DDS PERSON CENTERED ISP Department of Developmental Services

DDS PERSON CENTERED ISP Department of Developmental Services NE Staff Learning and Development

“I” IS FOR INDIVIDUAL Be Active Take Action Be Responsible

CONCEPTUAL FRAMEWORK The core of our efforts is to support individuals to achieve the quality of life they desire while assuring their needs are met. Service Coordinators and Provider representatives must base their work on a deep commitment to staying true to what is most important to the person, remaining personcentered, and upholding the Department’s Mission Statement and Guiding Principles.

CONCEPTUAL FRAMEWORK The Individual Support Plan (ISP) is the process the Department uses to support the individual to achieve his or her goals. Individual support planning is tailored to and by the individual and is responsive to changing circumstances in his or her life. Each participant in the ISP process is expected to have a continuing commitment to learn about the individual and about his or her current goals and circumstances, and to support the individual in particular ways to realize those goals.

BUILDING BLOCKS OF THE ISP “If dreams don’t scare you they’re not big enough. ” (Ellen Johnson Sirleaf)

WHO RECEIVES AN ISP? • Ricci Class members; • Individuals enrolled in an adult Home and Community-Based DDS Waiver program. • Individuals receiving residential supports provided or purchased by DDS, including supports that supplement Adult Foster Care; • Individuals receiving day or employment supports provided or purchased by DDS, including Day Habilitation or Adult Day Health Services when funded in whole or in part by DDS, and supports that supplement Day Habilitation or Adult Day Health programs. Individuals receiving minimal supports may or may not receive an ISP at the discretion of the Department. 6

WHO COMPRISES THE ISP TEAM? The ISP must be developed with the fullest possible participation of each of the following persons, • • • The individual; Members of the individual's family, if authorized; The individual's guardian(s), if any; The individual's Service Coordinator; Provider representatives to the individual, The individual's designated representative and others who provide friendship and support to the individual unless the individual or guardian knowingly objects to such persons' participation.

SUPPORT TO THE ISP TEAM The ISP process must be Culturally Sensitive Information must be presented in plain language. Information must be presented in manner accessible to persons who are limited English proficient. The location, timing, and duration of the ISP meeting must be consistent with the needs of the individual and other members of the ISP team.

ISP TIMELINE Assessments due, including Progress Summaries Pre-ISP Planning Activities including person’s Vision Proposed Objectives & Support Strategies due ISP meeting notification sent -60 -45 days -30 +80 days Pre-ISP Planning Activities +180 -15 days. -30 days Completed ISP reviewed, approved by DDS and mailed to team members THE days -15 days Annual Update Meeting +45 hours Updated ISP plan Implemented Proposed Updates of objectives & Support Strategies Due days Appeal rights expire Updated ISP reviewed, approved by DDS and mailed to team members UPDATE MEETING Progress Summaries due +24 DAY Assessments Due, including Progress Summaries ISP meeting Notification sent -60 -45 Full ISP Meeting -15 days Appeal rights expire ISP implemented +24 hours Progress Summaries Due +45 days +80 180 days 9

60 -45 Days Prior to ISP Meeting Service Coordinator: • • • Gathers information for vision statement Discusses Satisfaction w/current supports Meets with Individual/Guardian Explains purpose of the ISP Informs Individual/Guardian of different methods of service delivery • Date and time of meeting is documented in Meditech

30 Days Prior to ISP Meeting (At Least) Service Coordinator: • Sends out written notification to ISP members of the date, time and place of the ISP meeting. • Informs the Service Providers of the Individual’s Vision Statement and preliminary Goals (if any) • Informs the Service Providers of required assessments and /or professional consultations required.

15 Days Prior to the ISP Meeting Service Providers of services that are provided or purchased by DDS: • Complete all assessments and professional consultations consistent with DDS requirements. • Submit ISP progress summaries in DDS approved format to the SC • Develop preliminary Goals and Objectives with the input from the individual and/or guardian(s).

At Least 15 Days Prior to the Meeting Service Providers of services that are provided or purchased by DDS: Draft Objectives and Strategies submitted to the SC for review consistent with DDS requirements

7 Days Prior to the ISP Meeting (At Least) Service Coordinator: • Assessments are available to the ISP members upon request. • Review documentation sent by Service Providers • Return any assessments, Objectives and Support Strategies that do not meet DDS criteria

Prior to the ISP Meeting Service Coordinator: Prepare draft ISP document (Optional)

Day of Meeting Service Coordinator: • Facilitate the meeting • Assure Vision statement is clear and accurate • Finalize goals, Objectives and Support Strategies • Finalize the ISP

Within 45 Working Days of the ISP Meeting Service Coordinator, SC Supervisor, Area Director: • ISP is Reviewed • Approved by DDS • Mailed to ISP Team members for approval

Within 10 days of Receipt of the ISP Individuals, Guardians, Authorized Family Members: They have the right to a meeting with the Service Coordinator to review the ISP

35 Days After the ISP Has Been Mailed to Relevant Parties Service Coordinator, SC Supervisor, Area Director: ISP is accepted unless otherwise indicated by the individual or guardian

35 Days After the Mailing of the ISP Area Office: Appeal Period Ends

Semi-Annual Review The Service Coordinator must review the implementation of the ISP at least every 6 months based on the following: The ISP progress summaries submitted by the Service Providers Information gathered through conversations with ISP team members, meetings, and site visits Observations of the Individual HCSIS reports Meditech notes

ANNUAL ISP UPDATE The ISP team will meet to review the ISP no more than 365 days after the ISP meeting. The notification and assessment requirements are the same as for the ISP meeting

ISP Modification An ISP Modification is required whenever any of the following changes are proposed to be implemented prior to the individual’s next ISP review. § Change in the goals § Change in the types of supports or services or duration and frequency of such supports § A Change in the Strategies that will be used to meet unmet support needs.

Changes Continued § The implementation of a Targeted PBSP or Intensive PBSP § Initiation/or Modification of a Behavior Modification Plan § A change in the location of an individual’s home

Procedure for a Modification to the ISP The SC is notified of the change and a request for modification is made SC responds within 30 days of the request and will provide at least 10 days notice of the modification meeting to the following people: The individual and guardian (if any) Authorized family members A current provider of services and supports

MODIFICATION Within ten days of the modification meeting or waiver of such meeting, the SC will notify all parties that were required to be invited to the meeting of the decision on the requested modification and of their rights to appeal

THE PARTS THAT MAKE UP THE ISP DOCUMENT “The whole is greater than the sum of its parts” (Aristotle)

OUR VISIONS ARE MORE ALIKE THAN DIFFERENT The video you are about to view is meant to be inspirational, to show that regardless of a person’s abilities their desires, hope and dreams are more a like thn different.

The Vision “An exploration of what is important to the person in his or her life. ” - An image of a desired future. 29

Impossible I M POSSIBLE

VISION STATEMENT 1. What does (s)he identify as important activities and relationships to continue to be involved in? What other things would (s) he like to explore? § Gains insight into activities the individual enjoys. § Helps to identify potential community and work interests. § Helps to identify the important people in the person’s life. 31

Example Notations Example- Esther provided all the information to answer the 4 vision statements. Example- I spoke with Tammy’s guardian to review the 4 vision statements. Example-I met with Juan at his home and reviewed the 4 vision statement questions with him. Juan asked me to include his father in the discussion. Both contributed information to develop the Vison statement. This is Juan’ s first ISP.

EXAMPLE Esther’s family is very important to her. She has 8 siblings, all of whom she speaks weekly. She also visits them regularly in New York City and in the Dominican Republic when her financial resources permit her to do so. Esther is a member of her local synagogue and this is very important to her spiritually as well as providing many activities and social connections. She contributes both her time and resources to this community and plans to continue this connection. Ester works full time and she finds her work rewarding. Esther would like to find more time for friends.

VISION STATEMENT 2. What does (s)he think someone needs to know in order to provide effective supports? § Provides the insight into the do’s and don’ts of supporting the individual from his/her point of view. § Helps in identifying learning styles. § Helps the person to succeed when supporters understand what works and what doesn’t. § Identifies elements to emphasize when developing strategies to achieve Objectives. 34

EXAMPLE Esther is very independent and wants anyone who supports her to respect her ability to make decisions for herself even if they do not always agree with what she wants to do. She uses a Dynavox Maestro to communicate and her supporters need to know how to use this device.

VISION STATEMENT 3. What does (s)he think are his/her strengths and abilities? § Provides the ISP Team with the individual’s view of positive traits and skills. § Provides insight into possible career paths and job matching. § Supporting an individual to recognize his or her gifts promotes self worth and provides opportunities to recognize valued roles the person fulfills or aspires to. § Provides important information for use in addressing Goals and Objectives. 36

EXAMPLE Esther says that she is a good listener and is a kind supportive person to her family, her friends, and to the members for her faith community. She believes she has the ability to accomplish anything she sets her mind to given enough time and the right kind of support.

VISION STATEMENT 4. What would (s) he like to see happen in his/her life over the next two years? § The two year timeframe corresponds with the two year cycle of the ISP, but goals can have a longer or shorter focus. § The answer to this question will identify the Goals most important to the person. § Goals are aspirational. Encourage people to imagine the life of their dreams. 38

EXAMPLE Esther would like to explore the possibility of working part time so that she has more time to spend with friends. Ideally, she would like to work 3 days a week but is concerned about whether or not she will be able to maintain her current lifestyle on a reduced income. She wants help to figure this out.

ASSESSMENTS The purpose of ISP assessments is to obtain specific information that will assist the ISP Team in identifying the individual's capabilities, support needs, and opportunities for skill development. The content of the assessments will support the ISP Team in establishing goals, objectives and support strategies that are the least restrictive and likely to be effective in assisting the individual to attain his or her goals.

ASSESSMENTS CODE SERVICE NAME HCR SAFETY HEALTH & DENTAL FINANCIAL BEHAVIOR EMPLOYMENT PSYCHOTROPIC MEDICATION TREATMENT ADL 3150 Placement Services (Shared Living) Always Sometimes Never Sometimes 3153 Residential Supports (24 hour) Always Sometimes Never Sometimes 3163 Community Based Day Supports Never Always Never Sometimes Sometimes 3168 Individual Supported Employment Never Always Never Sometimes Always Never Sometimes 3169 Center Based Work Services Never Always Never Sometimes 3180 CIES Never Always? ? Never Sometimes Always Never 3181 Group Employment (Enclave) Never Always Never Sometimes 3182 Emergency Stabilization Residence Determined by contract Always Sometimes Sometimes 3285 Day Habilitation Supplement Never Always Sometimes Sometimes 3798 Community Living Supports Always Sometimes Never Sometimes 4157 State Operated Residential Always Sometimes Never Sometimes 4169 State Operated Centerbased work Never Always Never Sometimes Always Sometimes 41

VISION STATEMENT +ASSESSED NEEDS LEAD TO ACTION Objectives Vision This process is made possible by: Inquiry and Facilitation 42

PUTTING IT ALL TOGETHER: WRITING THE ISP “You Can Do Anything As Long As you Have The Passion, The Drive, The Focus and The Support” (Sabrina Bryan)

Current Supports CURRENT SUPPORTS is where the ISP Team indicates the needs the person has and the supports necessary to address those needs. The supports must be designed to address the person’s needs in order to accomplish the person’s VISION.

Current Supports-Areas of Review- 6 Areas § Home/Community § Medications § Employment/Day § Adaptive Equipment/ Assistive Technology § Health and Dental § Clinical 45

CURRENT SUPPORTS: HOME/COMMUNITY Where and with whom the person lives. Form of support within the home. Nature of the supports provided: Natural supports, DDS, AFC, PCA, etc. Average number of support hours (for people in less than 24 hour supports). Needs addressed in the specific living situation. Specialized equipment, individualized provisions for care/support needs.

EMPLOYMENT/DAY What the person does during the day. Types of support necessary for the individual to be successful during the day (including transportation needs). Nature of the support Average number of hours/day of employment or day activity Average number of hours of direct support to the individual Who provides support (DDS Provider, day hab, adult day etc. ). For people who are transitioning into a new form of service, a description of what the agency has done over the past year to identify an appropriate job match or community based activities.

HEALTH AND DENTAL GENERAL GUIDANCE: § Service Coordinator should use existing documentation as the primary source of information, including the Health Care Record and Health and Dental assessments. § All diagnosis and health care protocols must be supported by documentation from a licensed health care provider with expertise in the area of need. 48

HEALTH AND DENTAL Summarize health and dental support needs. Indicate the health care providers and specialists. List: Dates of health care visits Special staff support if needed Health care protocols Allergies Health care risks NOTE: HIV Status and treatment is “need to know” and must not be noted in the ISP document.

MEDICATIONS Identify if the individual is self medicating or the supports needed to take medication. Individuals who wish to become independent in managing their medications should have a specific goal and plan integrated into the ISP that conforms to MAP standards. List medications and the purpose. List any allergies to medications, history of side effects, or atypical reactions.

ADAPTIVE EQUIPMENT/ ASSISTIVE TECHNOLOGY List the types of adaptive equipment / assistive technology used by the individual. Indicate condition and who is responsible for maintenance. List any Health Related Supports used to achieve proper position and balance to permit the person to participate in ongoing activities. Indicate Health Related Protections ordered by a physician or licensed clinician.

CLINICAL All clinical supports must be based on assessments and consultations conducted by qualified clinicians. List the types and frequency of clinical supports received (OT, PT, SLP, Psychiatry, Psychology). Note any behavior modifying medication Roger’s requirements. including

CLINICAL POSITIVE BEHAVIORAL SUPPORTS Positive Behavioral Supports is a holistic, person-centered approach to understanding the reasons for behavior and applying evidence-based practices for prevention, proactive intervention, teaching and responding to behavior with the goal of achieving meaningful social outcomes increasing learning and enhancing the quality of life across the lifespan

CLINICAL: POSITIVE BEHAVIORAL SUPPORTS The Department of Developmental Services replaced it’s existing regulations governing behavioral treatment with new Positive Behavior Support regulations, designed to increase the independence and autonomy of people with disabilities. Positive Behavioral Supports has three tiers: Universal Supports, Targeted Supports Intensive Supports. Not all of these Tiers are referenced in the ISP.

Universal Supports Practices that are always in place to support every individual in each environment or setting. Universal Supports are intended to enhance quality of life. Universal Supports are consistent with the Federal standards relating to Person Centered Planning.

TARGETED SUPPORTS Targeted Supports are implemented fairly rapidly on an “as needed” basis for an individual or group at risk for developing problem behavior and needing intervention beyond Universal Supports.

INTENSIVE SUPPORTS Individuals are referred for Intensive Supports when there are concerns for the health, safety, or emotional well-being of the individual, or others, is at risk, or the individual’s quality of life is seriously impeded due to the challenging behavior.

Targeted and Intensive Supports requirements: • A statement of the areas of concern • A functional behavioral assessment(abbreviated or informal for Targeted Supports and formal for Intensive Supports) • A written Positive Behavior Support Plan (PBSP). (However, a PBSP is not required for Targeted Supports described at 115 CMR 5. 14(5) (b)5. )

SAFETY AND RISK § SAFETY § At Home: Evacuation, safety around the home § At Work: Limited depending on the setting but should address the person’s ability to respond to emergencies § Community: Safety in the community, knowledge of the community, street safety, recognizing danger, who to contact, etc. § Should correspond with information from Safety Assessment 59

SAFETY AND RISK § Description of circumstances where the individual poses a risk to self or others. § Supports provided: Staffing and special instructions to mitigate risk § Any special requirements for criminal justice involvement § Risk Plans developed as part of the DDS Risk Management system are not part of the ISP. Referencing a Risk Plan in the ISP violates established DDS Policy. reference that “the individual is followed by the However, it is appropriate to Area Risk Management Team”. 60

SAFETY AND RISK: BACK UP PLANS For individuals living independently and receiving less than 15 hours/week of supports, generic community supports serve as the backup plan. For people living with natural supports (i. e. family and friends) these natural supports serve as the backup plan. For people living with substantial residential supports (15 hours/week or greater, including Shared Living) the provider agency is responsible for being on-call and providing back up plans. For individuals self-directing their services, an explicit back up plan is created and included in the ISP.

LEGAL/FINANCIAL/BENEFITS STATUS LEGAL (Competent or Adjudication or Recommendation) Benefits • Guardian, Conservator, Roger’s Monitor, Health Care Agent and Alternate Health Care Agent including legally responsible person’s name, Mass. Health Designee, Power of Attorney • SSI, SSA SSDI, Mass. Health, Rep Payee, Financial • Trust Fund, Burial Plan, other

SUCCESSES, CHALLENGES, EMERGING ISSUES Events and experiences over the past two years that have significance to the individual are highlighted here. Satisfaction with services should be referenced in this section of the ISP. Positive Events provides the opportunity to celebrate success Challenging Issues should be noted when people are stuck and we need extra scrutiny of the issues. Emerging Issues are noted when new challenges or concerns have arisen that the Team needs to be aware of in the coming year.

UNMET NEEDS Unmet Needs must be based on assessments approved by DDS. Any Unmet Need must have a plan developed to address the need. Ricci Class members have the right to substantial provision of the services or supports recommended in his or her Individual Support Plan for so long as such services or supports are needed and authorized.

GOALS Use the Vision Statement to help the individual and the ISP Team focus and prioritize supports. Goals must be documented in the person’s and/or representative’s own words and should reflect the quality of life concepts important to the person.

Objectives and Support Strategies § DDS Review Standards § Objectives- Individualized, Measurable, Method to evaluate, Relates to the Vision or Needs § Support Strategies- Individualized, Specific, Measurable, Action oriented, Relevant to the individual’s abilities and needs, Time limited, Effective, Regularly reviewed and recorded 66

Objectives and Support Strategies § Support Objective § Should only be used if the individual does not need to develop skill to enhance independence. § Typically used to help the individual maintain involvement in activities that would not be possible without support. § Very appropriate when individuals are medically frail and need very specific interventions to support their well-being. § Are also appropriate for individual with Alzheimer’s and other forms of dementia. 67

SUPPORT STRATEGIES § Strategies § Foundation for Teaching § Written teaching plan § Guide for staff to understand the support necessary to provide effective and comprehensive teaching so the individual gains skill leading to greater independence. § Provides staff with a sequence of events to support the individual in learning new skills. 68

S. M. A. R. T. E. R Objectives and Support Strategies Specific Measurable Action/Achievable Relevant/Realistic Timely/Time Sensitive Evaluated/Enjoyable Reviewed and Recorded

SMART …Who § Who is performing the action or behavior? Use person’s name John will…… Pedro will…. . . 70

Smart : Action (What) § The action is the skill or behavior to be acquired or developed. § Single action § Use a specific action verb (count, walk, join, share) John will walk from his work station to the break room…. Pedro will deposit $2 of his weekly earnings into his vacation account…. 71

Smart : Conditions (When) The conditions describe the circumstances/level of assistance under which the action or behavior is to be performed, such as “during mealtime”, “upon entering the room”; “with partial assistance”; “ given one verbal reminder. ” The condition/level of assistance provides the context in which the identified action or behavior is to be performed.

Example: § John will walk from his work station to the break room with only visual supervision from staff. § Pedro will deposit $2 of his weekly earnings into his vacation account following 1 verbal reminder from staff. 73

Smart : Criteria § The criteria specifies the standard or degree of accuracy required for the action/behavior to be considered successfully performed. John will walk from his workstation to the break room with only visual supervision from staff, twice per day. Pedro will deposit $2 of his weekly earnings into his vacation account following 1 verbal reminder from staff, within 2 business days of getting paid. 74

Measurability You can also make it measurable by indicating a rate: 3 out of 4 times 3 minutes out of every 5 80% success § When using a rate, be sure you can specify and measure the "whole part. " In other words, if you say an individual will do something 80% of the time, specify the time frame, i. e. a 15 minute interval, for a week, for a month…. . 75

Smart : Stability Measure § Making sure that the skill/knowledge is adequately learned/mastered. A completion date. John will walk from his workstation to the break room with only visual supervision from staff, 2 times a day, for two consecutive months, by 5/31/22. By 8/31/22, Pedro will deposit $2 of his weekly earnings into his vacation account following 1 verbal reminder from staff, within 2 business days of getting paid, 90% of 30 opportunities. 76

Support Strategy The Support Strategy is the teaching plan and must be detailed enough to enable staff to effectively support the individual to learn.

Support Strategy Identifies where, when, and how the objective is addressed. Breaks down the skills to be developed The methods of teaching the skill (modeling, gesture, chaining, verbal cues, physical assistance, reinforcement, correction, etc. ) Frequency of teaching sessions Identifies the method for data collection and the frequency of review

Development of the ISP The goals, objectives and any supports or strategies identified in the ISP must be consistent with and promote the following outcomes for individuals: Rights and Dignity Individual Control Community Membership Relationships Personal Growth/Accomplishment Personal Well-being

IMAGINE “A World That Works For Everyone” (Beth Mount)