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4.13 SCL – Individual Goal Plans


The Case Manager/Program Coordinator will prepare documentation that supports individual outcome goals for an individual before providing personal services for the individual. The Case Manager/Program Coordinator will ensure the goal plan reflects the person-centered model of what is important for, what is important to, and displays personal choice, preferences, and outcomes.


  1. The Case Manager/Program Coordinator will attend the ISP meeting.
  2. The Case Manager/Program Coordinator will be responsible for developing individual goal plans in the electronic documentation system.
  3. The services offered and planned for each individual will be appropriate to the scope, frequency, need, steps to complete, path to employment and preference of each individual.
  4. The individual outcome goal plan may be based on personal interests, preferences, and outcomes for personal goals, path to employment, relationships with family and friends, participation in and/or roles in the community.  The outcome goal should be chosen by the individual and approved by the team.
  5. Direct Support Professionals (DSPs) will implement and document outcomes using the electronic forms.
  6. Documentation of outcome goal plan sheets will be evaluated during random program department audits and through monthly reviews by Case Manager/Program Coordinator. Any deficiencies must be addressed within 14 days of audit finding. The standards of conduct in Policy 2.15 outline corrective action measures for failure to complete documentation to meet standards.

Monthly Summary

The Case Manager/Program Coordinator is required to review and monitor all individual outcome goal plan and service delivery monthly. A summary must be completed to document the progress of individual goals. The assigned Case Manager/Program Coordinator must compile all data to complete the monthly summary documenting progress on all goals. The Case Manager/Program Coordinator must review progress to determine whether to continue, revise, or discontinue the outcome goal plan. Goal progress must be reviewed during ISP/PCP meetings. Monthly summaries are stored on shared file drive each month to review outcome progress.

Signed by:

Rebecca Sharp Porter
Chief Executive Director

Last Revised: 4/30/21

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