Person-Directed Planning for State Supported Living Centers

PDPSSLC, Section 1000 Introduction

Revision 07-0; Effective September 1, 2007

Person-directed planning (PDP) reflects a growing trend in the way services are delivered to people with developmental disabilities. When a person is offered intellectual disability services and supports, he or she works with a qualified intellectual disability professional (QIDP), family, friends, providers and other members of a Personal Support Team (PST) to develop a personalized plan of services and supports.

The QIDP and PST use a process that empowers the person to direct the development of a plan that meets his or her goals. This handbook provides some direction to consumers, families, professionals, providers and local authorities in the development of effective PDPs. The Appendix Section offers Tools the PST and staff members can use to develop a Personal Support Plan (PSP). The Forms Section offers the documents needed to prepare a PSP that will enable a person to make and achieve his or her goals.

Appendices, PDPSSLC

PDPSLLC, Appendix I, Tool I — Person-Directed Planning Terms

Revision 07-0; Effective September 1, 2007

 

Achievement/Abilities Worksheet — A document used to summarize achievements and abilities identified in assessments/worksheets. The qualified intellectual disability professional (QIDP) distributes the worksheet to the Personal Support Team (PST) no later than one week before the Personal Support Plan (PSP) meeting. The document is finalized at the meeting. See Form 6610, Achievements and Abilities.

Action Plan — A document used to reflect the person's desired goals and how his or her outcomes are supported. See Form 6622, Action Plan.

Assessments/Services the Person Uses/Needs — A document used to gather information and recommendations from assessments/summaries. The QIDP completes the form and distributes it to the PST no later than one week before the PSP meeting. The document is finalized at the PSP meeting. See Form 6611, Assessments/Services.

Communications Dictionary — A form used to determine how a person communicates basic wants and needs. See Form 6631, Communications Dictionary.

Discussion Records

  • General — A form used to record PST deliberation and resolution of issues (for example, resolution of discrepancies). See Form 6619, General Discussion Record.
  • Integration of Programs — A document used to explain how a program, such as an Individual Education Plan, is reinforced in the home setting. See Form 6621, Program Integration Discussion Record.
  • Living Options — A document used to record PST deliberation of the person's choice of home and supports that would be needed for the person to live in a community setting. See Form 6620, Living Options Discussion Record.

Learning Log — A tool used to document how a person responds to new experiences, such as community outings, meeting new people, etc. See Tool XI, Learning Log.

Personal Focus Worksheet (PFW) — An information-gathering document completed six weeks before the PSP meeting by the person, PST members and anyone else the person chooses. See Form 6605, Personal Focus Worksheet.

Personal Support Plan (PSP) — The plan that supports the hopes, dreams and visions of the person whose plan is being developed. See Form 6609, Personal Support Plan (PSP).

Personal Support Plan Addendum — A meeting in which the PST discusses and makes recommendations to change the PSP. See Form 6624, Personal Support Plan (PSP) Addendum, Form 6625, Personal Support Plan (PSP) Addendum – Living Options, Form 6626, Personal Support Plan (PSP) Addendum – Level of Supervision, Form 6627, Personal Support Plan (PSP) Addendum – Psychoactive Medication Algorithm State 1 Review of Behavioral Health and Environmental Interventions, Form 6628, Personal Support Plan (PSP) Addendum – Four or More Restraints in a 30-Day Period, and Form 6629, Personal Support Plan (PSP) Addendum – Medical High Risk.

Personal Support Team (PST) — A group of people, who, in some cases, is chosen by the person being served to develop, implement and monitor the effectiveness of the PSP.

Person-Directed Planning (PDP) — An approach in which people with developmental disabilities are systematically supported in terms of health, safety and what's important to them.

Preplan Meeting Addendum — A meeting conducted three weeks before the PSP in which the Risk Screening Tool is reviewed, and the Functional Analysis and Psychology Summary (if applicable) are reviewed to develop a Behavior Support Plan.

Preplanning Questionnaire — An information-gathering document sent to the legally authorized representative/family/advocate/correspondent with invitation letters six weeks before the scheduled PSP. See Form 6604, Preplanning Questionnaire.

Rights Assessment — A document completed at the PSP meeting to ensure that all rights issues have been addressed and receive due process. See Form 6614, Rights Assessment.

Risk Screening Tools — Forms completed six weeks before the PSP and used to identify significant risks to the person. See Form 6606-A, Risk Screening Tool – Constipation, Seizures, Specific Concerns, Form 6606-B, Risk Screening Tool – Aspiration/Choking, Dehydration, and Form 6606-C, Risk Screening Tool – Behavior.

Risk Tracking Record (RTR) — A document the QIDP uses to summarize information from the Risk Screening Tool and develop supports to minimize risks. The QIDP completes a draft and distributes to PST members no later than one week before the PSP meeting. The document is finalized at the PSP meeting. See Form 6612, Risk Tracking Record.

PDPSSLC, Appendix II, Tool II — Time Line Steps for Personal Support Planning

Revision 07-0; Effective September 1, 2007

For information about document accessibility, contact DADS at handbookfeedback@hhsc.state.tx.us.

PDF file for Appendix IITool II — Time Line Steps for Personal Support Planning

PDPSSLC, Appendix III, Tool III — Personal Support Plan (PSP) Notification Instructions

Revision 07-0; Effective September 1, 2007

 

PURPOSE

To obtain participation from designated staff in the development and planning of the PSP.

PROCEDURE

When to Prepare

Six weeks before the scheduled PSP

Responsible Party

Qualified intellectual disability professional (QIDP)

Steps to Notification

  • Notify designated staff to include home supervisor, psychologist and registered nurse via e-mail, mail or telephone of the scheduled PSP meeting (date, time and location) and date when all reports/assessments are due to the QIDP.
  • When applicable, instruct staff to come prepared to review the functional analysis and psychology summary for recommendations and input into the development of the Behavior Support Plan.
  • Remind staff to complete Form 6605, Personal Focus Worksheet, and the relevant Risk Screening Tools for the person served. Submit forms to the QIDP three weeks before the scheduled PSP.

Retention

QIDP file

PDPSSLC, Appendix IV, Tool IV — Personal Support Plan (PSP) Meeting Instructions

Revision 07-0; Effective September 1, 2007

PURPOSE

The PSP meeting is a process in which the person served, legally authorized representative (LAR) and Personal Support Team (PST) discuss and develop a plan to support the person in living a healthier and happier life.

PROCEDURE

When to Prepare

Annually

Participants

Person served, LAR/advocate, PST members and people chosen by the person participate in the meeting. The qualified intellectual disability professional (QIDP) completes Form 6609, Personal Support Plan.

Steps to Complete

Encourage the person to facilitate his or her own meeting if able. This will set the tone for who directs the PSP meeting.

  1. Introductions
  2. Review agenda.
  3. Review the PSP draft sent before the meeting for any discussion, revisions and approval.
    • Document any discussion and resolution of discrepancies on a discussion record.
    • Make revisions to the PSP as agreed upon by the PST.
  4. Complete Form 6614, Rights Assessment.
  5. Complete Form 6620, Living Options Discussion Record.
  6. Develop action plans based on all discussions, recommendations and information shared. Action plans will incorporate programming, services provided, what is important to the person, recommendations, etc.
  7. Complete Form 6621, Program Integration Discussion Record, to reflect how services from outside the facility will be integrated into the plan.
  8. Discuss any additional concerns and issues that need to be addressed.
  9. Complete CARE forms.
  10. Complete Form 6623, Personal Support Team Signature Sheet.
  11. The QIDP is responsible for finalizing the PSP document and distributing it per facility policy.

PDPSSLC, Appendix V, Tool V — Person-Directed Planning (PDP) Training

Revision 07-0; Effective September 1, 2007

For information about document accessibility, contact DADS at handbookfeedback@hhsc.state.tx.us.

PDF file for Appendix V Tool V-ATool V-A — Person-Directed Planning (PDP) Training Pretest

PDF file for Appendix V Tool V-BTool V-B — Person-Directed Planning (PDP) Training Post-Test

PDPSSLC, Appendix VII, Tool VII — Other Tools

Revision 07-0; Effective September 1, 2007

For information about document accessibility, contact DADS at handbookfeedback@dads.state.tx.us.

PDF file for Appendix VII Tool VII-ATool VII-A — Action Plan Desired Outcome Ideas
PDF file for Appendix VII Tool VII-BTool VII-B — People First Language

PDPSSLC, Appendix VIII, Tool VIII — Person-Directed Plan Scheduler

Revision 08-1; Effective June 26, 2008

How to Use the PDP Excel Scheduler

Step 1: Enter the person's full name into Column B.
Step 2: Enter that person's last annual meeting date into Column C (this will automatically fill in Columns D and E).
Step 3: Use the date in Column D to guide your discussion with the person to determine his or her preference regarding when he or she would like to have the meeting. For example, if the meeting is due 7/9/07, talk to the person to find out if he or she is in agreement with scheduling the meeting sometime before or on that date. Once a date is agreed upon, enter that date into Column F (this will automatically fill in Columns G through O).

 

Microsoft Excel file for Appendix VIII Tool VIIIPerson-Directed Plan Scheduler

PDPSSLC, Appendix IX, Tool IX — Value Tools

Revision 07-0; Effective September 1, 2007

People with mental retardation experience emotions common to all human beings: joy, sadness, anger, boredom and interest. They can learn, adjust socially and benefit from appropriate education, training, personal care and opportunities to work.

These tools will give you a better perspective on the challenges the people we serve deal with every day, as well as a better sense of the lives they lead.

PDPSSLC, Appendix X, Tool X — Living Options

Revision 10-1; January 8, 2010

For information about document accessibility, contact DADS at
handbookfeedback@dads.state.tx.us.

Tool X-A — Explanation of Services and Supports

PDF File for Appendix X Tool X-BTool X-B — Living Options Monitoring Instrument

PDF File for Appendix X Tool X-CTool X-C — Living Options Worksheet

PDPSSLC, Appendix XI, Tool XI — Learning Log

Revision 07-0; Effective September 1, 2007

Date:

Name of Person Attending Activity:

Name of Person Completing Form:

Please complete the Learning Log for experiences that are new for the person. These might include community outings, recreation experiences, visits with friends or unusual reactions or responses to events.

What did the person do? (What, where, when, how long, etc.)  
Who was there? (Names of staff, friends, etc.)  
Successes:
What did you learn about what worked? What did the person like about the activity? What needs to stay the same?
 
Observations, ideas to improve the experience: What did you learn about what didn't work well? What didn't the person like about the activity? What needs to be different?  

PDPSSLC, Forms

Form Title
6600 Personal Support Preparation Worksheet
6601 Legally Authorized Representative, Advocate, Correspondent Invitation Letter
6601-S Legally Authorized Representative, Advocate, Correspondent Invitation Letter (Spanish)
6602 Local Authority (LA) Invitation Letter
6604 Preplanning Questionnaire
6604-S Preplanning Questionnaire (Spanish)
6605 Personal Focus Worksheet
6605-S Personal Focus Worksheet (Spanish)
6606-A Risk Screening Tool - Constipation, Seizures, Specific Concerns
6606-B Risk Screening Tool - Aspiration/Choking, Dehydration
6606-C Risk Screening Tool - Behavior
6609 Personal Support Plan
6610 Achievements and Abilities
6611 Assessments/Services the Person Uses/Needs
6612 Risk Tracking Record
6613 Agenda for Personal Support Plan (PSP) Meeting
6615 Admission Personal Support Plan (PSP)
6619 General Discussion Record
6620 Living Options Discussion Record
6621 Program Integration Discussion Record
6622 Action Plan
6623 Personal Support Team Signature Sheet
6624 Personal Support Plan Addendum
6625 Personal Support Plan Addendum - Living Options
6626 Personal Support Plan Addendum - Level of Supervision
6627 Personal Support Plan Addendum - Psychoactive Medication Algorithm State Review of Behavioral Health and Environmental Interventions
6628 Personal Support Plan Addendum - Four or More Restraints in a 30-Day Period
6629 Personal Support Plan Addendum - Medical High Risk
6630 Personal Support Plan Quarterly Report
6631 Communications Dictionary

Informacion in espanol = form also available in Spanish.

PDPSSLC, Revisions

PDPSSLC, Revision 10-1, Updated Handbook Title and Link

Revision Notice 10-1;Effective January 8, 2010

 

Revised

The handbook title has been updated to reflect new terminology for state supported living centers (formerly state schools). In addition, links and references have been updated in Appendix X-A, Explanation of Services and Supports.

PDPSSLC, Revision 08-1, Revised Appendix VIII, Person-Directed Plan Scheduler

Revision Notice 08-1; Effective June 26, 2008

 

Revised

  • Appendix VIII, Person-Directed Plan Scheduler

This revision adds a column for sending a Personal Support Plan Invitation Letter to contracted or designated MRAs to meeting scheduling process.

PDPSSLC, Contact Us

For technical or accessibility issues with this handbook, email: handbookfeedback@hhsc.state.tx.us