SA

PFS training

Overview of the Plan for Support (PFS) Documentation

  • The Plan for Support (PFS) is comprehensively driven from various documentation sources.

  • Outside of the first page which may provide an overview, the majority of the plan is made up of notes derived from extensive assessments.

Objectives of the Plan for Support

  • The PFS should be detailed yet concise and person-focused.

  • It should allow others to step in, with no prior knowledge, and effectively support the individual based on the contents of the plan.

Components Needed for the PFS

  • Consult the PFS checklist to ensure all necessary documentation is utilized:

    • Both pages of the VIDES.

    • The Individual Service Plan (ISP) from the case manager.

    • The SIS, which is found in the iCap SIS folder on Azure.

    • Fall risk assessment.

    • Choking assessment.

    • Capacity evaluations (updated annually).

Assessments as Driving Forces

  • Emphasize utilizing assessments as foundational data since they inform much of the PFS.

  • Gratitude is expressed for feedback on assessments (fall and choking evaluations) and their integration into the PFS.

  • When new admissions occur, reliance on assessments is critical due to limited interaction with the individual beforehand.

Individual Service Plan (ISP)

  • The ISP serves as the global plan crafted by the case manager applying to all providers of support for the individual.

  • Key components of the ISP include:

    • Dates of the plan.

    • Participants of meetings.

    • Type of Waiver (e.g., Family Individual Supports - FIS).

    • Support preferences of the individual.

    • Talents and contributions highlighting strengths.

    • Important 2s (things important to the individual) and important 4s (things important for the individual but not recognized by them).

Important Notes on ISP Utilization

  • Even if the ISP information is lengthy, acquiring more information is generally preferable.

  • Areas of importance (2s and 4s) are incorporated into the PFS to represent a holistic view of the individual's life aspirations.

Essential Information in the ISP

  • Supported Decision Making Agreement: Establishment of stakeholders managing decisions.

  • General Power of Attorney (POA) status and significance.

  • Assessment of individual needs concerning medical and resource management.

Historical Medical and Behavioral Data

  • Historical hospitalization and surgery records are included.

  • Past medical history should be validated with recent doctor's records rather than relying solely on ISP entries.

Identified Risks and Routine Supports

  • Identified Risks: Particular known risks that have been documented (like fall with injury, self-harm, etc.). These must be monitored closely.

  • Potential Risks: Risks appreciated as possibilities