4.10 ICF – Person Centered Plan

Overview

Each individual receiving services through Open Door is required to have a Person Centered Plan (PCP). The PCP/OISP is the primary document defining services and treatment provided to the individual.

For ICF settings, the QIDP is responsible for coordinating and developing the PCP/OISP and it is developed through team assessments and evaluation of Comprehensive Functional Assessments (CFA) from all interdisciplinary team members.

The PCP/OISP and all team recommendations are discussed during team meetings; the QIDP is responsible for coordinating and co-chairing the meetings with the individual to the level that the individual wishes to participate. The individuals are encouraged to invite anyone they prefer to attend their meetings. 

Meetings must be held upon admission and within 30 days after admission for development of the initial PCP/OISP. Following the initial meeting, meetings are scheduled on a semi-annual basis with at least quarterly reviews of the plan. Additionally, any team member(s) or individual may request to have an addendum meeting to address any concern or need for change throughout the year.

The Seven Elements of a Person Centered Plan:

Open Door has adopted the “Seven Elements of a Person Centered plan” as outlined by the Ohio Department of Developmental Disabilities for development of individual service planning. The elements listed below are reflected in each individual’s plan:

1. Respectful and empowering: plan language is descriptive, respectful, empowering and uses everyday words that the person, those important to person and providers can understand
2. Focuses on the positive: plan identifies positive information and builds on strengths, using a trauma-informed approach
3. Makes connections: important ideas are organized and interwoven throughout plan
4. Detailed and thorough: “important to” and “important for” are specific, detailed, and reflected in outcomes and services
5. Clear outcomes and action steps
6. Includes clear description of services and supports necessary to address the needs and preferred methods for those to be delivered
7. For Medicaid-funded services: includes type of service, scope, amount, frequency, duration, and provider type

The PCP/OISP document focuses on what is important to the individual with clear identification of preferred outcomes and choices that allow the individual to become as independent as possible. The plan should also identify individual choices and desires in all areas of their life including their home, work, and community.

The plan documents must include the following: individual and/or guardian consents, CFA’s, formal programming, supports, treatments, risk/safety plans, medical needs, social history, discharge planning, and any other information that is pertinent to the individuals’ services.

When any change(s) or recommendation(s) are made to the PCP/OISP, the changes must be updated and reflected on the PCP. The updated PCP/OISP must then be reviewed by all staff to implement the PCP/OISP for the individual.

The current PCP/OISP documents will be stored on Brittco, the secured shared drive, and in each individual’s program chart. Our goal is to limit the amount of paper used; however, a copy of the PCP/OISP will be provided to the individuals’ guardian and at the request of the individual.

Last Revised: 11/3/23