If there is a need for service coordination between providers, include the name of service provider, contact person and telephone numbers, services being provided, and the names of staff responsible for coordination: STAFFING/SUPERVISION NEEDS: Person accesses support as needed Person requires some services, doesn’t require 24 hour plan of care Person needs 24 hour plan of care (may not require supervision at all times but there is someone identified/assigned that is responsible and accessible to the consumer in case of emergency. 24 hour plan of care required for individuals in ICF-MR and waiver eligible individuals). Person requires overnight supervision Person requires 24 hour awake supervision LEVEL OF SERVICES REQUIRED FOR HEALTH AND SAFETY SUPPORTS (check one): Current level of services required for health and safety supports (check one): Full day Partial day other (specify other): Can be without caregiver for minutes hours (check one) Other: Specific Plan: (Identify in detail any special arrangements which would need to be implemented in order for person to remain alone or unsupervised or identify where specific plan is located). OF SUPPORT REQUIRED FOR RESIDENTIAL SERVICES: Support person on premises at all times when individual is home. Can be unsupervised at home for minutes hours (check one) (Specify details of alone time if there are specific limitations or plans associated with alone time under the specific plan section.) Can be unsupervised in the community for minutes hours (check one) Specific Plan: (Identify in detail any special arrangements which would need to be implemented in order for person to remain alone or unsupervised or identify where specific plan is located). Does the person require a restriction of their rights as determined necessary to ensure the health, safety, and well-being of the person? Yes No If yes, indicate what right(s) are restricted: to the attached form for all additional requirements and documentation.) Rights Restrictions Can this person use dangerous items or equipment? Yes No If yes, address any concerns or limitations: Has it been determined by the person’s physician or mental health provider to be medically or psychologically contraindicated to use an emergency use of manual restraint when a person’s conduct poses an imminent risk of physical harm to self or others and less restrictive strategies would not achieve safety? Yes No Requested but have not yet received If yes, the company will not allow the use of the behavioral intervention/manual restraint to be used for the person. Health Needs
If there is a need for service coordination between providers, include the name of service provider, contact person and telephone numbers, services being provided, and the names of staff responsible for coordination: STAFFING/SUPERVISION NEEDS: Person accesses support as needed Person requires some services, doesn’t require 24 hour plan of care Person needs 24 hour plan of care (may not require supervision at all times but there is someone identified/assigned that is responsible and accessible to the consumer in case of emergency. 24 hour plan of care required for individuals in ICF-MR and waiver eligible individuals). Person requires overnight supervision Person requires 24 hour awake supervision LEVEL OF SERVICES REQUIRED FOR HEALTH AND SAFETY SUPPORTS (check one): Current level of services required for health and safety supports (check one): Full day Partial day other (specify other): Can be without caregiver for minutes hours (check one) Other: Specific Plan: (Identify in detail any special arrangements which would need to be implemented in order for person to remain alone or unsupervised or identify where specific plan is located). OF SUPPORT REQUIRED FOR RESIDENTIAL SERVICES: Support person on premises at all times when individual is home. Can be unsupervised at home for minutes hours (check one) (Specify details of alone time if there are specific limitations or plans associated with alone time under the specific plan section.) Can be unsupervised in the community for minutes hours (check one) Specific Plan: (Identify in detail any special arrangements which would need to be implemented in order for person to remain alone or unsupervised or identify where specific plan is located). Does the person require a restriction of their rights as determined necessary to ensure the health, safety, and well-being of the person? Yes No If yes, indicate what right(s) are restricted: to the attached Rights Restrictions form for all additional requirements and documentation.) Can this person use dangerous items or equipment? Yes No If yes, address any concerns or limitations: Has it been determined by the person’s physician or mental health provider to be medically or psychologically contraindicated to use an emergency use of manual restraint when a person’s conduct poses an imminent risk of physical harm to self or others and less restrictive strategies would not achieve safety? Yes No Requested but have not yet received If yes, the company will not allow the use of the behavioral intervention/manual restraint to be used for the person. Health Needs
CSSP-Addendum.docx