Services and FundingIndividual Support Plan (ISP)(Children ...



|[pic] |Services and Funding |

|Developmental Disabilities Services |Individual Support Plan (ISP) |

| |(Children’s In-Home Service Setting) |

|CDDP: |      |Service coordinator: |      |

|Child’s name: |      |DOB: |  /  /     |Prime number: |      |

|Parent/guardian: |      |

|CNA assessment date: |  /  /     |ISP start date: |  /  /     |ISP end date: |  /  /     |

Case Management

Waiver case management (must receive one qualifying waiver service monthly) Non-waiver case management

See Child Annual/Family Support Plan (SDS 4549 form)

| List specific anticipated case management activities, if not listed on the SDS 4549 form: |

|      |

| |

*What to put in the “Rate” box: [(Wage (PSW’s hourly) x Tax (county employer)) + Worker’s Compensation (.016)] + Wage/hour= “Rate”

[(Enter PSW's hourly x Enter Tax (county employer)) + .016] + Enter PSW's hourly = 0.016[pic]$0.01

| | | | | | |

|Service category |What and how |Authorized |Unit of service |

| |support is arranged |dates | |

| |(PSW, independent contractor, |(start and end) | |

| |agency provider or general business) | | |

|Financial management services (fiscal |      |Start:   /  /     |      |

|intermediary) | |End:   /  /     | |

|K-plan/GF Services (for service plans check a box: K-plan or General Funds (GF)) |

| K-plan GF |      |Start:   /  /     |      |

| | |End:   /  /     | |

|List and describe the supports identified in the functional needs assessment (address risk, goals and preferences): |

|      |

| K-plan GF |      |Start:   /  /     |      |

| | |End:   /  /     | |

|List and describe the supports identified in the functional needs assessment (address risk, goals and preferences): |

|      |

| K-plan GF |      |Start:   /  /     |      |

| | |End:   /  /     | |

|List and describe the supports identified in the functional needs assessment (address risk, goals and preferences): |

|      |

| K-plan GF |      |Start:   /  /     |      |

| | |End:   /  /     | |

|List and describe the supports identified in the functional needs assessment (address risk, goals and preferences): |

|      |

| K-plan GF |      |Start:   /  /     |      |

| | |End:   /  /     | |

|List and describe the supports identified in the functional needs assessment (address risk, goals and preferences): |

|      |

| K-plan GF |      |Start:   /  /     |      |

| | |End:   /  /     | |

|List and describe the supports identified in the functional needs assessment (address risk, goals and preferences): |

|      |

| K-plan GF |      |Start:   /  /     |      |

| | |End:   /  /     | |

|List and describe the supports identified in the functional needs assessment (address risk, goals and preferences): |

|      |

| | | | |

|List and describe the supports identified in the functional needs assessment (address risk, goals and preferences): |

|      |

| K-plan GF |      |Start:   /  /     |      |

| | |End:   /  /     | |

|List and describe the supports identified in the functional needs assessment (address risk, goals and preferences): |

|      |

| K-plan GF |      |Start:   /  /     |      |

| | |End:   /  /     | |

|List and describe the supports identified in the functional needs assessment (address risk, goals and preferences): |

|      |

| K-plan GF |      |Start:   /  /     |      |

| | |End:   /  /     | |

|List and describe the supports identified in the functional needs assessment (address risk, goals and preferences): |

|      |

| K-plan GF |      |Start:   /  /     |      |

| | |End:   /  /     | |

|List and describe the supports identified in the functional needs assessment (address risk, goals and preferences): |

|      |

| K-plan GF |      |Start:   /  /     |      |

| | |End:   /  /     | |

| |

|List and describe the supports identified in the functional needs assessment (address risk, goals and preferences): |

|      |

| K-plan GF |      |Start:   /  /     |      |

| | |End:   /  /     | |

|List and describe the supports identified in the functional needs assessment (address risk, goals and preferences): |

|      |

|Waivered services (for service plans check a box: Waiver or General Funds (GF); no calculation needed for case management) |

| Waiver GF |      |Start:   /  /     |      |

| | |End:   /  /     | |

|List and describe the supports identified in the functional needs assessment (address risk, goals and preferences): |

|      |

| Waiver GF |      |Start:   /  /     |      |

| | |End:   /  /     | |

|List and describe the supports identified in the functional needs assessment (address risk, goals and preferences): |

|      |

| Waiver GF |      |Start:   /  /     |      |

| | |End:   /  /     | |

|List and describe the supports identified in the functional needs assessment (address risk, goals and preferences): |

|      |

| Waiver GF |      |Start:   /  /     |      |

| | |End:   /  /     | |

|List and describe the supports identified in the functional needs assessment (address risk, goals and preferences): |

|      |

| Waiver GF |      |Start:   /  /     |      |

| | |End:   /  /     | |

|List and describe the supports identified in the functional needs assessment (address risk, goals and preferences): |

|      |

|State plan personal care services (also known as PC-20) |

|List and describe the supports identified in the functional needs assessment (address risk, goals and preferences) |

|Personal assistance tasks |      |Start:   /  /     |Hours per month (submit SDS 0546PC form to DD.PC-20@state.or.us for |

| | |End:   /  /     |payment) |

|Support service tasks |      |Start:   /  /     |Hours per month (submit SDS 0546PC form to DD.PC-20@state.or.us for |

| | |End:   /  /     |payment) |

|Exception hours |      |Start:   /  /     |Hours per month (submit SDS 0546PC form to DD.PC-20@state.or.us for |

| | |End:   /  /     |payment) |

| | | |***Follow exception process procedure. |

|Other services and supports |

|Services/supports |Provided by |Frequency and duration |

|(natural supports/community resources) | | |

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| |  /  /     | | |  /  /     |

|Parent or guardian signature |Date | |CDDP signature |Date |

| | | |Plan year grand total |$0.00[pic]$0.00 |

|K-plan services: | |Waivered services: |

|Assistive devices – 760 |Community nursing services – 764 |Case management |

|Assistive technology – 491 |Community transportation (non-medical) – 756 |Environmental safety modifications – 713 |

|Attendant care management training (ex: STEPS) |Environmental modifications – 753 |Family training (conferences and |

|Attendant care – ADL/IADL – 755 |Relief care – 759 |workshops) – 754 |

|Behavior support services |Skills training – 755 |Specialized medical supplies – 493 |

|(behavior consultation) – 750 |Transition costs – 495 |Vehicle modifications – 708 |

|Chore services – 490 | | |

|State plan personal care services: | | |

|Personal assistance tasks: |Support services tasks: | |

|Basic personal hygiene |Housekeeping |

|Toileting, bowel or bladder care |First aid and handling of emergencies |

|Mobility, transfer or repositioning |Arranging and assisting with medical appointments |

|Nutrition |Observing and reporting on health status |

|Medication or oxygen management |Cognitive assistance or emotional support |

|Delegated nursing tasks | |

| | |

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