Universal Individual ServicePlan (ISP)

Individual Service Plan (ISP)

Agency Information
Agency Name:
Agency Address:
City / State / ZIP:
Phone Number:
Email Address:

Purpose of This Plan

This Individual Service Plan (ISP) outlines the person-centered goals, services, and supports required to meet the needs of the client.

This plan is developed collaboratively with the client, family/representatives, and service providers, and complies with applicable Medicaid waiver programs, state regulations, and agency policies.

Section 1: Client Information
Client Full Name:
Date of Birth:
Medicaid ID (if applicable):
Program Type:
  • HCBS Waiver
  • Private Pay
  • Insurance
  • Other:
ISP Effective Date:
Next Review Date:
Primary Address:
Preferred Language:
Preferred Communication Method:
Section 2: Legal Representative / Emergency Contact
Legal Representative
Name:
Relationship:
Phone:
Email:
Emergency Contact
Name:
Relationship:
Phone:
Section 3: Service Coordination / Case Management
Service Coordinator Name:
Agency / Organization:
Phone Number:
Email Address:
Section 4: Comprehensive Assessment Summary
Medical Diagnoses / Conditions:
Physical Abilities & Limitations:
Cognitive / Behavioral Status:
Communication Abilities:
Strengths & Preferences (Person-Centered):
Areas Requiring Support:
Behavioral / Emotional Considerations:
Section 5: Person-Centered Goals & Outcomes
Goal 1
Goal Description:
Objectives / Action Steps:
Responsible Party:
Target Date:
Progress Notes:
Goal 2
Goal Description:
Objectives / Action Steps:
Responsible Party:
Target Date:
Progress Notes:
Section 6: Services and Supports Plan
Authorized Services:
  • Personal Care
  • Skilled Nursing
  • Companion Care
  • Behavioral Support
  • Respite Care
  • Homemaker Services
  • Transportation
  • Day Program / Adult Day Care
  • Medication Management
  • Therapy Services (PT / OT / ST)
  • Other:
Frequency:
Duration:
Provider / Agency:
Service Description:
Staff Responsibilities:
Section 7: Risk Management & Safety Plan
Identified Risks:
  • Falls
  • Wandering
  • Medication Errors
  • Behavioral Risks
  • Medical Conditions
  • Other:
Preventative Measures:
Emergency Plan:
Client Preferences & Safety Instructions (Dignity of Risk):
Section 8: Daily Living & Personal Care Needs
Daily Routine:
Activities of Daily Living (ADLs):
  • Bathing
  • Dressing
  • Grooming
  • Toileting
  • Feeding
  • Mobility / Transfers
  • Meal Preparation
  • Housekeeping
  • Other:
Dietary Needs / Restrictions:
Mobility / Equipment:
  • Wheelchair
  • Walker
  • Cane
  • Bed Rails
  • Oxygen
  • Other:
Section 9: Medical & Medication Information
Primary Physician:
Physician Contact:
Specialists:
Medication Management:
  • Self-Administered
  • Staff-Assisted
  • Nurse-Administered
Medication Details:
Allergies / Alerts:
Section 10: Rights, Consent & Advocacy
  • Client Rights Provided and Explained
  • Informed Consent Obtained
  • Grievance Procedure Explained
  • Privacy Practices (HIPAA) Reviewed
Advocates / Support Systems:
Section 11: Review & Authorization
Service Coordinator Signature:
Date:
Client / Guardian Signature:
Date:
Agency Representative Signature:
Date:
Additional Signature:
Date:
Section 12: Plan Monitoring & Review
Last Review Date:
Review Frequency:
  • Monthly
  • Quarterly
  • Annually
  • As Needed
Section 13: Plan Updates / Revisions
Date of Update:
Changes in Goals:
Changes in Services:
Changes in Condition / Needs:
Section 14: Additional Notes