIS 10 Fiscal Year ISP 10 Addressing Changes in Need Throughout the Year 12 Implementation of Services 12 ISP Review 13 Monitoring of Services 13 ISP Signature Page 15 ISP Process Flowchart – New to the System 17 ISP Process Flowchart – Annual Review 18 ISP Activities Timeline & Role Clarification – Supports Coordinator 19 ISP Activities Timeline & Role Clarification – Administrative Entity and

County Program 22 ISP Activities Timeline & Role Clarification – Providers 23 ISP Activities Timeline & Role Clarification – Individuals & Families 24

Section 2 25 Person Centered Planning 26 Everyday Lives 27 Positive Approaches 33

ISP Key Terms 35 Additional resources 39


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Preface The ISP Manual is a resource created by the Office of Developmental Programs (ODP) to support the implementation of the ISP Bulletin by outlining the expectations and responsibilities of various stakeholders involved in the ISP process. The manual defines:

1. The ISP process, 2. What constitutes a quality ISP, 3. ISP content requirements, and 4. Requirements and guidelines for planning, creating, implementing, and monitoring the ISP.

The content of this manual does not prescribe a “meeting format”, but rather a planning philosophy for services and supports. The goal of the ISP process outlined in this manual is to empower the individual in the process to evaluate and meet their needs. The involvement of the individual and his or her family, as applicable, is critical to making the ISP a success.


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Introduction/Background In 1991, ODP, formerly known as the Office of Mental Retardation (OMR), convened a planning retreat with members of its Planning Advisory Committee (PAC) for the purpose of developing an overall vision for Pennsylvania’s mental retardation service system. The PAC, which was the first advisory body to ODP to include people with disabilities and families as full participating members, focused its work on what people with disabilities and families said was important to them and what kind of supports they needed. The result of the PAC’s efforts was Everyday Lives, published by the Department of Public Welfare in 1991. Everyday Lives was updated in 2002 as Everyday Lives – Making it Happen. Since its publication, the values and vision expressed in Everyday Lives have provided the framework for planning, policy development, service design and all related activities in the mental retardation service system. As the mental retardation system evolved with the Everyday Lives philosophy, concepts such as Self-Determination, Person-Centered Planning and Positive Approaches and Practices emerged through the grassroots efforts of people receiving those services and their families, friends and advocates to enhance and better define the planning process. Individual Support Planning is based on those same exact philosophies and concepts of Everyday Lives, Person-Centered Planning and Positives Approaches and Practices that captures the true meaning of working together to empower the individual to plan and create a shared commitment for his or her future. The following sections serve as a tool to ISP team members to help them employ the above philosophies.


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Section 1

ISP Process


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General ISP Requirements An ISP must be completed and entered in HCSIS for: • Anyone who has been found eligible for mental retardation services and is receiving at least one

funded service, including Supports Coordination (regardless of the funding stream). • All Consolidated and Person/Family Directed Support (P/FDS) Waiver participants, prior to the

receipt of Waiver services. • All people funded through base dollars and receiving at least one paid service in addition to

Supports Coordination. Abbreviated ISPs may be completed for an individual receiving non-waiver services that cost less than $2,000 in a fiscal year; however a full ISP is encouraged.

• People residing in public and private Intermediate Care Facilities for Persons with Mental Retardation (ICFs/MR).

The process for developing and implementing ISPs for both individuals new to the system and individuals currently receiving services is demonstrated in flow charts on pages 17 and 18 (respectively) of this manual. The ISP is developed by the individual and his or her team and is facilitated by the Supports Coordinator who then creates the ISP document in HCSIS. The team consists of the individual; his or her family, guardian, surrogate1, or advocate; providers of service; and other people who are important in the individual’s life. For regulated services (55 Pa.Code §2380, 6400 and 6500), at least three members of the individual’s team, in addition to the individual if the individual chooses to attend, are required to be present at ISP meetings. The ISP is the sole source document for services and supports delivered to an individual that addresses assessed needs. For licensed services, the ISP will be the first source of review to determine compliance with planning and assessment regulations. Providers of licensed services must participate in the ISP assessment and planning process, including participation in ISP team meetings, and provide necessary information to the Supports Coordinator for incorporation into the ISP. Providers should maintain documentation of the submission of ISP information to the Supports Coordinator. Providers are not required to develop their own separate Individual Program Plans. Providers are, however, responsible for completing assessments and evaluations related to the individual that may impact the contents of the ISP and promote the ISP outcomes or be necessary to comply with regulations. Providers may also need to develop and maintain supplementary information that is necessary to ensure appropriate service delivery (e.g., Detailed goal plans to supplement outcome statements).

1 Not everyone can make legally binding decisions for themselves. This would include minor children and some adults who have substantial mental impairment. In these instances, a substitute decision-maker may be identified under State law. Substitute decision-makers have various legal titles, but for the purposes of this bulletin, they will be referred to as “surrogates.” “Surrogates” include the following:

• Parents of children under 18 years of age under the common law and 35 P.S. §10101. • Legal custodian of a minor as provided in 42 Pa.C.S. §6357. • Health care agents and representatives for adults as provided in 20 Pa.C.S. Ch. 54. • Guardians of various kinds as provided in 20 Pa.C.S. Ch. 55 (as limited by 20 Pa.C.S. §5521(f)). • Holders of powers of attorney of various kinds as provided in 20 Pa.C.S. Ch. 56. • Guardians of persons by operation of law in 50 P.S. §4417(c).

Any of these would be considered “legal representatives” as the Center for Medicaid and Medicare Services uses that phrase. Please see Application for a §1915(c) Home and Community-Based Waiver ]: Instructions, Technical Guide and Review Criteria [www.cms.hhs.gov/HCBS/02_QualityToolkit.asp].


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Individual Support Plan Preparation The individual, along with the Supports Coordinator, determines who they want present and involved in the development of the ISP and determines the date(s) and location of the team meeting(s). Preparation for the ISP meeting involves information gathering, which should include:

• Involvement of people who know the individual best and can offer rich and detailed information about the individual and his or her needs.

• Identification, coordination, and collection of information from team members and/or other

professionals by the Supports Coordinator in the following areas:

o Formal and informal assessments, as well as the ODP standard assessment for Waiver participants2

o Communication styles o Personal preferences o Personality traits o Interactions with others o Relationships that impact the individual’s quality of life o Learning styles o Physical development o Educational background o Employment preferences/experiences o Social/emotional information o Interest in Lifesharing, if applicable o Medical information o Environmental influences o Identification, evaluation and mitigation of risk (using, for example, incident histories,

medical histories, and personal safety information) o Independent Monitoring for Quality (IM4Q) considerations and results of other external

monitorings, if relevant o If a Lifetime Medical History (Bulletin 00-94-32, Lifetime Medical History) has been

completed, the information within should be available for the team meeting. Each team member ensures that information provided during the ISP process is current and is presented professionally and with sensitivity. Individual Support Plan Meeting Development/Review of Information Gathered

All team members play vital roles in the ISP process by fully participating to share knowledge, perspective, and insight. The information collected presents a complete and comprehensive picture of the individual. The team reviews this information during the assessment/information gathering stage of the ISP process to ensure that identified needs lead to outcomes and services that are based upon

2 Needs for Waiver participants must be identified using the ODP standardized needs assessment, the Supports Intensity Scale® and Pennsylvania Plus, as per the rollout strategy established by ODP.


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needs and personal preferences. Information that will impact the individual’s health and safety, services and supports, or ability to have an everyday life is incorporated during the development/Annual Review process. Outcome Development

• The team develops Outcome Statements and Actions to support the attainment of what is

important to the individual within the context of what is important for the individual. • Outcomes should build on gathered information, reflect the individual’s needs and preferences,

represent desired changes and important things that should be maintained or make a difference in the individual’s life, and signify a shared commitment to take action.

• There should be a clear connection between the individual’s needs and preferences, choices, or life aspirations and the Outcomes that are developed at the ISP meeting.

• The team and individual work together to find acceptable Outcomes that enable the individual to exercise his or her choices while at the same time meet needs, minimize risk, and achieve or maintain good health.

• Although every funded service requires an Outcome, not every Outcome must relate to a funded service. There may be Outcomes important to the individual that do not relate to or are supported by a funded service.

• Any barriers or concerns that prevent the Outcomes from being tangible and reachable must be addressed during the planning process, especially if they can impact the individual’s health and safety.

The planning process also investigates and implements whenever possible the most natural means of supporting the individual to achieve his or her desired outcomes. Examples of “natural means” would be supports through the use of family activities and routines and community participation (social, civic and/or spiritual activities). Integrated service options must be promoted and fully explored with every individual. Individuals with a need for vocational services shall receive information about Supported Employment; this exploration must be documented in the individual’s file. Individuals with a need for residential services shall receive information about Lifesharing options; this exploration must be documented in the individual’s ISP in the Were lifesharing options considered for Residential Services field. Identification of Services and Supports

• The team uses Outcomes as a guide to determine what services and supports are needed and

to ensure that services and supports reflect the actions needed to promote the Outcomes. • Natural supports in the community such as friends, family, neighbors, businesses, schools,

civic organizations, and employers are considered as well as and other funding streams such as the Pennsylvania Medical Assistance State Plan, Behavioral Health, and the Office of Vocational Rehabilitation.

• Each service or support must be linked to an Outcome. • The team should identify the types, duration, amount, and frequency of services and supports

that are needed. The ISP must reflect needed frequency, duration, and amount of services. The type of services is documented through the service name on the Service Details screen in HCSIS. Frequency of services is documented on the Outcome Actions screen in the Frequency and Duration of the actions needed field. Duration of services is documented through the start and end dates of the service on the Service Details screen in HCSIS. The


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amount of services is documented through the number of units included on the ISP on the Service Details screen in HCSIS.

A completed ISP should provide a means of achieving outcomes important to the individual, integrating natural supports as well as funded supports. All needs that affect the individual’s health and well-being, or if absent would cause the individual to be placed in an institutional setting, must be met. Choosing Providers for Funded Services The Supports Coordinator is responsible for the location of potential providers. Information on willing and qualified providers to provide necessary services is reviewed with the individual and his or her family, guardian, or advocate. Providers of Waiver services are qualified according to the standards established in the approved Waivers3. ODP recommends that providers of non-waiver services be qualified using the Waiver criteria. The individual and his/her family exercise choice in the selection of willing and qualified providers. This selection is documented through a service note in HCSIS and on the ISP Planning Process Participants’ Signature Page. The Supports Coordinator is responsible to make timely referrals to selected providers based on the selections made by the individual and his/her family. Prioritization of Urgency of Need for Services

• The ISP process should also involve a review of the individual’s PUNS, if the PUNS is active. • If the PUNS does not reflect the current needs of the individual, the Supports Coordinator must

update the PUNS to reflect current needs4 as per Bulletin 00-06-15, Prioritization of Urgency of Need for Services (PUNS) Manual.

• If needed service(s) that must be provided through public mental retardation dollars are unavailable due to a funding or other issue, the team determines if the individual will have any anticipated unmet needs in the next five years as well as the consideration of how to move in the direction of identifying any natural supports that might help address the need.

• If there are future unmet needs, the Supports Coordinator completes or updates PUNS with the individual or family. An unmet need may require the submission of an Individual Emergency Status Form (IESF) to the Administrative Entity (AE) or County Program.

• The PUNS should be reviewed at every ISP meeting, and as necessary based on changes in the individual’s needs.

ISP Planning Process Participants’ Signature Page

• At the conclusion of the ISP meeting, the individual and other participants of the team meeting should sign the ISP Planning Process Participants’ Signature Page. It is essential to have the individual attend his or her own ISP meeting. However, should the individual, family member, and/or provider choose not to be present, the reason must be documented in a Service Note in HCSIS and on the ISP Planning Process Participants’ Signature Page.

• The signature page should be signed and dated by everyone attending the meeting.

3 Reference Appendix C of the approved Consolidated or P/FDS Waiver for specific qualification criteria. 4 The current, assessed needs of Consolidated Waiver participants must be met within the scope and limitations of Waiver services. The current, assessed needs of P/FDS Waiver participants must be met within the scope and limitations of Waiver services and up to the individual cost limit.


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The Supports Coordinator develops the ISP based on the team’s recommendations for services and supports to meet the individual’s current assessed needs. Creating and Updating ISPs in HCSIS There are five ISP formats in HCSIS that are used in creating and updating ISPs. These are:

• Plan Creation – Plan Creation is used for the initial creation of the ISP, or for other individuals without a current ISP in HCSIS. The end date of this ISP should be June 30.

• Annual Review Update – An Annual Review Update is used to document the results of the Annual Review Meeting. If the Annual Review Update includes service or funding changes, it will require approval and authorization. If the Annual Review Update includes only demographic or medical information updates, it will require approval but not authorization.

• General Update – A General Update is used to update content that does not impact services or funding.

• Critical Revision – A Critical Revision is used to modify or add services or funding in the current ISP based on the individual’s needs. A Critical Revision will require approval and re-authorization of the ISP.

• Fiscal Year Renewal – A Fiscal Year Renewal should have a begin date of July 1 and an end date of June 30. The ISP created through a Fiscal Year Renewal will pre-populate with information from the previous ISP.

Initial ISP Initial ISPs are created by the Supports Coordination in HCSIS using the Plan Creation ISP format. The initial ISP is considered a “bridge plan”, with a start date 60 to 90 days after the initial ISP meeting, and an end date of June 30. The initial ISP does not encompass an entire Fiscal Year, due to the timing of the initial ISP meeting. The “bridge plan” is used to align the ISP start and end dates with the fiscal year. In HCSIS, the ISP and the authorization exist in a single document. The start date of the HCSIS ISP coincides with the start of the fiscal year, or July 1, with the exception of initial ISPs (please see paragraph below). The Fiscal Year ISP “expires” at the end of the fiscal year, or June 30. ISP’s are developed on a Fiscal Year basis in order to create authorizations that encompass the full Fiscal Year. Authorization takes place by service, and each service is assigned a start and end date. The Fiscal Year ISP can include up to one year of service. This process promotes efficiency in provider billing, as well as the ability to generate reports that accurately reflect all services and payments by fiscal year. Fiscal Year Renewal ISP After the authorization of the initial ISP, the Supports Coordinator creates a new ISP using the Fiscal Year Renewal option in HCSIS. The start date for the Fiscal Year Renewal ISP is July 1, and the end date is June 30. Annual Review Update ISP The Fiscal Year Renewal ISP is reviewed by the individual and their planning team at the Annual Review Meeting. The Annual Review Meeting takes place at least 90 calendar days prior to the


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Annual Review Update Date, which is 365 or less from the date that the initial ISP was approved and authorized. If the review of the ISP identifies changes that need to be made to the ISP that relate to a change in funding, the Supports Coordinator will update the ISP using a Critical Revision. If the review of the ISP does not identify any changes that impact funding, the Supports Coordinator will update the ISP using a General Update. The incorporation of the Annual Review Meeting preserves the ability of the ISP team to review and update the ISP at random times throughout the year (preventing a situation where all ISPs come due at the same time in the year) while allowing the use of a fiscal year authorization. The timeline below shows an ISP for an individual that began services on November 1, 2007:

o The initial ISP was created by using a Plan Creation on October 1, 2007. The Fiscal Year Begin Date for this “bridge plan” was entered as November 1, 2007. The Fiscal Year End Date of the initial ISP was entered as June 30, 2008 to coincide with the end of the 2007/2008 fiscal year. This will insure that all services authorized and billed will be limited to the 2007/2008 fiscal year.

o The initial ISP was approved and services authorized by the Administrative Entity or the County Program on October 30, 2007. The approval and authorization date for the initial ISP will be used as the Annual Review Update Date, or the date by which the ISP will be reviewed, updated, approved, and authorized each year.

o This first ISP only contains eight months of services. To provide a complete picture of the services that will be provided, the Supports Coordinator will developed a second ISP in HCSIS using a Fiscal Year Renewal. The Fiscal Year Renewal ISP has a Fiscal Year Begin Date of July 1, 2008 and a Fiscal Year End Date of June 30, 2009. When the draft of this second ISP is created it will pre-populate with the information from the initial ISP. The Supports Coordinator will need to revise the service begin and end dates and finalize the second ISP for approval.

o In the example above, the Supports Coordinator will have projected the services that the individual will receive for a total of 20 months (eight months in the initial ISP and 12 months in the Fiscal Year Renewal).

o The Supports Coordinator is, however, responsible to review and update the ISP at least once every 365 calendar days. In this example, the Supports Coordinator should schedule an ISP Annual Review Meeting no later than August 1, 2008 (90 days prior to the Annual Review Update Date of October 29, 2008). The Annual Review meeting is used to review the current ISP and discuss any necessary changes to meet the individual’s needs.

o The ISP should be updated as a result of the Annual Review Meeting using an Annual Review Update.

HCSIS training guides are available regarding this process on the Learning Management System.


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Fiscal Year Model – Example Diagram Initial ISP FY Begin FY End Created Date Date 10/01/07 11/01/07 06/30/08 Annual Review Annual Review I___________I__I______________I Meeting (no later Update Date Approved than) 08/01/08 10/29/08

& Authorized I_______I___________________I_________________I 10/30/07 FY Begin FY End Date

Date for FY for FY Renewal Renewal ISP ISP

07/01/08 06/30/09 Addressing Changes in Need Throughout the Year If an individual experiences a change in need throughout the year, this change must be reflected in the individual’s ISP. Upon verification of a change in need, the Supports Coordinator must document the change in a service note in HCSIS and initiate an ISP change.

• Waiver Participants: Individuals enrolled in a Waiver must have their needs fully met within the scope and limitation of the applicable Waiver, and therefore the ISP services and funding must be updated as necessary to address a change in need.

o If the change in need impacts the current services and funding, the Supports Coordinator must create a Critical Revision. The Critical Revision must be created, and submitted for approval and authorization within seven (7) calendar days of notification of the change.

o If there is sufficient funding, the Administrative Entity must approve and authorize the changes within 14 calendar days to ensure the individual’s new needs are met in a timely fashion.

o If the Administrative Entity has insufficient funding to address the change in need, they must request additional funds from ODP, as outlined in the current Administrative Entity Operating Agreement.

o If a change in need does not impact services or funding, the Supports Coordinator must create a General Update. The General Update must be created and finalized within seven (7) calendar days of verification of the change in need.

• Base-Funded Individuals: Base funding is utilized as per the Mental Health and Mental

Retardation Act of 1966. o If the change in need impacts the current services and funding, the Supports

Coordinator must create a Critical Revision. o The County Program must approve and authorize or deny the revised ISP, including the

attached funding within 14 calendar days. o If the new services or funding is denied, the individual must be provided with their due

process rights. In addition, the Supports Coordinator must update the individual’s PUNS.

Implementation of Services Services must be implemented as per the current ISP, including the start and end dates of services. Fiscal Year Renewal ISPs should be implemented as written, pending the Annual Review Meeting. If the Annual Review Meeting results in a change of services, the change must be documented in the


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ISP as an Annual Review Update. Upon approval and authorization of the change, if necessary, the ISP must be implemented as per the Annual Review Update. The ISP includes services based on the current assessed needs of the individual. If all units authorized on an ISP are not utilized, excess funds budgeted for the unused units are not transferable to future ISPs, unless accompanied by a change in need. Those responsible for service implementation are accountable for actions, services and supports as indicated in the ISP, and are responsible for documentation to support the provision of services as per Bulletin 00-07-01, Provider Billing Documentation Requirements for Waiver Services (or any approved revisions). ISP Review The Supports Coordinator should hold the ISP Annual Review Meeting with the individual and their planning team at least 90 calendar days prior to the ISP’s Annual Review Update Date. The purpose of this meeting is to:

• Review the current ISP. • Consider completed assessments and reassessments and discuss how the results translate to

needs. • Discuss services and supports to meet the needs of the person, based on the discussion of

the assessments/reassessments. • Review progress towards outcomes, and discuss necessary adjustments. • Discuss planning and services for the next year.

The Supports Coordinator must ensure that the ISP Annual Review Meeting(s) and the Annual Review Update is completed in HCSIS with sufficient time to ensure the approval and authorization for service or funding changes occur within 365 days of the previous Annual Review Update Date (see the Individual Support Plan Activities Timeline for Supports Coordinators).

• If the total cost of services exceeds the current total plan budget amount, the Administrative Entity or County Program is immediately contacted to discuss how to proceed.

After the Annual Review Update, the Supports Coordinator should create a Fiscal Year Renewal to start the ISP for the following fiscal year. The creation of the Fiscal Year Renewal must take place no later than 30 calendar days prior to the start of the next fiscal year. The Fiscal Year Renewal ISP should have a Fiscal Year Begin Date of July 1 and a Fiscal Year End Date of June 30.

Monitoring of Services Supports Coordination monitoring verifies that the individual is receiving the appropriate type, amount, duration, and frequency of services to meet the individual’s assessed needs and desired outcomes. For waiver participants, Supports Coordination monitoring must take place at the minimum frequency outlined in the current, approved Consolidated or P/FDS Waiver. For other individuals, Supports Coordination monitoring must take place at least annually, or at a frequency necessary to assure the health and welfare of the individual. In addition, the Supports Coordinator and team gather information and review the Outcomes and selected services on an ongoing basis to assure that the ISP continues to reflect what is important to and for the individual. The ISP is revised as needed based on these reviews. All revisions are discussed with the individual and/or his or her family, guardian, surrogate, or advocate and team.


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In addition, the individual may be asked to participate in other external monitoring, such as Independent Monitoring for Quality (IM4Q) surveys and oversight by the Administrative Entity, County Program, or Department of Public Welfare.

Service providers have the ongoing responsibility to review and validate the approved ISP, and to ensure services are implemented as documented in the ISP.

Administrative Entities and County Programs monitor Supports Coordination Entities to ensure Supports Coordination monitoring takes place at the required frequencies, and that reasonable safeguards exist for the individual’s health and welfare in the home and community.

ODP conducts monitoring of ISPs to ensure that ISPs are implemented as written, including implementation of services and outcomes. ODP also monitors ISPs to ensure that ISPs for waiver participants are developed in accordance with the current, approved Waiver and the ISP Bulletin and Manual. ODP monitors ISPs for non-waiver individuals to ensure they are developed in accordance with the ISP Bulletin and Manual.

Finally, all team members should work in partnership to ensure that the individual is making progress towards outcomes, and/or service outcomes are being met or remain relevant. The ISP must be a living document, responsive to the individual, and his or her needs. In order for the ISP to be responsive, changes to the ISP and service outcomes must occur throughout the year as necessary. If those changes do not impact the individual’s services or funding, a General Update is completed. In the event those changes impact the individual’s funding, a Critical Revision is completed.


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The following document is the standardized signature sheet for validating participants’ activities in the ISP development.

ISP PLANNING PROCESS PARTICIPANTS’ SIGNATURE PAGE

Date of ISP Meeting: _______________________

YES NO N/A I attended my Individual Support Plan (ISP) meeting. I have discussed the need for a Critical Revision to my ISP, if applicable. I have selected and agree with the identified services and providers in my ISP. I agree with the actions my providers will take to assist me. I have explored Lifesharing as a residential service option (if I need residential services). I am interested in Lifesharing and it is reflected in my outcomes (if I need residential services). I have been informed about Employment Options. I agree with the outcomes on my plan. I have had my PUNS reviewed and if needed, a PUNS Change of Status Form has been completed. I have been informed of the right to request a change in these services at any time. I have been informed of the right to select an alternate qualified, willing provider (including Supports

Coordination provider) at any time. I have been informed that if my approved services are reduced, terminated or suspended at any time, I

have due process rights. If in the Consolidated or P/FDS Waiver, I have been informed of the Department Fair Hearings and

Appeals process. I agree to let my Supports Coordinator bill for my Supports Coordination services.

I understand my Supports Coordinator will provide copies of my ISP to the individuals and/or agencies listed below who may also have Internet (HCSIS) access to the approved ISP.

Title/Agency or Printed Name Relationship to Individual Signature (if attended the meeting)

_______________________________________________________ ___________________________ Signature of Individual Receiving Services Date


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ISP Process Flowcharts and

Role Clarification Tables

The following sections of this manual contain flowcharts and timelines to provide guidance and promote efficiency in ISP development. Each team member’s responsibility towards producing a quality ISP is

outlined within the following charts and tables.

ODP, AEs, and County Programs are responsible to monitor against the timelines included in this section, to ensure that ISPs are developed and updated according to ODP requirements.


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Individual Support Plan Process FlowchartNew to the System

Step 1: Individual/family applies for mental retardation services.

Step 2: County Program/Intake determines eligibility for mental retardation services. *Ifapplication for Waiver is made, additional eligibility activities occur through the Administrative

Entity (AE) and Fair Hearing and Appeal rights apply.

If individual is determined NOT eligible,they have the right to exercise DueProcess under Local Agency Law at

this time.

Step 3: Eligible individual/family selects Supports Coordination Organization and indicates anypreferences for a Supports Coordinator (SC).

Step 4: SC conducts initial ISP meeting with individual/family and team members, to createOutcomes and identify available services/supports to meet the individual’s current needs.

Step 5: SC enters the ISP into HCSIS.

Step 7A: If needed services are NOT available, SC completes a PUNS with the individual/familyat this time.

Step 7B: If needed services are available, SC submits the ISP to the AE for authorization.

Step 8: AE authorizes services in HCSIS or requests revisions.

Step 9: SC notifies and sends the approved ISP to the individual/family and team members.Authorized providers have access to the ISP and service authorizations in HCSIS.

Step 10: SC creates a Fiscal Year Renewal of the ISP for the next fiscal year with a fiscal yearbegin date of July 1.

Step 6: SC submits the completed ISP to the County (for non-Waiver) or the AE (for Waiver),and responds to any revision requests.


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Individual Support Plan Process FlowchartAnnual Review

Step 1: Annual Review process begins 60 to 90 days prior to Annual Review Update Date.

Step 2: Supports Coordinator (SC) coordinates information gathering, assessment(s), ISPmeeting and invitations; records relevant assessment information for entry into the ISP in

HCSIS; and reviews and shares assessment results, monitoring results, and incident reportfindings with individual/family.

Step 3: Provider agencies and professionals provide relevant ISP information to the SC.

Step 4: Annual Review Meeting(s) occurs with individual/family and team members to review,and make any changes or additions, to the current ISP, including Outcomes and services and

supports to meet the individual’s current needs. The individual/family selects willing and qualifiedproviders and gives consent to share the ISP with providers in HCSIS.

Step 6: SC submits the completed ISP to the County Program (for non-Waiver) or the AE (forWaiver), and responds to any revision requests.

Step 8: AE authorizes services in HCSIS or requests revisions.

Step 9: SC notifies and sends the approved ISP to the individual/family and team members.Authorized providers have access to the ISP and service authorizations in HCSIS.

Step 10: SC creates a Fiscal Year Renewal of the ISP for the next fiscal year with a fiscal yearbeing date of July 1.

Step 7: SC updates ISP using an Annual Review Update.

Step 7A: If needed services have changed, SC submits the ISP to the County Program AE forauthorization 14 to 30 days prior to the Annual Review Update date.

Step 7B: If needed services have not changed, SC notifies County Program or AE of the AnnualReview Update.

Step 5: SC updates the ISP in HCSIS.


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Individual Support Plan Activities Timeline & Role Clarification Supports Coordinator (SC)

Please note: The following table outlines the general expectations for timelines and activities related to the development and update of ISPs. The timelines must, however, be expedited for emergency situations.

Initial and Annual Review ISPs Days Before ISP Annual

Review Update Date Activity Supports Coordinator Actions

90 Days Information Gathering

• Coordinate information gathering and assessment activity.

• Collaborate with the individual/family/provider agency/team to coordinate invitations and ISP/Annual Review Meeting dates, times and locations.

• Coordinate invitations with individual/family, send out invitations, and file copies.

• Record relevant assessment information in the ISP in HCSIS.

• Review and share assessment results, monitoring results, and incident reports with individual/family. Include external reviews.

• Enter information into “Draft” ISP. 60 Days ISP Meeting/Annual

Review Meeting

• Conduct ISP meeting/Annual Review with individual/family, and team to adapt or create Outcomes and identify services/supports to address those Outcomes.


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Documentation • If the Annual Review Meeting results in no changes to services, complete a General Update of the current ISP in HCSIS.

• If the Annual Review Meeting results in changes to services, Search Services and Supports Directory (SSD) and select services for Outcomes based upon individual’s/family’s choices. Once a provider is selected, complete a Critical Revision of the current ISP in HCSIS, contact AE if total cost of services exceeds total plan budget amount.

• Notify SC Supervisor of updates and/or changes, and respond to any revision requests.

• Complete/update PUNS with individual/family if ODP services are NOT available.

45 Days Submit for Approval • For ISPs updated through a Critical Revisions, finalize the updated ISP for AE approval.

14-45 Days Financial Authorization

• Receive and respond to alert for approval notice or revision request.

• Receive and respond to alert for authorization notice or revision request.

14 Days

Distribution • Notify providers that the updated ISP has been approved and is available in HCSIS.

• Send approved ISP to individual/family and team members for which the individual gave consent.

0 Days (As per service start date)

Service Implementation

• Monitor services as required after implementation.


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Fiscal Year Renewal ISPs

Days Before June 30 Activity Supports Coordinator Actions At least 60 Days Create New ISP • Create new ISP in HCSIS for the

next fiscal year using the Fiscal Year Renewal option.

• The ISP start date should be July 1, and the end date should be June 30.

45 Days Approval • Finalize the ISP to AE for approval. 14-45 Days Financial

Authorization • Receive and respond to alert for

approval notice or revision request. • Receive and respond to alert for

authorization notice or revision request.

14 Days

Distribution • Notify providers that the Fiscal Year ISP has been approved and is available in HCSIS.

• Send approved ISP to individual/family and team members for which the individual gave consent.



• Monitor services as required after implementation.


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Individual Support Plan Activities Timeline & Role Clarification Administrative Entity (AE) or County Program


Initial and Annual Update ISPs Days Before ISP Annual

Review Update Date Activity Administrative Entity Actions


• For Annual Update ISPs, provide total plan budget amount and last year’s expenditures before the ISP meeting.

ISP Meeting/ Annual Review

• Attend and participate in ISP meeting/Annual Review meeting (optional).

60 Days

Documentation • For initial ISPs, provide total plan budget amount after Annual Review Meeting.

• For Annual Update ISPs, review request to change total plan budget amount if the individual’s needs have changed.

Approval • If the Annual Review Meeting results in a Critical Revision, approve ISP in HCSIS or request revisions.

14-45 Days

Financial Authorization

• If the annual Review meeting results in a Critical Revision authorize services in HCSIS or request revisions.

• Authorization information is available to Providers.

14 Days

Distribution • Not applicable.

0 Days Service Implementation

• Not applicable.

Fiscal Year Renewal ISPs Days Before June 30 Activity Administrative Entity Actions

Approval • Approve ISP in HCSIS or request revisions.

14-30 Days

Financial Authorization

• Authorize services in HCSIS or request revisions.

• Authorization information is available to Providers.

14 Days

Distribution • Not applicable.

0 Days Service Implementation

• Not applicable.


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Individual Support Plan Activities Timeline & Role Clarification

Providers Please note: The following table outlines the general expectations for timelines and activities related to the development and update of ISPs. The timelines must, however, be expedited for emergency situations.


Review Update Date Activity Provider Actions


• Receive ISP meeting invitation, complete assessments and send to SC in a user-friendly format.

ISP Meeting/Annual Review

• Attend and participate in ISP meeting/Annual Review and be prepared to provide transaction codes associated with the needed services.

60 Days

Documentation • Not applicable. Approval • Not applicable. 14-45 Days Financial

Authorization • Access service authorization in

HCSIS.

14 Days

Distribution • Access ISP in HCSIS.



• Implement services as per approved ISP.

Fiscal Year Renewal ISPs

Days Before June 30 Activity Provider Actions Approval • Not applicable. 14-45 Days Financial

Authorization • Access service authorization in

HCSIS.

14 Days

Distribution • Access ISP in HCSIS.



• Implement services as per ISP.


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Individual Support Plan Activities Timeline & Role Clarification Individuals and Families



Review Date Activity Individual/Family Actions


• Respond to communication from SC to establish ISP/Annual Review Meeting, dates, times and locations.

• Receive notice of ISP meeting. • Provide assessment information. • Review assessment results.

ISP Meeting/ Annual Review

• Attend and participate in ISP meeting/Annual Review.

• Choose services/providers to meet the individual’s current needs.

60 Days

Documentation • Not applicable. Approval • Not applicable. 14-45 Days Financial

Authorization • Not applicable.

14 Days

Distribution • Receive ISP.



• Receive services. • Participate in SC monitoring of

services. Fiscal Year Renewal ISPs

Days Before June 30 Activity Individual/Family Actions 14 Days

Distribution • Receive ISP.



• Receive services. • Participate in SC monitoring of

services.


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Section 2

Person Centered Planning Everyday Lives

Positive Approaches and Practices


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Person Centered Planning Person Centered Planning discovers and organizes information that focuses on an individual’s needs, strengths, and preferences. It involves bringing together people the individual would like to have involved in the planning process, truly listening to the individual, describing the individual as fully as possible with a true focus on understanding who he or she is, and dreaming and imagining with the individual of possible ways things could be different, both today and tomorrow. In 1993, ODP published the document, Finding A Way Toward Everyday Lives, The Contribution of Person Centered Planning. This document introduced the concepts of Positive Approaches and Everyday Lives into the Annual Review process by emphasizing the importance of empowering the individual receiving services to drive and direct the planning process. Since then, ODP has supported numerous trainings on “Person Centered Planning” across Pennsylvania.

Key components of “Person Centered Planning”: • Action oriented – Planning identifies effective ways to address concerns and/or barriers that may

interfere with attaining Outcomes. • Collaborative and Respectful –The individual and people who are important to and know the

individual best are always viewed as experts in the development of the ISP. • Community focused –The individual’s membership and participation in the community is valued

and supported. • Individualized – Outcomes, services, and supports reflect what is important to the individual and

are tailored for the individual and the Outcomes they wish to achieve. • Outcome based – Planning focuses on what is important to the individual to have a meaningful,

quality everyday life. • Process based – Planning involves an open exchange that allows the team to be guided by the

individual. Discussions are facilitated to help an individual describe how they want to live and to engage others in making this happen.

• Skill, gift, talent based – The focus is on discovering each individual’s strengths and capacities by understanding the individual’s interests, sources of pride and talents that are already present, as well as identifying emerging gifts and interests to be nurtured.

• Supportive to the individual – Time is taken to determine what is needed to assist the individual in creating a quality everyday life.


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Everyday Lives The core values of Everyday Lives are choice, control, quality, community inclusion, stability, accountability, safety, individuality, relationships, freedom, success, contributing to the community, collaboration, and mentoring. Teams are strongly encouraged to use the Everyday Lives section of the ISP manual during the ISP planning process to ensure that the plan meets criteria for a quality ISP. The following are statements describing each of the Everyday Lives core values, along with a quality indicator and guiding questions for the individual, family and team to consider when developing Outcomes for the plan year. These indicators and guiding questions may also be used by Supports Coordinators, Supports Coordination Entities, Administrative Entities (for Waiver-funded ISPs), County Programs (for Base-funded ISPs), and ODP as a quality assurance tool for reviewing ISPs. Accountability Government (state and county), provider agencies, and support people are responsible for carrying out their roles, obligations and activities.

Quality Indicator: The ISP clearly defines who will do what as identified in the “Outcomes,” “Outcome Actions,” “Health Promotions,” and “Financial Issues” sections of the plan. Guiding Questions:

1. Does the ISP clearly state who is responsible for each Outcome? 2. Do the Outcomes and Action Plans support and promote the Individual Preferences and needs

identified in the ISP? 3. Does the ISP identify all the needed services and supports that the individual is receiving?

Does it outline when he or she needs them, and who is responsible for providing them? 4. Has the individual lost or is he or she in danger of losing supports that he or she needs? If so,

what steps have been included in the ISP to accommodate, restore, or prevent the loss of those services?

Choice and Control Having the power to make decisions in all areas of life and the power or authority to influence and direct decisions over all aspects of life Quality Indicator: The ISP documents the individual’s power to make, influence and direct decisions in all aspects of his or her life. Guiding Questions:

1. Does the information gathering include how the individual makes choices and exercises control in his or her life as well as the barriers to making choices?

2. Do information gathering and the Action Plan describe and promote the type of supports needed for the individual to make choices and exercise control in all areas of his or her life?


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3. Do the information gathering and Outcome sections of the ISP reflect the individual’s style of communication and identify steps to promote increased access to communication?

4. Does the ISP include opportunities for the individual to self-direct their services, if this control is desired by the individual?

Community Inclusion and Contribution to the Community Having opportunities to participate in the community and pursue chosen interests and relationships; a sense of fellowship, social connection, participation, sharing something in common with other people in the same area, town, etc. Quality Indicator: The ISP outlines how the individual connects to the community and provides evidence that the individual is supported to contribute to the community in ways that he or she values and chooses. Guiding Questions:

1. Do the Outcomes and Action Planning support the individual in exercising his or her choices and rights to actively and individually participate in and contribute to his or her community?

2. Is the ISP individualized to support the individual in developing, maintaining, or enhancing community connections and relationships?

3. Does the ISP include selected community membership opportunities (i.e., community employment or volunteerism, owning a home or renting an apartment, participating in social and spiritual gatherings)?

4. Does the plan describe the individual’s community roles? 5. Are the potential concerns/barriers related to community contribution identified and addressed

in the ISP? Collaboration All people/community/services/systems, etc. involved with the individual are communicating, cooperating, aiding each other, and working together to support the individual in achieving or maintaining his or her “everyday life”. Quality Indicator: The ISP provides evidence of communication and cooperation between all people and entities involved in planning with and support of the individual. Guiding Questions:

1. Does the ISP include the collaborative planning that is needed for a seamless bridge to support the individual’s movement through various life events (i.e. changing jobs, new living arrangement, graduation, etc.)?

2. Have alternatives to paid supports been considered and included, when appropriate, in the ISP?

3. Does the ISP indicate communication between all people and entities involved in the planning process?

4. Is the individual included and supported as needed in the collaborative process with the people, community, services, or systems?


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Freedom The individual has the freedom to have the life he or she wants and to negotiate risk. Quality Indicator: The ISP demonstrates respect for and support of the individual’s liberty and rights (including taking risks, determining the course of one’s life and living the life one chooses without being stigmatized or under another’s control). Guiding Questions:

1. Does the individual’s ISP reflect his or her freedom to express wants, needs, satisfaction and dissatisfaction in his or her everyday life?

2. Does the individual have the opportunity to exercise the rights that are afforded to all citizens? 3. Does the ISP reflect the individual’s expressions and the type and level of support necessary

for the individual to pursue a self-determined life? 4. Does the ISP demonstrate the efforts needed to ensure that the individual has the knowledge,

supports, experience and opportunities necessary to make informed decisions? 5. Does the ISP identify and address possible concerns/barriers to the individual expressing

rights and pursuing self-determination? Individuality Being known for their distinguishing character or qualities; being called by their name, and having privacy. Quality Indicator: The ISP outlines how an individual’s unique characteristics, qualities, hopes, and dreams are respected and supported. Guiding Questions:

1. Are the Individual Preferences sections of the ISP individualized and descriptive of the positive traits, qualities, preferences, hobbies, hopes, and dreams for the future, etc.? Do they reflect the uniqueness of the individual?

2. Does the Action Plan clearly describe the type and level of support necessary for the individual to pursue his or her hopes and dreams and participate in preferred activities?

3. Do the information gathering and Action Plan outline, promote and respect the privacy needs and wants of the individual (his or her mail, records, history, personal life, personal space, need for down time, etc.)?

4. Does the ISP recognize and address possible concerns to the individual pursuing his or her unique hopes and dreams?

Mentoring Learning from and working with people with disabilities and families who are trained as mentors toward increased understanding until they can do things on their own. Quality Indicator: The ISP reflects and promotes the individual’s awareness or expression of interest in a mentoring experience.


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Guiding Questions:

1. Has mentoring been explained to the individual and his or her family? 2. Does the individual or his or her family know where to get mentoring advice and/or

information? 3. Does the individual or his or her family want additional information or training available through

mentorship? 4. Is the individual or his or her family interested in becoming a mentor? Are the needed

supports reflected in the ISP? 5. Does the information gathering and planning reflect the supports needed for the individual to

access mentoring?

Quality Quality of life determined by the individual; having a life encompassing all core values of “Everyday Lives”. Quality Indicator: The ISP Outcomes reflect what is important to the individual and are within the context of his/her everyday life. Guiding Questions:

1. Are the core values of Everyday Lives evidenced in the individual’s ISP and life? 2. Are the paid and natural supports that enable the individual to achieve or maintain the life that

he or she desires included in the ISP? 3. Are the people responsible for supporting the individual to achieve his or her Outcomes clearly

defined in the ISP? 4. Are clear timeframes set for achieving the Outcomes in the ISP? 5. Are the Outcomes sections of the ISP individualized (based on needs and personal

preferences) and written to be achievable within the context of the individual’s everyday life? 6. Do the Outcome Actions consider obstacles or barriers to achieving the Outcomes along with

strategies to address all identified obstacles or barriers? Relationships The ISP supports and promotes the individual’s connection to community, a sense of belonging to family, and close associations with friends and loved ones. Quality Indicator: The ISP documents and supports the individual’s personal relationships (including family, friends, partners, community connections, etc.). Guiding Questions:

1. Does the ISP identify people with whom the individual has personal relationships (including family, friends, partners, community connections, etc.)?

2. Are the supports needed to maintain and develop the individual’s relationships with family and friends who are important to him or her included in the ISP and Action Planning?


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3. Does the ISP include meaningful activities which provide and expand community connections for the individual to begin, develop and nurture a variety of relationships?

4. Does the ISP identify and address possible concerns/barriers to personal relationships? Safety The ISP ensures freedom from harm or danger in the individual’s everyday life without being over protective or restricting the individual’s supports and services. Quality Indicator: The ISP is designed to ensure the individual’s health and safety without being overly protective or restrictive. Guiding Questions:

1. Are the Health and Safety focus areas of the ISP individualized? Do they clearly address the individual’s community and residential environments?

2. Does the ISP reflect and incorporate the individual’s demonstrated safety skills in a way that advances the individual’s life experience without being overly protective?

3. Do the Action Plan and Health Promotion Sections of the ISP reflect a balance between what is important TO the individual and what is important FOR the individual?

4. Are risk areas that have been identified addressed in the ISP? 5. Does the ISP recognize and address possible concerns or barriers to maintaining the

individual’s health and safety? Stability Changes in the individual’s life are made with his or her input and support, agreement, approval or permission. Quality Indicator: Changes to the ISP reflect the individual’s input and support, agreement, and involvement. Guiding Questions:

1. Is there evidence in the ISP that changes in the individual’s life (including life experiences, options and availability of supports and services, staffing, etc.) are presented and shared with the individual and his or her family along with opportunities for them to provide feedback regarding those changes?

2. Does the ISP demonstrate that the individual has the primary influence over changes that occur in his or her life?

3. Does the ISP demonstrate consistent and available access to things and people that are meaningful to the individual?

4. If the individual has a legal guardian, has the team done everything it can to promote this value?


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Success Accomplishing or gaining something desired, intended or attempted that brings fulfillment and happiness to the individual Quality Indicator: The ISP opportunities for the individual to experience big successes or small celebrations in areas of his or her choosing (including employment, independence, financial prosperity, etc.). Guiding Questions:

1. Does the ISP clearly describe areas in which the individual would like to strive for and experience success (including areas such as employment, independence, financial prosperity, relationships, etc.)?

2. Do the Outcomes and Action Plans incorporate the individual’s abilities, capacities, gifts and interests in providing opportunities to expand his or her successful experiences?

3. Do the ISP and Action Plan provide the individual with the necessary supports to successfully incorporate his or her desires and values into an “everyday life?”

4. Does the ISP include opportunities for past accomplishments to be integrated into the individual’s life?


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Positive Approaches and Practices The Positive Approaches paradigm is characterized by an integration of values, philosophies, and technologies; it defines the context in which we provide needed clinical and behavioral interventions to teach individuals the skills they need to make safe, appropriate choices. The purpose of “Positive Approaches” is to enable individuals to lead their lives as they desire by providing supports for them to grow and develop, make their own decisions, achieve their personal goals, develop relationships, face challenges, and enjoy life as full, participating members of their communities. History: Beginning in the late 1980s, ODP supported the Positive Approaches networks and trainings, which stemmed from a grassroots movement made up of people receiving services, families, friends and supporters who advocated for individuals to have more control over their own lives. They addressed issues such as reducing and eliminating restrictive and aversive procedures, maintaining contacts with family and friends and interacting with the community. They also developed practices, supports, trainings and publications that came to be known as Positive Approaches. The implementation of Positive Approaches is Positive Practices. Positive Practices utilizes State (Central and Regional), and local groups to explore and expand local capacity, training, resources, and cross system collaboration. These groups also focus on how to meet the needs of the local community, particularly for those individuals who are considered most challenging and those with a dual diagnosis (Mental Health and Mental Retardation).

Purpose: The purpose of Positive Approaches is to support individual growth and development, to enable people to make their own decisions, achieve their personal goals, develop relationships, and enjoy life as full, participating members of the community.

The Concept of Positive Approaches: • Enables people to achieve self-determination by supporting them to grow and

develop, make their own decisions, achieve their personal goals, develop relationships, and enjoy life as full members of the community.

• Involves working WITH people rather than FOR people. • Requires getting to know each individual by examining all aspects of the individual’s

life, including each individual’s living environment, relationships, activities, personal dreams, unique qualities, and personal history.

• Requires that all people involved are comfortable enough to speak freely, that we listen carefully and respectfully, take each individual seriously, and honor what we hear.

• Encourages us to see that all behavior has meaning and that an individual’s behavior can be a method to communicate needs and wants, or the manifestation of clinical issues, which lead to the development of viable alternatives and eliminate the need to rely on aversive and coercive methods.

• Measures success by the satisfaction of the individual being supported.


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Positive Approaches requires the ongoing effort of the entire support team to establish and ensure the likelihood that each individual will achieve an “everyday life” based on the principles of Everyday Lives, which are choice, control, quality, stability, safety, individuality, relationships, freedom, success, contributing to the community, accountability, mentoring, and collaboration. The team must attempt to look through the eyes and experiences of individuals and listen to their words, look at their actions, pay attention to their reactions, and attempt to identify what might be missing from their lives.

Positive Approaches and Positive Practices require continually exploring, educating, and advocating for creative and innovative ways for individuals to regain or establish their own “everyday lives.”


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Individual Support Plan Key Terms

Abbreviated Plan – A shortened ISP that may be used for someone who receives under $2,000 in

non-waiver services. An example of an abbreviated plan could be Family Supports Services (FSS) (Family Driven) or Life Management Plan. When completing an abbreviated plan, the following minimum screens must be completed:

• Demographics • Outcome Summary • Outcome Actions • Services and Supports Directory (Provider, Vendor, and/or

Financial Management Services agent) • Service Details

Administrative Entity – A county/joinder or non-governmental entity that performs waiver

operational and administrative functions delegated by the Department, under the Department’s approved Consolidated and P/FDS Waivers.

Amount (of services) – A term that refers to the total volume of funded services (measured in units)

that are authorized in the ISP and furnished to the individual. Annual Review Meeting – The team meeting(s) that is held annually to review the ISP. This

meeting is held at least 90 days prior to the Annual Review Update Date. Annual Review Process – Part of the ISP process that includes the review of information gathered,

outcome development, identification of services and supports, and choosing a provider. Annual Review Update – A plan category that is used to document the results of Annual Review

Meetings. Annual Review Updates without changes to services or funding do not require re-authorization; Annual Review Updates with changes to services or funding do require re-authorization.

Annual Review Update Date –The date by which the ISP will be reviewed, updated, approved, and

authorized (if applicable) every year. Monthly and quarterly reviews originate from this date. The team meets at least 90 days prior to this date.

Bi-annual Review – A process to review the ISP twice a year, or every six months. This review can

be used to edit or update an existing plan. A bi-annual review is a requirement for Pennhurst Class members.

Bridge Plan - An individual’s initial ISP, which has a timeline shorter than the Fiscal Year to

accommodate varying timelines for initial Annual Review Meetings. The bridge plan has a start date after the initial ISP team meeting, and an end date of June 30.

Community Supports - Services or organizations available within the individual's community. Consent To Share ISP – The individual and his or her family, guardian, surrogate, or advocate

provide consent to share the ISP with providers online in HCSIS after it is approved. This is a


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mandatory field in HCSIS and should be answered “yes” or “no” prior to submitting the ISP for approval.

Critical Revision – A revision to the ISP when an individual experiences major life changes. Major

life changes include an emergency, a change in services or a change in the amount of funding required to meet the needs of the individual. A major life change or emergency that has no impact on funding can be done as a General Update. A Critical Revision is completed if there are changes to the individual’s ISP throughout the year when major life changes occur (Note: A Critical Revision is not completed in response to an Annual Review Meeting; please see Annual Review Update.). A Critical Revision to an approved and authorized ISP must go through the approval and authorization process again.

Draft Plan – An ISP in HCSIS that can be edited or used by adding, deleting or revising information

in that ISP. Duration (of services) – The length of time that a service will be provided. Eligibility - The functional qualification of an individual to receive services funded by ODP. Fiscal Year Begin Date – For a Fiscal Year Renewal ISP, the Fiscal Year Begin Date coincides with

the beginning of the fiscal year, July 1. Note that the Fiscal Year Begin Date for initial ISPs should reflect the anticipated start date of the ISP.

Fiscal Year End Date – The Fiscal Year End Date of an ISP coincides with the end of the fiscal year,

June 30. Fiscal Year Renewal – An ISP in HCSIS that is used to renew the ISP for the following fiscal year.

The ISP will have a Fiscal Year Begin Date of July 1 and a Fiscal Year End Date of June 30. Frequency (of services) – How often a service will be furnished to an individual (ex. Three times per

week). General Update –A revision to the ISP that is used to update demographic or medical information,

not when modifying services and supports. A General Update is completed throughout the year when demographic or medical information changes (Note: A General Update is not completed in response to an Annual Review Meeting; please see Annual Review Update.). A General Update to an approved and authorized ISP will not require re-approval.

Independent Monitoring for Quality (IM4Q) - Part of ODP’s quality initiative to collect and track

outcome measures from the Core Indicators Survey and the Independent Monitoring Survey. Information from IM4Q should be considered in the ISP planning process.

Individual Monitoring (also known as Supports Coordination Monitoring) - The regularly

scheduled and ongoing monitoring of an individual's ISP to ensure that ISPs are implemented as written, including that services and supports are provided as indicated on the ISP.

Individual Support Plan (ISP) - An individual’s summary of their planned services and supports,

identified as a result of review by the individual, family, and Supports Coordinator of preferences, outcomes, health, safety, and medical information. The approved ISP is used to authorize services and supports that meet assessed needs.


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Intermediate Care Facility for the Mentally Retarded (ICF/MR) - A state-operated or nonState

operated facility, licensed by the Department in accordance with Chapter 6600 relating to intermediate care facilities for the mentally retarded, providing a level of care specially designed to meet the needs of individuals who are mentally retarded who require specialized health and rehabilitative services.

Natural Supports - Unpaid assistance to an individual. Outcomes – Outcomes are used in ISPs to describe what is currently important for the individual to

work on or maintain or to reflect changes an individual would like to see in his or her life. Outcomes are based on the individual’s needs and priorities identified by the individual and his or her family, are responsive to formal and informal information gathering, and are linked to the appropriate informal and formal supports and services. Outcomes supported by ODP funds must be in the context of supporting the health and welfare needs of the individual and assuring their continued life in the community. Outcomes that address other priorities of the individual should be represented and supported with other community, family, or non-traditional support services.

Plan Creation –A term used if an ISP is being created for the first time in HCSIS or if there is a time-

span between two ISPs. The team sets proposed ISP review dates, within the 365-day required timeline.

Prioritization of Urgency of Needs for Services (PUNS) – PUNS is the current process for

categorizing an individual's need for services. PUNS focuses on the existing services and supports received by the individual, the prioritization of urgency of need for requested services, and the categories of services needed. This information is used by Administrative Entities, County Programs, and ODP to prioritize waiting lists and for budgeting. The following are the PUNS categories of need:

Emergency Need - Indicates a need for services within the next six months. Critical Need - Indicates a need for services greater than six months but less than two

years in the future. Planning Need - Indicates a need for services greater than two years but less than five

years in the future.

Quarterly Review - Used by the provider agency Program Specialist for ISPs that must be reviewed at least every three months, originating from the date of the Annual Review. This form in HCSIS is used when conducting Quarterly Reviews.

Services and Supports Directory – An online database of all the service providers registered in

HCSIS that is accessible to families and individuals during the registration process to locate providers within a geographic area. The directory is intended to expand individuals' ability to make informed choices.

Supports Coordinators – Supports Coordinators facilitate individual ISP development, locate

provider services, coordinate the provision of services and supports, and monitor services and supports.

Supports Coordination Entity (SC Entity) - Any organization that has been approved to provide

supports coordination services.


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Total Plan Budget Amount – The total of the combined projected plan budgets across categorical

funding streams for an individual. Willing and qualified provider – A provider who meets applicable qualification criteria and agrees to

provide services to an individual as stated in his/her ISP. Waiver providers must meet qualification criteria included in the approved Consolidated and/or P/FDS Waivers. ODP recommends using the same criteria for non-waiver providers.


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The following resources provide additional information regarding ISP development and each stakeholder’s role.

• Administrative Entities • County Programs • Family Guide to the Individual Support Plan • Framework for Delivery of Supports Coordination Services Bulletin • Individual Support Plan Process Bulletin • Learning Management System (LMS) • Lifetime Medical History Bulletin • ODP Consulting System • Administrative Entity Operating Agreement • PUNS Bulletin and Manual • ODP Regional Program Offices • Intake Bulletin • Supports Coordinator Electronic Resource Guide • The Training Partnership

Documents

Commonwealth of Pennsylvania Department of Public · PDF fileOffice of Developmental Programs Individual Support ... mental retardation service ... to empower the individual to plan