Employment and Community Service Standard 5.C – Medically Fragile Specific Population Designation


The program plan that guides the delivery of the services includes:

  1. A description of the program including:
    1. The philosophy or mission statement of the program
    2. Program scope and goals
  2. Assurance that adequate resources are available to deliver the services
  3. Procedures for providing or arranging for crisis intervention services
  4. Procedures for coordinating and communicating with internal and external service providers
  5. A process for developing program policies and procedures that:
    1. Identifies the medical and healthcare competencies required by program staff
    2. Includes consultation with other medical and healthcare professionals as needed
  6. A process for the plan to be regularly reviewed and modified as needed
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Services are managed by an individual who has:

  1. The education, training, and experience needed to meet the needs of persons with medically complex needs
  2. The competencies needed to manage the services
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Initial assessments of each person served gather information as appropriate, including his or her:

  1. Developmental history, such as development age factors
  2. Motor development and functioning
  3. Health history and status, including:
    1. Medical
    2. Physical
    3. Mental
    4. Social/emotional
  4. Culture/ethnicity, including specific needs and preferences
  5. Educational history
  6. Communication functioning, including:
    1. Speech
    2. Hearing
    3. Language
  7. Visual functioning
  8. Learning style
  9. Intellectual functioning
  10. Family relationships
  11. Interactions with:
    1. Peers
    2. Sexual partner, if relevant
    3. History of use of alcohol or other drugs
  12. Current use of assistive devices or technology
  13. Other information relevant to the person served, as applicable
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Assessments are appropriate with respect to the person’s:

  1. Age
  2. Development, including physical and cognitive ability
  3. Culture
  4. Education
  5. Functional limitations, if applicable
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The program implements written procedures to ensure that assessments are updated:

  1. At least annually
  2. As needed:
    1. According to the specific needs of an individual
    2. Depending on changes in a person’s functioning
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Each person served and his or her family or guardian, as appropriate, have decision-making roles in the following:

  1. Individual services planning, including planning for transition and/or discharge if appropriate
  2. Coordination of care
  3. Referral to appropriate resourced based on the needs and preferences of persons served and their families
  4. Advance directives
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The service delivery team for each person served:

  1. Provides services that are consistent with:
    1. The needs and preferences of the person served
    2. The individual care plan
  2. Addresses:
    1. Emergent issues
    2. Ongoing issues
    3. Transitions in levels of care as needs change, including identifying the skills necessary to be successful in the next environment for:
      1. The person served
      2. Their families/caregivers
  3. Ensures that, based on ongoing assessments of the person served:
    1. Treatments change as appropriate
    2. Resource allocations change as appropriate
    3. Predicted outcomes change as appropriate
  4. Considers the impact of changes on:
    1. The person served and their families/caregivers
    2. The individual care plan of the person served
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The service delivery team for each person served is designed and modified as needed based on:

  1. The individual services planning process
  2. Initial and ongoing assessments
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There is a designated care coordinator for each person served who ensures:

  1. That all team members:
    1. Are aware of the plan of care for each person served
    2. Exchange information as appropriate
    3. Implements the plan of care/supports for each person served
  2. That all changes are communicated to the entire team
  3. Appropriate communications with:
    1. The primary care physician of the person served
    2. Other external stakeholders
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Before the person served moves from the program to another service or another level of care, transition planning is conducted and involves:

  1. The person served
  2. The family, as appropriate
  3. Service delivery team members
  4. Appropriate personnel from the next service, as available
  5. Consultation from the person’s primary care physician and other healthcare specialists, if applicable
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The program provides information to families/caregivers and the person served, as appropriate, about options as the person transitions through life stages.

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As relevant to the needs of the persons served and the scope of the program, staff members demonstrate competency in the following areas:

  1. The medical needs of the individuals served, including signs/symptoms requiring immediate response and appropriate actions
  2. Assistive technology, adaptive equipment, and medical devices used by the persons served
  3. Methods of communication
  4. Positive behavior support skills
  5. Learning styles
  6. Social, emotional, and sexual needs
  7. The effects of separation and placement on children and families or as adults transition to different living situations
  8. Grief and end-of-life support issues
  9. Other specific needs of the persons served
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The program collaborates with the healthcare providers who provide specialized medical, psychological/behavioral, and other therapeutic care to the person served.

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With the permission of the persons served, the program provides advocacy by sharing feedback from the person served regarding from other organizations and professionals providing ancillary services.

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The program assists families and caregivers to optimize resources and opportunities through involvement in support networks such as peer support groups, local advocacy groups, and self-help groups.

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If the program is responsible for medical equipment and devices used by persons served, it follows a written schedule according to manufacturers’ specifications for maintenance and/or calibration of the equipment.

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If services are provided in the home, the program identifies in-home safety needs of the person served and addresses as appropriate:

  1. Environmental risks
  2. Abuse and/or neglect by self or others
  3. Self-protection skills
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As appropriate to the scope of the program, end-of-life planning:

  1. Is directed by the wishes/desires of the person served and/or guardian
  2. Includes advocacy of hospice, palliative care, or other end-of-life choices as needed
  3. Includes spiritual or religious elements, if desired by the person served
  4. Includes the guidance of a medical professional, if desired by the person served
  5. Is submitted to the hospital in the required format, if applicable
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When a person served dies, opportunities are provided as appropriate to peers, other persons in the program, family/caregivers, and staff members to:

  1. Express grief and remembrance
  2. Develop and participate in:
    1. Memorial services
    2. Memorial rituals
    3. Other forms of grief expression, as desired
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The living environment provided for persons served is:

  1. Inclusive and integrated into the community
  2. Physically supportive to meet the needs of the persons living in the residence
  3. Psychologically supportive to meet the emotional and social needs of the persons served
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On-site support is available to meet the individual needs of the persons served.

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Persons served have input regarding and access to:

  1. Nutritious meals and snacks or enteral feedings
  2. Liquid refreshment on an ongoing basis, as appropriate for the person served
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There are separate beds and sleeping areas for persons served according to their:

  1. Ages
  2. Genders
  3. Needs
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The program provides for visits, including opportunities for privacy when appropriate, with:

  1. Family members and significant others
  2. Friends
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