Form Ddd-1270aforpf - Isp Checklist
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1
2ARIZONA DEPARTMENT OF ECONOMIC SECURITY
DDD-1270AFORPF (5-07)
Clear The Form
Division of Developmental Disabilities
ISP CHECKLIST
A. GENERAL ISSUES
YES NO
1. Have appropriate release of information forms been signed to obtain updated records (i.e., medical, IEP,
therapies, etc.)?
2a. Does the responsible person wish to be notified of incidents?
2b. Is current timeline for notification adequate?
3. Are FOCUS screens updated? (Service plan, consumer demographics, medical coverage, etc.)
4. Has the individual/family been informed of their right to choose a support coordinator and providers?
5. Has the person been assessed for risk, and has a Risk Assessment Plan been developed if needed?
6. Are all team agreements on the ISP document noted in the Action Plan, Part II – Agreements and Assignments?
7. Has the individual/family received the current Statement of Rights and is there a current signed Certificate of
Understanding in the file?
8. If the person is age 18 or older, has Voter Registration options been offered? Have males registered for Selective
Service?
B. MEDICAL ISSUES
YES NO
1. If the person is not currently ALTCS eligible, is a referral to ALTCS now appropriate? (i.e., significant changes in
medical or behavioral status; person now has financial assets of less the $2,000; person is now age 6 months, 3
years, 6 years or 12 years of age. ALTCS eligibility criteria change at these ages. Refer to pre-PAS for age-
appropriate criteria.)
2. Does the individual have an advanced directive? (If yes, obtain a copy and document in medical section of ISP. If
individual is 18 or older and on ALTCS. Give responsible person the booklet entitled “Decisions About Your
Healthcare”(PAD-588). Maintain the signed Certificate of Receipt and Understanding in the Medical Section of
the consumer’s file.
3. Have specific action items for needed medical appointments/evaluations been assigned with projected dates of
completion?
4. Does the individual have medical issues that require nursing assessment/monitoring? (Skin break down, ventilator,
etc.)
5. Are Durable Medical Equipment (DME) needs and/or status being monitored?
6a. If the individual is a female of appropriate age, has an annual gynecological exam, including mammography, been
completed?
6b. If not, is there documentation of a valid reason (i.e., the individual is only able to tolerate the exam under
anesthesia, and the legally responsible person has decided the risk of anesthesia outweighs the benefits of the
exam)?
7. Has the person received pneumonia vaccination and other needed immunizations?
C. SERVICE ISSUES
YES NO
1a. If Attendant Care or Housekeeping is being provided, has the Attendant Care/Housekeeping Agreement been
completed?
1b. Has monitoring/supervision taken place within mandated time frames?
1c. If skin breakdown is a concern, is nursing involved? (See ISP Support Information, DD-220)
2. If an Augmentative Communication Device is used or needed, are objectives and supports identified?
3. Have Action Items for teaching plans/strategies been assigned or are there dates of completion?
4. Have specific training needs of HCBS providers (i.e., medication administration, CIT, information about seizure
disorders, etc.) been identified and discussed? (See ISP Support Information, DD-220)
5. Does the ISP Action Plan, Part I (DD-219-1) contain complete, measurable outcomes for all individuals receiving
Day Treatment and Training, Habilitation or Therapy services?
6. Are identified service costs likely to exceed 100% ICFMR? Ex: Residential or DTA staff ratio 1:1 or 1:2, over 200
hours nursing and HCBS, Community Protection, Medical Group Home. If yes, complete CES.
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