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| Subdivision 1. Outcome-based services. (a) The license holder must provide outcome-based services in response to the consumer's identified needs as specified in the individual service plan. |
| (b) Services must be based on the needs and preferences of the consumer and the consumer's personal goals and be consistent with the principles of least restrictive environment, self-determination, and consistent with: |
| (1) the recognition of each consumer's history, dignity, and cultural background; |
| (2) the affirmation and protection of each consumer's civil and legal rights; |
| (3) the provision of services and supports for each consumer which: |
| (i) promote community inclusion and self-sufficiency; |
| (ii) provide services in the least restrictive environment; |
| (iii) promote social relationships, natural supports, and participation in community life; |
| (iv) allow for a balance between safety and opportunities; and |
| (v) provide opportunities for the development and exercise of age-appropriate skills, decision making and choice, personal advocacy, and communication; and |
| (4) the provision of services and supports for families which address the needs of the consumer in the context of the family and support family self-sufficiency. |
| (c) The license holder must make available to the consumer opportunities to participate in the community, functional skill development, reduced dependency on care providers, and opportunities for development of decision-making skills. “Outcome” means the behavior, action, or status attained by the consumer that can be observed, measured, and can be determined reliable and valid. Outcomes are the equivalent of the long-range goals and short-term goals referenced in section 256B.092 and any rules promulgated under that section. |
| Subd. 2. Risk management plan. (a) The license holder must develop, document in writing, and implement a risk management plan that meets the requirements of this subdivision. License holders licensed under this chapter are exempt from sections 245A.65, subdivision 2 Human Services Licensing Act - Abuse Prevention Plan Requirements, including Program Abuse Prevention Plan and Individual Abuse Prevention Plan, and 626.557, subdivision 14 Vulnerable Adults Act - Individual Abuse Prevention Plan, if the requirements of this subdivision are met. |
| (b) The risk management plan must identify areas in which the consumer is vulnerable, based on an assessment, at a minimum, of the following areas: |
| (1) an adult consumer's susceptibility to physical, emotional, and sexual abuse as defined in section 626.5572, subdivision 2, and financial exploitation as defined in section 626.5572, subdivision 9; a minor consumer's susceptibility to sexual and physical abuse as defined in section 626.556, subdivision 2; and a consumer's susceptibility to self-abuse, regardless of age; |
| (2) the consumer's health needs, considering the consumer's physical disabilities; allergies; sensory impairments; seizures; diet; need for medications; and ability to obtain medical treatment; |
| (3) the consumer's safety needs, considering the consumer's ability to take reasonable safety precautions; community survival skills; water survival skills; ability to seek assistance or provide medical care; and access to toxic substances or dangerous items; |
| (4) environmental issues, considering the program's location in a particular neighborhood or community; the type of grounds and terrain surrounding the building; and the consumer's ability to respond to weather-related conditions, open locked doors, and remain alone in any environment; and |
| (5) the consumer's behavior, including behaviors that may increase the likelihood of physical aggression between consumers or sexual activity between consumers involving force or coercion, as defined under section 245B.02, subdivision 10, clauses (6) and (7) Definition of “Incident”. |
| (c) When assessing a consumer's vulnerability, the license holder must consider only the consumer's skills and abilities, independent of staffing patterns, supervision plans, the environment, or other situational elements. |
| (d) License holders jointly providing services to a consumer shall coordinate and use the resulting assessment of risk areas for the development of each license holder's risk management or the shared risk management plan. The license holder's plan must include the specific actions a staff person will take to protect the consumer and minimize risks for the identified vulnerability areas. The specific actions must include the proactive measures being taken, training being provided, or a detailed description of actions a staff person will take when intervention is needed. |
| (e) Prior to or upon initiating services, a license holder must develop an initial risk management plan that is, at a minimum, verbally approved by the consumer or consumer's legal representative and case manager. The license holder must document the date the license holder receives the consumer's or consumer's legal representative's and case manager's verbal approval of the initial plan. |
| (f) As part of the meeting held within 45 days of initiating service, as required under section 245B.06, subdivision 4 Supports and Methods, the license holder must review the initial risk management plan for accuracy and revise the plan if necessary. The license holder must give the consumer or consumer's legal representative and case manager an opportunity to participate in this plan review. If the license holder revises the plan, or if the consumer or consumer's legal representative and case manager have not previously signed and dated the plan, the license holder must obtain dated signatures to document the plan's approval. |
| (g) After plan approval, the license holder must review the plan at least annually and update the plan based on the individual consumer's needs and changes to the environment. The license holder must give the consumer or consumer's legal representative and case manager an opportunity to participate in the ongoing plan development. The license holder shall obtain dated signatures from the consumer or consumer's legal representative and case manager to document completion of the annual review and approval of plan changes. |
| Subd. 3. Assessments. (a) The license holder shall assess and reassess the consumer within stated time lines and assessment areas specified in the individual service plan or as requested in writing by the case manager. |
| (b) For each area of assessment requested, the license holder must provide a written summary, analysis, and recommendations for use in the development of the individual service plan. |
| (c) All assessments must include information about the consumer that is descriptive of: |
| (1) the consumer's strengths and functional skills; and |
| (2) the level of support and supervision the consumer needs to achieve the outcomes in subdivision 1. |
| Subd. 4. Supports and methods. The license holder, in coordination with other service providers, shall meet with the consumer, the consumer's legal representative, case manager, and other members of the interdisciplinary team within 45 days of service initiation. Within ten working days after the meeting, the license holder shall develop and document in writing: |
| (1) the methods that will be used to support the individual or accomplish the outcomes in section 245B.06, subdivision 1, including information about physical and social environments, the equipment and materials required, and techniques that are consistent with the consumer's communication mode and learning style specified as the license holder's responsibility in the individual service plan; |
| (2) the projected starting date for service supports and the criteria for identifying when the desired outcome has been achieved and when the service supports need to be reviewed; and |
| (3) the names of the staff, staff position, or contractors responsible for implementing each outcome. |
| Subd. 5. Progress reviews. The license holder must participate in progress review meetings following stated time lines established in the consumer's individual service plan or as requested in writing by the consumer, the consumer's legal representative, or the case manager, at a minimum of once a year. The license holder must summarize the progress toward achieving the desired outcomes and make recommendations in a written report sent to the consumer or the consumer's legal representative and case manager prior to the review meeting. Eliminated requirement that quarterly written progress review reports for consumers under public guardianship must be provided to the consumer, designated family member and case manager. |
| Subd. 6. Reports. The license holder shall provide written reports regarding the consumer's status as requested by the consumer, or the consumer's legal representative and case manager. |
| Subd. 7. Staffing requirements. The license holder must provide supervision to ensure the health, safety, and protection of rights of each consumer and to be able to implement each consumer's individual service plan. Day training and habilitation programs must meet the minimum staffing requirements as specified in sections 252.40 to 252.46 and rules promulgated under those sections |
| Subd. 8. Leaving the residence. Each consumer requiring a 24-hour plan of care shall receive services during the day outside the residence unless otherwise specified in the individual's service plan. License holders, providing services to consumers living in a licensed site, shall ensure that they are prepared to care for consumers whenever they are at the residence during the day because of illness, work schedules, or other reasons. |
| Subd. 9. Day training and habilitation service days. Day training and habilitation services must meet a minimum of 195 available service days. |
| Subd. 10. Prohibition. Psychotropic medication and the use of aversive and deprivation procedures, as referenced in section 245.825 Use of aversive or deprivation procedures in facilities serving persons with mental retardation or related conditions and rules promulgated under that section, cannot be used as a substitute for adequate staffing, as punishment, or for staff convenience. |
| What is an acceptable outcome? |
| An outcome is “the behavior, action, or status attained by the consumer that can be observed, measured, and can be determined reliable and valid,” as defined in Minnesota Statutes, section 245B.06, subdivision 1, c. This definition is based on the Case Management Rule (Rule 185), Minnesota Rules, part 9525.0008, subpart 3. |
| Outcomes may include behavior acquisition or change, skill acquisition, or one-time actions taken to enhance a consumer’s quality of life. These may also involve actions related to the acquisition or improvement of a consumer’s status, for example becoming an active family member. |
| An outcome must be “observable,” which means that the result must be apparent to at least two observers watching at different times. It must be “measurable,” which means that the result can be expressed in a quantified way, such as an action was taken, a status was accomplished or a skill was performed a certain number of times. |
| For a result to be “reliable,” the measure of it must be stable or dependable. That is to say that different observers conducting the same measures will obtain the same results. If not, the differences may only be attributable to random error. |
| For a result to be “valid,” the behavior, action or status that makes up the outcome must be defined properly. In other words, is the measure really about the outcome or is it about something else? For example, if the measure relates to an outcome about tooth brushing, does it measure cooperation or skill or both? |
| The supports and methods required to achieve the outcome must also be identified including: |
| “methods that will be used to support the individual or accomplish the outcomes, including information about physical and social environments, equipment and materials required, techniques that are consistent with the consumer’s communication mode and learning style;” “projected starting date for service supports and the criteria for identifying when the desired outcome has been achieved and when the service supports need to be reviewed;” (the language must be clear enough so that the reader understands when the outcome has been achieved and when work on it has stopped); |
| “names of the staff, staff position or contractors responsible for implementing each outcome.” |
| What is a Risk Management Plan and why is it required? |
| The risk management plan is a written document that identifies area of vulnerability for a consumer and the plans staff must follow to protect the consumer in these areas. There are two processes that must be completed when developing a Risk Management Plan. First, an assessment of the consumer’s vulnerability must be conducted and then plans to minimize any identified areas of risk must be written. |
| The requirement for the Risk Management Plan is found in Minnesota Statutes, section 245B.06, subdivision 2 in the Consolidated Standards. |
| Must a Risk Management Plan be completed for all consumers, regardless of age? |
| Yes. The requirements of the RMP apply when providing services to consumers of any age. |
| When may license holders stop completing a program abuse prevention plan? |
| The PAPP may be eliminated when risk management plans have been developed and documented for all consumers at a particular according to the requirements as amended in Minnesota Statutes, section 245B.06, subdivision 2 effective July 1, 2003. All risk management plans completed after July 1, 2003 must include all required items. |
| What is an individual abuse prevention plan and is it required? |
| The IAPP is a written document that includes an assessment of a consumer’s susceptibility to abuse and the specific measures staff persons must implement to minimize the risk of abuse for that consumer. |
| The five areas of abuse that must be included in the IAPP include: |
| • financial exploitation. |
| • emotional (e.g. verbal or psychological) abuse. |
| The requirements for the IAPP are found in two different statutes that apply to adults receiving services. |
| Vulnerable Adult Act Minnesota Statutes, section 626.557, subdivision 14, (b), states: |
| “Each facility, including a home health care agency and personal care attendant services providers, shall develop an individual abuse prevention plan for each vulnerable adult residing there or receiving services from them. The plan shall contain an individualized assessment of the person’s susceptibility to abuse by other individuals, including other vulnerable adults, and a statement of the specific measures to be taken to minimize the risk of abuse to that person. For the purposes of this clause, the term “abuse” includes self-abuse.” |
| Human Services Licensing Act Minnesota Statutes, section 245A.65, subdivision 2, (b), (1), and (2) [Abuse Prevention Plans.] states: |
| “In addition to the requirements in section 626.557, subdivision 14, the individual abuse prevention plan shall meet the requirements in clauses (1) and (2). |
| (1) The plan shall include a statement of measures that will be taken to minimize the risk of abuse to the vulnerable adult when the individual assessment required in section 626.557, subdivision 14, paragraph (b), indicates the need for measures in addition to the specific measures identified in the program abuse prevention plan. The measures shall include the specific actions the program will take to minimize the risk of abuse within the scope of the licensed services, and will identify referrals made when the vulnerable adult is susceptible to abuse outside the scope or control of the licensed services. When the assessment indicates that the vulnerable adult does not need specific risk reduction measures in addition to those identified in the program abuse prevention plan, the individual abuse prevention plan shall document this determination. |
| (2)An individual abuse prevention plan shall be developed for each new person as part of the initial individual program plan or service plan required under the applicable licensing rule. The review and evaluation of the individual abuse prevention plan shall be done as part of the review of the program plan or service plan. The person receiving services shall participate in the development of the individual abuse prevention plan to the full extent of the person’s abilities. If applicable, the person’s legal representative shall be given the opportunity to participate with or for the person in the development of the plan. The interdisciplinary team shall document the review of all abuse prevention plans at least annually, using the individual assessment and any reports of abuse relating to the person. The plan shall be revised to reflect the results of this review.” |
| Effective July 1, 2003, the risk management plan requirements were revised to exempt license holders from the IAPP requirements if all consumers’ risk management plans comply with the revised RMP requirements. The 2003 statute amendment essentially incorporated the IAPP requirements for adult consumers into the RMP requirements and added a similar requirement for minors (consumers under the age of 18 years), based upon the definition of abuse in the Maltreatment of Minors Act (Minnesota Statutes, section 626.556). |
| The Legislature amended the VAA in 2002 to add consideration of susceptibility to abuse “by other individuals, including other vulnerable adults” when completing the assessment. Does this change the requirements of the assessment? |
| No. It was always intended that the assessment of susceptibility to abuse was to consider abuse by anyone a consumer may encounter, including other consumers. This language was simply added to emphasize this point because there has been a recent awareness of consumer-to-consumer aggression. |
| Even though a license holder is exempt from the IAPP requirements in the VAA when in compliance with all the risk management plan requirements in the Consolidated Standards, the susceptibility to abuse assessment must consider the possible abuse by ALL other persons including other vulnerable adults. |
| The 2003 changes to the RMP standards require that all plans for identified risk areas must include the specific actions staff persons must take to protect the consumer and minimize risks for the identified vulnerability areas. What does that mean? |
| The plans that address these five areas of abuse must identify consumer-specific measures. Some examples of consumer-specific measures are: |
| • verbally redirect the person away from the abusive situation and provide an explanation as to why s/he was redirected. |
| • any applicable outcome plans that may be being implemented that may reduce risk in an assessed area of vulnerability. |
| • any specialized training such as counseling, role modeling, etc. |
| • physically assist the consumer away from the abusive situation and provide an explanation as to why s/he was relocated. |
| Supervision levels, in and of themselves, do not constitute an adequate prevention plan, as they do not represent all reasonable measures being taken, or training being provided, to insure a lessening of the consumer's vulnerability to abuse. Therefore, any plans that only identify general supervision, monitoring, or assistance for the consumer to minimize the consumer’s risk to abuse are not sufficient and are in violation of the statutory requirements. |
| When assessing a consumer’s susceptibility to abuse, the license holder must consider only the consumer’s skills and abilities and not factor in staffing patterns, supervision requirements, the physical plant or other situational elements. Information excerpted from correspondence to a DHS license holder in January 1994 outlines this position: |
| “Assessments of persons’ susceptibility to abuse must assume nothing other than the person’s own natural supports [assessing the person’s own vulnerability without consideration for any type of external support, including, but not limited to, other persons or the environment]. A person’s susceptibility to abuse must not be evaluated in the context of the person’s placement. The service setting may not be considered in determining susceptibility. The ‘IAPP Assessment’ must be consistent with the person’s skills, abilities or need areas reflected in the person’s individual service plan (ISP) or in other assessments…The license holder’s formal support programs can, however, form the basis of the plan to minimize the risk of abuse in those areas where the person is found to be vulnerable.” |
| Must the residential license holder and day program use a combined RMP or can they maintain a separate plan? |
| License holders jointly providing services to a consumer should coordinate and use the resulting assessment of risk areas for the development of each license holder’s individual risk management plan or shared risk management plan. When license holders jointly provide services, license holders’ plans for the individual as outlined in the risk management plan should not be contradictory to each other. The county case manager may direct license holders jointly providing services to a person to develop a single shared risk management plan. |
| Does the Risk Management Plan and Assessment have to be signed by the consumer, legal representative, case manager, and residential/vocational designated coordinator? |
| This requirement was changed effective July 1, 2003, so that upon initiating services, a license holder must develop an initial risk management plan that is, at a minimum, verbally approved by the consumer or consumer’s legal representative and case manager. The license holder must document the date the license holder receives the consumer’s or the consumer’s legal representative and case manager’s verbal approval of the initial plan. |
| If you have received signatures upon service initiation you may review the Risk Management Plan at the 45-day review. If there have been no changes, you may document the team’s concurrence and do not need to obtain new signatures again. Thereafter, the plan must be reviewed at least annually and whenever a consumers needs or environment changes. |
| What do the terms “annual” or “annually” mean regarding review meetings and review of risk management plans? |
| Annual or annually is determined to be prior to or within the same month of the subsequent calendar year. For example, if you have an annual progress review on July 5 this year, you would hold the next meeting no later than July 31 of the following year. Minnesota Statutes, section 245A.65, subdivision 2 (b), (2) requires that the individual abuse prevention plan be reviewed at least annually and the Consolidated Standards (Minnesota Statutes, section 245B.06, subdivision 2) requires that the RMP be developed on or before services are begun for a consumer, and also reviewed at least annually. |
| If the annual review of the IAPP/RMP must be delayed for a reason beyond the license holder’s control, the license holder must maintain documentation of that reason. The source of the delay may not originate with the license holder unless the case manager and legal representative(s) specifically request that the review be delayed so that the person(s) affiliated with the provider who are unable to attend may be present at a later date. |
| Does everyone need a RMP that is in compliance with the new Risk Management Plan requirements effective July 1, 2003? |
| Yes. After July 1, 2004 all consumers must have a Risk Management Plan in place. |
| What is required regarding the Risk Management Plan for individuals transferring from one license holder’s program to another? |
| For individuals transferring from a license holder licensed under the Consolidated Standards, the new license holder may utilize the previous Risk Management Plan if dated prior to the first day of service delivery and at a minimum verbally approved by the consumer or consumer’s legal representative and case manager. The license holder must document the date they receive the consumer’s or consumer’s legal representative’s and case manager’s verbal approval of the initial plan. |
| Explain the assessment requirements of the Consolidated Standards as they relate to the case management requirements for assessment. |
| Under the case management rule (Minnesota Rules, parts 9525.0040 to 9525.0036, referred to as Rule 185) case managers must ensure that assessment information is completed for consumers in a variety of areas on an annual basis. The case manager in consultation with the consumer and their legal representative may waive these assessment areas. For individuals under public guardianship, the case manager must request a waiver to the assessment areas, from the public guardianship office. Assessments related to the health, safety, and protection of the person for the purpose of identifying service type, amount, and frequency, or assessments required to authorize services, must not be waived. |
| The intent is to allow teams to look at individual consumer needs, and then determine what assessments are needed accordingly. Based on this, the required assessments would be defined in the ISP and assigned to the license holder. |
| Clarify who is responsible for completion of paperwork for assessments. For example, if the case manager requests a psychological evaluation be done then does the license holder need to summarize the information from the psychologist? |
| If the license holder completes the assessment (i.e. hygiene, daily living skills, etc.) the license holder is responsible for completing the required written report. If the license holder has been assigned the responsibility for assuring a professional (i.e. psychologist, speech therapist, etc.) conducts an assessment the license holder is responsible for assuring the assessment is completed and submitted to the case manager. The license holder does not need to summarize the information given by the professional. |
| Why aren’t license holders identified as being able to establish the frequency of meetings (under the progress review section)? |
| The consumer, the legal representative and case manager are the individuals which drive this section of the standard (specifically related to the progress review meetings). The license holder is only one participant on the interdisciplinary team. However, there is nothing that precludes the license holder from contacting the team to hold a meeting in the event a situation arises that warrants input from everyone, or from assisting in facilitating the scheduling of meetings as they have been identified in the consumer’s ISP. |
| Clarify the quarterly reporting requirement for individuals under public guardianship. |
| This requirement was changed effective July 1, 2003, so those individuals under public guardianship would have a review schedule as determined by their interdisciplinary team. The requirement for quarterly progress review reports is no longer necessary. |
| What if there is no individual service plan or the ISP is not current? |
| The Division of Licensing does not have authority to enforce the requirements of the case management rule (Rule 185). There needs to be a current individual service plan for every consumer with a developmental disability who is receiving services given that an ISP directs the service license holder in the what, where, when, how, and by whom. |
| It is reasonable to expect that the license holder knows the nature of the services which are being requested of the agency or facility prior to providing services and on a continuing basis. In lieu of an ISP, licensors may look to a county contract which may describe expectations in general terms, a referral packet from the case manager, or a summary of the discussion at an initial or annual meeting at which the case manager was present. |
| If an ISP is no longer current, within the past 12 months, the license holder is required to comply with the most recent ISP unless some aspect of the service delivery has been modified. The modification must be documented (correspondence or meeting notes). |
| Clarify the meaning of “leaving the residence.” |
| Effective July 1, 2003 each consumer requiring a 24-hour plan of care shall receive services during the day outside of the residence unless otherwise specified in the ISP. |
| Can a person retire from day training and habilitation services? If so, how? |
| The case management rule describes the function of case management and the process for screening individuals. The process and screening document identifies an individual’s level of care, least restrictive services, and residential, training and habilitation, nursing facility, or family support needs. The screening team is composed of the person, the person's legal representative, if any, the person's case manager, and a qualified mental retardation professional (QMRP). |
| It is possible for a person to be identified as no longer needing day training and habilitation services through this screening process, and this would be the mechanism for "retirement.” It is important for license holders to note that they must comply with Minnesota Statutes, section 245B.06, subdivision 8 regarding the individual leaving the residence. (See 18 above) |
| Do any of the exemptions found in the Consolidated Standards allow intermediate care facilities for persons with mental retardation or related conditions to not follow any of the federal certification requirements? |
| No. ICFs/MR must comply with all requirements in the Code of Federal Regulations. The exemptions for ICFs/MR, found in the Consolidated Standards under Minnesota Statutes, section 245B.03, subdivision 2, (a), include the items that have similar requirements within the CFR. For these duplicative requirements, license holders must defer to the federal certification requirements. |
| Even if Minnesota Statutes, section 245B.06, subdivision 2 allows for Consolidated Standards license holders to be exempt from the requirements for program abuse prevention plans and individual abuse prevention plans, ICF/MR license holders must complete these plans, or similar plans, if required by the federal requirements. |
| People have the right to receive respectful and responsive services. In order to make team meetings as comfortable and productive as possible, the planning of team meetings will be completed in such a way as to recognize the uniqueness of each individual. |
| The goal of the individual’s team meeting is to reflect upon the last year, or designated period of time, and to facilitate a look into the future at opportunities that will result in increased well-being, skill enhancement, and valued role as friend, family member, and member of the community. |
| Things to consider when setting up the meeting |
| • Inquire where and when the individual would like their meeting to occur. |
| • Ask the individual who they would like to invite to attend their meeting. |
| • Create a comfortable and inviting meeting space. |
| • Inquire what the individual may like to offer during meeting, i.e., beverage or snack. |
| • Ask the individual or chosen team member, if they would like to tour guests or do introductions of the team members. |
| Questions that can assist in completing a person centered plan |
| What do you like about your home or work? Is there anything you do not like about your home or work? |
| Is there an activity or a skill that you would like to do or learn? |
| Are there places you’d like to go visit or see? Are there activities you’d like to go to in your neighborhood or city? Any places you might like to go to on a vacation? Is there anyone you’d like to have do these activities with you? Is there anything that should change so that you can do these activities? |
| Is there anything that upsets you or bothers you at home, work, or on the bus? |
| Is there anything that you would like to change in your life? |
| Annual meetings will be scheduled at least 6-8 weeks in advance. |
| Set aside time to gain input and feedback from the individual and persons that work most closely with him or her. |
| The following information will be sent out prior to the meeting for review by the team: |
| • Progress review of the past year |
| • Recommendations / suggestions for the upcoming year |
| • Proposed risk management plan |
| Consider how information will be presented at the meeting, verbally (written information distributed to team members), visually (visual outline of meeting). |
| Ask the individual if there are any issues he or she does or does not want discussed at the team meeting. A time can be set up prior to or separate from the team meeting to review any issues the individual does not want to discuss as necessary. |
| Introduction of team members (as necessary). |
| Sign in on a Guest Sheet. |
| Distribute or discuss meeting agenda. |
| Discussion will be respectful, positive, functional, productive and directed to the individual instead of “about” them. |
| Let there be no surprises. Discuss issues as they come up, but do not surprise individuals or team members with issues if they are not aware of them prior to the meeting. |
| Note any tasks that need to be completed. Determine who will complete the task, and set a timeline for completion. |
| Thank individuals for attending team meeting. |
| Send any follow up information from team meeting. |
| Follow up on any tasks that were assigned at the team meeting to ensure that they are completed. |
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| Frequency of Progress Review Meetings per ISP: |
| p Semi-Annually p Annually |
| p Other: _____________________ |
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| Frequency of Progress Review Reports per ISP: |
| p Semi-Annually p Annually |
| p Other: _____________________ |
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| Meeting - Period covering: |
| _____________ ______________ |
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| Report - Period covering: |
| _____________ _____________ |
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| ____________________________________ _________________________ ___________ |
| Signature Position DD/MM/YYY |
| Designated Coordinator Review and Approval: |
| _______________________________________ ___________ |
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| Copies distributed to the following individuals/agencies on: ___________ |
| Legal representative: _________________________________________________________ |
| Case Manager: ______________________________________________________________ |
| Other: _____________________________________________________________________ |
| Other: _____________________________________________________________________ |
| Other: _____________________________________________________________________ |
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| Narrative of Results (including quantification): |
| Period Data: _____% ____/____ trials Previous Period’s Data: _____% ____/____ trials |
| Starting Baseline: _____% ____/____ trials 3rd Quarter Data: _____% ____/____ trials |
| 1st Quarter Data: _____% ____/____ trials 4th Quarter Data: _____% ____/____ trials |
| 2nd Quarter Data: _____% ____/____ trials Annual Result: _____% ____/____ trials |
| Recommendations: ” Continue ” Revise ” Stop |
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| Narrative of Results (including quantification): |
| Period Data: _____% ____/____ trials Previous Period’s Data: _____% ____/____ trials |
| Starting Baseline: _____% ____/____ trials 3rd Quarter Data: _____% ____/____ trials |
| 1st Quarter Data: _____% ____/____ trials 4th Quarter Data: _____% ____/____ trials |
| 2nd Quarter Data: _____% ____/____ trials Annual Result: _____% ____/____ trials |
| Recommendations: ” Continue ” Revise ” Stop |
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| ____________________, 20_____ to ____________________, 20_____ |
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| Instructions: The Designated Coordinator summarizes team discussions/determinations about the identified issues in the following boxes. |
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| Describe the consumer’s conference participation: |
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| Review status of guardianship or conservatorship: |
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| Maximum amount person may be given: Amount $ _______________________ |
| without receipts per time period: Time Period:_____________________ |
| Permission for provider to manage funds: Yes_____ No_____ Limits $_______ |
| Permission for provider to handle funds: Yes_____ No_____ Limits $_______ |
| Permission for provider to store funds: : Yes_____ No_____ Limits $_______ |
| Permission for provider to limit funds: : Yes_____ No_____ Limits $_______ |
| Selection of Funds System |
| _____Cash _____Checking Account _____Savings Account |
| _____Income Reporting _____Income Maintenance Checks _____Income Taxes |
| Receipt & Disbursement Reporting to Legal Representative & Case Manager |
| Format: _____Itemized Receipt/Disbursements |
| _____Written Summaries of Receipts/Disbursement/No Itemized Reports |
| _____Monthly _____Quarterly _____Semi-Annually |
| _____Annually _____Other:_____________________________________ |
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| Describe any relevant health issues: |
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| Psychotropic Medication Use |
| If the individual is on psychotropic medications, is a minimal effective dose reduction plan possible at this time? If yes, describe the plan. If a minimal effective dose reduction is not implemented, the following items are documented: 1. The dates of prior MED attempts; and 2. The detailed reasons, in the form of risk-benefits analysis, why gradual reduction procedures cannot be undertaken. Also indicate if the IDT would like to monitor other than quarterly. Monitoring will occur according to the “Psychotropic Medication Use Checklist.” |
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| Describe any relevant behavioral issues: |
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| Other recommendations (include description, person/agency responsible for completion, & recommended deadline): |
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| Review of assessments & evaluations |
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| Professional Services Recommended by IDT |
| _____Psychologist _____Psychiatrist _____Mental Health |
| _____Registered Nurse _____Nutritionist _____Pharmacist |
| _____Physical Therapist _____Occupational Therapist _____Speech Therapy |
| _____Audiologist _____Ophthalmologist _____Attendant |
| _____Recreation Therapist _____Specialized Mobility _____Vocational Rehabilitation |
| _____Advocate _____Lawyer _____Ministerial |
| _____Other:____________________________ |
| _____Other:____________________________ |
| _____Other:____________________________ |
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| Criteria for Achievement: |
| Describe consumer interest in outcome: |
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| Criteria for Achievement: |
| Describe consumer interest in outcome: |
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| Support Strategy for Accomplishment: |
| Describe consumer interest in outcome: |
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| Support Strategy for Accomplishment: |
| Describe consumer interest in outcome: |
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| Progress Review Reporting |
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| Identify the ISP mandates for progress review meeting frequency and reporting frequencies: |
| _____Monthly _____Quarterly _____Semi-Annually |
| _____Annually ______Other:_______________________________ |
| _____Monthly ______Quarterly _____Semi-Annually |
| _____Annually ______Other:_______________________________ |
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| The Consolidated Standards (M.S. 245B.07, Subd. 1, (3)) require that in the absence of a current Individual Service Plan, the consumer and the legal representative must be notified of the consumer’s right to an ISP, and the right to appeal under M.S. 256.045 if it is lacking. |
| A current ISP is in the consumer’s files: _____Yes _____No |
| If no, was the Case Manager informed of the missing ISP, and _____Yes _____No |
| were the consumer & the legal representative informed of their _____Yes _____No |
| rights under M.S. 245B.07, Subd. 1, (3) & M.S. 256.045: |
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| Plan approved by (signatures): |
| ________________________________________________________________________________ |
| ________________________________________________________________________________ |
| _________________________________________________________________________________ |
| _________________________________________________________________________________ |
| Consumer’s Legal Representative |
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| All Team Members in attendance must sign, identify their title or role and indicate the date they attended. |
| ______________________________________________________________________________ |
| ______________________________________________________________________________ |
| ______________________________________________________________________________ |
| ______________________________________________________________________________ |
| ______________________________________________________________________________ |
| ______________________________________________________________________________ |
| ______________________________________________________________________________ |
| ______________________________________________________________________________ |
| ______________________________________________________________________________ |
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| Team Members Invited But Not Attending |
| (Note if phone or written input was given) |
| ___________________________________ ________________________________ |
| ___________________________________ ________________________________ |
| ___________________________________ ________________________________ |
| ___________________________________ ________________________________ |
| Justify why the consumer or the legal representative did not attend if one or both did not: |
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| SUMMARY OF ASSESSMENTS & RECOMMENDATIONS |
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| ____________________________________________________________ |
| ____________________, 20_____ to ____________________, 20_____ |
| ____________________________________________________________ |
| ____________________________________________________________ |
| ____________________________________________________________ |
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| This summary is completed ONLY if the Case Manager has directed the completion of assessments in writing or through the ISP, and then only for those particular assessments. |
| This summary serves as an example for residential services. It comes in 2 parts: Part I is the Summary of Assessments and Part II is the Recommendations. Part I consists of 6 domains: independent living, sensory ability & movement, use of the community, leisure & recreation, challenging behavior, & health. Summarize the results of all case manager directed assessments here, according to the consumer’s strengths, functional skills & an analysis of the those results. Part II consists of all recommendations that derive from the assessment results in Part I. |
| This document must be completed & distributed to all members of the Interdisciplinary Team prior to any meeting scheduled to consider the results of the assessments, including the annual meeting. The distribution must be documented in the last section. |
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| Part I--Summary of Assessments |
| Domain: Independent Living |
| Self-Care: Toileting, bathing, oral hygiene, grooming, dressing; |
| Domestics: Laundry, bed making, house cleaning, meal preparation, eating. |
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| Description of Functional Skills: |
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| Domain: Sensory Ability & Movement |
| Mobility: Movement of limbs, use of physical adaptations, navigating furniture, toilets & tubs, stairs, rooms, levels and buildings; |
| Sensory Use: Vision, hearing, smelling, tasting, feeling |
| Communication: Expressive & receptive language, communication systems. |
| Description of Functional Skills: |
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| Domain: Use of the Community |
| Finances: Handling, storing, carrying funds, budgeting, handling checking/savings accounts; |
| Transportation: Walking, biking, private & public transport; |
| Shopping: Selection & making purchases; |
| Telephone Use: Making & receiving calls, telephone shopping, etiquette; |
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| Description of Functional Skills: |
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| Domain: Leisure & Recreation |
| Recreation in the Community |
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| Description of Functional Skills: |
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| Domain: Challenging Behavior |
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| Description of Functional Skills: |
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| Current Diagnosis(es): Primary, secondary & tertiary; |
| Medications: Type, dosage, status of side effects, TD; |
| Health Concerns: Acute or chronic conditions & illnesses; |
| Cooperation with Health Providers |
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| Description of Functional Skills: |
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| Part II--Recommendations From Assessments |
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| Sensory Ability & Movement |
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| Cooperation with Health Providers: |
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| ____________________________________________________________ __________________ |
| Signature and Title MM/DD/YYYY |
| Designated Coordinator Review & Approval: |
| ____________________________________________________________ __________________ |
| Signature and Title MM/DD/YYYY |
| Copies sent to the following individuals/agencies on: _______________ |
| Legal Representative:______________________ Other:__________________________ |
| Case Manager:___________________________ Other:__________________________ |
| Other:___________________________________ Other:__________________________ |
| Other:___________________________________ Other:__________________________ |
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| Name: _____________________________________________________________________ |
| Date Completed (must be developed and documented within 10 working days of team meeting): |
| ____________________________________________________________________________ |
| Projected Starting Date: _______________________________________________________ |
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| Goal #: Person Centered Outcome: |
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| Instructions: Describe the required 245B components below. All items must be completed. |
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| Describe when & where the program is to be run: |
| Identify needed equipment & materials: |
| Identify the reinforcers to be used: |
| Describe how data are to be collected & charted, including how often: |
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| Describe the specific behavioral or teaching techniques to be used consistent with communication mode & learning style: |
| Describe the physical & social environments in which the program will occur (use examples when appropriate): |
| Staff name or position responsible for implementing: |
| These supports will be reviewed on a _______________________________________ basis. |
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| Consumer name: _________________________________________________ |
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| Staff persons to implement outcome: _________________________________________________________________ |
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| Implementation date: ________________ Review schedule (circle one): M Q A Other ________________________ |
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| Day(s)/ and Time(s) to work on outcome: ______________________________________________________________ |
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| How will the data be recorded? |
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| My preferred learning style is: |
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| My communication method is: ____ Verbal ____ Sign ____ Picture/symbol book ____ Other (describe) |
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| Equipment, materials, or resources needed to achieve outcome (include assistive technology as needed): |
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| Physical and/or social environments of activities (include environmental accommodations as needed): |
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| Method to help me achieve this outcome: |
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| Reviewed by: ___________________________________________________ Date: _________________________ |
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| The Consolidated Standards concerning the use of Risk Management Plans (RMP’s) were changed this legislative session to address a number of items currently found in a Facility Abuse Prevention Plan. Once a site has changed ALL RMP’s to be in compliance with the new standards, they no longer need to complete the Facility Abuse Prevention Plan. |
| While the statute does not require each county to develop a specific format for the RMP, many counties have chosen to do so. Until they complete revisions to their format, each provider is responsible for ensuring the new changes are incorporated into plans. |
| Here is a checklist of items that must be addressed to be in compliance with the new standards. The RMP must identify areas in which the consumer is vulnerable, based on an assessment, at a minimum of the following areas: |
| An adult individual’s susceptibility to |
| [ ] Financial Exploitation |
| A Minor individual’s susceptibility to |
| An individual’s health needs |
| [ ] Considering a person’s physical disabilities |
| [ ] Ability to obtain medical treatment |
| An individual’s safety needs |
| [ ] The person’s ability to take reasonable safety precautions |
| [ ] Community survival skills |
| [ ] Water survival skills |
| [ ] Ability to seek assistance or provide medical care |
| [ ] Access to toxic substances or dangerous items |
| [ ] Consider the program’s location in a particular neighborhood or community |
| [ ] Type of grounds and terrain surrounding the building |
| [ ] Individual’s ability to respond to weather-related conditions |
| [ ] Remain alone in any environment |
| [ ] Behaviors that may increase the likelihood of physical aggression between individuals |
| [ ] Behaviors that may increase the likelihood of sexual activity between individuals involving force or coercion (as defined in 245B.02, Subd 10, clauses (6) and (7) |
| When assessing vulnerability, only consider the individual’s skills and abilities, independent of staffing patterns, supervision plans, the environment or other situational elements. |
| Plans MUST INCLUDE specific actions a staff person will take to protect the consumer and minimize risks for the identified vulnerability areas. The specific actions must include proactive measures being taken, training being provided, or a detailed description of actions a staff person will take when intervention is necessary. |
| UPON INITIATION, the consumer or their legal rep and case manager must approve the plan at least verbally. Signatures can then be obtained at the 45-day review. |
| The plan must be reviewed at least annually and updated as needs change and changes to the environment. |
| Health, safety, environmental issues assessment |
| Current prescription medications |
| Directions: This is an assessment of risk, not an assessment of ability or skill. A CHECK MARK IN THE SQUARE BEFORE AN ITEM INDICATES THAT THIS IS A CONCERN AREA AND REQUIRES SUPPORT. Reference to the specific item and the plan for the needed support must be detailed below. |
| __ Seizures, controlled or uncontrolled |
| __ Vision, hearing or other sensory impairment |
| __ Problems with elimination (catheter, constipation, etc) |
| __ Special diet (diabetic, diet supplement, etc) |
| __ Precautions, restrictions due to medication (Medications listed in health section) |
| __ Psychotropic medication |
| __ Indicating when ill or injured |
| __ Cooperation with health care procedures and treatment |
| __ Ability to obtain medical treatment |
| Medical treatment support Plan: |
| __ Eating appropriate meal portions |
| __ Chewing, swallowing, choking |
| __ Adaptive equipment/positioning at bedtime |
| Eating/drinking support plan: |
| __ Walking (with or without supportive device) |
| __ Use of wheelchair or other mobility device |
__ Use of stairs, elevators, escalators
__ Responding to obstacles or hazards (ice, curb, etc) |
| __ Responding to fire and other emergencies |
| __ Regulating water temperature |
| __ Selecting/wearing appropriate clothing for weather |
| __ Seeking shelter in inclement weather |
| __ Protecting self from physical or verbal abuse |
| __ Reporting incidents of abuse or neglect |
| __ Remaining in bed or on adaptive equipment (mat tables, bolsters, etc) |
| __ Avoiding dangerous objects, places, stimuli |
| __ Refraining from dangerous or inappropriate sexual situations |
| __ Use of water survival skills/caution when in settings with water (pools, lakes, rivers, etc) |
| __ Use of materials and equipment at home and work |
| __ Ability to seek assistance or provide medical care |
| __ Access to toxic substances or dangerous items |
| __ Take reasonable safety precautions |
| Personal safety support plan: |
| __ Physical safety in all areas of home and work |
| __ Remaining alone in any environment (home, work, community settings) |
| __ Ability to respond to weather related conditions |
| __ Program's location related to neighborhood or community |
| __ Type of grounds and terrain surrounding the building |
| Environment Support Plan: |
| __ Crossing within the crosswalk |
| __ Responding to important signs (stop, danger, exit, private, etc.) |
| __ Walking on sidewalks and street/roads (facing traffic) |
| __ Finding own way to and from desired locations |
| __ Asking for assistance if lost |
| __ Observation of bicycle laws and safety precautions |
| __ Use of public transportation |
| __ Notification of destination and return time. Calling if delayed. |
| __ Community survival skills. |
| Community access support plan: |
| __ Identification of self and home address (spoken word, ID, other alternative means) |
| __ Communication of wants and needs (spoken word, gestures, alternative communication system) |
| __ Reponding to spoken word |
| Communication support plan: |
| __ Demonstration of appropriate social interaction |
| __ Exercising judgment regarding sexual activity |
| __ Respect for others privacy |
| __ Respect for property, own and others |
| __ Respect for the safety, welfare and rights of others |
| __ Behaviors that Increase likelihood of physical aggression between Individuals |
| __ Behaviors that Increase likelihood of sexual activity Involving force or coercion between individuals |
| __ Exercising Service Rights (refusal, termination, limits. payments for...) |
| __ Exercising Protection Rights: (information, complaints, privacy, communication) |
| __ Understanding of the facility internal reporting procedure |
| Miscellaneous support plan: |
| A check on the line before an item indicates that this is a concern area and requires support. The corresponding support plan does not include routine supervision but does include a specific description of what staff are to do. |
| __ Vulnerable to physical abuse |
| __ Vulnerable to self-abuse |
| __ Vulnerable to verbal/emotional abuse |
| __ Vulnerable to financial exploitation |
| __ Vulnerable to sexual abuse |
| Risk Management Assessment and Plan |
| I have participated in the completion of this Risk Management Assessment and Plan and cannot identify any other areas of risk at this time. |
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| Residential Designated Coordinator |
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| Day Program Designated Coordinator |
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