Individual Service Plan

ISP Data Mapping: (Kind = 66) Creation Wizard: Current date and Recommended date range for services and statements. Name ISP (default - ISP current Date) Letterhead (default to system option) Key: Changes First Line of Letterhead (ISP Information) LOGO (on rpt) Individual Service Plan Name of Person: Full Name ISP Effective Date: Important Date type = ISP Effective Date Medicaid #: Identification type = Medicaid # Review Date: Important Date, type = ISP Review Date Projected 6mo. Review: Important Date, type = ISP Projected 6mo Review Date of ISP Review: Face MSC Initials: Date of ISP Review: Face MSC Initials: To Face? To Face? Question Area = DateReview YN YN Section = 1 _FAW_ Notes FAW_ State Section = 4 _FAW_ Notes FAW_ State Section = 2 _FAW_ Notes FAW_ State Section = 5 _FAW_ Notes FAW_ State Section = 3 _FAW_ Notes FAW_ State Section = 6 _FAW_ Notes FAW_ State Face To Face? Question Area= FaceToFace Section = (1,2,3,4,5,6) FAW_State (1=Yes checked, 0=No checked) Yes and No are spelled out. DOB: Individual s DOB Social Security Number: Identification type = Social Security Number Diagnosis: Disability (ordered by priority asc) Telephone: Type = Home Phone Address: Individual s Address Section 1: The Narrative (Profile, the Person s Valued Outcomes and Safeguards) Profile: Include Selected Person-centered information about the person discovered during the planning process. For example, abilities, skills, preferences, relationships, health, cultural traditions, community service and valued roles, spirituality, career, challenges, needs, pertinent clinical information, or other information that affects how supports and services will be provided. Statement Category = Profile start/end dates match recommended dates, Code= 000000000 (one text box, pull from yr to yr) The Person s Valued Outcomes: List the person s Valued Outcomes that derive from the profile. Outcomes are brief, clearly stated and as specific as possible. Please ensure that there is at least one outcome for each Waiver habilitation Service that the person will receive, (e.g., Residential habilitation, Day Habilitation, Prevocational Service, and Supported Employment). List the outcome for each appropriate Waiver Habilitation Service in the HCB Waiver Service Summary. Statement Category = ValuedOutcomes - start/end dates match recommended dates, Code= 000000000 (add multiple valued outcomes) Safeguards: Individualized supports needed to keep the person safe from harm and actions to be taken when the health or welfare of the person is at risk. Fire safety is required. Statement Category = Safeguards start/end dates match recommended dates, Code= 000000000 (one text box, pull from yr to yr) Section 2: The Person s Individualized Service Environment Natural Supports and Community Resources: People, groups or organizations that are a resource to the person by providing supports and services, for example family, friends, neighbors, associations, community centers, spiritual, school groups, volunteer services, self-help groups, clubs, etc. Include the name of the

person, place or organization and a brief statement about what is being done to help the person. Assistance related to achieving a Valued Outcome should be noted. FormAnswer where QU_Area= NSCR, State is Textbox and Notes is Valued Outcome checkboxes.

Medicaid State Plan Services: For each service briefly state the name of the provider or agency (e.g. Dr. Smith, ARC Day Treatment Center, Southern DDSO Clinic); the type of service (e.g. physician, Article 16 clinic, day treatment, MSC, transportation, durable medical equipment, etc.); the frequency of the service (e.g. daily, 5 times a week, yearly); the duration (e.g. ongoing); the effective date (e.g. 5/14/99, or approximate time frame: within the past year, etc.) and the person s valued outcome (from Section 1 of the ISP) or reason for receiving the support or service. Examples of Medicaid State Plan Services: Medicaid Service Coordination, Day Treatment, Physical, Pharmacy, laboratory, hospital, Dental, Audio logical, personal Care, Certified Home Health Care, Durable Medical Equipment, Transportation, other. Note: Long term therapies provided in Article 16, 28 or 31. Clinics should not be included below. (See section Medicaid State Plan Services: Article 16, 28, or 31 Clinic Long Term Therapies Only ). However, medical or dental state plan service provided in an Article 16, 28, or 31 clinic should be described below. All Services with Type like Medicaid% Type of Medicaid Service: Service Name Narrative Medicaid (Question Area = Medicaid, Question Section = see below) Type of Medicaid Service: Name Medicaid State Plan Services- Article 16, 28, and 31 Clinics. Long-Term Therapies Only (Physical Therapy, Occupational Therapy, Speech, Rehabilitation Counseling, Nutrition, Psychology, Social Work and Psychiatry): For each service briefly state the name of the provider or agency (e.g., Metropolitan Article 28 Clinic, estern Article 16 Clinic): check the box to indicate the Clinic Certification Category (e.g., Article 16); the type of clinic service (e.g. physical therapy, speech pathology); the frequency of the service (e.g., 3 days a week); the duration (e.g., on-going) and effective date (e.g., 3/12/97 or approximate time frame: e.g., within the past year); the person s valued outcome (from section 1 of the ISP) or reason for receiving the support or service; and location the service will be provided (e.g., main clinic site, day program, or residential program). Not Receiving Clinic Question Area = Clinic Section = Checkbox _FAW_State All Services with Type like Clinic% Type of Clinic Service: Service Name

Name of Provider: Service staff: staff position, service location Article 16 Article 28 Article 31 (based on organization identification type = Agency%Type ) At what location will the services be provided (e.g., main clinic site or at the day or residential program)? Service setting Narrative Clinic (Question Area = Clinic, Question Section = see below) Type of Clinic Service: Name Article 16 Article 28 Article 31 Article At what location will the services be provided (e.g., main clinic site or at the day or residential program)? Setting Federal, State or County Funded Resources: For each service briefly state the name of the provider or agency (e.g. Access-R, HUD, NYS Office of the Aging, Education Department, BOCES, DOH, Department of Social Services); the type of service (e.g., Senior Citizen Services, educational services, housing); the frequency of the service (e.g. daily, 3 days a week, monthly); the duration (e.g. ongoing); the effective date (e.g. 5/14/99, or approximate time frame: within the past year, etc.) and the person's valued outcome (from Section 1 of the ISP) or reason for receiving the support service. All Services with Type like FSCR% Type of FSCR Service: Service Name Narrative FSCR (Question Area = FSCR, Question Section = see below) Type of FSCR Service: Name

HCB Waiver Service Summary: Complete a section below for each waiver service. For each service briefly state the name of the provider or agency (e.g., Sunshine Co. UCP, southern DDSO); the type of service (e.g., residential habilitation, supported employment, environmental modification); the frequency of the service (billing unit of service); the duration (e.g., on-going) and effective date (e.g., 1/1/99) and the person s valued outcome (from Section 1 of the ISP) or reason for receiving the support or service All Services with Type like Waiver% Type of Waiver Service: Service Name Narrative Waiver (Question Area = Waiver, Question Section = see below) Type of Waiver Service: Name Freq, Dur, and Effective Date will not print if the Type of Waiver Service = Not Receiving Below checkboxes, Not Receiving Waiver Question: Area = Waiver Section= Checkboxs _FAW_State piped a residential habilitation b supported employment c adaptive devices d fiscal/employer agent e transition services f prevocational services g environmental modifications h plan of care support services i consolidated supports and services j blended services k day habilitation l respite m family education and training Other Services or 100 % OPWDD funded supports and services: For each service briefly state the name of the provider or agency (e.g., Sunshine Co. UCP, southern DDSO); the type of service (e.g., family support services, individualized supports and services, 100% state funded supported employment, private health insurance, etc.); the frequency of the service (e.g., daily, monthly); the duration (e.g., on-going) and effective date (e.g., 1/1/99) and the person s valued outcome (from Section 1 of the ISP) or reason for receiving the support or service All Services with Type like OPWDD% (9/28/11: changed from OMRDD% ) Type of OPWDD Service: Service Name Narrative OMRDD (Question Area = OMRDD, Question Section = see below)

Type of OPWDD Service: Name Names of Service Providers receiving copy (s) of ISP and attachments: Provider Name: Date Sent Provider Name: Date Sent: Question Area =' ProviderName' Section = 1 _FAW_ Notes - FAW_ State Section = 5 _FAW_ Notes - FAW_ State Section = 2 _FAW_ Notes - FAW_ State Section = 6 _FAW_ Notes - FAW_ State Section = 3 _FAW_ Notes - FAW_ State Section = 7 _FAW_ Notes - FAW_ State Section = 4 _FAW_ Notes - FAW_ State Section = 8 _FAW_ Notes - FAW_ State (Report Only)Signatures: Person: Advocate: Service Coordinator: Service Coordinator Supervisor: PLEASE REFER TO THE NOTIFICATION & DISTRIBUTION FORM FILED AT THE FRONT OF THIS ISP DOCUMENT LOGO (on rpt) First Line of Letterhead (ISP Information) Individual Service Plan ADDENDUM Name of Person: Full Name Medicaid #: Id type = Medicaid # DOB: Individual s DOB Telephone: Type = Home Phone Social Security Number: Identification type = Social Security Number Address: Individual s Address Diagnosis: Disability (ordered by priority asc) On FAW_State See below changes were made to the Important Date type = ISP Effective Date Individualized Service Plan as follows: Question: Area = Addendum Section= Addendum FAW_Notes same FormAnswer as Date above. Medicaid State Planned Services: Question: Area = Addendum Section= Medicaid FAW_Notes Listed All Services with Type like Medicaid% and Clinic% for Data management Federal, State or County Funded Resources: Question: Area = Addendum Section= FSCR FAW_Notes Listed All Services with Type like FSCR% for Data management HCB Waiver Services: Question: Area = Addendum Section= Waiver FAW_Notes Listed All Services with Type like Waiver% for Data management Other Services or OPWDD Supports: Question: Area = Addendum Section= OMRDD FAW_Notes Listed All Services with Type like OMRDD% for Data management Valued Outcomes: Question: Area = Addendum Section= Outcomes FAW_Notes Listed All Statements with Category like Valued Outcomes for Data management

Report Mapping Document: (RS_Type = ISP ) 3_ISP.rpt and 3_ISPAddendum.rpt Tables: ViewIEP_NoSecurity and Form INNER JOIN on FM_ID Selection Formula: Form.FM_Kind=66 (WebForm passes the Form.FM_ID when run) Grouping: 1 Full Name, 2 Form ID Differences between WebForm and Report: Letterhead line1, Logo, Title, Name, and ISP Effective Date on Top of each page Last Page has Signature Lines with Date Lines All Green text does NOT print on Report All Purple are only on Report Revision History: 11/19/2010: Face To Face? Yes/No checkboxes added between Date of ISP Review and MSC Initials on the first page. 09/27/2011: o Changed wording of OMRDD text to OPWDD. o Service Type = OMRDD discontinued. Service type is now OPWDD with services (ie OPWDD, Speech) 12/2011: A Profile/Valued Outcome text revision will display the new text in all linked forms (ie Revisions, DayHab).