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4.10 SCL – Person Centered Plan

Overview

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

For SCL settings, the County Service Support Administrator is responsible for coordinating and developing the PCP/ISP document. The PCP is developed through team assessments and evaluations from all interdisciplinary team members. The Open Door Program Coordinator is responsible for completion of all tasks outlined on the Open Door ISP Checklist.

The PCP/ISP and all team recommendations are discussed during team meetings. The County SSA is responsible for coordinating and chairing meetings. The individual is encouraged to invite those that they prefer to attend their meetings. The individual is encouraged to participate to the level that they wish in their meetings. 

Meetings must be held upon admission for development of initial PCP/ISP. After initial meeting, meetings are scheduled at least annually. In addition, any team member may request to have addendum meeting to address any concerns or needs 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/ISP 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: individual and/or guardian consents, assessments, formal programming, all supports, treatments, risk/safety plans, medical needs, discharge planning, service authorizations, agreement pages, and any other information pertinent to individual services. 

When any change or recommendation is made to the PCP/ISP, the plan document must be updated. The plan must be reviewed by all staff in order to implement the PCP/ISP for all individuals. 

The current PCP/ISP documents will be stored on the secured Shared Drive and in each individual’s program chart.  A copy of the PCP/ISP will be provided to individuals and guardians.

Service plan documentation must be indicated as a need in the PCP. Open Door will ensure that documentation systems accurately reflect only the person-centered objectives for each individual and not just a standard data collection or additional supports not outlined as part of the person’s individual plan.

Last Revised: 8/25/21

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