John Smith-24 Hour Residential-SampleIndividual Support Plan – ODDS 6.18.2015
Person’s legal name: / John Smith / Preferred name: / John / Plan effective dates: / 8/12/15- / 8/31/16Person Receiving Services: / John Smith / Plan Effective Dates: / 8/12/15-8/31/16 / Page 1 of 13
John Smith-24 Hour Residential-SampleIndividual Support Plan – ODDS 6.18.2015
One Page Profile for: / Home /How to best support John
John talks in either single words or simple sentences.
He does not like people to rush him or push him out of their way.
When he's scared, he will yell or scream.
He dislikes chicken. It’s really hard for him to chew.
He is very social, likes joking around and throwing parties.
He likes holding hands to cross the street and around vehicles because he does not like using his walking stick.
When there are yellow lines, he thinks they might be a black hole. Let him know how he needs to walk near them.
Be aware of Johns health and safety needs:
* He cannot receive a blow to his chest because he had heart surgery.
* John is legally blind. He can see light, shapes, and can get around his house well without his walking stick, but likes to be supported around streets and cars.
* He cuts his food to the size needed.
* John has protocols mostly for safety.
* He has congestive heart failure and is getting arthritis.
Complete this page based on communicating directly with the person. If additional information is needed, include information from people who have direct knowledge of the person’s perspective.For alternate templates and additional instructions, visit
What people like and admire about John
John is very social and likes parties.
He very helpful; he loves to help around the house, especially in the kitchen and with dusting.
He enjoys joking around.
He is a morning person; he gets up with a smile at around 6am!
He's got great teeth! --no cavities
He knows what he wants and isn't afraid to ask for it!
He is fun to chat with and always very friendly.
What is important to John
WWE! Hulk Hogan!
I really like spending time my family.
I enjoy going to the movies with my mom.
Papa (my dad) and I talk on the phone a lot.
Playing video games with my nephews, Kevin and Pea.
People with a good sense of humor.
I like Christmas, and dressing up like Santa.
Being able to do my favorite job, mailers until I find a new job.
Eating corndogs and hotdogs.
I do not like chicken, I can't chew it easily.
Not to be rushed by people.
Not being around people who are loud and sarcastic
Having people around who listen to me and like to chat
Not having to tell someone new my whole story every time
Person Receiving Services: / John Smith / Plan Effective Dates: / 8/12/15-8/31/16 / Page 1 of 13
John Smith-24 Hour Residential-SampleIndividual Support Plan – ODDS 6.18.2015
To edit the footer: NAME and EFFECTIVE DATES fields are located on the top of the One Page Profile.
Desired Outcomes
Desired OutcomeWhat is the desired result? / Key steps to work toward the outcome / Is there a paid service that supports this outcome? If so, what is it? / Who is responsible? / Timelines
Frequency or
by when? / Where to record progress / Note if written implementation strategies (Action Plans, Service Agreement, etc.) are expected
Person Receiving Services: / John Smith / Plan Effective Dates: / 8/12/15-8/31/16 / Page 1 of 13
John Smith-24 Hour Residential-SampleIndividual Support Plan – ODDS 6.18.2015
John takes his annual trip to Hawaii. / John continues to save money, budget with staff, and get help from family. / Residential Services / John, PDQ Residential Services staff, and Family / By June 2016 / PDQ Activity Tracking Sheet / PDQ Action Plan to be developed by 09/10/2015John maintains his robust social life, doing the things he enjoys with people he has fun with and cares about. / John continues to get support from staff to contact friends and family as he requests. Staff will also support John with rides as needed. John will work on being more proactive with requesting rides and the supports he needs to maintain his relationships and doing his favorite activities. / Residential Services / John, PDQ Res. Svs. staff, Friends and Family / Currently taking place and expected to continue throughout the ISP period / PDQ Activity Tracking Sheet / PDQ Action Plan in place
Person Receiving Services: / John Smith / Plan Effective Dates: / 8/12/15-8/31/16 / Page 1 of 13
John Smith-24 Hour Residential-SampleIndividual Support Plan – ODDS 6.18.2015
Press Tab to add additional rows
Career Development Plan (CDP)
Education level completed:
Students (age 16-20) Expected date of exit from school:
Date by which CDP will be completed:
Attending school and wants to work now.
Attending school and receiving employment supports elsewhere.
Has an IEP Post-Secondary Goal with employment or training focus.
Attending school and not receiving any employment supports.
Status with Vocational Rehabilitation (VR) (age 16 and up)
Currently receiving VR services Want a referral to VR
Other/Not applicable, explain:
Working age adults (age 21-60) must choose one of the following statements: If the person is at least 18 years old and has exited school, complete this section instead of the “Students (age 16-20)” section.
Employed in integrated employment andchooses to: Check all that apply.
Retain current job.
Advance in current job (more hours, raise, new skills, promotion, etc.)
Get a new job.
Get an additional job.
Retire – isat least 60 or will be this ISP year.Employment Outcomes are not required.
No longer continue in integrated employment at this time. Complete Decision Not to Explore Employment section.
Currently not working in integrated employment and chooses to:Check all that apply.
Get integrated employment.
Explore interests in integrated employment through an Employment Path, Discovery, or other time-limited service.
Retire – isat least 60 or will be this ISP year. Employment Outcomes are not required.
Not explore integrated employment at this time. Complete Decision Not to Explore Employment section.
Potential barriers to working in an individualized, integrated job / How will this obstacle be addressed?Person Receiving Services: / John Smith / Plan Effective Dates: / 8/12/15-8/31/16 / Page 1 of 15
John Smith-24 Hour Residential-SampleIndividual Support Plan – ODDS 6.18.2015
Transportation not able to take him to/from work at scheduled times (work schedule). / John suggested working close to home so that he can get to work on time. Services Coordinator and providers will support John to look into alternative forms of transportation, including the local bus and other natural resources (e.g. John’s neighbors, Luke and Mara, are a potential natural support for rides to work intermittently. John and his residential providers will talk with them and see if they are willing and able to give John rides to work now and again.)Person Receiving Services: / John Smith / Plan Effective Dates: / 8/12/15-8/31/16 / Page 1 of 15
John Smith-24 Hour Residential-SampleIndividual Support Plan – ODDS 6.18.2015
Decision Not To ExploreEmployment *** Not applicable; Decision not to explore employment section removed. *** This section may be removed if not applicable; indicate by using the provided dropdown.
Person Receiving Services: / John Smith / Plan Effective Dates: / 8/12/15-8/31/16 / Page 1 of 15John Smith-24 Hour Residential-SampleIndividual Support Plan – ODDS 6.18.2015
Person Receiving Services: / John Smith / Plan Effective Dates: / 8/12/15-8/31/16 / Page 1 of 15John Smith-24 Hour Residential-SampleIndividual Support Plan – ODDS 6.18.2015
Desired Employment Outcomes
/ Is there a paid service that supports this outcome? If so, what is it? / Who is responsible? / TimelinesFrequency or
by when? / Where to record progress / Note if written implementation strategies (Action Plans, Service Agreement, etc.) are expected
Desired Outcome
What is the desired result? / Key steps to work toward the outcome
Person Receiving Services: / John Smith / Plan Effective Dates: / 8/12/15-8/31/16 / Page 1 of 15
John Smith-24 Hour Residential-SampleIndividual Support Plan – ODDS 6.18.2015
John works at a job he thoroughly enjoys; where he is making good money and can pay for a larger portion of his trip to Hawaii on his own. / John will be referred to VR and who will refer John Oregon Commission for the Blind by VR for Vocational Rehab Services.John likes Susan Deal with Q services and would like her to be his job developer. She will work with John to develop supports that will allow him to be as independent as possible at work. The CDP will be updated when John gets a job.
Job Developer from Q Services will look for a job that John can get to by using the local bus.
Long-term job coaching with
Q Services Inc. once he is stable in a job. / Employment Services / John, Employment Coordinator (with Q Services Inc.) and VR / SC will work with VR to make sure that VR timelines work.
Once VR finds John a Job, SC will support John to find a job and monitor timelines / Job Placement and Training Record (JPTR) / An action plan for job coaching will be created once an integrated office job is found and John hires a job coach.
Action Plan has been developed by Q Services for Employment Path Service outlining steps for gaining office job related skills.
John will increase his ability to communicate independently and to be on time. / When he is in the workshop, John will work on punctual attendance and different methods of communicating with his co-workers and supervisors.
Q Services will arrange 3 tours of community businesses per quarter for John. During these tours, staff will help John to observe clerical-related jobs as well as other jobs he may be interested in. Additionally, staff will support John to communicate as independently as possible when he is in the community. / Employment Services / John and Q Services Inc. / John will have had one scheduled tour by 09/15 and then 3 each quarter thereafter. / Signed Job Description and Time card.
Learning Log with information about experiences in Springfield. / Action Plan has been developed by Q Services for Employment Path Service outlining steps for gaining office job related skills.
Person Receiving Services: / John Smith / Plan Effective Dates: / 8/12/15-8/31/16 / Page 1 of 15
John Smith-24 Hour Residential-SampleIndividual Support Plan – ODDS 6.18.2015
Press Tab to add additional rows
Risk Management Plan
Emergency preparedness (natural disasters, power outages, community disasters, etc.) / Preventing abuse (physical, emotional, financial, sexual, neglect) / What happens if the person can’t be reached? (timelines for notifying others, who to contact, etc.)Person Receiving Services: / John Smith / Plan Effective Dates: / 8/12/15-8/31/16 / Page 1 of 15
John Smith-24 Hour Residential-SampleIndividual Support Plan – ODDS 6.18.2015
John's home and work providers have Emergency Preparedness Plans / John is around someone at all times who can help him protect himself. He advocates for himself and has trusted people around him at home, work, and with friends who he feels comfortable expressing concerns to, when necessary. John has reported in the past when someone has tried to take money from him. / John has a missing person’s plan located both at home and at work.Person Receiving Services: / John Smith / Plan Effective Dates: / 8/12/15-8/31/16 / Page 1 of 15
John Smith-24 Hour Residential-SampleIndividual Support Plan – ODDS 6.18.2015
Risk / X ifHigh risk / How is the risk addressed?Person Receiving Services: / John Smith / Plan Effective Dates: / 8/12/15-8/31/16 / Page 1 of 15
John Smith-24 Hour Residential-SampleIndividual Support Plan – ODDS 6.18.2015
Aspiration / Protocol at PDQ & Q ServicesDehydration / Protocol at PDQ & Q Services
Injury Due to Falling
Injury Due to Blow to Chest
Safety: New tool use / Safety Plan at PDQ & Q Services
Other Medical Risks: Congestive Heart Failure / X / Health/Medical Problem List at PDQ and at Q Services
Fire Evacuation Safety / Safety Plan at PDQ & Q Services
Household Chemical Safety / Safety Plan at PDQ & Q Services: all chemicals are locked up and John is supervised when he uses harmful chemicals
Vehicle Safety / Safety Plan at PDQ & Q Services: John is supported by staff when around vehicles. He will hold staff’s hand and stay close.
Potential for Financial Abuse / Financial Plan (PDQ), John also has a Rep Payee
Other Behavior Issues:Scaring others / Support Strategies at PDQ and Safety Plan at Q Services: Staff reassure John that he is safe when he is startled by others and screams or yells. John always has someone with him who can help others to not misconstrue John’s behavior and injure him.
Person Receiving Services: / John Smith / Plan Effective Dates: / 8/12/15-8/31/16 / Page 1 of 15
John Smith-24 Hour Residential-SampleIndividual Support Plan – ODDS 6.18.2015
Press Tab to add additional rows
Does this person have a Nursing Care Plan? No Needed Yes, where found: / Home: / In Medical section of John's record book / Work: / Medical file:RN consult
Back-up Plans, in the event that primary support is not available Focus on known, significant support needs and immediate health and safety support needs of the person that must be addressed if primary support is not available. Example: Cell phone of back-up contact.
Person Receiving Services: / John Smith / Plan Effective Dates: / 8/12/15-8/31/16 / Page 1 of 15John Smith-24 Hour Residential-SampleIndividual Support Plan – ODDS 6.18.2015
Home / Call mom (Nancy), 541-555-1592Work/School/Day Supports / Call group home, 541-555-9907
Other:
Other:
Person Receiving Services: / John Smith / Plan Effective Dates: / 8/12/15-8/31/16 / Page 1 of 15
John Smith-24 Hour Residential-SampleIndividual Support Plan – ODDS 6.18.2015
Chosen Case Management Services
Type:-----Waiver Case ManagementNon-Waiver Case Management / Chosen provider:Marion County CDDP / Prime number:XZOZXOOAAuthorized dates: Plan year / Start and end, if not same as plan year:
Required frequency of case management monitoring:--choose--Monthly case management monitoringQuarterly case management monitoringOther case management monitoring (specify)
Case management comments/descriptors of anticipated case management services during the year;unless already described elsewhere in this plan. (Include any risks marked “Possible” on the Risk Identification Tool.):SC will ensure that John’s next meeting is scheduled far in advance so that it can be at his mom’s house as he prefers, SC will coordinate planning and monitor that the supports in place are meeting his needs. SC will monitor desired outcomes and support provider to adjust action plans as necessary. SC will provide John with resources about activities he might like to try and will encourage John to let her know when he thinks of things he might like to try so she can update his Person Centered Information and inform him about things that meet his preferences as she hears about them. SC will check in on how protocols and other support documents are working or not working to keep him safe and healthy. SC will communicate regularly with VR to ensure that John’s services are meeting his needs and to help him advocate for his needs whenever he requests. SC will help John hire a job coach as soon as VR helps him find a job.
Person’s preference on how case management is provided:John likes to have meetings at his mom's house or the CDDP; he likes the smaller conference room. He likes the people he trusts and who know him best to be at his meetings. He especially likes for his mom to be involved. He wants enough time set aside so that he has enough time to talk about current issues and ask questions.
Natural Supports, Community Resources, and Other Voluntary Services and Supports
Describe chosen services/supports / Provided byPerson Receiving Services: / John Smith / Plan Effective Dates: / 8/12/15-8/31/16 / Page 1 of 15
John Smith-24 Hour Residential-SampleIndividual Support Plan – ODDS 6.18.2015
Employment Supports (Job Development). John needs support finding a job he likes and is good at. He needs support finding a job that matches his skills and interests (office work).John needs support from a low vision specialist to make needed changes to his workplace. / Future Job Development funded by OCB (once referred by VR)
Going to church. John needs support getting to and from church on time and support to socialize and include himself in church activities while at church. / Friends—either Ester or Diane pick him up to go to church
When John is home with his mom on weekends, she provides all his support needs naturally. She does not get paid. / Mom (Nancy)
Person Receiving Services: / John Smith / Plan Effective Dates: / 8/12/15-8/31/16 / Page 1 of 15
John Smith-24 Hour Residential-SampleIndividual Support Plan – ODDS 6.18.2015
Press Tab to add additional rows
Chosen State Plan Personal Care (SPPC) services *** Not applicable; SPPC section removed. *** This section may be removed if not applicable; indicate by using the provided dropdown.
Person Receiving Services: / John Smith / Plan Effective Dates: / 8/12/15-8/31/16 / Page 1 of 15John Smith-24 Hour Residential-SampleIndividual Support Plan – ODDS 6.18.2015
Person Receiving Services: / John Smith / Plan Effective Dates: / 8/12/15-8/31/16 / Page 1 of 15John Smith-24 Hour Residential-SampleIndividual Support Plan – ODDS 6.18.2015
Chosen K Plan Services *** Not applicable; Chosen K Plan services section removed. *** This section may be removed if not applicable; indicate by using the provided dropdown.
Person Receiving Services: / John Smith / Plan Effective Dates: / 8/12/15-8/31/16 / Page 1 of 15John Smith-24 Hour Residential-SampleIndividual Support Plan – ODDS 6.18.2015
Person Receiving Services: / John Smith / Plan Effective Dates: / 8/12/15-8/31/16 / Page 1 of 15John Smith-24 Hour Residential-SampleIndividual Support Plan – ODDS 6.18.2015