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Hear from COFAR
Voice your opinion
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Assessments and Consultations
In developing the ISP, DMR must conduct "assessments and consultations" in order to establish agreed-upon goals for your family member or ward and strategies for reaching those goals (CMR 6.22). Among the assessments that are required by the regulations to be reviewed by the service coordinator on an annual basis are:
- An assessment of the type of services needed by the person
- An assessment of the person's ability to make informed decisions about his or her financial and personal affairs; and
- An assessment of the person's financial status and eligibility for services or benefits from other entities such as the Social Security Administration [115 CMR 6.22 (3)].
The ISP Timetables
The timetables for ISP meetings and the development of ISPs themselves, as well as the timetables for reviews, approvals, updates, modifications and appeals of the ISP are spelled out in the DMR regulations. The following is intended to help you sort through these timetables so that you can better understand your rights and obligations and DMR's obligations concerning them. If there are delays in the scheduling or processing of your ward's or family member's ISP, it may be helpful to you to be able to determine whether a violation of DMR regulations was involved.
The ISP Meeting
The ISP process starts with the ISP Meeting, which is normally set up by your ward's or family member's service coordinator. The regulations [115 CMR 6.23 (1)] state that during the Meeting, the members of the ISP team must develop a plan that describes "goals for the individual as well as services needed to reach those goals." The plan must describe the availability of those services and must include strategies for meeting those needs of the person for which services may not be available.
Quality of Life Areas
The regulations [115 CMR 6.23 (2)] list six quality of life areas, within which, the services in the ISP must promote positive outcomes. The quality of life areas are: 1) Rights and Dignity 2 Individual Control 3) Community Membership 4) Relationships 5) Personal Growth and Accomplishments; and 6) Personal Well-Being (Health Safety and Economic Security). (These areas are similar to the six Principles listed under the DMR's Standards to Promote Dignity (115 CMR 5.03), which are discussed in Section 1 of this Advocacy Guide: Advocating Effectively on Behalf of Your Family Members and Wards.)
Under Personal Well-Being (Health, Safety, and Economic Security), as an example, the regulations state that the ISP must promote an outcome that ensures that:
"the individual receives health care and related services which are sufficient and appropriate to optimize the individual's health and well-being; he or she lives and works in environments that are safe, secure, and are adapted if necessary to meet the individual's needs, and safeguards are in place to respond to emergencies and threats to the individual's health or safety; [and] he or she has sufficient economic resources to meet his or her needs."
Components of the ISP Meeting
NOTE: Keep the following two checklists in mind when you attend your ISP Meeting:
ISP Checklist 1: The regulations [6.23(4)] stipulate that the ISP Meeting must cover the following areas at a minimum:
- Discussion of, and identification of, your family member's or ward's goals and desires in terms of the quality of life areas identified under 115 CMR 6.23(2) [see Quality of Life Areas above];
- Discussion of experiences and events in recent years that may affect the person's immediate future, general health, safety, or long-term goals; and
- Development of a "support agreement."
ISP Checklist 2: The ISP or "support agreement" must include following:
- Specific goals for each area referred to above [ask that the goals on your wish list be included in the ISP support agreement];
- Strategies and least restrictive services to reach these goals [ask that services on your wish list be included in the ISP support agreement];
- The expected duration and frequency of the services [ask that any specific statements about these on your wish list be included in the ISP support agreement];
- Criteria to be used in evaluating the effectiveness of the services;
- Any unmet needs for services and the strategies which will be utilized to address those needs;
- The team members' responsibilities for monitoring and reporting on the implementation of the support agreement as well as the format and frequency of such monitoring and reporting; and
- The date of the next review of the ISP, which can be no later than one year from the date of the ISP meeting.
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