Introduction to ISP Monitoring 1 - Amazon S3...Hello, my name is Sonya Hipple. Welcome to the...

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Course Number: 005-13-01

1Introduction to ISP Monitoring

This webcast includes spoken narration.

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The written version of the narration appears to the right of the screen.



Certificates of Achievement will be available to Administrative Entity staff, Providers, Supports Coordinators, and SC Supervisors after completing all course requirements. Please view and then save or print your certificate in order to receive credit for this course.

For SCs and SC Supervisors, course requirements include successful completion of a pre‐test and post‐test.



Hello, my name is Sonya Hipple. Welcome to the course, the Introduction on Individual Support Plan (ISP) Monitoring.

I am a Human Services Program Specialist, and I work in the Bureau of Supports for People with Intellectual Disabilities. My primary responsibilities are related to Supports Coordination business practices established by the Office of Developmental Programs.

I will be your narrator for this webcast.



During this webcast, we’ll refer to the Individual Support Plan Monitoring Tool (Word version) which can be found in the Resources section of the course. If you want to print a copy of the form to refer to later, use the pause button below and return to the webcast when you’re ready.

We’ll also spend some time looking at the language within both the Consolidated and Person/Family Directed Support Waivers and ODP’s Bulletin on Supports Coordination Services. Those links are also in the course but I recommend you do not print the documents out – they’re very large and I’ll be showing excerpts on screen as we talk through the concepts. The links are for your reference only – you may want to have them open in a separate window during the webcast or save them as favorites to refer to later.



We’ll talk about what monitoring is, placing it in the context of the Supports Coordinator’s role and other related processes. We’ll also review some information on how to prepare for, conduct, and follow‐up on monitoring. The webcast will include specific tips that will support you in timely, complete, and correct monitoring.

Please know that this webcast is intended to be an introduction to basic concepts of Individual Support Plan Monitoring. ODP intends to release more detailed information as part of SC Curriculum in 2014.



After reviewing this webcast and the course materials, you will be able to:

• Define monitoring in the context of the Supports Coordinator’s role

• Further understand ISP Monitoring as defined in the Consolidated and Person/Family Directed Support Waivers

• Understand the connection between the Individual Support Plan and Monitoring

• Grasp the interrelationships between ISP Monitoring and other important processes

• Gain insight into the support ISP Monitoring can provide for the individual’s health, welfare, and satisfaction

• Understand required frequency and location of ISP Monitoring in both the Consolidated and Person/Family Directed Support Waivers and

• Know how to prepare, conduct, and follow‐up on ISP Monitoring visits



As we get started, we want to review some basic terms and concepts. Many of these will be familiar to experienced Supports Coordinators, but they’re included so that everyone is on the same page, including new Supports Coordinators.

The Commonwealth of Pennsylvania now uses the term “intellectual disability” in an effort to reinforce the use of people‐first language, which places the person before the disability. Intellectual disability is commonly abbreviated “ID.” While intellectual disability is the more commonly used term at this time, it is always best to refer to the person by name.

In order to fully understand the importance of monitoring requirements, we need to keep in mind that the federal Centers for Medicare and Medicaid Services, due to their participation in funding for supports and services, requires states to ensure safeguards are in place for those receiving services. These are outlined in “assurances” within the Approved Waiver Agreement between CMS and Pennsylvania. Within the Consolidated and Person/Family Directed Support (P/FDS) Waivers, details of how the assurances are met are addressed within appendices. I’m being specific about the Waivers because, in a few minutes, we’ll be looking at exactly what they contain that you should know in order to meet monitoring requirements – for example, the Waivers contain detailed language about how often and where Supports Coordinators should conduct ISP Monitoring.

Throughout the presentation, I’ll use the abbreviation “SC” when referring to Supports Coordinators. You are familiar with the acronym “ISP” – I’ll talk about ISP Monitoring frequently throughout this webcast. Finally, when we talk about waiver monitoring, we are referring to monitoring for people who receive waiver‐funded services and supports – waiver participants.



Before we talk about the details within the waivers, though, there is a broader context for the role of Supports Coordination Monitoring. You know that to monitor is to keep track of – this definition adds “for a special purpose.” Monitoring is one of the three roles of the SC as defined in wavier service definition of supports coordination.

You’re also aware that SCs provide three basic services: locating, coordinating, and monitoring services and supports. So, before we even talk about monitoring within the context of waiver, keep in mind that it’s a function that an SC performs for every person he or she supports – whether or not the person receives waiver‐funded supports and services.



Let’s take a minute to illustrate the broader point of monitoring as a fundamental part of the SC’s role, whether or not the person is receiving the services and supports as outlined in the approved ISP.

Here are some examples of SCs performing the role of monitoring. In this context, we’re not talking about monitoring in the context of waiver‐funded services. Notice, however, that each of these examples show that the SC is following up and checking on how things are going for the people they support ‐ and also notice that each is connected to the person’s individual plan:

• Going to country music concerts with friends and family is one of Marianne’s outcome statements. Her Supports Coordinator, Brett, called her mom on Monday to ask how things went when Marianne went to a concert with her cousin.

• Josh visited Bill to see how things went at his first visit to the volunteer fire department. This was important to Bill because at the last couple of ISP meetings, he’s been talking a lot about making new friends and identified an interest in “hanging out with the guys” at the fire department.

• Jon’s team has been worried about the fact that his seizures have seemed to be more severe in the past month. Sue Ann called Jon’s dad to check on what his doctor said and learned more about a new medication the doctor prescribed. Sue Ann is first interested in how Jon is doing –but she also needs to make sure current medications are listed in Jon’s ISP.



Now that we’ve established that monitoring is a fundamental role of the Supports Coordinator, let’s build on the concept and talk about monitoring within the context of people who receive waiver‐funded services and supports.

We start with the basic idea of monitoring ‐ “to keep track of or check for a special purpose,” and then place it in the context of the Approved Waivers and ODP Supports Coordination Bulletin. Monitoring as understood in these documents includes specific actions, timelines, expectations, responsibilities, follow‐up, and methods for documentation.

To begin, let’s look at what the Approved Waivers say about monitoring.



Information about monitoring is contained in Appendix D.2.a of the approved Consolidated and P/FDS Waivers. Let’s start by looking at the elements within this quote and thinking about what they mean.

Note that telephone monitoring contacts are only appropriate within the P/FDS Waiver.



First, notice in this excerpt from the waivers that monitoring is connected directly to the ISP. In other words, it is not an isolated activity but is a “check” on whether services are meeting needs outlined in the plan, if the person has access to services and exercises choice in providers, and if specific services are being delivered according to the frequency and duration that is outlined in the plan. Because monitoring as defined in the Waivers is directly connected to the plan, we refer to the activity as “ISP Monitoring.” I’ll use that term for the remainder of the presentation.



The waivers are also very specific about how ISP Monitoring is done. Later, we’ll talk in more detail about frequency and location of ISP Monitoring.



This information is from ODP Bulletin #00‐10‐06, Supports Coordination Services. You can see how it continues the themes outlined in the waivers and provides more specificity: monitoring includes review of the ISP, especially appropriateness and progress toward outcomes. This is an example of how monitoring is directly connected to the ISP process –as we’ll discuss next.

Notice that this list from the Bulletin highlights the importance of reviewing the person’s health and welfare and includes an emphasis on incidents. In addition, it includes the person’s satisfaction as part of the monitoring process as well as quality of services and supports. Although the Bulletin mentions satisfaction with services and supports, it’s important to pay attention to the person’s overall satisfaction with how things are going. Services and supports might be adequate or even good, but the person may want to talk with you about new things to do or experience.

Keep this holistic approach to monitoring in mind throughout the remainder of the webcast.



So far, we’ve talked about how ISP Monitoring, when done correctly, fulfills requirements in the waivers and is connected to and supports other systems processes. But it does much more than that. Think of an SC who is visiting the person to complete monitoring – perhaps in a group home or day program where he or she receives services or even in his or her own home. What is the opportunity in such a situation? The SC may be perceived as someone more objective with whom the person can talk. The SC has an opportunity to ascertain whether or not the ISP is being implemented in a way that benefits the person and is helping to achieve his or her outcomes. Certainly, the SC should always be aware of the person’s health and safety – those things that are important FOR the person. But ISP Monitoring provides an opportunity to see whether those things that are important TO the person are known and understood, respected, supported, and nurtured. Does the person have real opportunities for choice of services and how they’re delivered? Does the person have control and stability in his or her life? Are relationships and opportunities to be a valued member of the community present?

Monitoring is an opportunity for the person to have a voice to express satisfaction with services and supports or dissatisfaction with services and supports without feeling retaliation. Each time the SC conducts monitoring, he or should be listening for what the person feels is going well and what needs to change.

ISP Monitoring is not only a requirement. It’s an opportunity to support a person‐centered approach that can support change benefiting the person.



To reinforce that monitoring is connected to the Individual Support Plan, I’ll borrow a concept from the world of quality management. You may be familiar with the “Plan, Do, Check, Act” approach to continuous quality improvement:

• PLAN is the first step in which desired results are established. In our analogy, planning is when ISP development occurs.

• DO is the next logical step after the ISP is written, approved, and authorized. It is when unpaid and paid services and supports are implemented to achieve the plan.



CHECK – sometimes referred to as “study” ‐ is when the plan is compared to the reality of what’s occurring for the individual. The reason we say “ISP” monitoring is because what the SC is doing during monitoring is, in large part, checking to see if the plan is being implemented as written and if it’s having the desired results. So it’s during the “check” phase of the model that ISP Monitoring comes in, and it is directly connected to the ISP planning and implementation process.

To complete the analogy between the Plan, Do, Check, Act model and ISP Monitoring, we need to remember that the SC’s responsibility continues after the actual monitoring activity is completed and includes follow‐up on concerns and issues found during the monitoring, as well as documentation of the findings. This is the “ACT” part of the Plan, Do, Check, Act model.

Notice that the model is circular – so that when monitoring findings imply a need to take action or change the plan, ACT leads back to the planning process.

Keep this model in mind as we continue to remind you that ISP Monitoring is connected to the ISP development process. But, ISP Monitoring is much more than completing requirements in the Waiver and continuous improvement to support quality in services and supports – you are representing the person.



Understanding that monitoring is required by the Waivers is only part of the picture, however. Monitoring also connects to other important processes. For example, when SCs monitor, they are to make note of incidents that have occurred in the person’s life. More than noting an incident, SCs can use the monitoring process to verify corrective actions and risk management strategies that have been implemented to eliminate future incidents.

For people who have been involved in the Independent Monitoring for Quality process, ISP Monitoring provides an opportunity to determine if issues have been acted on – or, ensuring that the loop has been closed.

Another example of how monitoring connects directly to other processes is the monitoring practices that ODP performs – specifically, Administrative Entity Oversight and Supports Coordination Organization Monitoring. ISP Monitoring forms are referenced during both processes and the SCO Monitoring process evaluates compliance with ISP Monitoring standards.



Let’s summarize some of the points we’ve covered and add a few more details.

First, monitoring is completed one person at a time. This one‐to‐one focus allows the SC to determine if the person is healthy and safe and if the ISP is being implemented as written. In addition, it allows the SC an opportunity to learn from what the person says and does whether or not he or she is satisfied with supports and services. Don’t forget: satisfaction is about more than supports and services – Monitoring is an opportunity to learn from the person what is going well and what needs to change ‐ therefore, Monitoring, done well, includes a person‐centered approach.

Later in this webcast we’ll talk about documentation of ISP monitoring findings and follow‐up to issues and concerns. Next, however, we’ll talk in more detail about monitoring location and frequency, as specified in the waivers.



The frequency of monitoring and locations in which monitoring occurs can be found in Appendix D.2.a of both waivers. However, each waiver differs in requirements for frequency and location. It’s vital for SCs to understand that the waivers are deliberately prescriptive about frequency and location – meaning that how often and where monitoring is performed is a black and white issue and that there is no room for interpretation. ODP evaluates Supports Coordination Organizations on compliance with monitoring requirements and each SCO uses its own methods to ensure SCs are meeting targets forrequirements for frequency and location of monitoring.

Let’s look at frequency and location of monitoring for each waiver.



When the waivers contain information on frequency and location, they’re paired concepts – meaning, the information is contained in the same section of the Appendix and that SCs should be thinking of both when they’re scheduling monitoring.

When you’re thinking of picking up the phone to schedule a monitoring, you should also have the correct location in mind, since it may impact the schedule. For example, if you know that you need to get a monitoring visit in before the end of the month and it needs to occur at the person’s day service – but he or she only goes two days per week – you want to be far enough ahead in scheduling the monitoring so that it occurs on time and happens at the day program.



The Consolidated Waiver specifies a minimum frequency of three face‐to‐face monitoring visits every three calendar months. (Notice the word “minimum” – we’ll talk more about that in a few minutes.)

Don’t confuse the words “every three calendar months” as meaning once per quarter. Monitoring once per quarter runs the risk of being out of compliance.

In order to be sure to remain in compliance with Consolidated Waiver monitoring frequency, many SCs interpret “three face‐to‐face” monitoring visits in three calendar months as one visit per month.

Technically, those three visits could be any time in a three‐month period, but ODP strongly recommends that SCs adopt the practice of conducting one monitoring per month for individuals who are receiving one or more Consolidated Waiver services in order to ensure compliance.



Location of monitoring in the Consolidated Waiver contains the word “must” – so there is no room for interpretation. Notice that the third bullet gives control to the person to say where he or she would prefer to have the monitoring take place – this could be another visit at home, where the person receives day service, or any place in the community. Three monitorings are required – if the person doesn’t have an authorized day program, that visit could be at the home or in the community.

The purpose of varying the location is to ensure that the SC can fully understand how the ISP is being implemented across the person’s life – at home, when receiving day services, and in the community.

When extenuating circumstances preclude varying location of monitoring visits, talk with your supervisor in advance and document the reasons on the monitoring form. There have to be very specific reasons why – for example, the person’s health keeps him or her from attending the day program. In a situation like that, in order to complete monitoring and remain in compliance, the SC must visit the person at his or her home until day services resume and the SC can begin visiting the person in that setting again.



To understand monitoring requirements within the P/FDS Waiver, we’re going to consider frequency and location together, since they influence each other.

Frequency and location of monitoring depend on the answer to several questions: first, determine if the person receives at least one P/FDS service each calendar month. Next, consider where the person lives – with a family member, or in another setting, such as personal care, domiciliary care or his or her own home.



When the person is receiving at least one P/FDS service per calendar month and living with a family member, then monitoring occurs at least once every three calendar months. There must be a face‐to‐face monitoring visit at least every six months. At least once per year, a visit must take place in the person’s home.

On the other hand, when a person lives in a setting other than with a family member (but still receives at least one P/FDS service every calendar month) monitoring requirements call for at least one contact every month – and at least one face‐to‐face contact every three months. The Supports Coordinator must conduct a monitoring in the person’s home at least every six months.

Some people receive P/FDS services less than once per calendar month. In those situations, frequency is the same, regardless of living situation: contact at least every calendar month with at least one face‐to‐face contact every three calendar months. Over the calendar year, at least two of those contacts must occur in the person’s home.



Compliancy with P/FDS Monitoring Frequency can seem complex. SCs must determine which scenario applies in each person’s circumstances and plan a schedule in advance.

Since frequency of monitoring in P/FDS depends on where an individual lives and how often he or she receives service, SCs need to be prepared to adjust monitoring when circumstances change. For example, someone who lived at home but recently moved to her own apartment will now need to be seen face‐to‐face once every three months and in the person’s home at least every six months.

A common misperception is that “every three calendar months” equates to once per quarter. However, every three calendar months actually means at least once every 90 days. Planning quarterly monitoring visits for individuals receiving P/FDS services risks non‐compliance if a visit occurs more than 90 days after the previous visit.



Both the Consolidated and P/FDS Waivers include parameters for deviation from required monitoring frequency and location.

Deviations should be seen as exceedingly rare and due to highly unusual circumstances –and must be approved in advance by ODP. For more information on deviation from standard monitoring frequency and location, refer to ODP Informational Packet #048‐11, Instruction on Request for Deviation in Monitoring Frequency, which is included as a Resource in the course where you found this webcast.



Remember that when we talked about frequency of ISP monitoring, it was in the context of a person who receives at least one waiver service per month. Both the Consolidated and P/FDS Waivers address what happens when a person does not receive at least one service per month.

The Consolidated Waiver states that, if a monthly service isn’t provided, the SC is required to perform at least one face‐to‐face contact every calendar month, during the time when a monthly service is not being provided.

For P/FDS, there must also be contact at least once every calendar month – however, this Waiver specifies that a face‐to‐face monitoring must be completed at least every three calendar months (again, remember that we’re talking about calendar months.) At least two of the monitoring visits must occur in the person’s home every calendar year, regardless of who the person lives with.

Both Waivers specify that deviations are not permitted for these circumstances.



As we’re ending the discussion on frequency and location of ISP Monitoring, I want to add an important point, ISP Monitoring implies responsibility on the part of Supports Coordinators to meet compliance for frequency and location. However, this responsibility is shared with the individual who, by virtue of the fact that he or she receives waiver services, is obliged to cooperate with the SC in the monitoring process – cooperation with monitoring is required for an individual to keep his or her status as a waiver participant. In addition to the fact that ISP Monitoring is a required activity for SCs, keep in mind that by performing monitoring, you are providing a safeguard for health and welfare.

The shared responsibility extends to agencies and individuals providing waiver services. Later in the presentation, I’ll talk about balancing the need to schedule monitoring with a respectful approach to people receiving services, families, and those providing waiver services and supports.



Now, I’ll talk about some concepts that you need to know to prepare for, conduct, and follow‐up on ISP Monitoring. Keep in mind, though, that this webcast is an overview of ISP Monitoring and that further information on this topic is planned for 2014.



In preparing for monitoring, two questions come to mind:

• What factors do I need to think about when scheduling the monitoring visit? and

• What information will help me during the monitoring?

Let’s talk first about information that will help you prepare for monitoring.



As we talked about earlier, monitoring is in an important step in the process connected to ISP development and implementation. The plan may be available at the site where the monitoring will occur – except perhaps community settings – but it’s recommended that the SC review the ISP in advance to frame the issues to be discussed. Examples of ISP information that the SC will want to check during monitoring are potential changes in medications or medical information, and changes in the person’s individual preferences since the most recent ISP Annual Update. The SC will also want to have a clear idea of the person’s outcome statements and outcome actions so progress can be recorded in monitoring.

It’s crucial to think in advance about health and safety when preparing for monitoring. Have there been changes in health status, abilities, or need for support for health and safety? Have there been new incidents – or are there previous incidents that need follow‐up? Have corrective actions been effective in preventing future incidents?

Changing needs may require a review of whether current services and supports are adequate. An SC should also have an idea of service utilization: whether or not the person has been using services, and the reason why. This kind of information may be apparent in a review of service notes. Service notes may also contain information on IM4Q follow‐up actions, medical appointments, health concerns, and other important information that may be useful during monitoring.

The most obvious documentation to use to prepare for monitoring is the previous monitoring documentation – in particular, issues and concerns. However, when thinking about reviewing previous documentation, there is a need to look beyond just the previous monitoring documentation.



Preparing for monitoring can make the difference between an adequate monitoring visit and a good monitoring visit. Preparation may entail taking a longer view than just the most recent information and keeping an eye on the longer trends in the person’s life over time.

For example, looking at the most recent monitoring visit may show that the person is expressing satisfaction with his or her life. However, is the person, over time, more or less often participating in community life? Is the person attending activities in the community –or is the trend toward forming relationships and growing toward someone who is welcomed as a valued and contributing member of the community? Perhaps health has been good in the month since the last monitoring visit, but is the trend toward improved health and wellness over time?



This is a list of documents and notes that you may want to have with you when you head out the door to a monitoring visit. It reflects the issues that we just discussed. This is not a mandated list of documents for an SC to take to a monitoring visit – and it is not a complete list of every form or document that may be necessary. The point is that you may be better prepared to conduct a complete and thorough monitoring visit if you prepare and have documentation available that is tailored to the unique situation of the person you support.

Note the reference to the Word version of the Monitoring form – we’ll talk about that more in the next section.

A caution: Always follow your agency’s policy on taking confidential information outside the office and exercising due diligence when handling information protected by the Health Insurance Portability and Accountability Act (HIPAA).



We’ve already spent some time talking about frequency and location of ISP Monitoring. The key is to know the requirements based on the person’s unique circumstances, the services he or she receives, and which waiver funds them. Many SCs schedule their monitoring a few months in advance to ensure they’re conducting the right visits at the right time and avoiding an end of month rush to get required monitoring in.

Another consideration when scheduling is the location of monitoring. As I mentioned, monitoring is a shared responsibility. The SC must perform it correctly, and the individual, family, and provider –because they benefit from waiver funds – are obliged to cooperate. Keep in mind as well that approaching ISP Monitoring in a person‐centered way, providing safeguards for health and welfare,and talking with the person about satisfaction – can be beneficial as well. If people perceive this as your intent in monitoring, they will be open to scheduling visits.

But, exercise sensitivity and look for ways to meet the requirement while considering the unique needs of individuals, families, and providers. For example, you might consider your approach, tone, and actions when conducting a monitoring visit at a person’s work site or in the community and make every effort to avoid calling unwanted attention to the person in front of coworkers. Some SCs try to avoid scheduling monitoring visits during shift changes at group homes. When contacting a family, it’s important to remember that you’re asking to visit someone in their private home – and to allow them sufficient time to prepare, if needed.



Next, we’ll talk about conducting the monitoring visit. We’ll talk about when to use the version of the form that includes medication information and the Individual Monitoring Tool (Word version), used to collect information during the visit.



When conducting a monitoring visit, SCs select whether to use a version of the form that includes information about medications. ODP’s expectation is that SCs use the version that includes medication information for every individual who takes medications – even if the person does not take medications in the setting that the SC visits. To be clear, if an individual only takes medications at home, the SC would still use the form with medication information when visiting the person at the day program. The reason for this is that, even if a person doesn’t take medications while she’s at the day program, it’s important to check that day program staff are aware of potential side effects that may occur during the day. The version of the form that does not include medications is only to be used when an individual does not take medications at all.

Next, we’ll take a look at the Individual Monitoring Tool (Word version). This form is included in the Resources section of the course.



Let’s talk about information that you collect during monitoring visits. First, you’re familiar with the general approach of asking who, what, when, and why framing questions. As you’re considering each question in the monitoring form, keeping the “four w’s” in mind will help you gather thorough information.

While you’re monitoring, it’s the perfect opportunity to learn from the person’s words and actions. You can – and should – ask questions about how things are going to gauge the person’s satisfaction with services and supports. Don’t forget to use active listening, engage the person in a conversation that helps you learn more – but pay attention to actions and reactions, which may tell you as much or more than words. Is the person confident in his or her responses and interactions – or is there more to the story? How will you find out? How does the person interact with others and with his or her environment? Paying attention to the person during monitoring visits will often yield the most valuable information – both what the person says and what he or she communicates in nonverbal ways – for example, through body language, whether he or she seems comfortable, etc.

Next, think about the monitoring form itself. For each question, you have the opportunity to add comments and/or issues. Comments contain information that further elaborates on the question in the context of the person’s life and circumstances. Consider that this might be useful as you prepare for future monitoring visits to help you remember what was happening in the person’s life.

Issues are situations that require corrective action and follow‐up. We’ll talk more about issues in the next section.



The Individual Monitoring Tool (Word version) contains the same questions as the monitoring form in HCSIS. It’s recommended that the SC take a copy of the tool to the monitoring visit to take notes to use for entry into HCSIS after the visit.

The tool also contains annotations that describe what to look for during the visit.

Next, we’ll finish this webcast by exploring the actions that occur as follow‐up after the monitoring visit.



In your busy work day, you already know it’s important to reserve time for data entry. Some SCs plan time in their schedules to complete entry of monitoring findings at the same time they’re scheduling the monitoring visit – that way, they’re more likely to get the entry done within the required time frame. Monitoring findings are to be entered into HCSIS and in completed status within 14 calendar days of the date of monitoring.

Every contact with an individual must be documented in a service note, including monitoring activities. The completed monitoring form in HCSIS contains all of the detail that you noted during the visit, including the date of the monitoring visit, comments, and issues. However, a service note that matches the date of the monitoring visit must be entered into HCSIS to capture a summary of the monitoring visit. There is no need to reproduce all of the details in the corresponding service note, but it is not sufficient to simply say, “Conducted ISP Monitoring.” Instead, the service note will contain a brief summary of the most important findings and list those issues that require follow up with the provider or need to be investigated during the next monitoring visit. In addition, the service note will contain a reference to the completed Monitoring form. As a reminder, service notes are required to be entered in HCSIS within 7 calendar days of the date of the ISP monitoring visit.

Finally, follow‐up may include updates to other documents, such as the ISP or PUNS. For example, if during a monitoring visit, the SC learns that Mary Sue has gained new skills in cooking and using kitchen appliances, a general update to the Health and Safety Focus areas of the ISP should be completed.



Let’s establish what we’re talking about when we refer to follow‐up. ODP Bulletin #00‐10‐06, Supports Coordination Services states that the purpose of the monitoring process is to document and recommend resolutions to issues and comments.

Comments further elaborate on the question being answered and can include commendations – what is going well – or anything else that is noteworthy. Comments may need further team action – but not of an immediate nature.

On the other hand, issues ARE of a more immediate nature – notice that the definition includes the words, “timely response.” Issues are those circumstances which can have a negative impact, demonstrate a deviation of supports and services that are outlined in the ISP, or addressing dissatisfaction.

Comments may require follow‐up by the team, or may simply be additional information that needs to be documented. Issues always require follow‐up. Let’s continue to think about follow‐up over time versus follow‐up that must occur immediately with two examples.



When ISP Monitoring reveals issues or concerns that must be documented and followed up on, the SC must use judgment to determine how quickly to act, and the support and next steps that are needed. Here is an example of follow‐up that requires team discussion and planning over time:

When Joy Lynn conducted monitoring at Ellen’s group home, she asked Ellen and the staff how her new 1200 calorie diet plan was going. The staff and Ellen both said that following the plan was difficult but that, for the most part, Ellen was doing okay. Joy Lynn heard from the staff that Ellen was really unhappy and complaining about the new diet quite a bit. Ellen’s perspective was that she wasn’t complaining but that she felt frustrated about what she thought was a limited range of menu choices and was tempted to cheat because she was eating the same things over and over. Joy Lynn suggested to Ellen that a few team members get together with the nutritionist and talk about options to increase Ellen’s choices and control of her diet. Ellen agreed this was a good idea. When she returned to the office, Joy Lynn followed up by contacting the nutritionist and beginning to schedule a time for the team to meet.

In this first example, Joy Lynn identified an issue that needed follow‐up, proposed an idea to Ellen and her staff, and followed up when she returned to the office. Although supporting Ellen to gain control and greater acceptance of her diet is an issue that the team needs to address, the fact that Ellen is “doing okay” means there is no immediate risk to Ellen’s health or safety. Ellen and her team will need time to talk through different ideas with the nutritionist. Joy Lynn noted this as an issue on the ISP Monitoring form and then documented the subsequent team discussions in service notes. When she monitors at the group home again, she’ll comment on this issue again with new information. Joy Lynn will continue to “carry this thread” through monitoring and service notes until the issue is resolved. This may include updating information in the ISP to reflect new strategies to support Ellen as she gains control of her diet.



The next day, Joy Lynn visited Ralph, Jerry and Pete at their group home. Joy arrived at the home and rang the doorbell. No one answered the door even though the agency van was in the driveway and she could hear the television playing. She then tried to knock, but again no one came to the door. Joy turned the doorknob and it was open. She could see Ralph and Jerry watching TV but no staff were visible. She greeted the men and asked them where everyone was. Ralph said “No staff.” Joy found Pete in the kitchen looking in the cabinets. He said he was hungry.

Joy called out for staff but it became obvious no one was in the home. Joy immediately called her supervisor to report that the men were unsupervised. She then followed up with a call to the Provider’s Main office. She spoke to the Residential Program Director who immediately made arrangements to send staff to the home. The Director also drove to the home to offer assistance. In the meantime, Joy remained at the home with the men to ensure their Health and Safety.

Joy Lynn’s supervisor also informed the AE of the issue since he knew that the ODP Supports Coordination Bulletin requires SCOs to do so when an issue identified through monitoring presents an imminent risk to health and welfare.

The Residential Director arrived onsite and agreed to file an incident report for Neglect of Supervision. The staff person who was on‐shift appeared at the home about 45 minutes later. He had left the home to go to the Convenient Mart to pick up snacks. He had left the men unattended and was suspended immediately from his job.



This example illustrates a need to take immediate action when ISP Monitoring reveals an imminent risk to health or safety. Notice that Joy Lynn not only acted right away – she sought the assistance of others in resolving the issue. She also remained at the home until the men had proper supervision. She later followed up on the incident report and neglect investigation. She documented the follow up on the monitoring form in HCSIS and in service notes.



SCs should use good judgment to distinguish issues which will need to be followed up over time for those which will need immediate action by using the problem‐solving skills of the person and team. In both cases, it’s important for the SC to carefully document the resolution in service notes and, if resolution takes time, in subsequent monitoring documentation. The point is that the SC’s documentation of any issue in ISP Monitoring should be followed by documentation that provides further information on how the issue is addressed and resolved. Being able to follow the trail from identification to resolution within documentation is crucial.

Using the first example, Joy Lynn documented Ellen’s comments about her diet in the ISP Monitoring form; service notes over the next month contain information about Joy Lynn’s coordination of a team discussion and the team’s new plan. In addition, the ISP was updated to include new information on how Ellen will manage her diet.



When SCs learn about issues requiring follow‐up during ISP Monitoring – whether the follow‐up is needed immediately or will unfold over time – there is an opportunity to demonstrate to the person that he or she is being heard and that health and safety are being respected. Clear follow‐up action and documentation also holds all of us accountable and contributes to moving the ISP forward to make the person’s life better.



During this webcast, we discussed that monitoring is one of three roles of the SC and that within the Consolidated and P/FDS Waivers, monitoring includes specific responsibilities, frequency, and locations. Each Waiver has distinct requirements for frequency and location. We also discussed that ISP Monitoring is connected to other important processes and provides information for them, as well as opportunity to follow‐up and learn more.

We also talked about the fact that ISP Monitoring is a safeguard for the person’s health and welfare. But it is more than that, ISP Monitoring, when done in a person‐centered way, allows the person to express satisfaction about services, supports – even in a general sense. In other words, during ISP Monitoring, the person has an opportunity to talk with the SC – someone more objective – about what is going well or needs to change in his or her life. We have emphasized the point that you are an important support in the person’s life several times throughout this presentation, especially so that you understand that ISP Monitoring is more than meeting a requirement – it can be an opportunity for you to be the person’s advocate.

This webcast included specific information and examples for preparing, conducting, and following up on ISP Monitoring.



This webcast has been developed and produced by the Office of Developmental Programs Consulting System on behalf of the Pennsylvania Department of Public Welfare, Office of Developmental Programs.

Thank you for participating in this lesson.



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