3.020 Appendix A INDIVIDUAL SUPPORT PLAN MONITORING AND REVIEW GUIDELINES

FACILITATING LONG-TERM SERVICES AND SUPPORTS - Individual Support Plan Monitoring and Review will include review of the ISP, talking with the individual, observation, and review of documentation. Identify if the ISP needs to be updated based on findings.

Are there any unresolved findings from previous visits or nursing reviews?
This information can be obtained from APTS Consumer Specific Report prior to the monitoring visit.

Review the ISP. Is the ISP being implemented as written? Specify evidence present that reflects progress is or is not being made. Evidence could include the following; Interview individual, family, staff, review progress notes and monthly reports etc. to determine progress. Evidence can be in the form of documentation, family reporting, demonstration, etc. SC shall review each authorized service and document information related to the Outcome and what progress is occurring. If noted progress is not occurring to meet the individual’s outcomes, appropriate follow-up should occur.

People Participate in Meaningful Daily Activities of Their Choice

Individuals make informed choices and are encouraged self-determination in pursuing daily activities of their choice while exploring the full range of options including employment, volunteering, use of free time and participating in activities of their choice.

During the face-to-face visit, it appears that the person is being supported and engaged in a routine and activities that are typical to the environment, time of day and what is important to and important for the person.

How does the individual spend their day? = Consistent with ISP

Does the setting reflect the individual’s needs and preferences as outlined in the ISP?

Services & Staff/ ISP Implementation/Setting Reflects Needs

Is the individual making their own choices and are their choices being respected?

Does the individual continue to be happy with their current home/setting?

Rights/Decision Making/Satisfied with setting

Do staff provide the individual with information they need in order for the individual to make their own decisions?