Employment and Community Service Standard 2.B – Individual-Centered Service Planning, Design, and Delivery

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:

  1. Their role in setting their individual service goals
  2. How service planning is conducted
  3. 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:

  1. Strengths
  2. Abilities
  3. Preferences
  4. Desired outcomes
  5. 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:

  1. Relevant medical history
  2. Relevant psychological information
  3. Relevant social information
  4. Available information on previous direct services and supports
  5. Other relevant assessments, when available
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2.B.5.a-f.

A coordinated individualized service plan:

  1. Is developed with the active involvement of the person served
  2. Identifies:
    1. The person’s overall goals
    2. Specific measurable objectives
    3. Methods/techniques to be used to achieve the objectives
    4. Those responsible for implementation
    5. How and when progress on objectives will be regularly reviewed
  3. Is communicated in a manner that is understandable to:
    1. The person served
    2. The persons responsible for implementing the plan
    3. Others, as appropriate
  4. Is reviewed on a regular basis with respect to expected outcomes
  5. Is revised as appropriate based on the:
    1. Changing needs of the person served
    2. Satisfaction of the person served
  6. Reflects timely transition planning when a person served moves:
    1. From one level of services/supports or program to another within the organization
    2. 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:

  1. Assistive technology
  2. Reasonable accommodations
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2.B.7.a-b.

When applicable to the person and his or her goals and outcomes:

  1. The person and/or family served and/or their legal representatives are involved in:
    1. Assessing potential risks to each person’s health in the community
    2. Assessing potential risks to each person’s safety in the community
    3. Deciding whether to accept situations with inherent risks
    4. Identifying actions to be taken to minimize risks that have been identified
    5. Identifying individuals responsible for those actions
  2. 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:

  1. On a timely basis
  2. For each person who leaves the organization’s services
  3. That summarizes results of service received
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