4.13 ICF – Individual Goal Plans
The purpose of Program Training Plans (PTPs)/goals is to assist Direct Support Professionals (DSPs) to consistently implement formal skill training for goals identified by the person-centered planning team. Program training plans need to address deficits in self-medication abilities, money skills, and activities of daily living, use of adaptive equipment and/or visual aids, and communication.
The QIDP is responsible for developing and implementing the Program Training Plans/goals identified by the IPP team at the annual, semi-annual or addendum IPP meeting.
Timeline for Completion
The Program Training Plans should be developed and implemented no later than the first of the month following the IPP meeting in which the goal was developed. For a new admission, the PTPs/goals should be developed and implemented no later than thirty (30) days from the date of admission.
At the IPP meeting, the team should develop goals/objectives for implementation to teach an individual a new skill, refine a current skill, or assist in preventing skill deterioration. The QIDP should write PTPs based on the goals identified. The individual’s name, the program title, the initiation date, and the meeting date should be filled in. Each section of the PTP/goals should then be completed.
The goal should be stated in terms of a single targeted outcome and in terms that provide measurable indices of performance. A number should be assigned to the goal for tracking purposes. The goal should identify the priority of the program. For instance, the goal deemed the most important by the team would be goal #1.
The current objective is the first step in meeting the goal. It should be stated in the form of a single targeted outcome and in terms that provide measurable indices of performance. The objective should be relative to the goal and based on a skill that is required to meet the goal. Note: Objectives should be listed in progressive order (when using forward chaining techniques). For instance, if the goal is to complete laundry, the 1st objective may be to sort clothes into darks and lights, the 2nd objective may be to place clothes in washer, etc.
The number of times in a month the program/goal should be implemented to ensure the individual has the opportunity to obtain the skill. The frequency should be stated in a range of time, for instance 10 – 20x a month etc. it is important to be sure that the frequency is set at a number that is obtainable for the individual. For instance, a PTP/goal on going to the bank to cash a paycheck may only be able to be done twice a month.
The amount of time each trial should take. This should be stated in a range of time, for example, 5-10 minutes, 1-5 minutes, 30-60 minutes etc.
This should identify the person responsible for monitoring the PTP/goal to be sure that it is being implemented appropriately. For most PTPs/goals this will be the QIDP, however, for specialized therapy PTPs/goals, it may be the therapist or therapist assistant.
This should identify who is responsible for implementing the PTP/goal. For most PTPs/goals this would be the DSPs, Case Managers, and QIDPs. However, for specialized therapy goals, it may be the therapist or therapist assistant.
This is the date when it is anticipated that the objective/goal will be met. The target dates for each PTP/goal should be individualized for the objectives/goals and should not be the same.
These are the next steps/objectives that the individual should be trained on to meet the goal. They should be organized to reflect the developmental progression appropriate to the individual. The projected objectives should be stated in terms of a single targeted outcome and in terms that provide measurable indices of performance. The projected objectives should be relative to the goal and based on a skill that is required to meet the goal.
The task content should list the step or steps that the individual is required to complete for the program/goal.
This section should be completed to provide direction to DSPs on when and how to implement the training program/goal. It should identify any needed materials for the program/goal, times that would be best to implement the program/goal, ways to approach the individual to complete the program/goal, etc. This section should include directions on how to document the individual‘s response to the training on the data sheet. PTP/goal objectives can be designed to train the individual on an entire task or broken down into the steps required for a task. For instance, a meal preparation program/goal may train on how to prepare a boxed food item or may train on one step of that task such as mixing the ingredients or adding ingredients to a pan.
Opportunities for Continuous Training
This should be completed to indicate times when this skill may be informally taught to the individual. For example, if an individual is on a program/goal to heat an item in the microwave, DSPs may encourage the individual to display the same skills (using the microwave) when they are not implementing the PTP/goal.
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Last Revised: 4/29/22