ID Team Minutes for Development of Needs and Services Plan (ISP)

January 18, 2010

The individual Needs and Services plan should include the following for an all inclusive assessment and development of objectives.


Date of Admission, Age, DOB, Height, Weight, Physician, Legal Status, Identifying Number, Social Security Number, and Regional Center CSC

Family names, addresses, and phone numbers

Assessment data: Communication, Expressive, Receptive, Mode of Communication

Day program

Social Integration


Bathroom Skills

Eating, Mealtime

Bathing, Dressing, Hygiene

Health, Seizures, Allergies, Diagnosis, Mobility, Hand use

Vision and Hearing

Other sections should include Key Relationships, Special needs and Adaptive Equipment, Preferences, Communication Supports Needed, Behavioral Supports Needed, Community Supports Needed, Social/Sexual Supports Needed, Vocational Status, Personal Self Care Supports needed, Supports needed to Utilize Adaptive Equipment, Money Management Supports Needed, Capability of Self Administration of Medicines, Recreational Interest Survey, Vision for the Future.

Next, Health Information; Health Status, Medication, Nutritional Status, Mobility, Dental Status.

Information for Training Objectives should list each objective, the responsible person and Progress which has been made (or not). Following the list of Training Objectives should be the ID team recommendations and items for follow up.

The Legal Status must be addressed; own guardian? under age of 18, parents are legal guardians? under guardianship/conservatorship?

Informed Consent Representation is addressed outlining who will give written consent for placement, medical treatment, rights, and financial decisions. This will be the individual, the guardian or conservator, or closest available relative who is close in terms of blood or marital ties who cares for the individual.

Lastly, a Financial Review indicating the balance of the personal account and the date of the last deposit into the account.

All persons participating in the development of the Needs and Services Plan should sign a dated attendance sheet.

The ID Team

January 18, 2010


Each individual must have an individual program plan developed by an interdisciplinary team that represents the professions, disciplines, or service areas that are relevant.


Participation by the individual, his or her parent (if a minor), or the legal guardian is required unless the participation is unobtainable or inappropriate. Meetings should be scheduled and conducted to facilitate the participation of all members of the team, but especially the individual, unless he or she is clearly unable or unwilling, the individual’s parents (except in the case of a competent adult who does not desire them to do so), or the individual’s guardian or legal representative. The ICF/MR is expected to pursue aggressively the attendance of all relevant participants at the team meeting. (eg. a conference call with a consultant during the meeting).


Appropriate facility staff must participate in the ID team meetings, typically the R.N., QMRP, and facility lead staff.


Participation by other agencies serving the individual is encouraged.


Professional program staff must participate as members of the ID team in relevant aspects of the active treatment process.

Title 22

A minimum of 3 of the following disciplines, “in numbers and disciplines appropriate to meet the clients needs”:

Clinical psychologist

Recreational Therapist

Occupational Therapist

Physical Therapist

Social Worker with a Master’s Degree

Speech Therapist






The individual’s ID team is composed of those individuals (professionals, non-professionals, and paraprofessionals) who possess the knowledge, skills, and expertise necessary to accurately identify the comprehensive array of the individual’s needs and design a program which is repsonsive to those needs.

There is no correct number of individuals who comprise the ID team. The regulation also does not speciafy the professional disciplines which make up the ID team. Based upon outcomes, assess whether the expertise available to the team was appropriate to meet the needs of the individual.

Ongoing Notes/Changes to records

January 16, 2010

-Anytime there is a change to psychotropic medication outside the parameters set by the ID team, new consent forms must be completed and signed.

-Anytime a behavior management program is changed or added to the ISP, a new consent form must be completed an signed.

-Any changes made to the ISP need to be noted by the QMRP

-Any special concerns or communications with the day program should be documented in the record.

-Any communications and concerns discussed with the family should be documented in the record.

-Any time individual information is released to a 3rd party a consent must be obtained.

ISP Development and Data Collection

January 16, 2010

The QMRP should develop plans and strategies once the ID team has met and the objectives have been determined. Objectives and plans have specific guidelines identified in the regulations. Each objective must be for one behavior or skill. The data collection system must be developed for each measureable objective. Also, a schedule of data collection must be developed.

30 Day Post

January 16, 2010


1. The Comprehensive Functional Assessment must be completed prior to developing the 30 Day post.

2. Utilizing notes, communication with family, consumer, regional center, consultants, develop an extensive strengths/preferences/needed support list including the following areas:

Self help

Independent Living

Self Advocacy


Motor/Physical Development







Objectives are suggested based on consultant evaluations, recommendations, and reports.

Once an objective is agreed upon by the ID team and an outline of the plan and objectives has been discussed, formally write the objectives and develop data collection forms.

The 30 day post minutes are filed in the individual’s record

Begin implementing as soon as possible.

Annual and Semi Annual Reviews

January 16, 2010

1. Inform all members of the ID Team several weeks ahead of the scheduled review to ensure attendance.

2. Prepare the Annual outline in advance, reviewing consultant recommendations

3. Complete or update the Comprehensive Functional Assessment including personal preferences and desires. Tip: the contents of the individuals record includes all updated information and reports. This can be considered a Comprehensive Functional Assessment)

4. Complete updated Psychotropic Medication consent, if applicable.

5. Complete updated Behavioral Programming consents for each behavioral objective.

6. After review, make changes to the ISP and data collection. File.

QMRP Documentation Responsibilities

January 16, 2010

Based on Title 22 or CMS regulations, the following paperwork is required from a QMRP:

1. Annual Individual Reviews

2. Semi-Annual Individual Reviews

3. 30 Day post review

4. Development of the ISP and Data Collection

5. Monthly ISP Reviews by QMRP

6. Ongoing notes in the individual record

7. Human Rights Committee meeting documentation

8. Admissions

9. Discharges

10. Injury and Incident Documentation (Special Incidents)


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