Community Services Programs
Children Mental Health Rights; Rules of General Applicability -
Indivdualized Support Plans
A. Recipients hive the right to an individualized
support plan which shall be coordinated and monitored
by a community support worker.
B. These plans shall be developed based upon consideration
of the recipient's housing, financial, social, recreational,
transportation, medical, dental, emotional and psychiatric
and/or psychological strengths and needs as well
as his or her potential need for crisis intervention
services. The plan shall reflect full consideration
of the least restrictive appropriate treatment and
related services taking into account factors that
are supportive of each recipient's exercise of his
or her basic rights, consistent with each individual's
strengths, needs and treatment requirements pursuant
to this section. Such considerations shall include
accommodation of particular needs involving communication
and physical accessibility to all treatment programs.
C. The recipient and the legally responsible parent,
guardian or custodian shall be notified of all ISP
meetings, and shall be actively encouraged to attend.
If the recipient and/or the legally responsible
parent, guardian or custodian does not attend an
ISP meeting, the Community Support Worker shall
relay their views to other members of the team.
The legally responsible parent, guardian or custodian
may invite other persons to ISP meetings. Persons
unable to attend the meeting shall be notified that
they may submit information in writing for consideration
at the meeting.
D. ISP's shall be developed in a timely manner
and shall be reviewed and revised no less frequently
than every 90 days. Plans may be reviewed more frequently
as necessary to address substantial changes in the
recipient's life, such as hospitalization.
E. The ISP shall be developed by a team consisting
of the recipient, the legally responsible parent,
guardian or custodian, and others among whom there
exists the authorization to exchange information
and who are needed to ensure that the recipient's
needs are adequately assessed and that appropriate
recommendations are made, based upon a comprehensive
assessment of the recipient The plan shall contain
but not be limited to:
- A statement of the recipient's specific strengths
and treatment needs.
- The ISP should include a description
of any physical handicap and any accommodations
necessary to provide the same or equal services
and benefits as those afforded non-disabled
individuals.
- A description of services to assist the recipient
in meeting identified needs. Goals shall be written
for each service. Short-range objectives shall be
stated such that their achievement leads to the
attainment of overall goals. Objectives shall be
stated in terms which allow objective measurement
of progress and which the recipient, to the maximum
extent possible, both understands and adopts.
- The description of services shall be
based upon the actual needs of the recipient
rather than on what services are currently
available. If at the time of the meeting,
members know on the basis of reliable information
that the needed services are unavailable,
they shall note them as “unmet” service
needs” on the ISP based upon available services
which meet, as nearly as possible, the actual
needs of the recipient.
- A description of the manner of delivery of
each service to be
provided. The manner of delivery shall be one which
maximizes the recipient’s strengths, independence
and integration into the community.
- A statement of the rationale or reason for
specifying certain
treatment or services to meet identified goals.
- A specification of treatment responsibility,
including the responsibility and involvement of
staff, recipient and parent or guardian to attain
treatment goals.
F. Within one week of the meeting, the recipient
and his or her parent, custodian or guardian shall
be offered a written copy of the [SP. The recipient
shall also be notified, by means he or she will
most likely understand, of the right to file a grievance
should he or she disagree with any aspect of the
plan or the assessments upon which the Wan is based,
or later be dissatisfied with the plan's implementation.
G. All agencies providing Community Support Worker
services shall maintain specific written guidelines
describing their practices concerning development
of ISP's.
H. The legally responsible parents, guardians
or custodians shall be actively involved in individualized
support planning, to the maximum extent possible.
The Department of Health and Human Services acting
as legal custodian has an affirmative duty to be
fully and actively involved in individualized support
planning.
