ODP Bulletin 00-20-02 provides the Office of Developmental Programs’ (ODP) requirements and standardized processes for preparing, completing, documenting, implementing, and monitoring Individual Support Plans (ISPs) to ensure they are:

• Developed to meet the needs of the individual.
• Developed and implemented using the core values of Everyday Lives: Values in Action, LifeCourse Principles, Positive Approaches and Practices, and Self Determination to result in an enhanced quality of life for every individual.
• Compliant with the approved Consolidated, Community Living, and Person/Family-Directed Support (P/FDS) Waivers and MA State Plan as it pertains to Targeted Support Management (TSM).

This bulletin and attachments have been updated to align with the October 1, 2019 amendments of the Consolidated, Community Living, and P/FDS Waivers and provide clarification regarding approved waiver service definitions.

A full ISP is required for any individual who:

• Is enrolled in the Consolidated, Community Living, or P/FDS Waiver.
• Receives Targeted Support Management.
• Is not eligible for Medical Assistance and receives $2,000 or more in non-waiver services in a Fiscal Year.

Or

• Is eligible for Medical Assistance and in reserved capacity for waiver enrollment.

An abbreviated ISP may be completed for any individual who is not eligible for Medical Assistance and receives under $2,000 in non-waiver services in a Fiscal Year. Base-Funded Case Management services are not included in the $2,000 limit. Administrative Entities or Supports Coordination Organizations still have the option of completing a full ISP and are encouraged to do so.

All ISPs, including abbreviated ISPs, must:

• Be completed using the standardized format in the Home and Community Service Information System (HCSIS).
• Be based on assessed needs of the individual.
• Be developed using a person-centered planning process to capture information including health and welfare and the individual’s preferences and desires, all of which are intended to identify and implement appropriate services and supports.
• Be updated, approved, and have services authorized at least annually (every 365 calendar days) and when warranted by changes in the individual’s needs.
• The Consolidated, Community Living, and P/FDS Waivers state that ISPs for individuals enrolled or enrolling in any of these waivers must contain the following additional information:
  • All unpaid natural supports and funded supports to meet assessed needs. The ISP shall include documentation of services provided through other agencies (for example, Insurance, Office of Vocational Rehabilitation, Aging, Drug and Alcohol, and Education).
  • The frequency, amount, type, and duration of each service.

Further, the Consolidated, Community Living, and P/FDS Waivers stipulate that Supports Coordination Organizations (SCOs) must ensure that ISPs are thoroughly reviewed to assure services accurately reflect an individual’s needs prior to submission to the Administrative Entity for approval and authorization. Upon receipt of the ISP, the Administrative Entity is responsible for:

• Ensuring all necessary services (both paid and unpaid by ODP) are included on the ISP prior to approval.
• Ensuring the services are eligible for reimbursement prior to approval and making a service authorization decision.

Once the ISP is approved and authorized by the Administrative Entity, the Supports Coordinator is responsible to provide a completed copy of the signature form to all team members and distribute all approved ISPs to all appropriate team members unless otherwise requested. Providers that have access to the approved ISP in HCSIS are responsible for distributing the ISP to all appropriate staff within their agencies.

ISPs are not required, but are encouraged, for individuals residing in an Intermediate Care Facility for Persons with an Intellectual Disability (ICF/ID). For individuals residing in ICFs/ID, the ICF/ID personnel are responsible for developing the individual plan (outside of HCSIS) in accordance with ICF/ID regulations. This includes ensuring that services in the plan meet the individual’s needs. Although Supports Coordinators are not required to develop an ISP for individuals residing in State Centers and private ICFs/ID, they are responsible for maintaining regular contact with the ICF/ID facility, evaluating the individual, and participating in plan development as required under the County Intellectual Disability Service regulations – see 55 Pa. Code §6201.14 (relating to aftercare services). For individuals residing in State Centers and private ICFs/ID, the County Program is not responsible to authorize the plan.

ATTACHMENTS:

• Attachment 1: ISP Manual for Individuals Receiving Targeted Support Management, Base-Funded Services, Consolidated, Community Living or P/FDS Waiver Services or Who Reside in an ICF/ID
• Attachment 2: ODP Role Expectations and Required Timeline for ISP Activities
• Attachment 3: DP 1032 Individual Support Plan Signature Form (Spanish form: DP 1032-S)
• Attachment 4: Annotated Individual Support Plan
• Attachment 5: The Basics of the LifeCourse Framework to Guide the Development of the ISP
• Attachment 6: Questions to Help Facilitate the Development of the ISP
• Attachment 7: DP 1022 Waiver Service Request Form

OBSOLETE DOCUMENTS:

• Bulletin 00-17-03, Individual Support Plans for Individuals Receiving Targeted Services Management, Base Funded Services, Consolidated, or P/FDS Waiver Services or Who Reside in an ICF/ID.
• ODP Communication 023-18, ISP Manual Update: Life Sharing Codes in the Consolidated and Community Living Waivers
• ODP Communication 012-18, ISP Manual Update: Respite Camp Codes in the Consolidated, P/FDS, and Community Living Waivers.