2.B.1.
Prior to the planning of services, information is gathered from a new person entering services about his or her desired outcomes from services.
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2.B.2.a-c.
The persons served are given information about:
- Their role in setting their individual service goals
- How service planning is conducted
- Requirements for their continued participation in service
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2.B.3.a-e.
An individualized service plan is developed based on the person’s:
- Strengths
- Abilities
- Preferences
- Desired outcomes
- Other issues, as identified by the person served
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2.B.4.a-e.
As appropriate to the persons served and the scope of the services provided, the following information is considered for service planning:
- Relevant medical history
- Relevant psychological information
- Relevant social information
- Available information on previous direct services and supports
- Other relevant assessments, when available
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2.B.5.a-f.
A coordinated individualized service plan:
- Is developed with the active involvement of the person served
- Identifies:
- The person’s overall goals
- Specific measurable objectives
- Methods/techniques to be used to achieve the objectives
- Those responsible for implementation
- How and when progress on objectives will be regularly reviewed
- Is communicated in a manner that is understandable to:
- The person served
- The persons responsible for implementing the plan
- Others, as appropriate
- Is reviewed on a regular basis with respect to expected outcomes
- Is revised as appropriate based on the:
- Changing needs of the person served
- Satisfaction of the person served
- Reflects timely transition planning when a person served moves:
- From one level of services/supports or program to another within the organization
- Externally to another provider
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2.B.6.a-b.
When it has been determined that there is a need, the following are addressed in the plan:
- Assistive technology
- Reasonable accommodations
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2.B.7.a-b.
When applicable to the person and his or her goals and outcomes:
- The person and/or family served and/or their legal representatives are involved in:
- Assessing potential risks to each person’s health in the community
- Assessing potential risks to each person’s safety in the community
- Deciding whether to accept situations with inherent risks
- Identifying actions to be taken to minimize risks that have been identified
- Identifying individuals responsible for those actions
- Risk assessment result are documented in the individual service plan
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2.B.8.
The persons served are informed about resources to assist them in securing and retaining related benefits for which they are eligible.
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2.B.9.
If a person served needs services/supports that are not available through the organization, referral to other providers or resources are suggested to the person served and/or referral source, as appropriate.
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2.B.10.a-c.
An exit summary report is prepared:
- On a timely basis
- For each person who leaves the organization’s services
- That summarizes results of service received
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