Section 120.160  Individual service/support plan


a)         Subsequent to eligibility determination, a preliminary individual service plan shall be prepared by the PASARR agent or service provider that includes individual strengths, needs and recommended services/supports.  Within 30 days after service initiation, an individual service/support plan shall be prepared describing service and support needs of the individual and specifying how those needs will be met.  The preparation of the plan shall be part of a planning team process which includes the individual, the guardian, if one has been appointed and is willing or able to participate, other persons chosen by the individual and a qualified mental retardation professional.  The planning team process shall also include provider agency staff, service coordinator, staff of the facility of discharge, if applicable, and other professionals as needed.  Depending on the individual's needs, planning team participation may include  health professionals (physicians, nurses, dentists), psychologists, social workers, dietitians and physical, speech and occupational therapists.


b)         The individual service/support plan shall include the following written elements and be incorporated into the individual's record:


1)         Individual assessment information, including individual strengths, relevant barriers and impediments to full community participation and natural supports available;


2)         Annual Inventory for Client and Agency Planning (ICAP) (DLM Teaching Resources, One DLM Park, Allen, Texas 75002 (1986)) or Scales of Independent Behavior (SIB) (DLM Teaching Resources, One DLM Park, Allen, Texas 75002 (1985));


3)         Individual's and guardian's personal goals, desired future outcomes, preferences and choices;


4)         Service and support needs;


5)         Functional goals and measurable objectives with timeframes for completion, if the individual is receiving habilitation services;


6)         Identification of all services and supports to be provided, regardless of provider or funding source, including type, training methods if applicable, frequency, duration and staff assigned;


7)         Documentation of any medical prescriptions, self-medication training, medication administration and oversight, and efforts to reduce reliance on psychotropic medications;


8)         Identification of all staff and other persons contributing to the plan, including relationship to the individual, title and agency if applicable;


9)         Signature of the individual or guardian and of the qualified mental retardation professional; and


10)       Termination summary, when appropriate.


c)         The written individual service/support plan shall also identify the team consensus concerning the balance between the individual's rights and abilities to make informed decisions and have privacy and access to the community, and the responsibility of those persons providing services and supports to ensure the individual's health, safety and well-being.


1)         The written plan shall identify those community and home situations when the individual may be away from the direct supervision of provider staff during those hours when staff are responsible for the individual.


2)         When an individual's choices may result in potential harm to the individual, the individual's record shall document ongoing efforts by the service provider to inform the individual and guardian of the potential harm, to suggest alternatives and to minimize the potential harm.


3)         When an individual's choices are not honored, the reasons shall be documented in the plan or the individual's record.  Efforts to support the individual's choices shall also be documented.


d)         The written individual service/support plan or individual record shall identify activities to ensure continuity of care during planned therapeutic absences, such as home visits or vacations, if residential services are part of the plan.


1)         If absences are regular or known well in advance, the plan should include a goal of maintaining/increasing social contacts with family or friends.  The plan should describe staff responsibilities for sharing information before and after the absences and for being available for consultation/assistance during the absences.


2)         The individual record shall document the following staff activities if they occur:


A)        Staff contacts (e.g., telephone, notes, in person) with family, friends or other persons providing care during the absence to explain behavioral programming, medications, expectations about chores/behavior, training and other service/support plan implementation issues that should be continued during the absence;


B)        Notification concerning which staff to contact if assistance or advice is needed or if the individual needs to return early;


C)        Staff contacts during the absence; and


D)        Information received after the absence that may affect service/support plan implementation.


e)         The individual service/support plan shall be reviewed at least annually by a planning team process as described in Section 120.130(a) of this Part. The plan shall be amended in writing as necessary.  The qualified mental retardation professional who is working with the individual shall review the plan and the individual's progress, health, safety, and well-being at least once every three months.


(Source:  Amended at 20 Ill. Reg. 4762, effective March 8, 1996)