12VAC35-105-660. Individualized services plan (ISP).

C. This ISP shall be developed based on the initial assessment with the full participation and informed choice of the individual receiving services. To ensure the individual’s participation and informed choice, the provider shall explain to the individual or his authorized representative, as applicable, in a reasonable and comprehensible manner, the proposed services to be delivered, alternative service or services that might be advantageous for the individual, and accompanying risks or benefits. The provider shall clearly document that this information was explained to the individual or his authorized representative and the reasons the individual or his authorized representative chose the option included in the ISP.

Comment: If the ISP is a person-centered plan, completed with the individual/AR/Legal guardian then documenting the reason why an option is chosen in an ISP seems to be redundant documentation.

12VAC35-105-675. Reassessments and ISP reviews.

D. The provider shall review the ISP at least every three months from the date of the implementation of the ISP or whenever there is a revised assessment based upon the individual's changing needs or goals.

2. These reviews shall document evidence of progression towards or achievement of a specific targeted outcome for each goal and objective.

Comment: Reassessment and ISP reviews do not always result in progress. This line indicates there is always progress. It should end with an or …  this would lead into the next line of what to do if there is no progress.

3. For goals and objectives that were not accomplished by the identified target date, the team shall meet to review the reasons for lack of progress and provide the individual an opportunity to make an informed choice of how to proceed.

Comment: the line that states teams shall meet implies a face to face meeting with all parties working with the individual at every review / reassessment. This is not always possible for all cases and across all disabilities. Documenting care coordination on an ongoing basis and on an as needed basis should be sufficient.