CMS-approved state plan amendment – 2017 (PDF), CMS-approved state plan amendment – 2018 update (PDF), CMS-approved state plan amendment – 2019 update (PDF), Minn. Stat. §256B.0949

Individual treatment plan (ITP) development and progress monitoring: An EIDBI service that covers the development of the person’s initial ITP and ongoing monitoring of the person’s progress.

ITP and Progress Monitoring, DHS-7109: The person-centered, individualized plan of care for a person who meets medical necessity criteria for the EIDBI benefit. The ITP incorporates the person’s and family’s information from the comprehensive multi-disciplinary evaluation (CMDE). The qualified supervising professional (QSP) uses DHS-7109 to document the person’s initial plan of care and progress-monitoring updates.

Medical necessity determination: A decision made by a qualified provider about whether a person with autism spectrum disorder (ASD) or a related condition has a medical need for, and therefore is eligible to receive, EIDBI services.

Person-centered services: Services that:

For more information, refer to DHS – Person-centered practices.

This page provides guidance to QSPs and otherwise qualified EIDBI providers on how to complete ITP and Progress Monitoring, DHS-7109.

The QSP must:

For training on how to complete the ITP, refer to EIDBI – Individual EIDBI provider trainings – CMDE and ITP Overview.

In this section, the QSP must select the ITP type:

In section A, the QSP must document:

In section B, the QSP must document the QSP and EIDBI provider agency information.

If the agency has multiple EIDBI locations, the QSP must indicate the specific taxonomy code for the location where the person will receive services.

In section C, the QSP must:

Service setting distribution and rationale

In the service setting distribution and rationale section, the QSP must:

Functional needs and treatment focus

The QSP must use the developmental domain scores and overall impact score they enter in the functional needs and treatment focus section to support:

In the functional needs and treatment focus section, the QSP must:

1. Document the developmental domain scores from the CMDE for the following core functional domain areas:

Note: The developmental domain scores from the CMDE establish:

If the QSP updates the developmental domain scores from the CMDE based on the person’s current presentation and progress, they must support the updated scores with current, objective, person-specific assessment information.

2. Add the developmental domain scores to calculate the person’s overall impact score.

3. Document supporting evidence/assessment sources for each developmental domain score in the evidence/assessment source column. Sources may include:

The documentation must show a clear connection between the person’s CMDE findings, functional needs, assessment information, severity ratings, overall impact and treatment recommendations. The QSP may use clinical judgment to interpret assessment information, but they must support their recommendations with objective, person-specific information rather than clinical opinion or caregiver preference alone.

Recommended service intensity

To complete the recommended service intensity section, the QSP must:

Clinical supervision frequency

In the EIDBI clinical supervision frequency section, the QSP must either:

The clinical rationale must include:

Exceptions

The medical review agent must review and approve all alternate supervision plans (i.e., those that do not meet the 1:16 clinical supervision ratio during the service authorization process. For more information, refer to EIDBI – Clinical supervision.

Observation and direction rationale

In the observation and direction rationale section, the QSP must indicate the amount of observation and direction requested relative to overall intervention service hours. They must select one of the following options:

If the QSP requests observation and direction at a higher rate, they must document all the following information in the ITP:

Exceptions

The medical review agent must review and approve requests for observation and direction above 20% of total intervention service hours during the service authorization process. For more information, refer to EIDBI – Observation and direction.

The QSP must base their service authorization requests on the person’s medical necessity determination and CMDE recommendations. Services included in the ITP must meet all applicable requirements on EIDBI – Medical necessity criteria.

In section D, the QSP must provide the following information about each service they request for authorization:

The QSP must use the service units and average hours per week to calculate the requested units.

The recommended treatment intensity in section C should match the total units requested in section D. Requested service hours must be within the daily service limits on the EIDBI billing grid (PDF).

In section E, the QSP must describe:

DHS recommends the QSP complete and document a functional behavior assessment (FBA) if they either:

In section F, the QSP must document if the person received an FBA and either:

Section G establishes the individualized, functional and measurable goals that inform all EIDBI services. The QSP must include:

The person’s goals and objectives must:

A well-written objective contains the following elements:

Long-term treatment goal

In the long-term treatment goal section, the QSP must summarize:

Developmental goal domains

In the development goal domains section, the QSP must identify:

For each goal, the QSP must document:

Status

In the status subsection, the QSP must add or update goals by selecting one of the following options that best describes the person’s progress for that objective:

The QSP must indicate the rationale or data for the status they selected. For more information, refer to section J on this page.

In section H, the QSP must:

Case management

In the case management section, the QSP must identify people who coordinate, locate or manage the person’s services (e.g., case manager, care coordinators, other service coordinators involved in the person’s care), when applicable.

School services

In the school services section, the QSP must indicate whether the person attends preschool or school. If the person attends preschool or school, the QSP must complete and attach the Week-In-The-Life Schedule (Addendum C), DHS-7109C (PDF) to show how EIDBI services:

Other current services (current and within the past 12 months)

In the other current services section, the QSP must document the following information for each applicable service:

For more information on coordination with other services, refer to EIDBI – Services – Coordination with other services.

The coordinated care conference is a covered service under the EIDBI benefit. For more information, refer to EIDBI – Coordinated care conference.

In section I, the QSP must document whether a coordinated care conference occurred.

If a coordinated care conference occurred, the QSP must document:

If a coordinated care conference did not occur, the QSP must describe the rationale.

In section J, the QSP must:

The QSP must submit an ITP progress monitoring update at least every six months of treatment.

The QSP does not need to complete section J for the person’s initial ITP development. For the initial ITP, the QSP can enter “N/A” in this section.

All treatment plans must include a general transition plan, even if no transition is currently planned. As the person’s discharge from EIDBI services approaches, the QSP must update the transition plan to be more specific to the person and family’s needs.

Description and discharge planning criteria

In the description and discharge planning criteria sections, the QSP must document:

Long-term treatment review (if applicable)

For people who have received EIDBI services for more than 36 months, the QSP must complete a long-term treatment review to assess:

In the documentation subsection, the QSP must document the following information:

EIDBI providers must coordinate with the person’s caregiver/guardian to develop a safety plan when the person has identified safety risks or interfering behaviors.

In section L, the QSP must indicate whether safety risks or interfering behaviors are present and whether there is a defined safety plan in place for the person.

When a safety plan is in place, the QSP must:

For details about safety plans and a template, refer to the Addendum F: Safety Plan section below.

For additional safety plan templates and resources, refer to the Minnesota Autism Resource Portal – Safety.

Once DHS-7109 is complete, the following people must sign and date the ITP signature page:

The signatures and dates must be either handwritten or use an approved electronic signature with a time and date stamp (refer to MHCP Eligibility Policy Manual – Signature).

The signatures confirm understanding and agreement with the treatment plan and service recommendations. They serve as consent for the person to begin or continue receiving EIDBI services.

Note: Only people who can consent to treatment and make legal decisions can sign the form. This may not include all caregivers/guardians. Providers must make sure the person who signs the form has the legal authority to do so.

Timeline

The caregiver/guardian must sign the ITP for service authorization. The caregiver/guardian signature date must be on or before the requested service authorization start date. Signatures do not need to occur on the same day. The ITP is considered complete on the date the last person signs the signature page.

The interpreter signature date does not affect service authorization dates.

The CMDE may be completed and signed on the same day as the ITP, but the CMDE cannot be completed after the ITP.

Signature pages

ITP Signature Page – English (PDF)
ITP Signature Page – Hmong (PDF)
ITP Signature Page – Russian (PDF)
ITP Signature Page – Somali (PDF)
ITP Signature Page – Spanish (PDF)
ITP Signature Page – Vietnamese (PDF)
Note: The English version also is included in ITP and Progress Monitoring, DHS-7109.

Providers must:

When a transition or discharge occurs, the QSP should download and electronically complete EIDBI transition and/or discharge summary, DHS-7109A. On DHS-7109A, the QSP must:

The caregiver/guardian signature on DHS-7109A indicates they approve of the transition/discharge plan. If the caregiver/guardian does not agree with the transition/discharge plan, review EIDBI – Rights and responsibilities (including appeal rights).

For more information about service termination, refer to EIDBI – Service transition, discharge and termination.

For help with technical issues downloading the form, refer to DHS – eDocs frequently asked questions.

ITP and Progress Monitoring Week-In-The-Life Schedule (Addendum C), DHS-7109C (PDF) is an optional document to help providers and families identify potential service times and schedule conflicts.

When the provider completes Addendum C, they should account for all hours in the week (i.e., complete all available boxes).

DHS-7109C should reflect the following recommendations in the ITP:

If the person does not have scheduled activities or therapy sessions, the QSP should enter “no activity scheduled” or “free time.”

The QSP is not required to submit this document for authorization.

EIDBI Safety Plan Template, DHS-7109F is an optional document to help providers create a safety plan.

A safety or crisis plan is a plan of action created before a crisis occurs, so the person and their support network know exactly what to do in an emergency. The QSP and other qualified EIDBI providers should develop the plan with all team members, including natural supports and other providers.

A person’s safety needs can change as they get older or when they experience a sudden change in their routine. The QSP must update the safety plan on a regular basis.

A case manager or support planner also can help the person and their family develop a plan or coordinate additional supports to prevent or recover from an emergency or crisis.