115 CMR, § 6.23 - Development of Individual Support Plans

(1) ISP Meeting. The service coordinator shall convene and facilitate a meeting with the individual and other members of the ISP team in order to develop a support plan which sets forth the vision statement and goals of the individual; the supports needed by the individual in order to attain those goals, which shall be based on the assessed needs of the individual without regard to the availability of such supports; the availability of needed supports; the party responsible for providing supports; the frequency and duration of supports; and strategies for meeting the support needs of the individual. If the individual refuses to attend the ISP meeting, the team shall consider what, if any, adjustments could be made in the ISP meeting to encourage greater participation by the individual.

(2) Outcomes. The goals, objectives and any supports or strategies identified in the ISP must be consistent with and promote the following outcomes for individuals:

(a) Rights and Dignity. The individual's rights are respected, he or she is supported in the responsible exercise of those rights, and other supports are in place to assist, as necessary, in protecting the individual's human and civil rights; the individual's dignity is recognized and affirmed in the individual's home and community and in the manner in which supports are provided.

(b) Individual Control. The individual has opportunities to exercise control and choice in his or her life, and has access to education, experiences, and supports to increase his or her self-determination; the individual's opinions and preferences are listened to and treated seriously; the individual's needs and preferences are reflected in his or her activities and routines.

(c) Community Membership. The individual has a home which is similar in appearance to surrounding homes, which offers safety, refuge, rest, and satisfaction to the individual, and into which the individual can invite friends, family, neighbors and others to whom he or she wishes to offer hospitality; he or she has many and varied opportunities to participate in and contribute to the life of his or her community through work and through integrated social and recreational activities in culturally typical settings.

(d) Relationships. The individual has opportunities and support, as needed, to develop, sustain, and strengthen varied and meaningful relationships with family, friends, neighbors and co-workers.

(e) Personal Growth and Accomplishments. The individual has access to the supports necessary to enable him or her to contribute to his or her community, be as self-reliant as possible, develop his or her unique talents and abilities, and achieve his or her personal goals.

(f) Personal Well-being (Health, Safety, and Economic Security). The individual receives health care and related services which are sufficient and appropriate to optimize the individual's health and well-being; he or she lives and works in environments that are safe, secure, and are adapted if necessary to meet the individual's needs, and safeguards are in place to respond to emergencies and threats to the individual's health or safety; he or she has sufficient economic resources to meet his or her needs.

(3) Timing of the ISP Meeting. The service coordinator shall convene a meeting to develop an ISP within 60 days after the individual begins receiving supports which require the development of an ISP pursuant to 115 CMR 6.20(4) and every two years thereafter.

(4) ISP Components. The ISP meeting shall include but shall not be limited to the following:

(a) Discussion of the individual's vision statement and goals;

(b) Discussion of recent experiences and events that may affect the individual's immediate future, general health, safety, or long-term goals;

(c) Discussion of the individual's current circumstances, including his or her home, day or employment, behavioral supports, as well as any supports being provided, in terms of the individual's satisfaction and changes which must occur in order for the individual to achieve his or her goals;

(d) Identification of goals which may be related to the individual's vision statement and which address assessed needs of the individual; and

(e) Development of a support agreement which sets forth:

1. specific objectives related to the individual's goals identified pursuant to 115 CMR 6.23(4)(d);

2. the strategies and supports that are the least restrictive and that will be utilized to assist the individual to attain these goals and objectives, which may include but shall not be limited to instruction in skills related to health and safety, self-care, communication, home living, work, leisure, social interactions, community use, self-direction and functional academics, provision of medical, dental and specialty services such as physical or occupational therapy, psychiatric or psychological services, and legal or advocacy services, and the party responsible for their provision or implementation;

3. the settings in which the strategies will be implemented and the supports provided;

4. the expected duration and frequency of the supports;

5. the criteria to be utilized in evaluating the effectiveness of such supports in achieving the individual's goals;

6. any unmet support needs and the strategies which will be utilized to address those needs;

7. the ISP team member(s) responsible for monitoring and reporting on implementation of the support agreement as well as the format and frequency of such monitoring and reporting; and

8. the date of the next review of the ISP, which can be no later than one year from the date of the ISP meeting.

(f) Discussion of newly identified changes in an individual's abilities or life circumstances, if any, that require monitoring by the ISP team over the course of the ISP year.

(5) Distribution, Approval, and Implementation of the ISP.

(a) Within 45 days following the ISP meeting, the ISP shall be reviewed by the Area or Facility Director or his or her designee, approved or disapproved in part or in whole, and mailed to the individual, family, if authorized, guardian, designated representative, if any, and providers. A notice of appeal rights that are available under 115 CMR 6.30 through 6.34 will be mailed with the ISP. The service coordinator shall notify the individual, his or her family, if authorized, and guardian(s), if any, of their right to have a meeting, upon request, with the service coordinator to explain the ISP within ten days of their receipt of the ISP.

(b) If the Area or Facility Director or his or her designee disapproves the ISP, in whole or in part, he or she shall discuss with the service coordinator his or her reasons for disapproval and suggest changes to the ISP. If the suggested changes would be considered modifications of the ISP pursuant to 115 CMR 6.25, the service coordinator shall consult with the individual and other team members regarding the proposed changes to the ISP. The service coordinator may reconvene the ISP meeting for the purpose of revising the ISP in accordance with the recommendations of the Area or Facility Director at the request of the individual or his or her family or guardian or if the service coordinator determines that the ISP meeting must be reconvened in order to develop an appropriate ISP.

(c) The individual, his or her guardian(s), if any, and any family members who participated in the development of the ISP will be asked to signify, in writing, their approval or appeal of the ISP. Any participant with a right of appeal under 115 CMR 6.32, will be deemed to agree to the plan unless an appeal is filed within 35 days of mailing of the ISP or of the explanatory meeting held pursuant to 115 CMR 6.23(5)(a).

(d) When feasible and with the approval of the Area or Facility Director or designee and all parties having a right of appeal under 115 CMR 6.32, as well as the provider, the ISP or any portion thereof may be implemented prior to completion of the distribution and approval process set forth in 115 CMR 6.23(5).

Notes

115 CMR, § 6.23

Amended by Mass Register Issue 1311, eff. 4/22/2016.