Form Ddd-1270aforpf - Isp Checklist Page 2

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DDD-1270AFORPF (5-07)-REVERSE

7a. Is there documentation of the reasons why objectives were not met or were revised as appropriate?

7b. If the person is receiving services, has the provider submitted current progress reports to the division?

7c. If the person is receiving Attendant Care, Housekeeping, Respite or Habilitation Independent (HAI) for IDLA, has

a back-up plan been developed by the team?

8. Is there an Action Plan item indicating who will notify the Support Coordinator if an authorized service is not

initiated or received?

9. If the Individually Designed Living Arrangement is being planned, has the IDLA Checklist been completed?

10. Are indirect services (i.e., therapies in schools, respite through behavioral health) included on the Service Plan?

11. If a home modification is needed, has all necessary follow-up been completed and submitted to the Home

Modification Unit?

D. FINANCIAL ISSUES

YES NO

1a. Has the ISP Spending Plan been completed (if needed)?

1b. Does the person has sufficient income to support his or her expenses?

2. Is the person responsible for reporting account balances to ALTCS and/or Social Security identified on the Action

Plan, Part II? (This includes trusts, bank accounts, group home or day program accounts, etc.)

3. Is the person responsible for sending pay stubs to the Social Security Administration identified on the Action Plan,

Part II?

E. RESIDENTIAL ISSUES

YES NO

1. Has the Support Information for Group Home Services been completed?

2. If applicable, has the ISP Worksheet for Individuals Residing in Group Homes Equipped with a Pool or Spa been

completed?

3a. Has an annual inventory of the individual’s possessions been provided to the responsible person?

3b. Is it accurate?

4a. Are there limits on the amount of money an individual can carry or receive in cash from earnings and noted in the

ISP?

4b. If yes, is there something being done to teach the person to more effectively manage his or her money?

5. Has drinking alcohol or smoking been addressed?

6a. If an individual uses diapers, is a medical reason documented?

6b. If not, is there something being done to teach the person more independent toileting skills?

F. BEHAVIORAL ISSUES

YES NO

1. Are consents for psychotropic medication signed by the legally responsible person on file?

2. If the individual takes behavior-modifying medications, is there a behavior treatment plan and medication

treatment plan?

3. Is the behavior treatment plan monitor(s) identified on the Action Plan, Part II?

4. Is consultation with a Qualified Behavioral Health Professional (QBHP) required for this person?

5. Have behavioral health objectives and services been documented on the Action Plan, Part I?

6. Does the individual need more than one staff person present during transportation and is this reflected in the plan?

7. Does the Action Plan, Part II document who and how behavioral health information is to be shared with the

Primary Care Physician (PCP)?

8a. Has RIMS/ASSISTS been updated?

8b. Is the proper behavioral health code on the ASSISTS Service Plan?

9. Is an Emergency Contact Plan required/completed for discharge/transition of individuals with severe behavioral

challenges (per Administrative Directive 69)?

Equal Opportunity Employer/Program

Under Titles VI and VII of the Civil Rights Act of 1964 (Title VI & VII), and the Americans with

Disabilities Act of 1990 (ADA), Section 504 of the Rehabilitation Act of 1973, and the Age Discrimination Act of 1975, the Department prohibits

discrimination in admissions, programs, services, activities, or employment based on race, color, religion, sex, national origin, age, and disability.

The Department must make a reasonable accommodation to allow a person with a disability to take part in a program, service or activity. For

example, this means if necessary, the Department must provide sign language interpreters for people who are deaf, a wheelchair accessible location,

or enlarged print materials. It also means that the Department will take any other reasonable action that allows you to take part in and understand a

program or activity, including making reasonable changes to an activity. If you believe that you will not be able to understand or take part in a

program or activity because of your disability, please let us know of your disability needs in advance if at all possible. To request this document in

alternative format or for further information about this policy, contact the Division of Developmental Disabilities ADA Coordinator at 602 542-0419;

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