Unique ID
Individual Support Plan
I. Essential Information
Contact Information
|Legal Name: |Sarah Gwen Baker |Preferred Name: |Sarah |
|Date of Birth: |06/22/64 |Gender: |F |
|Medicaid #: |990012228775 |Medicare #: |231-09-0045 |
|Home Street Address: |8441 Vida Lane |Insurance: |N/A |
|Mailing Address or P.O. Box:| |SSN#: |223-90-0008 |
|City: |Vida, VA |Zip Code: |26698 |
|Home phone: |703-998-7723 |Cell phone: |N/A |
|Work phone: |N/A |Email address: |N/A |
Emergency Contacts / Representation
|Name |Phone: |Fax: |Email: |
|Relationship: |Address: |
|Legal Guardian: |Phone: |Fax: |Email: |
|Relationship: |Address: |
|Authorized Rep: |Phone: |Fax: |Email: |
|Relationship: |Address: |
|Family #1: Glen Baker |Phone:703-663-8585 |Fax: |Email:glenb@ |
|Relationship: brother |Address:65 Carter Road Vida, VA 24998 |
|Family #2:Addie Haines |Phone: 633-858-5412 |Fax: |Email:AddieH@ |
|Relationship: sister |Address:988 Victoria Circle Wetbrook, CT 69887 |
|Family #3: |Phone: |Fax: |Email: |
|Relationship: |Address: |
|Power of Attorney: |Phone: |Fax: |Email: |
|Relationship/Type: |Address: |
|Emergency Contact: |Phone: |Fax: |Email: |
|Relationship: |Address: |
|Conservator: |Phone: |Fax: |Email: |
|Relationship: |Address: |
|Representative Payee: |Phone: |Fax: |Email: |
|Relationship: |Address: |
|Physician 1: Dr. Huffman |Phone: 703-663-8585 |Fax:703-663-8585 |Email: |
|Specialty: PCP |Address:1233 East Sparrow Road Vida, VA 26985 |
|Physician 2: |Phone: |Fax: |Email: |
|Specialty: |Address: |
|Physician 3: |Phone: |Fax: |Email: |
|Specialty: |Address: |
|Physician 4: |Phone: |Fax: |Email: |
|Specialty: |Address: |
|Dentist: |Phone: |Fax: |Email: |
|Address: |
|Other: |Phone: |Fax: |Email: |
|Relationship: |Address: |
|Other: |Phone: |Fax: |Email: |
|Relationship: |Address: |
Support Coordination and Provider Contacts
|Support Role: SC |Agency: Vida CSB |
|Name: Grace Givens |Address:3344 Conway Road Vida, VA 24998 |
|Phone:703-889-5656 |Fax:703-887-3698 |Email:gg@ |
|Support Role: DSS Eligibility |Agency: Vida DSS |
|Name: Martha Johns |Address:1265 Valley Drive Vida, VA 24998 |
|Phone:703-833-0058 |Fax:703-833-6658 |Email:mj@ |
|Support Role: Residential |Agency: Vida Residential |
|Name: |Address:8441 Vida Lane VA 24998 |
|Phone:703-998-7723 |Fax:703-998-7724 |Email:VidaGH@ |
|Support Role: Day support |Agency: Vida Day |
|Name: |Address:980 Massey Lane Vida, VA 24998 |
|Phone:703-886-9987 |Fax:703-998-7724 |Email:VidaDay@ |
|Support Role: Companion |Agency: Companions, Inc. |
|Name: Dottie Hodges |Address:5536 2nd Street Vida, VA 24998 |
|Phone:703-989-3696 |Fax:703-989-3697 |Email:dottieh@ |
|Support Role: |Agency: |
|Name: |Address: |
|Phone: |Fax: |Email: |
|Support Role: |Agency: |
|Name: |Address: |
|Phone: |Fax: |Email: |
|Support Role: |Agency: |
|Name: |Address: |
|Phone: |Fax: |Email: |
Communication and Sensory Support
|Preferred language: |Please check one) English Spanish |
| |Vietnamese Other (Please Specify): |
|Describe supports needed for communication (if any): |Sarah is able to communicate through spoken English. Sometimes it takes her a moment to form her |
| |statements, which usually happens when she is nervous or excited. After a moment, she begins |
| |sharing her ideas and thoughts. |
|Do I have any difficulty reading a magazine or | Yes No |
|newspaper? |If yes, please describe. Sarah can recognize a few words in print and needs support |
| |understanding printed text. |
|Would a professional evaluation related to sensory or | Yes No |
|communication abilities be beneficial? | |
Adaptive Equipment, Assistive Technology and Modifications
|Please describe any adaptive equipment and assistive |Sarah uses a wheelchair with a lap belt and an adaptive device for personal care in the restroom.|
|technology supports (if any): | |
|Would a professional evaluation related to adaptive | Yes No |
|equipment, assistive technology or other modifications| |
|be beneficial? | |
Health Information
|Advanced Directive |
|Do you have an advanced directive? | Yes No If yes, please provide a copy to all relevant parties. |
|Medication: |Physician: |Reason(s) prescribed: |
|Dosage: |Route: |Frequency: |Location of potential side effect information: |
|1:Carbamazepine |Huffman |Seizures |
|800mg |PO |BID |all provider records |
|2: | | |
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|HEALTH TOPIC |DESCRIPTON |
|Date of my last complete physical exam. |Date:11/14/07 |
|Date of my last dental exam. |Date:11/16/07 |
|Do I have any mental health support needs? | Yes No If yes, please describe: |
|Do I have any allergies to medication, food, or environmental | Yes No If yes, please describe: Prednisone |
|elements (e.g., mold, dust, etc.)? | |
|Please describe all recent physical complaints & medical |Sarah has a seizure disorder and averages approximatley 2 seizures month. She also |
|conditions. |has type 2 diabetes and is at risk for falling without her lap belt fastened. She |
| |tested negative for TB at her last physical in November. |
|Do I have any issues with physical intimacy, pregnancy or child | Yes No If yes, please describe: |
|rearing? | |
|Do I have any chronic health conditions? | Yes No If yes, please describe: Diabetes (type 2), seizure disorder |
|Do I have any communicable diseases? | Yes No If yes, please describe: |
|Do I have any limitations or restrictions on physical activities? | Yes No If yes, please describe: lap belt needed during waking hours |
|Have I had any serious illnesses, serious injuries, and/or | Yes No If yes, please describe: Sarah was treted for viral meningitis in |
|hospitalizations in the past? |1996. |
|Have there been any serious illnesses or chronic conditions among |Mother also has type 2 diabetes. |
|my parents, siblings, or grandparents? | |
|Have there been any serious illnesses or chronic conditions among | |
|significant others in my household (if any)? | |
|Have I ever smoked cigarettes/cigars or used smokeless tobacco? | Yes No If yes, please describe: |
| | |
|a. How often do I drink alcohol? |a. Number of times and number of drinks per week: 0 |
|b. Does my current use of alcohol cause problems in any area of my| |
|life? |b. Yes No If yes, please describe: |
|Does my current use of prescription medication cause problems in |[Any benzodiazepine, sedative-hypnotic or narcotic under Medications should trigger |
|any area of my life? |an SA evaluation. (b) addresses drug tolerance and possible dependence.]N/A |
|Have I found that I have to take more and more of any prescription| |
|medication to feel an effect? | |
|Have I ever been in treatment for a problem with, or resulting |. Yes No If yes, please describe what type of treatment, was provided and |
|from, use of alcohol, drugs, or prescription medicine? |when. |
|Is there any other health history or medical information or health|Sarah’s mother reports that Sarah is diagnosed with Type 2 diabetes, has a seizure |
|preferences that I would like to share? |disorder and uses a wheelchair with a lap belt to prevent falls. Sarah checks her |
| |blood glucose levels before meals with support and follows a diabetic diet. Sarah’s |
| |mother states that Sarah had her tonsils out as a young child and underwent surgery |
| |for back pain as a young adult. Her mother states that Sarah is not sexually active, |
| |has no children, no history of communicable diseases and no history of sexual or |
| |physical abuse. Sarah’s family has a history of diabetes and heart disorders. Sarah |
| |is checked annually by her physician for heart rhythm irregularities due to family |
| |history. Sarah has no known history of alcohol or illicit drug use. |
Summary of Social/Developmental/Behavioral/Family History
|Briefly describe my relevant social, |Sarah’s mother reports that Sarah experienced a typical childhood and that she and her brother, Glen, |
|developmental, behavioral and family history. |have always been close.. She lived with her mother until 1994, when she began receiving Medicaid |
| |Waiver. Since that time, she has lived in Vida Group Home. Sarah’s mother states that Sarah has always |
| |liked her privacy and wants to do as much for herself as possible. When Sarah does become upset it is |
| |usually in loud environments and may include her yelling out loud. Taking a break away from the setting|
| |is usually helpful. |
| | |
| | |
Summary of Employment and Educational Background
Education: None Elementary Middle School Some High School High School
Some College College degree Some Graduate School Masters Degree or Higher
Current Employment status: Unemployed, but want to work Unemployed, not able to or interested in work Employed, Part-Time Employed, Full-time Retired
|Describe my employment and educational |Sarah has not worked in a paid job according to her mother. Sarah attended North Meriwether Occupational |
|histories. |School through her graduation in 1974 |
|Describe any volunteer activities in |Note: Please include the types of things you did, the organization(s) involved, and when you volunteered. |
|which I now am involved or have been |Sarah volunteered for the Animal Society in 2006 for three months. |
|involved in the past (if any). | |
Exceptional Support Needs
|Were any support needs identified on the risk | Yes No |
|assessment? |If yes, please provide a description of each support need below: |
|(If yes, each need must relate to a goal in | |
|the ISP’s Personal Goal section.) | |
|(Provide any existing plans for exceptional | |
|support needs.) | |
| |1) Diabetes Type 2 |
| |2) Seizure Disorder |
| |3) Risk of falling |
| |4) |
| |5) |
| | |
| | |
Ability to Access Services and Supports
|What concerns do I have about being able to | Yes No If yes, please provide a description and a plan to resolve the concern(s): |
|access services and/or supports? | |
| | |
Legal and Advocacy
|Do I have any current legal issues or | Yes No If yes, please describe: |
|problems? | |
|Do I need any legal advice? | Yes No If yes, please describe: |
|Do I need any support with voting? | Yes No |
|(Understanding my rights, registering or |If yes, please provide brief description of how I will be supported: |
|voting) | |
Back-up and / or Discharge Plan
|Am I receiving a Medicaid Home and Community | Yes No |
|Based Waiver? |If Yes, please identify which Waiver:ID Waiver; and please describe or attach my back-up plan. Sarah's |
| |back up plan is that she receives 24 hour support. |
|Describe any transition/discharge plans for |None at this time. |
|any services I currently receive (if | |
|applicable). | |
Review or Revision Date: 6/22/08
Essential Information completed by:
Name (print):Grace Givens
Signature: Title: Date: _____________
II. Personal Profile
Please indicate whose perspective is involved in the completion of this profile: (check all that apply)
Self Family Friend Guardian Provider: All Partners
|Please provide a description of what having a good life means to me. |
| |
|A good life for Sarah means meeting new people, spending time with friends and staying in touch with her family. She has many interests including |
|movies, bowling, shopping and sporting events. She says that she wants to “earn more money,” which we think means that she wants a paid job. Sarah loves|
|to be around people and may enjoy belonging to a group or club where she can make some ongoing friendships. |
| |
|List of my talents and contributions. |Describe what this means. |
|(What do people who know and care about me say? Contributions to friends, |(How do my talents and contributions help connect with or affect others?) |
|family and community?) | |
|Sense of humor. |Sarah smiles at teasing and makes others smile easily. |
|Kind. |Doesn’t complain; easy to be around; aware of how others are feeling. |
|Giving. |Shares pictures and paintings with others. |
|Making others comfortable. |Sarah smiles and speaks first to others.Sarah is fun to be around and |
| |laughs at jokes. |
|Profile Questions |
|Describe each area and include what’s working? |What’s not working? |
|Things I would like to stay the same |Things I would like to see changed. |
|Home |
|home Sarah lives in a Vida Residential group home, with 3 other women, she calls |Sarah watches Martha Stewart on occasion and wants to try some of|
|“friends.” She moved into the home in 1994, has her own room that she chose to paint |her ideas to jazz up her bedroom. It has been awhile since it was|
|yellow several years ago. She has a television that she likes to watch in the evenings,|last painted, and she might want something different. Sarah also |
|a radio and a small desk for art projects. She likes to help cook dinner and spends a |talks about going out more – she loves sporting events and |
|lot of time in the living room in her home, talking with whoever’s home at that time. |festivals. |
|routines Sarah likes coffee in the morning and usually likes to have toast and eggs | |
|for breakfast. She likes going to the same grocery store (Food World) each week. | |
|independence No. Sarah likes the help she receives to be only for those things she |Sarah has talked about wanting to learn how to drive her power |
|absolutely needs, and for it to be provided subtly around others. She does not |wheelchair on her own, especially in grocery stores and shopping |
|complain, but we know she wants to do more on her own. |malls. |
|privacy More privacy is needed for Sarah. |We think that Sarah would like more privacy and independence with|
| |her personal care, but she doesn’t want to talk about it in front|
| |of everyone. |
|safety in my home Sarah says that she feels safe in her home. | |
|Community and Interests |
|community Sarah lives in Vida a small community in Central Virginia. She lives near a |Sarah doesn’t know many of her neighbors. It would be nice if we |
|strip mall that has a Chinese restaurant, a grocery store, a department store and a |could find a way for her to meet some of them. |
|bank. There is a larger shopping mall about 15 minutes away, where Sarah likes to go | |
|shopping the most. Sarah enjoys walks through the neighborhood when the weather is | |
|nice. | |
|safety in my community Sarah says that she feels safe in her community. | |
|things I enjoy Sarah enjoys shopping, bowling, painting and spending time with other |Sarah might enjoy some type of social group or club. She likes |
|people. She also likes going to dances whenever she can.Sarah likes sitting on the |bowling, movies and baseball too. Sarah doesn’t like sad music. |
|back porch and listening to the birds early in the morning. She wants to travel and |She doesn’t like being told that it’s time to go to bed, if she’s|
|talks about it frequently. |not ready yet.Sarah would like to have sitting on the back porch |
| |a regular morning routine. We can also help her plan a trip. |
|hobbies Sarah likes arts and crafts - especially giving things she makes to others. |Saraqh doesn't get to make enough crafts and jewlery lately. |
| | |
|Relationships |
|family and friends Sarah has one brother (Glen) and one sister (Addie). She talks with |Sarah might like to talk with family more often or write letters.|
|them on the phone, usually on holidays. She lives with three people at home and has | |
|good relationships with all, but one of them (G.S.), which is occasionally difficult. | |
|Sarah used to have contact with a teacher from her occupational school, but hasn’t | |
|heard from her since last year. Sarah also gets along well with the people at her day | |
|support center and at Vida County Parks and Recreation. | |
|being understood by others: Those who support Sarah understand when she is | |
|communicating her likes and dislikes. | |
|qualities of those who support Sarah likes people who are patient and who listen to |Sarah does not like people with loud voices. |
|her. | |
|culture, traditions Sarah likes celebrating the holiday season and enjoys baking | |
|cookies to give as gifts each year. She also likes to attend holiday parties whenever | |
|she can. | |
|religion, spirituality Sarah does not express any religious preferences. | |
|Work and Alternates to Work |
|days Sarah gets up at 7:30 each morning. She receives support with personal care and |Sarah has expressed an interest in paid work. |
|breakfast before going to day support at 9:00am. A residential DSP takes her there at | |
|9:00am and picks her up at 2:30pm. She enjoys painting, shopping, watching TV, helping| |
|clean her home, cooking dinner and attending parks and recreation in the evenings. | |
|weekends Sarah likes going shopping on weekends and says she likes having Day Support | |
|on Saturdays. She usually cleans up around her home on Sundays and likes seeing movies | |
|each weekend both at home and at the theater when possible. | |
|Learning |
|accomplishments, experiences, and learning Sarah stated that she wants to “work less” |Sarah might like to get a paid job. Driving her wheelchair by |
|and “earn more money.” Sarah calls her day support “work” – so we think it means that |herself. |
|she wants a paid job on some days instead of day support.Sarah says she would like to | |
|learn to drive her wheelchair. | |
|Money |
|money, finances Sarah’s residential program serves as her Representative Payee. |Sarah could help with weekly budgeting for the things she likes. |
|Transportation and Travel |
|transportation Sarah rides with residential to different events and places in her | |
|community. | |
|travel Sarah says she wants to go to California, New York and New Jersey. |She says she wants to travel and needs support planning a trip. |
|Health and Safety |
|foods, cooking, meals and supplements Sarah likes to eat out. She follows a diabetic |We could try to find more “free foods” that don’t affect Sarah’s |
|diet and likes many sugar free foods. She tends to want to eat a lot. |blood sugar that she can have for snacks. Sarah always seems |
| |interested in learning about what foods are best for her diet. We|
| |could schedule more time to talk with her about this when we plan|
| |for meals and for shopping. |
|exercise Sarah loves to attend dances. She enjoys moving her arms to the music, |Sarah might like aerobics since she likes dancing so much. |
|smiling and laughing the whole time. | |
|List what’s important to me for planning this year. |Please describe (where, with whom, how often, etc). |
|“I want to cook.” |Going to cooking classes and making dinner at home for herself and others. |
|“I want to see more movies.” |Going to the movie theater with friends at least weekly. |
|Sarah enjoys arts and crafts (per sister). |Making jewelry and ceramic pottery for herself and others. |
|“Go to the beach.” |Sarah would like to visit the beach because she says she has never been. |
|“Go to California, New York and New Jersey.” |Partners agree that Sarah is expressing interest in traveling to another |
| |state. |
|“Learn to drive my wheelchair.” |Sarah wants to be able to operate her own wheelchair when she’s out shopping.|
|“No work, more money.” |Partners agree that Sarah is wanting to attend day support (which she calls |
| |“work”) less often and get a paid job. |
|Watch baseball games and go bowling with friends. |Sarah likes watching baseball games and bowling with others. |
|Stay in touch with friends/family (per sister). |Ongoing contact via phone, visits and sending cards and letters. |
|Privacy with personal care (personal topic). |Being able to take care of her own personal care. |
|What’s important for my health, safety and well-being? |What this means for me. |
|Support for her diabetes. |A diet that she can follow without feeling deprived. Checking blood sugars |
| |and responding as identified in her protocol. |
|At risk of falls. | Helping her stay relaxed and stress-free. Watching for seizures and |
| |supporting her to rest as needed. |
|Seizures. |A lap belt that she can unhook herself. |
|Medications. |Opening her bubble packages and assisting with water in the morning and |
| |before bed. |
|Medical appointments. |Getting to the doctor and ER as needed. |
|Fire safety. |Recognizing danger and exiting buildings. |
|Range of motion exercise. |Improving the strength and use of her left hand as described in her PT |
| |notebook. |
|Support with bathing. |Physical support with her preferred bathing, hair care and lotions. |
|Brushing hair and teeth. |Someone to brush her teeth, gently and thoroughly. |
|Personal care. |Subtle physical support with her personal care. |
|A clean house. |Help with keeping her home clean. |
III. Plan
|# |What are my desired outcomes? |When would I like to accomplish each |
| | |outcome? |
|1 |Sarah attends a monthly cooking class and cooks dinner at home at least once each weekend. |6/30/09 |
|2 |Sarah budgets her money and buys movie tickets for herself and a friend once each week. |6/30/09 |
|3 |Sarah enrolls and participates in a pottery class and makes jewelry and other items she can |6/30/09 |
| |use as gifts for others. | |
|4 |Sarah budgets her money and goes to the beach. |9/5/08 |
|5 |Sarah goes on a vacation to another state. |6/30/09 |
|6 |Sarah drives her own wheelchair when shopping at the grocery store and mall. |6/30/09 |
|7 |Sarah has a paid job that she likes. |6/30/09 |
|8 |Sarah does routine activities with friends each week, such as going to ballgames and bowling.|6/30/09 |
|9 |Sarah stays in touch with friends and family weekly. |6/30/09 |
|10 |Sarah lives in her own home and receives support with housekeeping and personal care. |6/30/09 |
|11 |Sarah has privacy with her personal care. |6/30/09 |
|12 |To be healthy and safe and receive supports as agreed to in my plan |6/30/09 |
|Actions and Supports |
|Outcome |What actions and supports are needed? |Responsible Partner |How Often or |How long? |Weekly Total |
|# | | |By When? | |or Date Completed |
|1 |Grocery shopping. |Residential |Wed |2 hours |2 hours |
|1 |Reviewing diabetic recommendations. |Residential |Wed |1 hour |1 hour |
|1 |Going to cooking classes. |Day Support |Mon |2 hours |2 hours |
|1 |Cooking dinner once each week. |Residential |Wed |4 hours |4 hours |
|2 |Budgeting for movies. |Residential |Wed |15 min |15 min |
|2 |Inviting friends to movies. |Residential |Friday |30 min |30 min |
|2 |Buying tickets and attending movies. |Companion |Sat |2 hours |2 hours |
|3 |Enrolling in a pottery class. |Day Support |August 1, 2008 |N/A |N/A |
|3 |Going to pottery classes. |Day Support |weekly |2 hours |2 hours |
|3 |Buying jewelry supplies. |Residential |Friday |2 hours |2 hours |
|4 |Day trip to the beach. |Residential |9/5/08 |N/A |N/A |
|4 |Budgeting for a beach trip. |Residential |weekly |1 hour |1 hour |
|5 |Learning about travel in other states at the |Day support |Sat. |2 hours |2 hours |
| |library. | | | | |
|6 |Learning to use her wheelchair. |Residential |Mon, Wed, Fri |1 hour |3 hours |
|6 |Learning to use her wheelchair. |Day support |Sat |1 hour |1 hour |
|7 |Completing a referral to DRS. |Support Coord. |8/15/08 |N/A |N/A |
|8 |Enrolling in a bowling league. |Residential |8/1/08 |N/A |N/A |
|Outcome |What actions and supports are needed? |Responsible Partner |How Often or |How long? |Weekly Total |
|# | | |By When? | |or Date Completed |
|8 |Going to baseball games. |Day support |Mon |3 hours |3 hours |
|9 |Calling and writing letters to friends and family.|Residential |Tues. |30 min |30 min |
|10 |Bathing, hair care and lotions, and brushing |Residential |Daily |1 hours |7 hours |
| |teeth. | | | | |
|10 |Preparing balanced, diabetic meals and snacks. |Residential |Daily |1 hours |7 hours |
|10 |Daily house cleaning. |Residential |Daily |30 min |3.5 hours |
|10 |Weekly house cleaning. |Residential |Weekly |3 hours |3 hours |
|11 |Privacy with personal care and support with using |Residential |Daily |30 min |3.5 hours |
| |adaptive device. | | | | |
|12 |Support with her diet, blood sugar checks and |All |Daily |30 hour |3.5 hours |
| |emergencies. | | | | |
|12 |Support with seizures. |All |Over-night and |30 min |3.5 hours |
| | | |as needed | | |
|12 |Lap belt to prevent falls. |Day Support |Daily |15 min |1.75 hours |
|12 |Lap belt to prevent falls. |Residential |Daily |30 min |3.5 hours |
|12 |Medications twice each day. |Residential |Daily |15 min |1.75 hours |
|12 |Scheduling and attending medical appointments. |Residential |As needed |30 min |3.5 hours |
|12 |Fire safety. |All |Monthly |1 hour |15 min |
|12 |PT/Range of motion exercises for left hand. |Residential |Daily |30 min |3.5 hours |
|12 |Receive periodic supports with residential |Residential |Weekly as |7 hours |7 hours |
| |outcomes as needed during the ISP year | |needed | | |
|12 |Receive active support coordination services |Support Coordinator |Monthly |1 hour |1 hour |
IV: Agreements
|Signatures of partners who agree to help me with my plan: |
|Individual |Date |
| | |
|Support Coordinator |Date |
| | |
|Guardian/ Authorized Representative |Date |
| | |
|Partner |Relationship/service/support |Date |
|Partner |Relationship/service/support |Date |
|Partner |Relationship/service/support |Date |
|Partner |Relationship/service/support |Date |
|Partner |Relationship/service/support |Date |
|Partner |Relationship/service/support |Date |
| | | |
|Names of partners who contributed to my plan and were not here for planning: |
| | | |
| | | |
| | | |
|Comments: |
Appendix 1: Risk Assessment
Please circle the appropriate number to indicate how much support is needed for each of the items below. Please be sure to complete ALL items. (Note: N/A indicates “Not Applicable”)
| |No |Some |Extensive |
|Additional Supports/Risk Assessment |Support |Support |Support |
| |Needed |Needed |Needed |
|Caretaker and Environmental Risks (for persons living at home) |
|Incapacitated caretaker or loss of primary caretaker/natural supports - may become homeless, or |0 |1 |2 |
|environment is not appropriate for the person’s medical conditions. Any current health and safety issue.| | | |
|Housing issues related to family dwelling- may become homeless, or environment is not appropriate for the|0 |1 |2 |
|person’s medical conditions. | | | |
|History of neglect and/or abuse |0 |1 |2 |
|Refusal of services by caretaker– caretaker is refusing to follow person-centered plan. |0 |1 |2 |
|Criminal activity by caretaker e.g. criminal activity needs to be watched for due to past history that |0 |1 |2 |
|may not be safe for the person. | | | |
|Individual Behavioral Risks |
|Housing related issues and/or homelessness (due to individual) – e.g. person may be homeless in the next |0 |1 |2 |
|60 days. | | | |
|Pregnancy and/or parenting issues- e.g. person is pregnant and/or has no parenting skills. |0 |1 |2 |
|Criminal justice involvement & convicted requires controlled environment/24-hour supervision with rights |0 |1 |2 |
|restrictions in place | | | |
|Criminal justice involved, but NOT convicted requires controlled environment/24-hour supervision with |0 |1 |2 |
|rights restrictions in place | | | |
|Refusal of critical services or treatment- e.g. person refuses to go to the doctor for medication shots, |0 |1 |2 |
|or for therapy related to serious behavior. | | | |
|Health Risks |
|Multiple unplanned hospitalizations- such as for impactions, COPD, or seizures. |0 |1 |2 |
|Complex post hospital care needs not psychiatric issues -e.g. person broke leg and has continued PT, had |0 |1 |2 |
|surgical procedure that needs follow-up. | | | |
|Significant change in medical status- now has seizures or physical condition is going down hill |0 |1 |2 |
|Chronic eating disorders and/or including obesity- e.g. person has pica, dehydration issues, or will only|0 |1 |2 |
|eat pizza if left to purchase food. | | | |
|Swallowing/choking/aspiration disorders e.g. person has tongue thrusts; eats too quickly; requires close |0 |1 |2 |
|supervision when eating at a restaurant, dysphasia. | | | |
|Chronic medical problems (e.g. diabetes, congestive heart failure, COPD, asthma, constipation) |0 |1 |2 |
|Complex medication issues due to multiple medications and side effects– Has 2 or more medications with |0 |1 |2 |
|side effects that need to be watched or specific medication like a blood thinner. | | | |
|Uses poor judgment in unsafe situations which could cause severe ;health issues |0 |1 |2 |
|Risk of falling, e.g. unsteady gait, wears helmet, seizures, or other issue that effects falling. |0 |1 |2 |
Notes:Diabetes Type 2, Seizure Disorder, Risk of falling
Completed/recorded by: Grace Givens (print name)
__________________________________ (sign) Date: ________________
|ISP Change Note |
|Individual: Sarah G. Baker |
|Medicaid Number: 990012228775 |Medicare Number:231-09-0045 |
|Provider: Vida Residential |
|Support Coordinator: Grace Givens |
|Start Date: 9/1/08 ISP Dates: From 7/1/08 to 6/30/09 |
|Outcome |Ending Outcomes |Outcome achieved? |Total Decrease |
|# | | | |
|5 |Sarah goes on a vacation to another state. | Yes No |N/A |
| | | Yes No | |
|Outcome |Starting Outcomes |
|# | |
|13 |Sarah rides a horse. |
| | |
|Outcome # |Modify Existing Outcomes |
| | |
|Outcome |What actions and supports |Responsible Partner |How Often or |How Long? |Weekly Total or |
|# |are needed? | |By When? | |Date Completed |
|13 |Budgeting money for riding classes |Brother |Weekly |30 minutes | |
|13 |Transportation and participation in riding classes |Residential | Monthly |4 hours |1 hour |
|Total Increase = 1 hour/week |
|Describe reason for changes: |
|Sarah went on vacation to California with her family last month. Since her return, she has expressed interest in learning to ride horses and has a new |
|outcome and supports beginning 9/1/08. |
|Is an ISAR needed with this change? Yes No |
|Have other affected partners been informed of these changes? Yes No |
|If yes, please list each partner: Vida Day Support |
|Signatures: |Date |
|Individual: | |
|Guardian/Authorized Representative: | |
|Case Manager: | |
|Requesting Provider: | |
Appendix 2: ISP Change Note
Appendix 3: Support Instructions
(Complete to describe how supports and action steps will be provided)
|ISP: Support Instructions |
| |
|ISP Start: 7/1/08 End: 6/30/09 Quarterly review dates: 1- 9/30/08, 2- 12/31/08, 3- 3/31/09, 4- 6/30/09 Provider: Vida Residential |
|Outcome |Instructions for Sarah’s supports |Start |End |
|# | | | |
|1 |Enrolling in a cooking class - DSP will help Sarah to locate and enroll in a cooking class. |7/1/08 | |
|1 |Grocery shopping - DSP will help Sarah plan the menu for Wednesday night. DSP will review with Sarah her diabetic selections and recipes from her cooking |7/1/08 | |
| |class. DSP will make a shopping list with Sarah, take her to Food World and help her to find and purchase her groceries. DSP will assist Sarah with using | | |
| |kitchen appliances and with using proper sanitary procedures in the kitchen. Sarah enjoys stirring items and helping with cleanup. Sara will be supported to | | |
| |invite a friend or her AD companion if she chooses each week as well. | | |
|1 |Reviewing diabetic recommendations - DSP will help Sarah plan the menu for Wednesday night. DSP will review with Sarah her diabetic selections and recipes from|7/1/08 | |
| |her cooking class.. | | |
|2 |Budgeting for movies - DSP will help Sarah review and discuss her money each week. DSP will assist each week by reviewing and discussing her personal budget |7/1/08 | |
| |and by holding open the white envelope marked Movies while Sarah places $4 dollars or the amount she chooses inside. | | |
|2 |Inviting friends to movies - DSP will help Sarah decide who would like to attend the movies with her over the weekend. DSP will help by reviewing her address |7/1/08 | |
| |book with her and by dialing the number. DSP will place the phone in Sarah’s left hand so that she may talk. Following Sarah’s conversation, DSP will confirm | | |
| |plans with the other party and write in the support log for review over the weekend. | | |
|3 |Buying jewelry supplies - Sarah has chosen to develop her ability to make jewelry to share with others. Once each week, DSP will take Sarah to the craft store |7/1/08 | |
| |where she will purchase supplies for completing jewelry making. Sarah typically has $5 that she can afford to spend on supplies. She can pay for the items | | |
| |herself, but requires some support to be sure that she stays within budget. Sarah can hand the money to the cashier if placed in her left hand. DSP will | | |
| |support Sarah with crafting jewelry from the supplies selected each week upon returning home. | | |
|4 |Day trip to the beach - Sarah will receive support going to Virginia Beach for a day trip this year. DSP will provide transportation and support Sarah with |7/1/08 | |
| |seeing the ocean, going shopping, meals and personal care as needed during the trip. | | |
|4 |Budgeting for a beach trip - DSP will support Sarah to save the $85 dollars needed to go to the beach for a day. DSP will support Sarah with budgeting weekly |7/1/08 | |
| |spending money and with setting aside $5 dollars each week to meet her goal by holding open the white envelope marked Beach while Sarah places $5 dollars or | | |
| |the amount she chooses inside. | | |
|6 |Learning to use her wheelchair - DSP supports Sarah to learn to drive her power wheelchair. DSP will assist Sarah to an open area (outside patio on good |7/1/08 | |
| |weather days, inside den other times). DSP will explain to Sarah how to use her hand to control the chair. Sarah will learn to move the chair forwards, | | |
| |backwards, and to turn around. She will also learn to drive the chair up the ramp and to enter her home on her own. DSP will provide spoken directions and | | |
| |physical support as needed. | | |
|8 |Enrolling in a bowling league - DSP will support Sarah with contacting local bowling alleys to find and enroll in a local bowling league. |7/1/08 | |
|9 |Calling and writing letters to friends and family - DSP supports Sarah to maintain contact with her friends and family. DSP will ask daily if Sarah would like |7/1/08 | |
| |to contact anyone in her life by phone or mail. DSP will discuss the different people Sarah knows and support her by physically handing Sarah the telephone and| | |
| |then locating and dialing the desired number. DSP may assist with writing a letter by writing down word for word onto paper the message that Sarah would share | | |
| |with her friend or family. DSP will assist by locating a stamp and going with Sarah to the mailbox to mail the letter. | | |
|10 |Bathing, hair care and lotions, and brushing teeth. - DSP supports Sarah with personal care based on her preferences. Sarah will be supported with bathing each|7/1/08 | |
| |morning following her personal care protocols. Her teeth will be gently brushed for several minutes using mint toothpaste. She will receive total support with | | |
| |applying Lubriderm lotion each morning to her legs, arms and back. She will brush her own hair with her (red brush) each morning and DSP will assist by | | |
| |applying a small amount of hair gel and will complete styling. | | |
|10 |Preparing balanced, diabetic meals and snacks. - DSP will support Sarah with preparing 3 meals and 2 snacks each day. Sarah likes to help by stirring dishes |7/1/08 | |
| |with her left hand and by setting the microwave with spoken instructions. | | |
|10 |Daily house cleaning.- DSP will support Sarah with cleaning up after herself at home. DSP will provide Sarah with reminders and physical support to straighten |7/1/08 | |
| |up when finishing dinner or painting or other activity. Sarah will be supported to gather items and wipe the table following a meal or activity. | | |
|10 |Weekly house cleaning. - DSP will support Sarah with maintaining a clean home. DSP will assist with laundry and housecleaning each Sunday. Sarah can dust the |7/1/08 | |
| |furniture with reminders and spoken instructions. DSP will support Sarah with sweeping and moping, bathroom cleaning and with cleaning the kitchen appliances. | | |
|11 |Privacy with personal care and support with using adaptive device. |7/1/08 | |
|13 |DSP will support Sarah with locating a therapeutic riding program, completing paperwork and enrolling by 10/1/08. |9/1/08 | |
|13 |DSP will provide transportation and physical and spoken support as needed to participate in therapeutic riding classes at least once each month. DSP will |9/1/08 | |
| |support Sarah as needed to express her thoughts and questions with the riding instructor during all sessions and will provide transportation home afterwards. | | |
|Outcome |Safety Supports |Start |End |
|# | | | |
|12 |Support with her diet, blood sugar checks and emergencies. - DSP uses lancet device before meals and records reading in the support log. If blood sugar is |7/1/08 | |
| |below 90 DSP will provide Sarah with an 8 oz glass of orange juice and recheck in 1 hour. DSP will respond as needed to medical emergencies by contacting 911 | | |
| |and/or support Sarah to reach her doctor office or a local emergency room. | | |
|12 |Support with seizures.- when signs are noted that Sarah is becoming non-respondent or ceases an activity, DSP will speak with Sarah in a calm tone to inquire |7/1/08 | |
| |how she is feeling. If Sarah demonstrates signs of a seizure such as shaking his limbs, DSP will clear the area of objects and others. DSP will provide Sarah | | |
| |with continued monitoring until she has rested enough to move to an alternate location. Staff will call physician and guardian for guidance. DSP will | | |
| |identify an appropriate location for Sarah to rest, which may be her bed, a sofa, a park bench, etc. until she is ready to proceed with activity. Sarah will be| | |
| |supported in these steps during both home and community outings. | | |
|12 |Lap belt to prevent falls. - DSP will support Sarah to assure that her lap restraint is in place when moving in her home and community. DSP will remind Sarah |7/1/08 | |
| |to use the restrain as prescribed by her doctor and that opening the clasp puts her at risk of falling. DSP will support Sarah to refasten the clasp as needed | | |
| |during time in her home and community. | | |
|12 |Medications twice each day DSP will support Sarah with taking her medications each morning. DSP will provide Sarah’s medication by popping them out of the |7/1/08 | |
| |bubble package into her left hand for Sarah to take the pills without support - unless requested. | | |
|12 |Scheduling and attending medical appointments -DSP will monitor Sarah for signs of medical need and will assist by calling the appropriate physician for |7/1/08 | |
| |consult or for medical treatment. DSP will transport Sarah to the medical provider or contact 911 as appropriate. Sarah’s brother, Glen, will be contacted once| | |
| |the emergency has been addressed. | | |
|12 |Fire safety - DSP will support Sarah during emergencies and during fire drills to leave the house safely. DSP will ask Sarah to evacuate the home upon noting |7/1/08 | |
| |emergency or during fire drill by stating “Sarah, there is a fire and we need to get out of the house.” DSP will then support Sarah as needed to safely reach a| | |
| |distance of 200 feet from her home. | | |
|12 |PT/Range of motion exercises for left hand. - DSP will provide support with Sarah’s range of motion exercises as described by her physical therapist to |7/1/08 | |
| |increase flexibility and decrease contracture. PT exercise pamphlets kept in Sarah’s personal notebook. | | |
|Outcome |General Supports |Start |End |
|# | | | |
| | | | |
|Outcome |Periodic Supports |Start |End |
|# | | | |
|12 |DSP will offer Sarah a variety of choices from her ISP goals # 3 and 4 or another community outing of Sarah’s choice (such as taking a walk or visiting a |7/1/08 | |
| |friend) when missing her regularly scheduled day support activity. DSP will document in the Support Log when periodic supports are used describing what goals | | |
| |were addressed. | | |
|Outcome |Support Coordination |Start |End |
|# | | | |
|12 |Example from SC plans: Support Coordinator will coordinate, link and monitor services and supports during Sarah’s ISP year by completing referrals as needed, |7/1/08 | |
| |meeting with her face-to-face at least once every ninety days and by making a monthly contact with someone in her life either in person or by phone or mail. | | |
| |Support Coordinator will complete needed paperwork to maintain services and supports including quarterly reviews that confirm satisfaction with supports. | | |
|Signatures: Date |
|Individual: | | |
|Legal Guardian: | | |
|Provider: | | |
|Use the following blocks to record hours at the start of the annual plan and as changes occur at least quarterly. |
|Weekly hours =54.25 |1st 55.25 |2nd |3rd |4th |
|Increase/Decrease |1st 1 hour/week |2nd |3rd |4th |
|Safety Supports = 3.5 |1st 3.5 |2nd |3rd |4th |
|Periodic Supports =7 |1st 7 |2nd |3rd |4th |
|Total Billable = 64.75 |1st 65.75 |2nd |3rd |4th |
|General Supports (Respite, Companion | | | | |
|and PA billing only)= 0 |1st 0 |2nd |3rd |4th |
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