N.M. Admin. Code § 8.371.5.14 - DEVELOPMENT OF THE INDIVIDUAL SERVICE PLAN (ISP) - CONTENT OF INDIVIDUAL SERVICE PLANS
Each ISP shall contain.
A. Demographic information: The individual's
name, age, date of birth, important identification numbers (ie., medicaid,
medicare, social security numbers), level of care address, phone number,
guardian information (if applicable), physician name and address, primary care
giver or service provider(s), date of the ISP meeting (either annual, or
revision), scheduled month of next annual ISP meeting, and team members in
attendance.
B. Long term vision:
The vision statement shall be recorded in the individual's actual words,
whenever possible. For example, in a long term vision statement, the individual
may describe him or herself living and working independently in the
community.
C. Outcomes:
(1) The IDT has the explicit responsibility
of identifying reasonable services and supports needed to assist the individual
in achieving the desired outcome and long term vision. The IDT determines the
intensity, frequency, duration, location and method of delivery of needed
services and supports. All IDT members may generate suggestions and assist the
individual in communicating and developing outcomes. Outcome statements shall
also be written in the individual's own words, whenever possible. Outcomes
shall be prioritized in the ISP.
(2) Outcomes planning shall be implemented in
one or more of the four "life areas" (work or leisure activities, health or
development of relationships) and address as appropriate home environment,
vocational, educational, communication, self-care, leisure/ social, community
resource use, safety, psychological/behavioral and medical/health outcomes. The
IDT shall assure that the outcomes in the ISP relate to the individual's long
term vision statement. Outcomes are required for any life area for which the
individual receives services funded by the developmental disabilities meadicaid
waiver.
D. Individual
preference: The individual's preferences, capabilities, strengths and needs in
each life area determined to be relevant to the identified ISP outcomes shall
be reflected in the ISP. The long term vision, age, circumstances, and
interests of the individual, shall determine the life area relevance, if any to
the individual's ISP.
E. Action
plans:
(1) Specific ISP action plans that
will assist the individual in achieving each identified, desired outcome shall
be developed by the IDT and stated in the ISP. The IDT establishes the action
plan of the ISP, as well as the criteria for measuring progress on each action
step.
(2) Service providers shall
develop specific action plans and strategies (methods and procedures) for
implementing each ISP desired outcome. Timelines for meeting each action step
are established by the IDT. Responsible parties to oversee appropriate
implementation of each action step are determined by the IDT.
(3) The action plans, strategies, timelines
and criteria for measuring progress, shall be relevant to each desired outcome
established by the IDT. The individual's definition of success shall be the
primary criterion used in developing objective, quantifiable indicators for
measuring progress.
(4) Provider
agencies shall use formats to complete strategies relating to the ISP action
plans during or after the IDT meeting. Separate provider agencies working to
coordinate specific strategies to achieve the same action plans shall develop
their strategies jointly. Service provider agencies shall develop strategies
that are clearly integrated and associated with the individual's long term
vision, outcomes, action plans and therapy recommendations identified by the
IDT. Therapists shall provide input into the development of strategies either
directly or through review and revision prior to submission to the case
manager. Provider agencies shall submit strategies for inclusion into the ISP
to the case manager within two weeks following the ISP meeting. The case
manager shall review the strategies for consistency.
(5) Supports and services, including services
available to the general public, determined by the IDT and indicated in the
ISP, shall be relevant to the individual's long term vision, desired outcomes
and action plans. Supports and services shall be the least restrictive, not
unduly intrusive and not excessive in light of the individual's
needs.
F. Assistive
technology: Necessary support mechanisms devices, and environmental
modifications including the rationale for the use of assistive technology or
adaptive equipment when a need has been identified, shall be documented in the
ISP. The rationale shall include the environments and situations in which
assistive technology is used. Selection of assistive technology shall support
the individual's independence and functional capabilities in as nonintrusive a
fashion as possible.
G.
Availability of supports and services:
(1)
Identification of potential supports and services for individuals by the IDT
should be undertaken without regard to the cost of the supports and services or
whether they are actually available at the time in the community.
(2) For individuals who receive services
through state general fund or developmental disabilities medicaid waiver but
who are NOT Jackson class members, the IDT, exercising
professional judgment, may take into account the availability of supports and
services in specifying in the ISP the supports and services required to be
provided. If supports or services are identified in the ISP, but not required
to be provided in the exercise of professional judgment taking into account the
availability of services, the IDT shall promptly submit a list of these
unavailable supports and services to the DDSD.
(3) For Jackson class
members, the ISP shall include the supports and services identified by the
IDT.
(4) The DDSD shall use these
lists to identify appropriate community resource needs and develop strategies
to add community supports and services, generally, for persons with
developmental disabilities, subject to appropriations for this
purpose.
H. Signature
form:
(1) A signature form, containing the
name, phone number and role on the IDT of all team members shall be included in
the ISP. All individuals participating in the annual IDT meeting shall sign the
signature form to indicate their participation in the planning
process.
(2) Signing this form does
not affect the individual's or guardian's right, if any, to dispute all or part
of the ISP or to initiate a complaint or grievance procedure. The case manager
shall explain the right to dispute or to file a grievance to the individual and
guardian at the IDT meeting. The case manager shall inform the individual and
guardian of the DDSD, office of quality assurance, its role and function in
monitoring services in the community, as well as the role and function of any
other relevant monitoring agencies, such as the licensing and certification
bureau of the division of health improvement and adult protective services
program of the aging and long term services department. The case manager shall
give the individual and guardian their business address and phone number, as
well as the 800 number of the DDSD's office of quality assurance and other
relevant numbers.
I.
Budget page: For individuals receiving services through the developmental
disabilities medicaid waiver, a proposed budget page developed by the case
manager in consultation with the various service providers shall be included in
the ISP.
Notes
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