Adult Sample Forms

Transcription

Adult Sample Forms

Adult Sample Forms
sam•ple Noun. a portion or piece that is
representative of a whole
This packet includes adult sample versions of
the following 11.18.11 ISP forms:
• Personal Focus Worksheet (PFW) with
examples of updates
• Risk Tracking Record Cover Sheet
• Risk Tracking Record (RTR)
• Aspiration Protocol for home
• Financial Plan for home and work
• ISP Meeting Agenda
• Individual Support Plan (ISP)
• Change Form with new Action Plan
SAMPLE --Personal Focus Worksheet for John Smith
PFW – SPD 9.9.09
Section I
Describes what is important to John from his/her perspective
1. Describe the relationships in John’s life:
“Mom” (John likes spending time with his mom, Nancy. He likes to go to her house about twice a month. They go to
movies and visit other family. John likes to talk about the weekend; he will initiate the conversation.)
“Papa” (John calls his dad, Mark, on the phone whenever he wants. He loves him very much and tells people this
regularly. He talks a lot about his papa. John sees Mark about every other month; he moved recently to Aberdeen, WA
and travels a lot.)
“You know—those people” (John doesn’t like people to say “hurry up” or push him out of their way (or even pretend to);
he calls them “those people”.)
“Kevin” or “Pea” (These are John’s nephews, Kevin and Peter. He calls Peter, Pea. John goes to movies with them a
few times a year.)
Fran is John’s sister (mother of Kevin & Pea). Bradley is John’s brother-in-law. (John likes to spend holidays with
them.)
“Phil is best” (Phil is John’s best friend. They have known each other for about 12 years. They talk on the phone and
make plans to do things at least once a week. They chose a variety of things to do. Their favorite thing to do is hang
out at the park in the summer and “soak up sun.”)
John likes people who have a good sense of humor and that helps him when doing daily routines such as brushing his
teeth or making his lunch. At work, he likes people who make the work fun. He enjoys working with people who have a
good sense of humor and like their “leg pulled”—as he put it.
John has a few friends from high school that he still keeps in touch with, usually an occasional letter but mostly by
phone calls. John has his friend’s phone numbers in his “personal” (when John says it, it sometimes sounds like
“purse”) book.
Agenda question: Are there any relationships that should be developed or changed?
Since neither John nor Phil drive, it could be helpful if John learned how to arrange transportation to see him.
2. Describe what John enjoys and list his/her interests:
• “Kitchen” (John likes to make his own lunch and help make dinner.)
• “Movies” (John likes going to movies but not too scary. He reads reviews with his mom and that helps him figure
out which ones he wants to go to.)
• “Hulk Hogan” (John likes to watch WWE wrestling. He has a ‘trophy’ belt that he displays in his bedroom and
shows anyone who comes into his room.)
• John’s favorite lunch is peanut butter and jelly on raisin bread.
Date of this PFW:
1-12-12
Page 1 of 13
PFW – SPD 9.9.09
• John really likes to play games in the dining room on the large table. One of his favorite games is Uno.
Another favorite game is Sorry. Kevin Squirt 4/2/12
• John loves corndogs. (John likes hotdogs, too)
• John likes going places with his nephews (Kevin and Pea). He likes to play video games, go to movies, and just
joke around with them.
• “Walk” (John walks to the neighbor’s mailbox, about 50 yards, without staff assistance daily.)
• “Mailer” (John likes to tri-fold and stuff envelopes.)
• “Office” (John seems to talk about the office staff and has talked about wanting to help them with their work.)
• John likes making outlet boxes and other jobs related to them such as sorting the parts by color or assisting with
packing them.
• John’s favorite holiday is Christmas. He likes to decorate his house and pretend to be Santa Claus.
Agenda question: Which of these interests are not happening as much as John would like?
From the team’s perspective, which of these interests, if any, need to be limited?
John has a low-salt diet and cannot eat regular hot dogs; working with John on an alternative is needed.
John would prefer to only do jobs he liked and was good at. He wants to help office staff with some of their tasks.
3. Describe what John dislikes:
¾ “You know—those people” (John doesn’t like people to rush him, say “hurry up,” or push him out of their way.)
¾ “Chicken” (John doesn’t like chicken unless ground because he has a hard time chewing it.)
¾ “Table” (John doesn’t like cleaning tables. He’s indicated he did this so much as the School for the Blind that he’s
“over it”.)
¾ John doesn’t like his salt restricted diet.
¾ John doesn’t like it when there is no raisin bread.
¾ “Joseph” (John doesn’t like when people he loves die. Joseph was a friend of his that died when he was 20. He
cries when he misses them.)
¾ John doesn’t like people talking to him like a child or have his head touched. (He may be short but he likes to be
treated like an adult.)
¾ John does not like people talking critical about wrestling.
¾ John does not like using his walking stick (anytime).
Agenda question: Which of these dislikes needs to be explored, changed or stopped?
•
•
•
With some of John’s food restrictions and dislikes, it might be helpful if John helps with the menu.
Something to explore: Modeling how John can joke around without going too far (he sometimes yells) and
when someone says something he does not like such as criticizing wrestling.
Staff need to know how to support John, that works best for him, when he misses people who have died.
Date of this PFW:
1-12-12
Page 2 of 13
PFW – SPD 9.9.09
4. Describe what John wants to accomplish in the future:
• “Hula” (John wants to go to Hawaii as often as possible. He’s talked about moving there especially in the winter.)
• John talks about living with a roommate in town.
• John has been more interested in computers. He has stated that if the screen was bigger, he might be able to see
things better.
• John likes to work and has been talking about helping the office staff. He has also mentioned helping office staff
around town.
Agenda question: What steps could be taken over the next ISP period to move toward these
goals?
•
•
If John had a budget for going to Hawaii on a regular basis, this might help so he gets there as often as he
wants.
Job assessments or job opportunities that John may really enjoy, that include working in an office and the
ability to be social, could be looked into because it has been a few years since his other job experiences.
John could be a great asset to a business in Springfield.
5. List and describe what is most important to John from his/her perspective:
The answer to this question must be transferred directly to the ISP.
• “Mom” (John likes spending time with his mom, Nancy.)
• “Papa” (John sees his dad, Mark, about every other month. He lives in Aberdeen, WA and travels a lot.)
• “You know—those people” (John doesn’t like people to rush him, say “hurry up,” or push him out of their way; he
calls them ‘those people’.)
• “Hulk Hogan” (John likes to watch WWE Wrestling. He has a ‘trophy’ belt that he displays in his room and shows
anyone who comes into his room.)
• “Work” (John has said that he likes working with people who understand him. He seems to really enjoy working.
Mailers are his favorite job. He has talked about working with office staff.)
• “Talking” (John likes talking with people he knows. He likes to joke around.)
• “Walking to mail box” (John likes walking alone to the neighbors’ mailbox. He can do this independently.)
• “Hula” (John loves taking vacations in Hawaii. He has family there.)
• John likes to talk about sentimental events in his life; he likes quality time to talk about this.
Agenda question: What is most important to John that is not happening or needs to be
strengthened?
¾ John says he wish he worked where people did not scare him.
¾ John would love to meet Hulk Hogan.
¾ John wants to work with office staff. He currently does not have a job in Springfield.
¾ John wants to make sure he always goes to Hawaii at least once a year. He needs to develop a budget.
Date of this PFW:
1-12-12
Page 3 of 13
PFW – SPD 9.9.09
Section II
Describes what is happening in John’s life from anyone’s perspective
6. Describe what people like and admire about John:
John is very funny and has a great laugh. He has a great sense of humor and can make people laugh (regularly). He is
very pleasant to be around and people want to hang out with him. He is easy to talk with and engages in good
conversation (even though he uses few words).
He processes information verbally. It is great to watch and assist him, when necessary, with dealing with issues and
problems. He really talks through the situation and does it without others always hearing him. Once he’s done that, he
usually feels a lot better or understands the situation.
“Cheese” (John says this with a big smile and wants you to smile while joking around with him.)
John has a positive outlook on life and likes to talk about it. He shows pictures from his life and family photos. He really
helps a person feel better when they are down; he will always put a bright spin on any situation or just give you his big
smile (with his head to the side). John really knows what he likes and will not let people talk him into anything he
doesn’t want to be talked into. This is both at home and at work.
Others really admire John for his relationship with his whole family. He makes a point to call or write (with assistance)
his mom, dad (papa) and his sister’s family. At work, if they are around, they may just stop in to see him. Everyone
likes seeing his family and they are great about showing up at break or lunch time, so it’s easy for others to socialize
with them as well.
At home, he has an amazing WWE wrestling collection. (He doesn’t like to wrestle himself, just talk about it especially
after seeing it on television.)
Agenda question: Could any of these qualities be strengthened?
N/A
7. Describe how John interacts socially with others:
John interacts with others very well at home and at work. He has many interests and finds people who have those
same interests. He went to the School for the Blind and learned a lot about positively interacting with others.
John will scream if one of “those people” gets too close and he gets scared. This happens at home or work but not as
often around town (most often at work). When he’s in town, he typically stays close to someone he knows (usually
staff). When he’s out with Phil, Phil helps him avoid some people. These people are identified in the staff log at work.
When John was 21, someone at work pushed him and he fell over; this was very scary for John.
John is very social, likes parties but needs to know the place he is going or go with someone he likes. Parties that
aren’t too loud are better for John. At work, he really enjoys any holiday party. He will help with the ideas for the party
and tell co-workers daily until the party.
Date of this PFW:
1-12-12
Page 4 of 13
PFW – SPD 9.9.09
Staff need to know that when parties are scheduled that people are notified only 1 week ahead of time, so John’s
coworkers do not get annoyed with him talking about it daily. From previous incident reports, nine days was the
smallest number of days when others became disruptive about the constant talking about the party.
John says he has enough friends. People like to be around him, so that helps. He does get sad when a friend
disappoints him, cancels something, or stops calling. Friends are important but when he needs to vent, he stays up late
and talks with staff. His family is very active in community activities and he knows a lot of people, too.
At work, he may just sit there when out of work but sometimes, he will bang on the table and says things like ‘work,
work’ or ‘come on’. It works best for staff to know how much work he has and regularly check his work. If he’s in a
joking mood, he may take someone else’s work, just to get them to tell his supervisor that he did it. If he is not feeling
well, he will just sit there and it takes him longer to do his work. Also, when not feeling well, he jokes around less and
won’t bang on the table when he’s done with work; he might put his head down. He has said he doesn’t like to miss
work even when not feeling great.
Agenda question: Does anything about John’s social interactions need to change or be
enhanced?
Currently, John does practice telling others to walk around him or moving out of the way safely. With him getting
older and for his safety, practicing this could happen more often and in a variety of locations.
John could increase his paycheck if he communicated more efficiently with his supervisor.
John likes parties and he could have his own annual, or twice annual, party that he coordinates.
8. Describe any of John’s spiritual, religious, and/or cultural considerations:
• “Church” (John goes to United Methodist Church on 12th Street. He has gone there for 12 years. He likes to
take cookies on special occasions. He goes to Wednesday evening services twice a month.)
• “Sher-Sher” (The minister at his church is named Sherman and John jokes with him and calls him ‘SherSher’—sounds like ‘sure-sure’)
• John’s family went to a Lutheran church while he grew up. His family says they are just glad he enjoys going to
church. Also, they know he has friends from the United Methodist Church and are glad he has friends there.
• John likes to spend time in his room thinking about his life. He doesn’t like to be interrupted and will tell you to
go away if you come to his room during those times.
• Going to Hawaii is one of John’s favorite places. He has a calmer demeanor when he comes back.
About Church, John likes going to the Wednesday services weekly now. Ingrid Moore 5/1/12
Agenda question: Are there any spiritual, religious, or cultural considerations that need to
change or be enhanced?
John may enjoy going to evening church services each week especially during the winter.
Date of this PFW:
1-12-12
Page 5 of 13
PFW – SPD 9.9.09
9. Describe John’s living arrangements:
John lives at 1863 Lynn Street. He lives with 4 other men. He says he likes his housemates. John does not like it when
people are too loud. He is a morning person; he is usually up by 6am every day. He might sleep in until 7:30am on the
weekends. There are a few things about his morning routine that are pretty consistent each day.
He likes to brush his teeth after he eats. Even though his bedroom is downstairs, he likes to use the main floor
bathroom sink to brush his teeth. When he gets home from work, he makes his lunch for the next day. He always
chooses what he wants for lunch but it is usually peanut butter and jelly on raisin bread. He does choose other things
but not very often. Also, he may have bologna on raisin bread. He’d prefer people not be grossed out by it; he loves
raisin bread. John asks for help when he needs it in the kitchen. He learned a lot about using kitchen utensils at the
School for the Blind.
John is very social, so he likes to chitchat with anyone at the house. Sometimes, he needs reminders if he is
interrupting a conversation. John initiates games and other activities by either taking someone to the game or bringing
it to the table if he can carry it. One of his favorite games is Uno; he is able to see the large numbers and different
colors.
John helps out around the house. He likes to help in the kitchen and he likes keeping a clean house. His favorite chore
is dusting. He usually likes to do dusting on Saturday morning twice a month. He doesn’t really like vacuuming; he says
it’s too loud. Doing dishes is challenging for him because he needs a stool to do things in the sink. He doesn’t like using
a stool; he’s afraid of falling.
When John wants to call any family member, he asks for help to make sure he dials the number correctly from his
book. He has his own phone with larger keypad; this has been helpful for him and is asking for less help. He keeps a
‘personal’ book (which sounds like purse) with important numbers and key information for John. He will show it to staff
when he wants to.
John has a walking stick but doesn’t use it. When staff suggest he uses his walking stick, he raises his voice and tells
the person to shut up.
Agenda question: Is there anything about John’s living arrangements that needs to change or
be enhanced?
John could be more independent if he used his walking stick.
John makes little mistakes using his phone. It would be nice to figure out with him about his lack of
confidence sometimes while calling others on his own phone.
John could make his own dinner and learn a variety of different dishes.
10. Describe John’s employment/alternative to employment program/school:
John works at Q Services Inc., a sheltered workshop. John use to say “scared” or “hurt” when talking about
assessment sites or other jobs. He, also, said “safe” when talking about the workshop. He is very scared to receive a
blow to his chest and knows staff are aware of it and help him. Since he has been talking about helping the office staff
Date of this PFW:
1-12-12
Page 6 of 13
PFW – SPD 9.9.09
at Q Services and other place, he seems to be more open to looking at other job opportunities. Also, this year, he has
had fewer times that “those people” have bothered him.
He needs contrasting colors at his workstation because he has low vision (legally blind). This means if the job has
mostly white products like mailer or t-shirts, the background or table needs to be black. A piece of big, black paper will
work to tape to the table; there are some tables that have the contrasting color that he sometimes likes to work on.
When getting up and down a lot, this means either John isn’t feeling well or he doesn’t like the job. His supervisor
needs to simply ask him which one it is. He will be honest. He will say, “no like” or “not well.” He sometimes puts his
head down when he doesn’t feel well, too.
John needs assistance coming into the building; usually a housemate walks him in. When walking, it needs to be slow,
not rushed, and talk with about what is around –colored lines or bumps in the walkway. Whenever the ground is
uneven or has many lines (especially yellow), John needs more assistance to assure he doesn’t fall.
Money doesn’t seem to be the best motivator for John. Doing a good job with people he likes seems to be the best
motivator for good quality work. Jobs that require very good fine motor skills aren’t the best. Always try them but work
very closely with him. He loves doing mailers. They need either an ‘X’ written on them where the label goes or use a
fixture for those types of envelopes. There are fixtures for tri-folding papers, too. He has been doing mailers for 12
years and is very familiar with this job and says he really likes it.
John sits with various people during lunch. He is friends with some coworkers outside of work. He talks about all the
fun stuff he does in his life with the people he likes. When using the vending machine, John needs some assistance
(read his Financial Plan for specifics).
Agenda question: Is there anything about John’s employment/ATE program/school that needs
to change or be enhanced?
John has not worked with the office staff or tried an assessment in an office. He has asked to do this.
John can practice more often about the best positive way to let people know that they scared him.
At work, new fixtures may need to be created or purchased when he’s trying a new job.
11. Describe how John communicates and the supports he/she needs with
communication:
When something is bothering John, he will wait to be alone with his favorite staff (usually). He stays up late to talk with
staff sometimes.
John typically communicates using single words but does use simple sentences, too. He is very patient with others to
figure out what he means. He will continue using different words to help others understand him. He uses some phrases
regularly and over time will expect people to understand those phrases such as “those people” or “cheese”. Home and
work keep a separate ‘familiar phrase’ sheet and what they mean; this is added upon as needed.
Date of this PFW:
1-12-12
Page 7 of 13
PFW – SPD 9.9.09
John will yell when he is afraid. He gets scared when people rush by him or tell him to “hurry up”. He usually stops
walking and yells. He may back up against a wall if he knows someone is there. He has scared others in the past with
his yelling.
John has an expressive face; staff who work with him say it’s easy to know what he means. When he is joking around,
he will have a big smile and laugh a lot; when he is sick, he will not smile, joke and usually puts his head down.
Agenda question: Are there any supports that could change or be enhanced that would
improve John’s ability to communicate with others?
Continued practice of the more positively reacting to others that are rushing him or scaring him.
Section III
Describes what is important for John from the perspective of those who know and care
about John
12. Describe what is needed for John to be healthy and safe?
John is legally blind (some vision) and needs some guidance especially when near curbs or numerous yellow lines.
When he goes to familiar places, he is fairly independent; he will ask for help when he needs it. When he’s at an
unfamiliar place, he wants to hold hands with someone to make sure he doesn’t trip on anything. He does great with
just verbal cues about the environment in all situations.
John has a low-salt diet because he is beginning to get arthritis in his ankles. At work, John needs help picking certain
items out of the vending machine. Even with a low-salt diet, he is allowed to have anything from the work vending
machine. Due to short stature and heart issue, his doctor doesn’t want John to gain weight. He has a low-fat diet.
John has no issues with going to the doctor. He’s had the same doctor since he was a child.
John cannot receive a blow to his chest because he had heart surgery as a child and now has congestive heart failure.
Everyone who works closely with him needs to know this; John will tell people. It’s important if he is working with
equipment at work that he has supervision to assure he uses it correctly. In the past, he used the mop incorrectly and it
fell on him, scaring him. (He doesn’t like mopping at work since then.)
John eats slowly and knows what foods are easy for him to chew or not easy for him to chew. He doesn’t like eating
chicken unless ground or cut into dime sized pieces. His doctor didn’t order a chopped diet because John already cuts
his food to correct size independently.
John tends to be cautious trying new foods. He has never choked while at Lynn Street but did when a child at home.
Agenda question: Does anything about these supports need to change or be enhanced?
With John’s low-salt and low-fat diet, he could assist with developing the menu, so he understood his diet better.
Date of this PFW:
1-12-12
Page 8 of 13
PFW – SPD 9.9.09
13. Describe any supports John needs to participate in activities that are important to
John:
John needs extra time to do any of his favorite activities at home or work. When planning activities, it is very important
to know the timeframes, so there is no rush and others don’t rush him by pushing him. Also, if extra time isn’t possible,
staff need to not seem rushed, so that others do not push or shove John.
John only needs additional support when near a curb or yellow lines. His mother told his team that yellow lines seem
like a black hole in between them. His depth perception is very weak. John needs a stool to get into any vehicle other
than a car. He refuses to use his walking stick.
At work, fixtures are needed on many jobs. The fixtures are labeled with the jobs. They need to be laminated, so that if,
for example, a label is put on and it is partially on the fixture that it can be easily removed.
John carries a wallet but do not buy an expensive one because he seems to lose it regularly. He carries a homemade
ID and keeps his real one in his bank bag for when he travels outside of the city. His mom says that he’s always had
an issue about losing his wallet.
When doing something new, it works best for John to be able to touch the job or activity or hear a detailed description
of the job. John needs support when doing something new. It is usually watching to assure he is doing it right. Once he
has something down, he tends to do it correctly from then on such as washing a table or doing laundry.
Agenda question: Does anything about these supports needs to change or be enhanced?
Nancy would like John to use his walking stick; she thinks he would be even more independent around town by
using it.
Section IV
Describes what would enhance John’s life from anyone’s perspective
All answers below must be transferred directly to the ISP Meeting Agenda.
14. What could improve John’s ability to be independent?
If John used his walking stick, he could go more places independently at home, work, or around town.
John could be more independent at work if new jobs had specific fixtures for him. Make sure work that takes precision
(good eyesight) has a fixture. With fixtures, he can touch and know how to complete his work. Usually showing him
once and watching a second time is all it takes for John to ‘get it.’
John could be more independent on the computer if he had a magnifier on the screen. John has just begun to show
interest but no specific programs have been requested. He is just trying different ones using the IntellieKeys at work.
He has played some games at home.
John could be more independent if he scheduled his transportation with his friend, Phil.
Date of this PFW:
1-12-12
Page 9 of 13
PFW – SPD 9.9.09
15. How could John be more involved in activities or events in his/her community?
• John could be more involved in community activities if:
o He attended a church group more often
o Joined other groups he’s interested in
• If John had a budget to know about his expenses he would have more control over his money.
16. What would improve John’s ability to increase his/her income?
John could increase his income if he had a steadier job. (John is a very dependable worker. He has many skills to work
in town rather than the workshop. He could be very successful and an asset to any company. John would need
adaptive equipment for many jobs.) He has talked about assisting office staff.
John might be able to increase his income through assuring he has the correct benefits. Benefits counseling would be
important to know about his social security money and subsidies reported. His team doesn’t know if this has ever been
done.
17. What would improve John’s ability to contribute to his/her household and/or
community?
John could contribute more to his community if he participated in his churches evening activities more often.
18. What does John want to learn?
• John wants to spend more time with his friend, Phil, and he wants to learn to coordinate transportation to see
him more.
• John wants to learn jobs that assist office staff. He doesn’t like working alone.
• John said he would like to learn all different aspects of assembling clocks.
• John wants to help interview new staff at home and at work.
19. What does John need to learn?
• John needs to learn to develop his menu to understand his low-salt, low-fat diet better.
• John needs to learn to communicate respectfully with coworkers.
• Nancy feels that John should learn about his budgeting, so he can have a more active role with his money.
Date of this PFW:
1-12-12
Page 10 of 13
PFW – SPD 9.9.09
Section V
Describes any conflict between important to and important for John from anyone’s perspective
All answer below must be transferred directly to the ISP Meeting Agenda.
20. Describe any areas of conflict between health and safety supports and what is
important to John.
Nancy tries to have him use his walking stick but John really does not want to. He says he prefers holding someone’s
hand when on unsteady surface.
John doesn’t like chicken but it is on the menu sometimes; he’d prefer not to ever eat it.
John loves corndogs but he has a low salt and low fat diet.
Date of this PFW:
1-12-12
Page 11 of 13
People who contributed to John Smith’s PFW
Name
Title/Relationship
John Smith
Self
Michelle Manor
House Manager
Jane Doe
Direct Support Staff
Billy Burke
Molly Reynolds
Kevin Squirt
Ingrid Moore
Employment Coordinator
Laney Jansen
Employment Supervisor
Mark Lang
Employment Supervisor
Leslie Spangle
Past Job Coach
Nancy Smith
Mom
Mark Smith
Father
Fran Johnson
Sister
Date of this PFW:
1-12-12
PFW – SPD 9.9.09
Page 12 of 13
PFW – SPD 9.9.09
PFW Updates Page for John Smith
Use this page to update any information in this PFW. Follow team agreements for communicating
new information to other team members. Sign and date each entry. Incorporate any updates into
next year’s PFW, as needed.
Question 15: John is going to Wednesday Church group each week now. So far, he is enjoying it.
Laney Jansen 5/1/12
For question 3, John doesn’t seem to like Nabisco’s Nilla Wafers. He spit them out during lunch
when someone gave him one; this has happened each time for the last month. I asked the person
to not give John Nilla Wafers anymore. Mark Lang 5/16/12
Page 13 of 13
RTR Cover Sheet – SPD 9.9.09a
Risk Tracking Record Cover Sheet
Signatures and Updates
Person Receiving Services:
John Smith
Date
Name
Relationship to
1/17/2012
Michelle Manor
House Manager
1/17/2012
Ingrid Moore
Employment Coordinator
Signature
Ingrid participated over the phone
RTR Updates:
Date of update:
Updated with changes to
question number(s):
Notes:
Date of update:
Updated with changes to
question number(s):
Notes:
Signatures of person(s) completing update:
Signatures of person(s) completing update:
Complete this form when reviewing the RTR every year at the Pre-Meeting. Keep the RTR current at all times.
Record any changes made throughout the year in the RTR Updates boxes. An additional RTR Updates page is available.
Remember to also complete an ISP Change Form if any risks change mid-year. See ISP manual for more details.
-- SAMPLE --
RTR – SPD 9.9.09
Risk Tracking Record
1.
2.
3.
4.
5.
6.
7.
8.
9.
This section of the RTR looks at indicators related to this person’s risk of Aspiration/Choking.
Questions
Yes
Does this person have a diagnosis of dysphagia, or has this person been identified to be at risk for
aspiration by a Physician, Speech/Language Pathologist, or Occupational Therapist?
If Yes, add risk of Aspiration to ISP.
Does someone else put food, fluids, or medications into this person’s mouth?
Does this person cough or choke while eating or drinking (more than occasionally)?
If Yes, add risk of Aspiration to ISP. Requires a current evaluation to determine risk of aspiration (see
the ISP manual).
Has this person been diagnosed with gastroesophageal reflux (GER)?
the ISP manual).
Does this person complain of chest pain, heartburn, or have small frequent vomiting (especially after
meals) or unusual burping (happens frequently or sounds wet)?
the ISP manual).
Does this person have a feeding tube?
Does food or fluid regularly fall out of this person’s mouth?
the ISP manual).
Does this person drool excessively?
the ISP manual).
Does this person have chronic chest congestion, pneumonia in the last year, rattling when breathing, and
persistent cough or frequent use of cough/asthma medication?
the ISP manual).
Risk Tracking Record for: John Smith
-- SAMPLE --
No
Page 1 of 13
-- SAMPLE --
RTR – SPD 9.9.09
Aspiration/Choking Questions, continued
10. Does this person regularly refuse food or liquid (or refuse certain food/liquid textures)?
the ISP manual).
11. Does this person need his/her fluids thickened and/or food texture modified?
the ISP manual).
12. Does this person eat or drink too rapidly?
If Yes, add risks of Aspiration and Choking to the ISP. Requires a current evaluation to determine risk of
aspiration (see the ISP manual).
13. Does this person stuff food into his/her mouth?
If Yes, add risk of Choking to the ISP. Requires a current evaluation to determine if the person is also at
risk of aspiration (see the ISP manual).
14. Does this person have extreme food seeking behavior?
If Yes, add risk of Extreme Food Seeking Behavior to the ISP. Requires a current evaluation to
determine risks of aspiration and choking (see the ISP manual).
15. Does this person have extreme liquid seeking behavior?
If Yes, add risk of Extreme Liquid Seeking Behavior to the ISP. Requires a current evaluation to
determine risks of aspiration and choking (see the ISP manual).
Record any notes related to Aspiration/Choking questions:
Yes
No
Even though John’s evaluation shows no dysphagia or risk of aspiration, his team feels that the support
document assures his safety and doesn’t interfere with anything important to him. M. Manor 9/19/09
Team wants to continue the supports. M. Manor 10/7/10.
Team continues to feel this protocol assures John’s safety. M. Manor 1/17/12.
-- SAMPLE --
Page 2 of 13
-- SAMPLE --
RTR – SPD 9.9.09
This section of the RTR looks at indicators related to this person’s risk of Dehydration.
Questions
16. Does this person regularly refuse fluids?
If Yes, add risk of Dehydration to the ISP. Requires a current evaluation to determine risk of dehydration
due to dysphagia (see the ISP manual).
17. Does fluid regularly fall out of this person’s mouth?
18. Does this person need to have his/her fluids thickened?
19. Does this person regularly cough or choke while drinking?
20. Does this person drool excessively?
21. Does this person have chronic chest congestion, pneumonia in the last year, rattling when breathing, and
persistent cough or frequent use of cough/asthma medication?
22. Does someone else put fluids into this person’s mouth?
If Yes, add risk of Dehydration to the ISP.
Yes
No
Questions continue on next page
-- SAMPLE --
Page 3 of 13
-- SAMPLE --
RTR – SPD 9.9.09
Dehydration Questions, continued
23. Does this person need to ask for or routinely require assistance to get something to drink?
24. Has this person required intravenous (IV) fluids due to dehydration in the past year?
Record any notes related to Dehydration questions:
Yes
No
John’s evaluation does not show that he has dysphagia; however his team determined that due to other health
issues, a Dehydration Protocol can be helpful for John to keep healthy. John was involved in the conversation
to have this protocol. M. Manor 1/17/12
Record any oral motor skills evaluations that were completed for the Aspiration/Choking or Dehydration sections:
Evaluation type: Oral Motor Skills Evaluation
Date of evaluation: 5/24/2011
Document location: Medical—archive/perm file
Evaluation type:
Date of evaluation:
Document location:
-- SAMPLE --
Page 4 of 13
-- SAMPLE --
RTR – SPD 9.9.09
This section of the RTR looks at indicators related to this person’s risk of Constipation.
Questions
25. Does this person take routine bowel medications for constipation or has this person received prn
medications for constipation more than two times a month within the past year (do not include fiber)?
If Yes, add risk of Constipation to the ISP.
26. Has this person required a suppository or enema for constipation within the past year?
27. Does this person take a medication that causes constipation and this person would not recognize or
communicate if he/she were constipated?
28. Has this person had more than one episode of complaining of pain when moving his/her bowels, more
than one episode of hard or small BMs, or more than one episode of extremely large and hard BMs
within the past year?
If Yes, add risk of Constipation to the ISP. Requires a consultation with physician to determine risk of
constipation, unless risk has been previously identified by question 25, 26, or 27.
Record any notes related to Constipation questions:
Yes
No
Record any consultation with physician that occurred for the Constipation section:
Physician name:
Date of consultation:
Document location:
-- SAMPLE --
Page 5 of 13
-- SAMPLE --
RTR – SPD 9.9.09
This section of the RTR looks at indicators related to this person’s risk of Seizures.
Questions
Yes
29. Does the person have a diagnosis of seizures or epilepsy? See ISP manual for an exception.
If Yes, add risk of Seizures to the ISP.
30. Does this person take medication for seizures?
31. Has this person’s seizure medication, type or dosage, been changed in the past six months?
If Yes, add risk of Seizures to the ISP. The Seizure protocol(s) must address safety
precautions such as water, bicycle use, safety equipment, etc.
32. Has this person had a seizure in the past year?
If Yes, add risk of Seizures to the ISP. The Seizure protocol(s) must address safety
precautions such as water, bicycle use, safety equipment, etc.
33. Has this person had a seizure in the past five years?
Record any notes related to Seizure questions:
-- SAMPLE --
No
History
Page 6 of 13
-- SAMPLE --
RTR – SPD 9.9.09
This section of the RTR looks at indicators related to this person’s risk of specific health and medical concerns.
Questions
Yes
No
34. Does this person have a diagnosis of being Pre-Diabetic or Diabetic?
If Yes, add risk of Complications of Diabetes to the ISP. Ensure that supports include diet and exercise.
35. Does this person have an ostomy or tube, such as a gastric feeding tube, urinary catheter, colostomy, etc?
If Yes, add risk of Complications Associated with (list type of tube or ostomy) to the ISP.
36. Is this person unable to clearly communicate when this person is in pain?
If Yes, add risk of Unreported Pain to the ISP.
37. Does this person regularly refuse medical services or require mechanical, physical, or chemical restraint
to receive medical services?
If Yes, add risk of Not Receiving Medical Care to the ISP.
38. Does this person need support to keep from falling and suffering from injury?
If Yes, add risk of Injury Due to Falling to the ISP.
Record any notes related to specific health and medical concerns:
#38: There is information about ‘injury due to falling’ in John’s medical archived file at home and medical
section/main file at work. The information from John’s doctor is dated 8/15/2003. John can fall on his bottom
but it’s about falling forward and the possibility he could receive a blow to his chest. John’s support document
includes recommendations provided by his doctor. M. Manor 9/19/09
John’s doctor stated at last appointment 5/24/11 that these supports should continue and no changes in his
recommendations. M. Manor 1/17/12
-- SAMPLE --
Page 7 of 13
-- SAMPLE --
RTR – SPD 9.9.09
This section of the RTR looks at indicators related to this person’s risk of other health and medical concerns
that have not been addressed through previous questions.
Question
Yes
39. Does this person have a serious health issue or medical concern not addressed through the previous
questions in this section?
If Yes, list the risk(s) below and add to the ISP.
Congestive Heart Failure (CHF)
No
Record any notes related to other health and medical concerns:
John was diagnosed with CHF on 3/15/89 by Dr. Jones; information is in his medical archive file. M. Manor 9/19/09
-- SAMPLE --
Page 8 of 13
-- SAMPLE --
RTR – SPD 9.9.09
This section of the RTR looks at issues relating to this person’s Safety and Finances.
Questions
40. Is this person able to remain at home or at work/community inclusion without support for any length of
time? **If the person is under the age of 18, you must mark No.
If Yes, add risk of At Home Without Support and/or At Work/ATE Without Support to the ISP.
41. Is this person able to be away from home, without support, for any length of time?
If Yes, add risk of Away From Home Without Support to the ISP.
42. Does this person need any assistance to adjust water temperature?
If Yes, add risk of Safety Issue: Water Temperature to the ISP.
43. Does this person need any assistance to evacuate when a fire or smoke alarm sounds?
If Yes, add risk of Safety Issue: Fire Evacuation to the ISP.
44. Does this person need any assistance to remain safe around household chemicals?
If Yes, add risk of Safety Issue: Household Chemicals to the ISP.
45. Does this person need any assistance to remain safe around traffic, while getting in or out of vehicles or
while riding in vehicles?
If Yes, add risk of Safety Issue: Vehicle Safety to the ISP.
46. Does this person have any court mandated conditions or restrictions that are not a result of this person’s
behavior?
If Yes, add risk of Safety Issue: Court Mandated Conditions to the ISP.
47. Does this person have any other important, serious safety issues while at their employment/community
inclusion workplace that are not otherwise addressed in these questions?
If Yes, add risk of Workplace Safety Issue: (list specific issue) to the ISP and list issue(s): New tool use
48. Does this person have any other important, serious safety issues not addressed through the previous
questions in this section?
If Yes, add risk of Safety Issue: (list specific issue) to the ISP and list issue(s):
Yes
No
-- SAMPLE --
Page 9 of 13
-- SAMPLE --
RTR – SPD 9.9.09
Safety and Finances questions, continued
49. Does this person need any assistance to manage his/her finances?
**If the person is under the age of 18, you must mark Yes.
If Yes, add risk of Financial Exploitation to the ISP.
Record any notes related to the Safety and Finances questions:
Yes
No
#40: John’s had an assessment and can be at home for no longer than 1 hour without support. At work, he can
work up to 3 hours without support, depending on the job; his safety plan outlines these requirements.
M. Manor 1/17/12
-- SAMPLE --
Page 10 of 13
-- SAMPLE --
RTR – SPD 9.9.09
This section of the RTR looks at risks relating to this person’s behavior or the status of their mental health.
Questions
Yes No History
50. Does this person ingest non-edible objects or have a diagnosis of pica?
If Yes, add risk of Ingesting Non-Edible Objects and Aspiration/Choking to the ISP. See ISP
Manual for specific Support Document requirements.
51. Does this person place non-edible objects in his/her mouth that may cause poisoning, aspiration or
choking?
If Yes, add risk of Non-Edible Objects in Mouth and Aspiration/Choking to the ISP. See ISP
Manual for specific Support Document requirements.
52. Does this person engage in physical aggression?
If Yes, add risk of Physical Aggression to the ISP.
53. Does this person engage in self-injurious behaviors?
If Yes, add risk of Self Injury to the ISP.
54. Does this person engage in property destruction?
If Yes, add risk of Property Destruction to the ISP.
55. Does this person leave or attempt to leave supervised settings and is unsafe to do so?
If Yes, add risk of Leaves Supervised Settings to the ISP.
56. Does this person engage in the unsafe use of flammable materials?
If Yes, add risk of Unsafe Use of Flammable Materials to the ISP.
57. Does this person use illegal drugs or abuse drugs?
If Yes, add risk of Drug Abuse to the ISP.
58. Does this person abuse alcohol?
If Yes, add risk of Alcohol Abuse to the ISP.
59. Does this person engage in unsafe social behavior?
If Yes, add risk of Unsafe Social Behavior to the ISP.
60. Does this person engage in undesirable sexual behavior?
Is Yes, add risk of Undesirable Sexual Behavior to the ISP. Requires a current evaluation by a
qualified professional to determine the current level of risk and support needs.
-- SAMPLE --
Page 11 of 13
RTR - SPD 9.9.09
Behavior/Mental Health questions, continued
61. Does this person engage in behavior that is harmful to animals?
If Yes, add risk of Harm to Animals to the ISP. Requires a current evaluation by a qualified
professional to determine the current level of risk and support needs.
Yes
No
History
62. Does this person use weapons or objects in an attempt to injure himself/herself or others?
If Yes, add risk of Use of Objects as Weapons to the ISP. Requires a current evaluation by a
qualified professional to determine the current level of risk and support needs.
63. Does this person engage in illegal behavior?
If Yes, add risk of Illegal Behavior to the ISP.
64. Does this person have any court mandated conditions or restrictions that are a result of this
person’s behavior?
If Yes, add risk of Court Mandated Conditions: (list court order and date) to the ISP.
65. Does this person have a psychiatric diagnosis?
If Yes, add risk of Mental Health Diagnosis to the ISP. See ISP manual for more information.
66. Does this person engage in suicidal attempts, gestures or threats?
If Yes, add risk of Suicide to the ISP. Requires a current evaluation by a qualified professional to
determine the current level of risk and support needs.
Record any notes related to the Behavior/Mental Health questions:
Record any evaluations that occurred for the Behavior/Mental Health section:
Evaluation type:
Date of evaluation:
Document location:
Evaluation type:
Date of evaluation:
Document location:
-- SAMPLE --
Page 12 of 13
RTR - SPD 9.9.09
This section of the RTR looks at indicators related to this person’s risk of other Behavior/Mental Health concerns
that have not been addressed through previous questions.
Question
Yes
No
67. Does this person have an important, serious Behavior/Mental Health issue not addressed through the
previous questions in this section?
If Yes, list the risk(s) below and add to the ISP.
Record any notes related to other Behavior/Mental Health concerns:
End of Risk Tracking Record
-- SAMPLE --
Page 13 of 13
Aspiration/Choking Protocol – SPD 9.9.09
SAMPLE – ASPIRATION/CHOKING PROTOCOL
You do not need permission to call 911
Describe how you know John is at risk for aspiration and/or choking:
Aspiration: John is at risk for aspiration because food falls out of his mouth while eating, he drools
excessively while talking and does need some of his food chopped to specific size. He does not
have a diagnosis of aspiration or dysphagia from his Oral Motor Skill Evaluation but he does like
some of his food chopped. He can independently cut most of his food. These supports have been
in place to assure John doesn't aspirate (or choke) and his team feels this is important prevention.
SECTION 1: Description of Preventions
__________________________________________________________________________________________________________________________________
z Food texture: Meats needs to either be
ground or cut into dime sized pieces. Other
than chicken, John cuts his own food into
dime sized pieces
z Small portions: Check serving sizes on
packages or chart in recipe binder, John
should receive 1/2 of the serving size at a
time. If he wants seconds, he may have the
other half.
SECTION 2: Signs and Symptoms of Aspiration/Choking
__________________________________________________________________________________________________________________________________
z Gagging or choking while eating, drinking,
or tube feeding
z Persistent coughing during or after eating,
drinking, or tube feeding
z Wheezing or breathing is rapid and difficult
Person receiving services:
Protocol for use at: Home
John Smith
sample
Date 10/14/2010
Page 1 of 2
Aspiration/Choking Protocol – SPD 9.9.09
SECTION 3: What to do if any signs and symptoms are observed
__________________________________________________________________________________________________________________________________
z STOP FOOD AND FLUID IMMEDIATELY
z Keep John sitting upright and encourage coughing
z Provide first aid as trained
z Take and record John’s temperature as soon as able
1. Contact and follow any instructions given:
Physician Dr. Jones 541.555.1234
2. Document incident in:
Progress notes
3. Notify:
Work
Family/Guardian
Incident Report
CALL 911 AND START EMERGENCY AND
FIRST AID PROCEDURES AS TRAINED, IF ANY OCCUR:
SECTION 4:
z John appears gravely ill or you are concerned about their immediate health and safety
z John is blue, not breathing, or is having difficulty breathing
__________________________________________________________________________________________________________________________________
After calling 911,
Contact and follow any instructions given:
Supervisor
After John is stable, document incident in:
Progress notes
z Incident report
Written by:
Michelle Manor
Protocol for use at: Home
John Smith
sample
Date 10/14/2010
Page 2 of 2
Financial Plan – SPD 9.9.09a
FINANCIAL PLAN
Describe John’s ability to make financial decisions
John needs assistance to budget his money. He can tell the difference between coins because of
how they feel; he has a harder time with dollar bills. He learned how to fold them to distinguish
them but needs assistance to do this. He also loses his wallet often, so he should not carry large
sums of money unless he has support to not lose his wallet.
John has a Representative Payee. Name: Nancy Smith
Person’s responsibility for spending money
John accesses and/or receives cash, prepaid debit cards, or gift cards.
John asks on either Monday or Tuesday for spending money for the week. He receives only one
dollar bills to help him know which bills they are and he folds them himself (to help him know they
are ones) but will ask if he needs help.
John can be independently responsible for up to: $10.00
Are receipts required to be kept for purchases made by John?
Yes
No
Program responsibility for money management
Residential provider manages cash, prepaid debit cards, or gift cards for John.
House Manager logs all money that is put into the “daily” money bags and it is signed off by
another staff. The money bag is filled with a minimum of $20 per week and John’s given $10 at a
time. His budget shows when more is needed and Nancy works close with the House Manager
with his budget. All information is recorded on his Personal Money Record (PMR).
Employment/ATE provider manages cash, prepaid debit cards, or gift cards for John.
About twice a year, John plans a large outing or party for some coworkers, so home sends the
necessary funds. These events occur during work hours but it is planned by John off site from
work. Work staff document John’s spending for these events on a Money Exchange Record (MER)
and afterwards, if anything is left over, above $10, it is sent to the House Manager. Anything below
$10 is given to John and the House Manager is called with the information.
Describe the manner and frequency of reconciliation of program-managed financial records:
The Fiscal Director audits all books twice annually for home and a monthly accounting of John’s
account is done by the Financial Manager. This is recorded on the PMR.
At work, the Human Resources Director receives information when the two events occur and upon
the event spending being done, the Director reconciles all receipts with the MER.
2/3/12
Person receiving services: John Smith
Financial Plan for: Work and Home
Date: 1/17/2012 MM
Page 1 of 2
Financial Plan – SPD 9.9.09a
ISP Team responsibility for money management
Approval required for total individual expenditures over: $500 per month.
Approval required for single purchases over: $150.
How approval will be obtained to exceed these limits and where approval will be
documented: On the Financial Approval Record
All personal property valued at or purchased over $75 and any items of sentimental value
will be recorded on a Personal Property Record.
Who is responsible for reporting wages to Social Security? House Manager and John work
together to do this
Income
Approximate amount
Wages
$785.00/month
SSDI
$548.00/month
SSI
$124.00/month
Expenses
Room and Board
Residential Offset
Medications
WWE Magazine subscription
Approximate amount
$485.00/month
$25.00/month
$24.00/year
Budgeting
An individual spending budget is maintained for John.
Describe or indicate where located: John keeps his budget in his notebook. The House
Manager keeps a copy with his PMR.
Additional Information
Other information:
John would like to purchase a new bed set with drawers underneath for approximately $800;
he needs one that is not very tall and they are more expensive. John’s ISP team preapproves anything up to $825 and requests to be informed when purchased. MM 2/3/12
Written by: Michelle Manor (with Ingrid Moore)
2/3/12
Financial Plan for: Work and Home
Date: 1/17/2012 MM
Page 2 of 2
Agenda – SPD 11.18.11
ISP Meeting Agenda
John Smith
Meeting date:
2/3/2012
Prior to the ISP Meeting
How does John participate in planning his/her life? John takes an active role in planning his life. He
arranges his own weekend events with either friends or family. He needs support to do this and
will ask if he needs more than typical. John asks for help to budget his money so he can do fun
things like travel and throw parties.
Draft the Discussion Topics including all of the following required points.
a. Anything John wants to talk about at the meeting.
b. Any supports the person needs to more fully participate in planning his/her life and to
understand his/her ISP.
c. All topics from the Agenda Questions on the current PFW.
d. All topics from questions 14-20 in Sections IV & V of the current PFW.
e. Any Items for Consideration (below) marked “Yes.”
f. Any deferred items from last year’s agenda that need to be addressed again.
g. Other items not yet addressed that the team needs to discuss.
h. After reviewing current ISP, include any topics that need to continue to be addressed or that
were not fully addressed in the last year.
Yes
No
Items for Consideration
Does John want to self-administer medications? Consider any training needs John
may have and how self-administration will be monitored.
Does John need a Health Care Representative?
Are there any unfinished tasks from the RTR or Support Documents that are not
yet completed?
Are there any Support Documents that interfere with what’s most important to
John?
Does any team member have an objection to any Support Document listed on the
ISP Risks page?
Does John need financial planning or benefits counseling in order to maximize
resources?
Is John at risk of exceeding financial resource limits?
Are there any variances requiring team approval?
Are the hours of Employment/ATE less than the standard unit of service?
Are the hours of school less than entitled?
Page 1 of 4
ISP Meeting Agenda
John Smith
Meeting date:
2/3/2012
At the ISP Meeting
1. Celebrate achievements from the previous year
Share one significant accomplishment John has achieved in the last year, regardless of whether or not
it was in his/her ISP. Consider accomplishments that reflect what is important to John.
Home: John took a trip to Crater Lake and Lassen Volcanic Park this past year. He
loves traveling and wanted to go to different places (and Hawaii which is a given).
Work/ATE/School: John really likes to be efficient at work and he helped with a major
rearranging of the work area that was extremely helpful. He volunteered to help do it (he
got paid).
2. Review Action Plans and Discussion Records in the previous ISP
Share outcomes so the team can identify areas that need to continue to be addressed.
3. Revise and/or approve other drafted ISP materials
Drafted ISP materials are shared with team members in advance of the team meeting. Use meeting time
if needed to discuss any questions or additional needs regarding drafted materials. Make changes to
drafted materials as needed.
4. Address the Employment First Policy for working age adults
For people who are of working age, assure the ISP has an action plan and/or discussion record that
addresses the person’s interest or goals in pursuing a path to employment.
5. Team discussion
Ensure that all identified discussion topics are appropriately addressed and note what action was
taken. Add additional discussion topics during the meeting as needed.
6. Final review of the new ISP and current support documents
At the end of the ISP meeting, the Services Coordinator/Residential Specialist leads the team to review
the finished ISP and Support Documents. Ensure the plan is complete and that it meets John’s
preferences and support needs, then complete the box at the bottom of the ISP signature page.
Page 2 of 4
ISP Meeting Agenda
John Smith
Discussion Topics
Include all topics identified on page one of this Agenda. Each
topic only needs to be written once. Group similar issues
together into a single discussion topic, making sure to include
all of the relevant detail about the topic. Omit any items John
does not wish to discuss at the meeting.
Reviewed drafted action plan for work
Meeting date:
2/3/2012
Action Taken
Decided at ISP meeting. Examples
may include: Discussion Record,
Action Plan, Issue Resolved (note how
it was resolved), Deferred until ___,
Added to Safety Plan, etc.
Added information to drafted AP
Discussion Record ***
John wants to make sure he always goes to Hawaii at least
once a year (regular basis). He needs to develop a budget.
Action Plan ***
• A budget can help him have more control over his money.
• Nancy feels John can take a more active role with his
money.
• John is at risk of exceeding financial resource limits.
Financial Plan ***
It could be helpful if John learned how to arrange transportation to see
his friend, Phil. John could be more independent if he scheduled his
transportation and it would allow him to spend more time with Phil.
Action Plan
John wants to help interview new staff at home and at work.
Discussion Record *** Action Plan
John would love to meet Hulk Hogan.
Resolved—surprise from Fran on 1/19/12
with VIP tickets to meet HH on
1/28/12. Done!
Action Plan ***
John likes parties and he could have his own annual, or twice annual,
party that he coordinates.
Work/job
John would prefer to only do jobs he liked & is good at. He
wants to help office staff. He has not worked or had an
assessment in an office before; he asked to do this. He
currently does not have a job in Springfield and will an asset
to any company.
Job assessments or job opportunities include:
• Working in an office
• The ability to be social, not working alone
• John says he wishes he worked where people did not
scare him.
• New fixtures (or adaptive equipment) may be needed
(create/purchase) when he’s trying a new job; this can
also help him be more independent.
John could increase his paycheck if he communicated more
efficiently with his supervisor. He could increase his income
if he had a steadier job and the correct benefits. Benefits
counseling would be important to know about his social
security money and subsidies reported.
Discussion Record
Action Plan ***
Not all
agenda
topics are
included in
the
SAMPLE
ISP (***
included).
AP
Page 3 of 4
ISP Meeting Agenda
John said he would like to learn all different aspects of
assembling clocks.
Meeting date:
AP
Something to explore: Modeling how John can joke around without
going too far (he sometimes yells) and when someone says something
he does not like such as criticizing wrestling.
• John needs to learn to communicate respectfully with
coworkers.
DR
AP
John can practice more often about the best positive way to let people
know that they scared him or rushed him. (more often and in a variety
of locations)
DR
AP
Staff need to know how to support John, that works best for
him, when he misses people who have died.
Resolved. Staff guidelines to support
John in this area was developed 1/30/12.
John could be more involved in community activities if:
• He attended a church group more often (he may enjoy going to
evening church services each week especially during the winter.)
• Joined other groups he’s interested in
AP
John could make his own dinner and learn a variety of
different dishes/meals.
AP ***
John makes little mistakes using his phone. It would be nice to figure
out with him about his lack of confidence sometimes while calling
others on his own phone.
Deferred until next ISP. John said he
had a lot of other (“more important”)
things to accomplish.
John could be more independent on the computer if he had
a magnifier on the screen. Interest has just begun but no
specific programs requested. He tries different ones with the
IntellieKeys at work. He has played some games at home.
DR
AP
If John uses his walking stick, he could go more places independently
at home, work, or around town. Nancy thinks he would be even more
independent by using it; she tries. He says he prefers holding
someone’s hand when on unsteady surface. (#20)
Medical—diet
¾ John has a low-salt and low-fat diet and cannot eat
regular hot dogs and corndogs; working with John on an
alternative is needed.
¾ With some of John’s food restrictions and dislikes
(especially chicken), it might be helpful if John helps with
the menu, so he understood his diet better.
DR
AP
DR
AP
2/3/2012
Not all
agenda
topics are
included in
the
SAMPLE
ISP (***
included).
Page 4 of 4
ISP – SPD 9.9.09a
INDIVIDUAL SUPPORT PLAN
Does John have a Legal Representative/Guardian?
No
Yes, name:
Meeting Date: 2/3/2012
ISP start date: 2/21/2012
ISP end date: 2/21/2012
What’s most important to John:
• “Mom” (John likes spending time with his mom, Nancy.)
• “Papa” (John sees his dad, Mark, about every other month. He lives in Aberdeen, WA and travels a lot.)
• “You know—those people” (John doesn’t like people to rush him, say “hurry up,” or push him out of their way; he calls them ‘those
people’.)
• “Hulk Hogan” (John likes to watch WWE Wrestling. He has a ‘trophy’ belt that he displays in his room and shows anyone who comes
into his room.)
• “Work” (John has said that he likes working with people who understand him. He seems to really enjoy working. Mailers are his favorite
job. He has talked about working with office staff.)
• “Talking” (John likes talking with people he knows. He likes to joke around.)
• “Walking to mail box” (John likes walking alone to the neighbors’ mailbox. He can do this independently.)
• “Hula” (John loves taking vacations in Hawaii. He has family there.)
• John likes to talk about sentimental events in his life; he likes quality time to talk about this.
John said he really likes spending time with Kevin and Pea, too. Michelle Manor 2/3/12
John Smith
Meeting Date:
2/3/2012
Page
of
ISP – SPD 9.9.09a
Risks
John is at risk of, or has a risk
related to, the following (as identified
on the Risk Tracking Record)
List the title of each Support
Document that will be used
to support the risk
Support Document Information
Home
Work/ATE
Aspiration
Aspiration Protocol
Date
10/14/10
Dehydration
Dehydration Protocol
10/14/10
Where kept
Med. Admin.
Record-MAR
MAR
Injury due to Falling
Health/Medical Problem List
5/20/09
MAR
1/12/12
Protocol book
At Home without Support
Safety Plan
2/4/11
Chart Book
n/a
n/a
Safety Issue: Fire Evacuation
Safety Issue: Household Chemicals
Safety Issue: Vehicle Safety
Safety Plan
2/4/11
Chart Book
2/3/11
Training file
At Work/ATE without Support
Workplace Safety Issue: New tool usage
Safety Plan
n/a
n/a
2/3/11
Training file
Congestive Heart Failure
Heart Safety Protocol
5/20/09
MAR
n/a
n/a
Safety Plan
n/a
n/a
2/3/11
Training file
Financial Plan
1/17/12
Personal Money
MM 2/3/12 Record-PMR
Financial Exploitation
John Smith
Meeting Date:
2/3/2012
Date
10/15/10
Where kept
Protocol book
10/15/10
Protocol book
1/17/12
Money Exchange
MM 2/3/12 Record
Page
of
ISP – SPD 9.9.09a
Professional Services John Uses/Needs
* See Residential Individual Summary Sheet for current names of specialists
Type of
List the specific reasons why John sees this How often or
Where to
Notes
specialist*
specialist
date due
record
Physician’s
Doctor visits increased to 2x/year since
Primary
Annual physical, check heart/lung
Every 6
Visit/Order
he was in the hospital in 2003; in 2011,
Physician condition for any underlying issues
months
Dentist
Annual cleaning
2x/year
Ophthalmolog
Annual eye exam, check prescription
ist
1x/year
Rheumatologi
st
1x/year
Monitor arthritis
Form
Physician’s
Visit/Order
Form
Physician’s
Visit/Order
Form
Physician’s
Visit/Order
Form
doctor still requests 2x/year
John has no cavities
John is legally blind and his glasses
prescription usually changes annually.
This sometimes upsets him.
Schedule this annual appointment at
least 2 weeks prior to Annual Physical
Does this person have a Nursing Care Plan at home?
No
Yes, where found: Medical‐RN section No
Yes, where found: Protocol Book-RN section
Does this person have a Nursing Care Plan at work?
No
Yes, where found: Home: MAR Work: Protocol Book
Does this person have a Health/Medical Problem List?
No
Yes, appointment date:
Does this person have a Health Care Representative?
Self-appointed
ISP Team appointed Where is the document located?
If yes,
John Smith
Meeting Date:
2/3/2012
Page
of
ISP – SPD 9.9.09a
Action Plan
Issue
Desired Outcome
John has not taken an active role with his budget lately. John
participated in budgeting in the past but refused until asked why a few
months ago. He complained that the form doesn’t work for him
because pictures work better than icons. John wants to make sure he
goes to Hawaii at least annually and has expected Nancy (his mom) to
arrange his flights.
John budgets his money for going to Hawaii and other large items,
so he understands saving money, has control of his money, and is
able to go to Hawaii regularly.
Measurable steps that will be taken
to reach desired outcome
A: John and staff will create a budget
sheet that he can see, and utilize
pictures, to develop monthly budget
B: With budgeting, John will prioritize the
items he wants to buy including
accommodations for Hawaii
C: John will put money from his paycheck
into savings account/automatic
deduction
Where:
H W O
X
X
X
Who is
responsible
How often
or date due
House
Advocate and
John
House
Advocate and
John
Employment
Supervisor
and John
Start 3/1/12
then
1x/month
Review
Quarterly
JS’s Budget Start with April’s budget and
Sheet
identify annual expenses (such as
magazine subscription)
JS’s Budget
Sheet
Due by
4/1/12,
review
every 6 mo.
Begin in
August & at
least 3 x
Credit
Union
Statement
House Advocate will give the
amount to be deducted after initial
budget
Print outs
about flight
information
At least 2
wk prior to
vacation
Vacation
Req. Form
John, Fran and House Manager
will work together to assure
transportation to the airport,
depending on who goes with John
Work will keep vacation request
form
D: John will work with Fran about
scheduling his vacation in Hawaii,
looking at flights and talking with family
X
X John, Fran
(and House
Manager)
E: Once time is scheduled for vacation,
John will submit vacation request form
X
House
Manager
Does this Action Plan enhance:
John Smith
Independence
Meeting Date:
Where to
record
Integration
2/3/2012
Notes
Productivity
Page
Skill Building
of
ISP – SPD 9.9.09a
Action Plan
Issue
Desired Outcome
John helps in the kitchen, makes his own lunch but doesn’t make his
own dinner. He says “kitchen” when he wants to help. He has been in
the kitchen more often during dinner time, watching food prep. John is
legally blind and doesn’t use a sharp knife right now. He also has a
hard time doing dishes if they don’t go straight into the dishwasher.
Staff are not sure the types of meals he’d like to make for dinner.
A: Using the internet for real photos, John
will look at various meals and choose
at least 5 to try over the next 6 months
B: John and Advocate develop grocery list
at least a day before the meal
Where:
H W O
Who is
responsible
X
House
Manager
X
C: John with assistance from DSS go
shopping for meal
X
D: John will prepare food for dinner and
have staff write down the tasks he can
do independently
E: John will rate each meal at the end on
the ease for him and if he liked it
X
X
John Smith
How often
or date due
Review
1x/week
Where to
record
Notes
Meal prep
list
Document each review and the
meal choice if identified
John & House 2x/month
Advocate
Grocery
receipt*
*mark receipt with John’s name;
kept with Lynn St receipts, make
copy for John’s file
John and
2x/month
Direct Support
Staff
John and
2x/month
DSS
Grocery
receipt
Food prep
worksheet
John and
DSS
Food prep
worksheet
(check all that apply)Does this Action Plan enhance:
John makes a variety of dinners for himself so that he knows the
meals he can do more independently and when he needs
assistance.
2x/month
Independence
Meeting Date:
Integration
2/3/2012
Productivity
Page
Skill Building
of
ISP – SPD 9.9.09a
Action Plan
Issue
Desired Outcome
John coordinates his own party at least once a year in order to
John likes parties and wants his own annual, or twice annual, party
have friends get together and decorate his house (or other
that he coordinates. He has not coordinated his own party. He plans
the party during work hours and needs assistance during these hours places).
to purchase items for the party. While having partial vision, he needs
assistance to find items at different stores and with handling large
amounts of money. He has had parties in the past and needs help with
the guest list to assure “those people” aren’t invited or have necessary
support with them.
Where:
Who is
How often
Where to
Notes
record
H W O responsible or date due
A: John will figure out the theme or event X
John & House Due by
Notes
Theme: ___________
for his party
Manger (HM) 4/30/12
section
Copy of
Date of party: _____________
Within 2
B: John will develop invite list for the party X X X John, Emp
invite list
Coord, HM & months
Nancy
prior to the
party
Copy of
Do this immediately after
John and
Within 2
C: John uses the computer to create
X
invitation/
developing invite list
invitations for the party—both paper
House
months
Evite
and Evite invitations
Advocate
prior to the
party
John, Emp
3 weeks
Receipts
Receipts are kept at work in MER
D: John and staff will buy items needed
X X
for the party, depending on location of
Coord &
before the
and at home in PMR
party
House Man.
party
One month Task list for
E: John asks people to help decorate and X X X John, Emp
assist on the day of the party
Coord, HM & before party party
Nancy
John Smith
Meeting Date:
2/3/2012
Page
of
ISP – SPD 9.9.09a
F: John asks people to help clean up after
the party
X
G: John decides if he wants to plan
another party or event
X
H: Gather information that worked and did
not work about the party
X
X
X
X John, Emp
Coord, HM &
Nancy
John and
House
Manager
John, Emp
Coord, &
House
Manager
John Smith
One month Task list for
before party party
Within 1
month after
to the party
Within 2
weeks after
of the party
Progress
notes
Task list for
party
Independence
Meeting Date:
Develop another action if
necessary if he wants to do
another party
Keep this list to help with other
parties
Integration
2/3/2012
Productivity
Page
Skill Building
of
ISP – SPD 9.9.09a
Action Plan
Issue
Desired Outcome
Where:
H W O
Who is
responsible
How often
or date due
Where to
record
Notes
A:
B:
This ISP is not complete. Additional Action Plans
would be included as per ISP Meeting Agenda.
C:
D:
John Smith
Independence
Meeting Date:
Integration
2/3/2012
Productivity
Page
Skill Building
of
ISP – SPD 9.9.09a
Discussion Record
Issue:
John wants to go to Hawaii on a regular basis (at least annually). He has not taken an active role in all aspects of his budget. He has relied on
Nancy (his mom) for arranging flights and dates to go to Hawaii. Nancy feels that John should learn about his budget, so he can have a more
active role with his money.
Discussion:
• John said he is okay about figuring out how to budget his money. He would like his advocate to help because he likes her and they get
along.
• Nancy said she’d really like Fran to assist John, so he can get use to other people’s style and she’s better with computer issues than her.
• Nancy talked with Fran before the meeting and she is okay with helping John especially since Pea and Kevin are getting older and like
hanging out with their uncle.
• Michelle is glad to hear that John wants to participate in his budgeting and she thinks it will be good for him to pick out the pictures that
work for him rather than staff using icons or trying to figure out what will work for John without him.
• Ingrid hopes that with John having a bit more money this year (exceed financial limit) that he could plan two trips to Hawaii. It seems that
John wants another job, so she’s not sure what type of vacation policy will be with another job, and they are pretty flexible but do want at
least a two week notice prior to a vacation.
• Carrie wants to make sure that John is given the time necessary to prioritize all the other things he wants/needs to budget. Is there a way
that a constant amount of money can go into John’s saving from his work check?
• Ingrid said that Q Services Inc. can do automatic deductions with their associated credit union.
• Michelle said John hasn’t used the paycheck deduction option yet.
Decision:
John will begin budgeting and planning his trip(s) to Hawaii. Fran will help John plan his trip to Hawaii and his House Advocate will help with
budget, working with Fran, too.
Is there an Action Plan associated with this issue?
No
Yes
John Smith
Meeting Date:
2/3/2012
Page
of
ISP – SPD 9.9.09a
Discussion Record
Issue:
John wants to help interview new staff at home and at work. John has not been in conversations about BOLI (laws) that need to be followed in
regards to interviewing people. John has two different providers at home and at work, so it will look different and others need to be in the
conversation about if this can happen. John’s team is not sure this is a good fit for John.
Discussion:
Currently at work, interviews take place after John has left work. It doesn’t mean it can’t change but we’ll have to include the HR Director in
this discussion. The HR Director and John get along very well and they talk on a regular basis, so she is comfortable talking with John about
why he wants to help. They could talk about the laws/rules necessary when interviewing.
At home, the interviews usually happen when he is at work. Michelle said they cannot pay John to do this but can arrange for it to happen at a
better time for him if he’s okay with not getting paid.
John is not sure if he wants to do it (at home) if he’s not paid. He said he wanted to think about that. He likes “money”.
Carrie wants to know if other people supported assist with interviews. Michelle said they do not. Ingrid said it has happened in the past and
has worked well but no one but John has shown an interest in the past year.
Nancy thinks with some training and some time that John can understand the rules needed to follow while interviewing.
Decision:
The team feels that more information is needed and the right people to help with making these decisions aren’t here. John is okay with waiting
until others can be talked with. An initial action plan will be written to address this and if it able to move forward, another action plan will be
added to the ISP later.
John Smith
Meeting Date:
2/3/2012
Page
No
Yes
of
ISP – SPD 9.9.09a
Discussion Record
Issue:
Discussion:
This ISP is not complete. Additional Discussion
Records would be included as per ISP Meeting
Agenda.
Decision:
John Smith
Meeting Date:
2/3/2012
Page
No
Yes
of
ISP – SPD 11.18.11
Service Supports
Employment/ATE/School
Individual Supported Employment
Group Supported Employment
Facility-based Employment
Job Development
Volunteer
Alternative to Employment
School
Other:
Residential
24-hour Residential Services
Supported Living Program
Proctor Care
Other:
Name and Address of Responsible Organization
Q Serives Inc.
3886 Wilson Road
Springfield, Oregon 97212
Name and Address of Responsible Organization
PDQ Residential Services - Lynn Street
1863 Lynn Street
Springfield, Oregon 97212
Responsible Provider
Transportation
Weekly Schedule
Monday - Friday 8:30am to 2pm
Employment/ATE/School
PDQ Residential
Medical Appointments
Lynn Street
Transportation method and contact information
Kirkwood house (503.222.6556) drives John to
work and RX Public home (503.222.5555)
House vehicle (or staff car, as needed)
Other
Team members must ensure that this plan is designed to enhance the person’s independence, integration and productivity.
Independence: Having control and choice over one’s own life.
Integration: Living near and using the same community resources and participating in the same activities as, and together with,
people without disabilities.
Productivity: Engaging in work that contributes to a household or community; or engaging in income-producing work that is
measured through improvements in income level, employment status or job advancement.
John Smith
Meeting Date:
2/3/2012
Page
of
ISP – SPD 11.18.11
ISP Signature Page
All team members will be contacted to obtain verbal approval for any changes to this ISP and support documents.
Exceptions: List any special circumstances or specific team members who need to be contacted for approval of certain documents.
Mark, John's father, does not want to give approvals to any changes because he's not always available. He does want a copy
of any changes mailed to him.
Signatures of Team Members below indicate approval of this ISP and all support documents listed on the ISP Risks page
Objections to the plan
Present at Team Member
Date
Team Members
Relationship to John
Signature
or support documents
meeting?
or Guest
John Smith
Person Receiving Services
Yes
No
Team Member
2/3/12
Parent/Family Member
Yes
No
Team
Guest
2/3/12
Legal Representative/Guardian
Yes
No
Team
Guest
CDDP Services Coordinator
Yes
No
Team
Guest
2/3/12
Father
Yes
No
Team
Guest
2/3/12
Residential Provider Representative
Yes
No
Team
Guest
2/3/12
Employment/ATE Provider Rep.
Yes
No
Team
Guest
2/3/12
Friend
Yes
No
Team
Guest
2/3/12
Yes
No
Team
Guest
Yes
No
Team
Guest
Nancy Smith, mother
n/a
Carrie Jones
Mark Smith
Michelle Manor
Ingrid Moore
Phil Mesh
SC/RS Initials
__CJ____
Team’s acknowledgement of the person’s involvement in planning and balance of preferences and needs
The team reviewed this plan and support documents to ensure that they meet the person’s preferences & support needs.
__ CJ ___
Any conflicts between the person’s preferences and supports provided have been addressed in a discussion record in this plan.
If the person was not present for this meeting, explain why n/a
→ If the person was not present, an action plan must be completed that describes who will assist the person to understand the contents
of the plan, and timelines for completion. See ISP manual for further information.
CDDP Services Coordinator/ODDS Residential Specialist signature: ________________________________ Date: __2/3/12_______
John Smith
Meeting Date:
2/3/2012
Page
of
CHANGE FORM
Individual Support Plan
Reason for Change
Change Form – SPD 11.18.11
Date of change:
Indicate which document(s) you are changing, adding, or discontinuing.
Safety Plan
Financial Plan
List Specific Change(s)
Protocol(s),
title:
4/19/2012
Other Document(s),
title:
Where is the change documented?
John's action plan about using Discontinue of his current action plan for computer use and replace with ISP Action Plan and PMR for
the computer needs to be
this new action plan attached
items purchased
changed. He has shown
interest in specific programs
and has tried a few different
adaptive devices and found
some that work best for him.
Check each team member who gave approval for this change and write their name and title.
Residential Provider: Michelle Manor, House Manager
Person
Check here if there is a Change
Parent/Family: Nancy, mother
Emp/ATE Provider: Ingrid Moore, Employment Coord Form Approval page attached
Svs. Coord/Res. Spec.: Carrie Jones, Svs Coord
Other:
Date sent to CDDP Services Coordinator/
Signature and title of the person initiating the change:
Residential Specialist
4/20/12
Page 1 of _____
Action Plan
ISP – SPD 9.9.09a
Person Receiving Services: John Smith
Meeting Date:
Issue: John could be more independent on the computer if he has specific
adaptive equipment. John has tried many types and found some that work better
at home and at work. His ISP team is not sure how these will be paid for. John
wants to be able to use Facebook but has been challenged to be able to read
everything.
Where:
H
W O
4/19/2012
Desired Outcome: John uses a computer with adaptive equipment so that he
can communicate with family through email or social media and be able to more
independently use programs that can help him with his party planning.
Who is
responsible
How often
or date due
Where to
record
Notes
A: John will have magnification device for any
John and
Employment
Coordinator
Purchase by Receipt of
June 30, 2012 purchase
John only uses the computer 2x a
month to record specific work
information.
B: John will enter data for the office, using
John and HR
Director
2x/month,
MJPTL
after magnifier
arrives
The type of data will vary to see what
John does best
C: John will research the cost and if insurance
John, Nancy
and House
Manager
By May 31,
2012
Progress
notes
Nancy is rep payee and wants to be
assist to help John understand
D: If insurance pays for screen reader, John will
John, Nancy
and House
Manager
After
insurance
approval
Receipt/PMR
If insurance cannot pay, see "E"
computer he uses at work; work will purchase
because it will be useful for other people, too
IntelliKeys
covers a screen reader
purchase one of his favorites (Zoomtext 8.1
or JAWS)
(Check all that apply) Does this Action Plan enhance:
Independence
Integration
Productivity
Skill Building
Page _____ of _____
Action Plan
ISP – SPD 9.9.09a
Person Receiving Services: John Smith
Meeting Date:
4/19/2012
Desired Outcome: Continued:
Issue: Continued:
John could be more independent on the computer if he has specific adaptive
John uses a computer with adaptive equipment so that he can communicate with
equipment. John has tried many types and found some that work better at home family through email or social media and be able to more independently use
and at work. His ISP team is not sure how these will be paid for. John wants to be programs that can help him with his party planning.
able to use Facebook but has been challenged to be able to read everything.
Where:
H
W O
E: If insurance cannot pay in full or at all, John
will begin saving money for a screen reader
Who is
responsible
John, Nancy
and House
Manager
How often
or date due
After
information
from
insurance
Where to
record
Budget sheet
Notes
Nancy said that if they will not pay at all,
she will talk with family about helping
John get this
F:
G:
H:
(Check all that apply) Does this Action Plan enhance:
Independence
Integration
Productivity
Skill Building
Page _____ of _____

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