ISP Reading Requirement/Training Review Form

Your Name *

First

Last

Date *

Email *

Phone

Client Name *

First

Last

Client Phone

PA County of Client

Services Provided (These are the ones that go to Sandata)

W1726 Companion Level 2 (1:1)
W7060 IHCS Level 2 (1:1)
W7061 IHCS Level 2 (1:1) Enhanced
W9862 Respite Unlicensed Level 3 (1:1)-15 Mins
W9798 Respite Unlicensed Level 3 (1:1)- Day

These are the others we do, but don't currently go to Sandata:

W5996 CPS Community (1:1)
W7095 Behavioral Supports Level 1
H2023 Supported Employment Job Finding
W9794 Supported Employment Job Support (1:1)

Examples: (BSC/IHCS and Enhanced/Job Finding, Coach/CPS/Respite/Nursing/Companion)

The Frequency and duration of services you provide

Provide Contact Information in the following section:

#1. Describe your client’s living accommodation; lives at home, in a group home, with a respite provider etc. *

Who is the primary contact at this location? Please add this information to your phone for emergency purposes.

Name (Primary Contact) *

First

Last

Phone (Primary Contact) *

Email (Primary Contact)

If known

Behavior so, Phone

#2. Does your client have a Behavior Consultant? *

If so please provide contact information. If not, answer N/A. If yes, please add BSC contact information to your phone for emergency purposes.

Section Divider

#3. Are there other staff on this case? If so, please provide their role:

#4. Is there a Nurse assigned to this case? *

CATHY ARE THESE INTERACTIVE QUESTIONS?

5. Please note the following requirements (Goals and

Outcomes)and or suggestions as noted in the ISP and

Increase/Maintain/Decrease- Needs to be written for each goal and each goal should have
an objective statement with it.
6. 7. Goal 1: Increased time in the community
Objective: John will go into the community with staff a minimal of two times per week for a minimal of 25 minutes each outing.
8. *Staff would be required to then write in their notes if John went into the community for
a minimal of 25 minutes during each session. Based on their notes: they can objectively
select:
9. Increase- John went into the community a minimal of 2 times for an average of 26
minutes or higher.
10. Maintain- John went into the community two times for 25 minutes each outing.
11. Decrease- John went into the community 1-2 times per week but didn’t reach the 25
minute mark during each outing.
12. Current monthly: Question- Within the last 30 days, what skills did your client maintain?
What skills have been improved? What skills need to be improved? -
13. Then
14. Last question: Staff has to answer why they selected Increased, maintained, decreased?
15. ** They seem very redundant.
16. Staff Monthly Report Question Suggestions
17. 1. Did your client demonstrate increased independence with any tasks?
18. 2. Did your client engage in any behavioral concerns? If so, what were the triggers?
19. 3. What daily living skills (hygiene, cooking, money management, etc) were practiced?
20. 4. Did the family/caregivers provide any feedback about progress/challenges at home?
21. 5. Were there any changes in home routines, supports, or expectations this month?
22. 6. What strategies worked best this month, supporting your client?
23. 7. What challenges did staff face in providing support with your client?

24.25. describe how you will assist with EACH of these

needs as you write got each goal and each goal should

have an objective statement with it:

(Goal 1:

A. Medical and Dietary-

B. Community Navigation (Walking difficulty,

Wheelchair, Walker, ability to self-navigate-

C. Preferred Mode of Communication: Is there an

assistive device? If so, how will you assist-

D. Adaptive equipment (e.g. CPAP, oxygen, hearing

aids, etc.)

E. What medications are you willing to disperse?

26. What are the individual's likes and dislikes? What

are the individual’s preferred activities?

27. Is the individual interested in volunteering or

finding a job? How will you assist in this process. Please

describe:28. If you are a job coach, is there a fade plan in place,

why or why not? Please describe. If you are not a job

coach for this client, answer N/A.

29. If you answered yes to question 2, above (is a

Behavioral Consultant on the case); have you read the

Positive Behavior Support Plan and have you been in

contact with the BSC? Please provide a SHORT

synopsis of the behavioral needs of your client based on

the support plan. How will you assist with the strategies

in the plan? Have you been in contact with the BSC?

30. What are the client’s supervision of care needs

based on the ISP? Please be thorough!

31. Given the ISP, write a short billing note using the

attached guide; include an idea as to how you plan to

how to keep them safe.

32. Do you need any additional questions or have any

comments to share?

Thank you for your attention to this very important

document! Your admin team appreciates your hard