{"ref":"LA-HC-SP-01","title":"Individual Service Plan","category":"Service delivery","summary":"Sets how the Agency develops a person-centered individual service plan (ISP) for every client upon admission and before services begin, based on the comprehensive assessment, with the client taking part; what the ISP must contain under LAC 48:I.5041.F; how a Medicaid plan of care (LT-PCS or waiver) is used; how every worker is informed of and trained on the plan; and how the plan is reviewed no less than annually and whenever the client's needs change.","inShort":["Every client has a written individual service plan, made with the client before services begin.","Read the plan before your first visit and sign the staff briefing. Ask your supervisor about anything you do not understand.","Do the tasks in the plan, the way the client wants them done, at the time and place assigned.","For LT-PCS clients, never add tasks or hours beyond the plan of care. Write each task in the service log as you do it.","Tell your supervisor when the plan no longer fits the client; plans are reviewed at least once a year and whenever needs change."],"primaryCitation":"LAC 48:I.5041","citations":["LAC 48:I.5041","LAC 48:I.5041.A","LAC 48:I.5041.B","LAC 48:I.5041.C","LAC 48:I.5041.D","LAC 48:I.5041.E","LAC 48:I.5041.F","LAC 48:I.5041.G","LAC 48:I.5041.H","LAC 48:I.5041.I","LAC 48:I.5041.J","LAC 48:I.5003","LAC 48:I.5039.A","LAC 48:I.5049.A.9","LAC 48:I.5055.C.10","LAC 48:I.5055.G.1","LAC 48:I.5055.H.1.i","LAC 48:I.5055.M.2","LAC 48:I.5055.M.5","LAC 48:I.5057.A","LAC 48:I.5057.A.2","LAC 48:I.5081.A","Medicaid Services Manual, Chapter 30, §30.7","Medicaid Services Manual, Chapter 30, §30.8"],"federalCitations":["42 CFR §441.301(c)(4)"],"surveyorAsks":["Show me this client's individual service plan. Was it in place before the first visit, and what assessment is it based on?","Who took part in developing the plan? Where did you document that you consulted the client about who should be involved, and who attended?"],"forms":[{"ref":"LA-HC-SP-01-A","title":"Individual Service Plan"}],"headings":["Terms of Reference","1. Purpose","2. Scope","3. Definitions","4. Policy Statement (LAC 48:I.5041)","5. When the ISP Is Developed","6. The Planning Process","7. What the ISP Contains (LAC 48:I.5041.F)","8. Medicaid Plans of Care (LAC 48:I.5041.H)","8.1 LT-PCS beneficiaries","8.2 Waiver participants","9. Informing and Training Staff on the ISP","10. Carrying Out the ISP","11. Review and Revision","12. Coordinating the ISP With Others","13. Responsibilities","14. Records and Compliance Monitoring","15. Staff Training","16. References","17. Related Policies and Forms","18. Approval","19. Revision History"],"version":"1.0","sample":false,"pack":"la-hca","state":"Louisiana","service":"Home care","guides":[{"path":"/guides/home-care-agency-policies/","h1":"What policies does a home care agency need?"}],"agency":{"name":"Sample Agency","legalName":"Sample Agency, LLC","logo":null}}