Services and Fundingindividual Support Plan (ISP)(Children S In-Home Services)

Services and Funding Individual Support Plan (ISP) Developmental Disabilities Services (Children’s In-Home Service Setting) CDDP Service : coordinator: Child’s DOB / / Prime name: : number: Parent/guar dian: CNA assessment / / ISP start / / ISP end / / date: date: date: Case Management Waiver case management (must receive one qualifying waiver service monthly) Non-waiver case management See Child Annual/Family Support Plan (SDS 4549 form) List specific anticipated case management activities, if not listed on the SDS 4549 form:

*What to put in the “Rate” box: [(Wage (PSW’s hourly) x Tax (county employer)) + Worker’s Compensation (.016)] + Wage/hour= “Rate” [(Enter PSW's hourly x Enter Tax (county employer)) + .016] + Enter PSW's hourly = $0.01 Service category What and how Authorized Unit of service Monthly Plan year support is arranged dates Quantity Rate* amount (PSW, independent contractor, (start and end) per (per line) total agency provider or general business) month (per line) Enter the number of units or months; choose type (months, each, units or other); specify other if chosen. Financial management Start: / / $0.00 $0.00 services (fiscal (# of units/mnths) Months: (Specify other) intermediary) SDS 0151 (7/14) Page 1 of 9 Individual Support Plan (Children’s In-Home Services) CDDP : Child’s ISP start / / ISP end / / name: date: date:

Service category What and how Authorized Unit of service Monthly Plan year support is arranged dates Quantity Rate* amount (PSW, independent contractor, (start and end) per (per line) total agency provider or general business) month (per line) Enter the number of units or months; choose type (months, each, units or other); specify other if chosen. End: / / K-plan/GF Services (for service plans check a box: K-plan or General Funds (GF)) K-plan GF Start: / / $0.00 $0.00 Select service (# of units/mnths) Months: (Specify other) End: / / List and describe the supports identified in the functional needs assessment (address risk, goals and preferences):

K-plan GF Start: / / $0.00 $0.00 Select service (# of units/mnths) Months: (Specify other) End: / / List and describe the supports identified in the functional needs assessment (address risk, goals and preferences):

K-plan GF Start: / / $0.00 $0.00 Select service (# of units/mnths) Months: (Specify other) End: / /

List and describe the supports identified in the functional needs assessment (address risk, goals and preferences):

K-plan GF $0.00 $0.00

SDS 0151 (7/14) Page 2 of 9 Individual Support Plan (Children’s In-Home Services) CDDP : Child’s ISP start / / ISP end / / name: date: date:

Service category What and how Authorized Unit of service Monthly Plan year support is arranged dates Quantity Rate* amount (PSW, independent contractor, (start and end) per (per line) total agency provider or general business) month (per line) Enter the number of units or months; choose type (months, each, units or other); specify other if chosen. Select service Start: / / (# of units/mths) Months: (Specify other)

End: / /

K-plan GF Start: / / $0.00 $0.00 Select service (# of units/mths) Months: (Specify other) SDS 0151 (7/14) Page 3 of 9 Individual Support Plan (Children’s In-Home Services) CDDP : Child’s ISP start / / ISP end / / name: date: date:

Service category What and how Authorized Unit of service Monthly Plan year support is arranged dates Quantity Rate* amount (PSW, independent contractor, (start and end) per (per line) total agency provider or general business) month (per line) Enter the number of units or months; choose type (months, each, units or other); specify other if chosen. End: / /

K-plan GF Start: / / $0.00 $0.00 Select service (# of units/mths) Months: (Specify other) End: / / List and describe the supports identified in the functional needs assessment (address risk, goals and preferences):

Service category What and how Authorized Unit of service Monthly Plan year support is arranged dates Quantity Rate* amount (PSW, independent contractor, (start and end) per (per line) total agency provider or general business) month (per line) Enter the number of units or months; choose type (months, each, units or other); specify other if chosen. K-plan GF Start: / / $0.00 $0.00 Select service (# of units/mnths) Months: (Specify other) End: / / List and describe the supports identified in the functional needs assessment (address risk, goals and preferences):

K-plan GF Start: / / $0.00 $0.00 Select service (# of units/mnths) Months: (Specify other) End: / / List and describe the supports identified in the functional needs assessment (address risk, goals and preferences): SDS 0151 (7/14) Page 5 of 9 Individual Support Plan (Children’s In-Home Services) CDDP : Child’s ISP start / / ISP end / / name: date: date:

Service category What and how Authorized Unit of service Monthly Plan year support is arranged dates Quantity Rate* amount (PSW, independent contractor, (start and end) per (per line) total agency provider or general business) month (per line) Enter the number of units or months; choose type (months, each, units or other); specify other if chosen.

Waivered services (for service plans check a box: Waiver or General Funds (GF); no calculation needed for case management) Waiver GF Start: / / $0.00 $0.00 Select service (# of units/mnths) Months: (Specify other) End: / / List and describe the supports identified in the functional needs assessment (address risk, goals and preferences):

Waiver GF Start: / / $0.00 $0.00 Select service (# of units/mnths) Months: (Specify other) End: / / List and describe the supports identified in the functional needs assessment (address risk, goals and preferences):

Waiver GF Start: / / $0.00 $0.00 Select service (# of units/mnths) Months: (Specify other) SDS 0151 (7/14) Page 6 of 9 Individual Support Plan (Children’s In-Home Services) CDDP : Child’s ISP start / / ISP end / / name: date: date:

Service category What and how Authorized Unit of service Monthly Plan year support is arranged dates Quantity Rate* amount (PSW, independent contractor, (start and end) per (per line) total agency provider or general business) month (per line) Enter the number of units or months; choose type (months, each, units or other); specify other if chosen. End: / / List and describe the supports identified in the functional needs assessment (address risk, goals and preferences):

Waiver GF Start: / / $0.00 $0.00 Select service (# of units/mnths) Months: (Specify other) End: / / List and describe the supports identified in the functional needs assessment (address risk, goals and preferences):

State plan personal care services (also known as PC-20) List and describe the supports identified in the functional needs assessment (address risk, goals and preferences) Personal Start: / / Hours per month (submit SDS assistance 0546PC form to DD.PC- tasks End: / / [email protected] for payment)

Support Start: / / Hours per month (submit SDS service tasks 0546PC form to DD.PC- End: / / [email protected] for payment)

State plan personal care services (also known as PC-20) List and describe the supports identified in the functional needs assessment (address risk, goals and preferences) Exception Start: / / Hours per month (submit SDS hours 0546PC form to DD.PC- End: / / [email protected] for payment) ***Follow exception process procedure.

Other services and supports Services/supports Provided by Frequency and duration (natural supports/community resources)

/ / / / Parent or guardian signature Date CDDP signature Date Plan year grand $0.00 total

K-plan services: Waivered services:  Assistive devices – 760  Community nursing services – 764  Case management  Assistive technology – 491  Community transportation (non-  Environmental safety  Attendant care management training medical) – 756 modifications – 713 (ex: STEPS)  Environmental modifications – 753  Family training (conferences and  Attendant care – ADL/IADL – 755  Relief care – 759 workshops) – 754  Behavior support services  Skills training – 755  Specialized medical supplies – (behavior consultation) – 750  Transition costs – 495 493  Chore services – 490  Vehicle modifications – 708

State plan personal care services: Personal assistance tasks: Support services tasks:  Basic personal hygiene  Housekeeping  Toileting, bowel or bladder care  First aid and handling of emergencies  Mobility, transfer or repositioning  Arranging and assisting with medical appointments  Nutrition  Observing and reporting on health status  Medication or oxygen management  Cognitive assistance or emotional support  Delegated nursing tasks

SDS 0151 (7/14) Page 9 of 9