Part 1: Assessment
Today’s training will be about the individualized support plan or ISP. You are responsible for implementing each person’s individualized plan. Currently most of the information you’ll need is in the ISP section of Therap or there may be some information in the white binders at your home. This training will help you become familiar with the contents and format of the ISP itself as well as the assessments we do to help our individuals be successful in their lives. The goals of assessment are to: Ensure awareness of the person’s health and safety issues to develop support and interventions while restricting the person the least Get a picture of the whole person by having a plan that is individualized, realistic and complete Detect Changes in the person’s conditions and circumstances that we should address with them Discover what the person wants for his or her own future by making sure the plan starts with the individual’s own vision and that it is meaningful to the person, all the while not trying to “fix” someone, as people are not to be thought of as broken. Use a Person-centered/People – First approach when giving your support to the individuals you serve. Again, people aren’t broken; they just may need some assistance in part of their lives. Our plans are custom made and reflect the person’s own dreams and goals. You may need to read assessments in a person’s ISP to get a picture of the person’s skill level in a particular area. You may be asked to participate in assessment from time to time because daily contact with individuals will make you an expert on their skills, abilities, vulnerabilities and interests. In either case, you should understand these rules about how skills are assessed: The skill should not be assessed unless observed. Often, the assessor will need to talk with the individual, the guardian, family and other service providers, in order to get accurate information. The assessor is not allowed to guess or “give the benefit of the doubt.” Capability is often different from actual performance. An assessment is inaccurate and much less useful if the person doing it is rating what the person thinks that individual could
be able to do, instead of what s/he’s actually doing. You are supposed to be rating actual current level of performance
. “N/A” should truly be “Not Applicable.” It does not
simply mean “Not Assessed.” There should be a very good reason to label as skill “not applicable” to an individual, and that reason should be noted on the assessment. Definition: Working DocumentA working document (sometimes called a draft document
) is a type of technical report that is a work in progress, a preliminary form of a possible future document. A working draft indicates a commitment on the part of the issuing organization to do further work in the area outlined in the document. Several revisions of the working draft may be issued before the final document is written, or the document may be made obsolete by future developments.We have many working documents that we use here at Dungarvin and in the field of direct care in general. Besides the ISP and assessments, documents like the T-logs, MAR, and communication logs (or s-comm’s) are all different working documents because we continually add information. We begin with a blue print and fine-tune that document throughout the years, evolving when there is a need for change. Whereas something like a GER is not a working document in that we are documenting a singular incident, just the one time. Upon arrival to Dungarvin and then continually on a regular basis we use assessments to help define where a person is in their lives currently, identify how we can help, see what significant changes the person has made over a period of time and assist in their quality of life.The Water competency and Anti-Scald DeclinationThese two assessments are used to see if a person can feel heat or cold and more importantly identify if something is too hot, too cold, or even pain related in regards to water. You will assist in this assessment by placing or asking the person served to place their hand underneath cold water and hot water and seeing their reaction or asking their thoughts. If a person jerks their hand back or states it is hot when it is hot and vice-versa for cold than we can sign off that they understand the temperatures of water. If they can not identify the differences of hot and cold then again we can sign off that they do not understand this. In the above cases we would then not need to do this assessment ever again unless there is a significant change during the time they are with us here. It becomes problematic when a person puts their hand under the water and isn’t sure if it is hot or cold, or doesn’t make much of a reaction, etc. If that is the case we would need to do these tests every 6 months in hopes of determining or helping to teach the difference. If we are able to sign off we would use a declination.Resident EvacuationThe resident evacuation form is a state issued form that we use to know how a resident will act in an evacuation. There are several questions it goes through to help us define each person’s needs.
- Will they resist evacuation?
- Do they have impaired mobility?
- Could they experience a partial or total loss of consciousness during an emergency?
- Is there need for extra staff in a resident evacuation situation?
- Can/Will the individual respond to simple directions?
- Will they wake up to alarms and have they been tested to do so?
- What is their response to fire drills?
Initial Assessment and 30-day Plan 1. Medications, Treatments, Physician Orders, OT/PT/Speech 2. Daily Routines: (what time he/she get up in the am; what time does he/she go to bed; naps during the day; shower in am/pm; favorite TV programs; visit with family or friends on certain days of the week)?3. Day Programming4. Describe how feelings and emotions are communicated5. List “Likes”6. List “Dislikes”7. List Food Preferences8. “Must Haves” to succeed in community setting9. “Desirables” to succeed in a community setting10. Describe a good housemate match11. Special training/skills direct support staff will need12. RN/LPN/Dietician necessary procedures needed13. Medical protocols needed14. Self-Cares15. Mental/Emotional Health16. Physical Health17. Behaviors:(past/present)18. Preferences for social interaction and alone time19. Information from past that is important for direct support staff to know about: The Risk assessment and Safety PlanThe Safety Plan is reviewed at least semi-annually and revised as needed, or when there is a significant change in condition, hospitalization, medication or treatment orders. It will be implemented the day the individual begins receiving services. Any new staff must be oriented to the plan before they work with the individual and The individual/guardian must be oriented to the Safety Plan within 72 hours of service initiation. The Risk and safety Plan identifies what a person is at risk for. We use the following question’s to better understand where a person is at in regards to their personal safety. As a direct care professional it is highly likely that you would take part or even be in charge of asking these questions and working with an individual in their first few days to help fill out this form. The following is taken directly from the risk assessment form. PERSONAL SAFETY QUESTIONS
- Ask questions such as: Does he/she immediately remove his/her hand, etc., from anything hot to the touch such as a stove burner, a flame, hot water?” Discuss with the team and discuss any other issues within this area. If there are negative answers mark “at risk” and develop a plan to keep him/her safe.
- Use the “Water Temperature Training Competency Test,” PR6-9, to determine: Does the individual react between cold and hot water through contact with the skin? Does the individual test water temperature with fingers prior to exposing larger areas of skin to the water? Does the individual expose larger areas of skin to water only if initial testing proves the water temperature to be desirable? Does the individual turn the cold-water faucet to get cold water? Does the individual turn the hot water faucet to get hot water? Does the individual regulate hot and cold-water faucets to produce desired temperature? Does the individual realize the appropriate use of hot, warm, and cold water for such things as washing, bathing, or drinking? Does the individual display safety and caution when choosing the appropriate water temperature? Mark “at risk” until all skills have been tested and competency has been achieved for each item. Develop a plan to keep him/her safe if he/she is at risk. Follow Policy B-21, “Regulating Water Temperature.”
- Does he/she smoke? Does he/she light his/her own cigarettes? How often? Where? If someone must be present to ensure safety or if he/she smokes in bed or doesn’t make sure a smoked cigarette is extinguished, mark “at risk” and develop a safety plan. Does he/she make sure ashtrays are cool before dumping them? If not, mark “at risk” and develop safety plan.
- Unless you have direct knowledge of abusive use, ask: Does he/she drink or smoke excessively? Does he/she use prescribed medications excessively, ask for them excessively? Does he/she use illegal drugs? If the answer is yes to any of these questions, mark “at risk” and develop a safety plan.
- Ask questions such as: Does he/she have any issues with ascending or descending stairs? Has he/she ever tripped/fallen on steps? If it is determined that he/she needs guidance on stairs, mark “at risk” and develop a safety plan. A Risk Assessment for falls should be completed upon admission, when there is a significant change in condition, or a move to a new living environment, and annually thereafter.
6. Ask questions such as: Does he/she carry a key? Where does he/she carry the key? Does he/she use a key to enter his/her home? Does he/she have any trouble unlocking the door? Has he/she ever lost his/her key? Does he/she know whom to contact if he/she loses or forgets the key? If it is determined that he/she is unable to use key to enter his/her home, mark “at risk” and develop a plan to make sure he/she has staff available. Perhaps the team will decide that he/she needs a goal of learning how to use a key. Does he/she lock doors and windows when home alone/before going to bed? If not, mark “at risk” and develop a plan with the team. Does he/she ask who is at the door or use the peephole before opening it? Does he/she refuse to open the door to a stranger? If an answer is negative, mark “at risk” and develop a safety plan.
- Unless you have direct knowledge of his/her ability to use the telephone, ask if he/she has learned to use the telephone. Ask details about answering and calling others. The team should decide if this needs to be a goal. If the questions are answered in the negative mark “at risk” and develop a safety plan.
- Ask if he/she understands the reasons to dial 911. Ask if he/she can dial 911. If the answer is no, mark “at risk” and develop a safety plan.
- Does he/she remove his/her hand away from anything hot, from anything dangerous?
- Stove: Ask if he/she is able to use a stove without injury. Does he/she regulate the temperature appropriately? Does he/she turn off burners as soon as finished cooking? Does he/she use hot pads? Does he/she constantly attend to whatever is cooking? If he/she cannot use the stove safely, mark “at risk” and develop a safety plan.
- Oven: Is he/she able to use an oven without injury? Does he/she use hot pads? Does he/she constantly attend to whatever is baking? Does he/she turn off the oven when finished? If he/she cannot use the oven safely, mark “at risk” and develop a safety plan.
- Microwave: Does he/she know which dishes/pans can be used in a microwave (and not to use metal.)? Does he/she know how to set the time and not to overdo the time? Does he/she use hot pads? If any questions are answered no, mark “at risk” and develop a safety plan.
- Toaster: Does he/she know how to set controls on the toaster? Does he/she know not to put metal fork, etc. into toaster while it is plugged in? Does he/she know to keep toaster oven door closed if a fire starts and to unplug the toaster oven? If answers are negative mark “at risk” and develop a safety plan.
- Can opener-electric or manual: Does he/she know how to use an electric or manual can opener? Does he/she know how to safely remove the top of the can once it is opened? Does he/she unplug an electric can opener before washing it off and know not to immerse it in water? If an answer is negative, mark “at risk” and develop a safety plan.
- Blender: Does he/she know to put cover on before blending anything? Does she/he know not to put an object such as spoon or scraper into the blender while it is running? Does he/she know not to put hot things in the blender? Does he/she know to unplug the blender before washing and not to immerse the machine in water? If an answer is negative, mark “at risk” and develop a safety plan.
- Vacuum: Does he/she know to wear shoes when vacuuming? Does he/she know not to pick up broken glass, staples, and other small, hard objects with the vacuum? Does he/she unplug the cord before checking vacuum for anything that is caught or not working right? Does he/she change the bag when it is full? Does he/she go to the wall outlet to pull the cord from the wall? If an answer is negative, mark “at risk” and develop a safety plan.
- Dishwasher: Does he/she know how to load the dishwasher to prevent small plastic objects from falling to the bottom of the dishwasher? Does he/she know to be cautious when opening the dishwasher because of steam that may escape? Does he/she know appropriate soap to use? If an answer is negative, mark “at risk” and develop a plan.
- Washing machine: Does he/she know not to overload machine? Does he/she know how to be cautious if using hot water? Does he/she know how to readjust if unbalanced? Does he/she know not to put hands in a spinning washing machine? If an answer is negative, mark “at risk” and develop a plan.
- Dryer: Does he/she know to clean the lint trap each time the dryer is used? Does he/she know not to overload the dryer? Does he/she know not to touch hot buttons/zippers? If an answer is no mark “at risk” and develop a plan.
- Knives & other sharp implements: Does he/she know how to use sharps safely? Is this a person who needs the sharps locked up for safety and is this documented as a restriction endorsed by the team?
- Other: Any other appliances that he/she uses? If so ask appropriate safety questions about each one.
- Ask the individual, staff, and team (including guardian/family and case manager/broker) questions such as: Have you ever seen him/her eat things that are not food? Have you ever seen him/her eat improperly prepared food or beverages, such as raw meat, rotten food, or hot drinks before they cool down? If so, mark “at risk” and develop a plan to keep him/her safe. Does he/she require a special diet or special food preparation?
- Ask if there are any safety concerns in his/her bathroom, garage, backyard, basement, etc? Walk through these areas and check them. If any safety issue is noted, make sure to ascertain if he/she is safe around the specified objects or in the specified areas? If an answer is negative, mark “at risk” and develop a safety plan. Does he/she need line of site supervision at all times in their home?
In addition to the questions we have gone through there is an initial page identifying things like medications, restrictive measure protocols, Fall prevention issues and strategies and partial payee information.The next section of the assessment goes into community risk factors and home safety scenarios. Again the document lists several suggested questions and methods to find out the information needed to identify these risks. The Plan goes on to identify a plan for SEXUALITY SAFETY, RIGHTS SAFETY, ABUSE SAFETY, DAILY LIVING SKILLS SAFETY, HEALTH SAFETY, FINANCIAL SAFETY, COMMUNTY AND HOME SAFETY and BEHAVIORAL SAFETY. When finished making this plan we should all have a pretty good understanding of the risks involved with this individual. More over, when a new hire reads the plan it should be a simple to read assessment so that the employee can get a good understanding of his or her new client. In the end we all need to ask “what is this person at risk for and what is my job in assisting this person in regards to risk?” Now that we have concluded learning about all the assessments we do with individuals lets move on to the ISP itself. One of the initial things we are going to do in creating an ISP is to ask questions to gather more information. We are going to ask these of the individual, of course, but we also may ask the guardian, case workers, therapists, family members, former caregivers from the previous company they were clients of and so fourth. Here are those initial questions:
- What characteristics/traits do you like about me?
- What accomplishments do you feel I have made in the past year?
- Who are the significant people in my life? Who are people in my life I would like to become closer to or form a relationship with including pursuing a relationship with a significant other?
- What are some items you feel are important and/or non-negotiable to me in my life?
- What do you see as my likes? What do you see as my dislikes?
- What do you think people need to know in order to provide quality support services to me? Helpful hints and what really works when supporting me? (Include info about my past that people may need to support me.)
- What behavior patterns/concerns have you noted in the past year? Are you able to make a connection between a cause and a behavior response I made? Do you feel I react differently to stressors depending on where I am? Do you have any ideas to help alleviate some of the stressors that cause me to become upset? Do you have any ideas for those who work with me to help calm me down when I am upset?
- What changes and/or events do you anticipate happening in the next year that I may need assistance with from my support team or that will affect my life?
- What is not working in my life right now or with my support services? What needs to be figured out?
- What choices and decisions do you feel I should make independently? What choices and decisions do you feel must be made with the assistance of my support team?
- What are the community activities/organizations I participated in this past year? What things do you feel I would like to participate in this year?
- Do you feel it is appropriate for me to vote? What assistance do you feel I may need to vote?
- What assistance do you feel I require with arranging for transportation in my community? What modes of transportation available in the community to you feel would work for me?
- What additional information do you think is important to have in my plan?
- What do you see as a hope or dream I have that I would like to accomplish this year?
- What do you see as a goal I would like to work on to become more independent either in my home or another setting this year?
Part II: ISPWe will then take all the information we have gathered so far and use that information to help you through the Therap Module for ISP.While you will be using Therap everyday to document goals for the ISP, every six months PD’s will update the resident’s ISP using the six month and annual review forms to be consistent with where a person is at in their life. Sometimes you can be a part of that task as well so we are going to look at those forms.As a part of the ISP we will also do a personal items inventory with the individual. The inventory sheet is a record of items owned by the individualand is not necessarily a complete listing but does containat least the following: 1. Items that have an individual value of $25 or more (i.e. stereo, furniture)2. Items that are stored outside the individual's bedroom or private space valued over $25.00, (i.e., bikes, luggage, T.V. located in a common living area such as a living room)3. Items owned jointly including the other owners and the terms of the ownership (Refer to Policy B-12, Section VI, E.)4. All clothing valued over $50.00.5. Any other items deemed appropriate by the individual, guardian or team.This inventory will be completed by the Program Manager or designee upon the individual's initiation/discontinuation of services, updated as changes occur, audited annually and maintained in the individual's file. It is not at all unheard of for a CSP to take the lead on such a form. Writing Desired Outcomes & Objectives Any part of the ISP that becomes a formalized program requiresthat a goal sheet be written. However NOT EVERY GOAL in aPerson’s life will be a formalized program. Once you have gotten to know the individuals well, you mayParticipate in writing goals and objectives. Who better? You’ll be the one who has seen the person’s performance of skills first-hand, and the one most likely acquainted with the person’s preferred learning style
. Again, we need to make sure we get our terms right. We need to differentiate between goals, desired outcomes, and objectives. Data CollectionTo make a good goal sheet we need to begin again with data collection.There are many ways to go about this and this terminology should assist you in identifying the best way to begin gathering information for a formalized goal.Baseline: The baseline is where a person begins. If someone wishes to have a goal of completing the laundry we would need to identify what they already are able to do before starting the goal. Is the individual’s baseline in regards to laundry that they can carry the clothes down to the washer but nothing else? Or maybe they can put the clothes in the washer but not use the buttons to turn on the machine? There are several ways to describe and record what is going on. The main thing is to be as precise and measurable as possible—whether you are writing a progress note, or using a data collection form. Accurate data can be charted or graphed, showing patterns and progress you might not see otherwise. Here are some basic methods for accurately recording information:Checklist. With a checklist, you are recording whether a behavior or event occurred or not: it’s a yes-no measure. Frequency measure. As you might guess, this means counting. You may count the number of times someone engages in a target behavior during a specified time period; or you might count how many prompts a person required during a goal work trial. The rule is, whatever you are measuring must have a definite beginning and end so that it is easily countable. Sneezes would usually be easy to count. Snores might not be if one is running into the next. Duration measure. In recording duration, you are recording how long something is happening. Example: timing how long a seizure lasts. Intensity or severity measures. This one can be a little subjective, but still useful. How about this: “Janet bit herself hard enough to leave a slight imprint on her right wrist” vs. “Janet bit herself hard enough that it broke the skin on her right wrist.” Behaviors that can be described along a continuum are good candidates for this type of measure: say, a “whispering-to-yelling” continuum or a “strolling-to-running” continuum and so on. A-B-C recording. Stands for “Antecedent-Behavior-Consequence” recording. This type of data collection is used when you are trying to find out what is happening just before and just after
a target behavior occurs. The “target” behavior is the specific behavior you are analyzing. The antecedent occurs before
the target behavior does. It is also known as a “precursor” or a “precipitating factor.” It can be internal: a thought or feeling or symptom. Or, it can be external: something in the environment. That would include where you are; what the climate is—as in temperature, noise level and the like; how many people were there and who; and what people were doing and saying.The consequence comes after, by that I mean immediately
after the target behavior. This often has a lot to do with what is said and done in reaction to the behavior.Antecedents and consequences tend either to encourage or to discourage repetition of a behavior—so helping a person change a behavior depends on changing the antecedents and consequences. Additional FormsIn addition to all the forms I have gone over with you today there are a few others of importance you may see:(Briefly go over the rest of the forms identified below)Acknowledgement form (HP-01a)Authorization for Medical treatment (MD3-57Annual Medication Update (MD3-11)Service Agreement (PR-01)CBRF resident satisfaction form (PR6-50) Conclusion:
To recap, please remember the following when developing or implementing the ISP.
- We want to ensure awareness of the person’s health and safety issues
- Get a picture of the whole person by having a plan that is individualized, realistic and complete
- Detect Changes in the person’s conditions
- Discover what the person wants for his or her own future
· And Use a Person-centered/People – First approach