MODULE 5 DSP NOTEBOOK

INDIVIDUAL SERVICE PLAN

DEVELOPMENT
AND IMPLEMENTATION
Module 5 DSP Notebook Individual Service Plan Development & Implementation

TABLE OF CONTENTS
INTRODUCTION.............................................................................................................. 2

WHAT IS THE INDIVIDUAL SERVICE PLAN (ISP)? ........................................................ 3

DESCRIPTION OF INDIVIDUAL SERVICE PLAN FOR ADULTS ....................................... 4

ACTIVITY: ....................................................................................................................... 5

ISP SCAVENGER HUNT ................................................................................................... 6

WHAT IS THE IDT? ......................................................................................................... 8

WHO MAKES UP THE INTERDISCIPLINARY TEAM? ...................................................... 9

FAMILY INVOLVEMENT ................................................................................................ 12

WHAT IS PERSON-CENTERED PLANNING? ................................................................. 13

QUIZ - WHAT IS PERSON-CENTERED PLANNING? ...................................................... 14

DEFINITIONS ............................................................................................................... 15

NATURAL RHYTHM OF LIFE.......................................................................................... 16

COMMUNITY INCLUSION ............................................................................................. 17

THE ROLE OF THE DSP IN SUPPORTING COMMUNITY INCLUSION ........................... 18

RESOURCES AVAILABLE FOR VOCATIONAL OPPORTUNITIES .................................... 20

TEACHING FUNCTIONAL SKILLS ................................................................................. 21

TIPS FOR TEACHING FUNCTIONAL SKILLS ................................................................. 22

STIMULATION ACTIVITIES COMPARED TO REAL ACTIVITIES ................................... 23

LEARNING STYLES........................................................................................................ 24

TASK ANALYSIS ............................................................................................................ 26

TECHNIQUES FOR TEACHING NEW SKILLS ................................................................. 29

DISCOVERING REINFORCERS...................................................................................... 31

PERSONAL REINFORCERS EXERCISE .......................................................................... 32

DOCUMENTATION ........................................................................................................ 33

DOCUMENTATION SCENARIO ...................................................................................... 38

A PENNY IS...............? .................................................................................................. 39

MARTIN LUTHER KING SAID: ...................................................................................... 40

SECTIONS OF THE SERVICE PLAN ............................................................................... 41

1
R-09-01-13
Module 5 DSP Notebook Individual Service Plan Development & Implementation

INTRODUCTION

"My name is April. This year I ran my own ISP meeting by myself.
To get ready for the meeting I told my staff at my house what was
important to me and they made a list for me. I told staff the most
important things first.

We talked about me moving to a new house. This was most

important to me. I invited people to my meeting. I told my house
manager that I wanted to have food at my meeting so he brought
some. I was a little shy at first but then I told everyone what I
wanted."

Submitted by April, self-advocate from Chicago Heights, IL

2
R-09-01-13
Module 5 DSP Notebook Individual Service Plan Development & Implementation

What is the Individual Service Plan (ISP)?

The Individual Service Plan (ISP) is the written details of the supports, activities, and
resources required for the individual to achieve personal goals. The Individual Service
Plan is developed to articulate decisions and agreements made during a person-centered
process of planning and information gathering. The general welfare and personal
preferences of the individual are the key consideration in the development of all plans.

The individual and his/her team are responsible for developing the
individual plan of support. These teams, called interdisciplinary
teams (IDT), are composed of people who care about and know the
individual. The team may also ask specialists, consultants, or specific
provider staff to contribute to the plan by completing evaluations, or
by observing and collecting information that is basic to the
preparation of the plan.

The IDT is ultimately responsible for assessing and documenting each

person’s:

• Personal choices and preferences.

• Significant health care, mental health or behavioral needs and related

maintenance needs.

• Safety and financial skills.

The teams translate this information into goals and objectives, which are then contained
within the written plan. The plan results in outcomes that maintain or change services or
supports to reflect what is most important to and most important for the individual in
their daily life.

Service plans could be known as:

IPPs' Individual _________________________ Plans

ISPs' Individual _________________________ Plans

IHPs' Individual _________________________ Plans

IEPs' Individual _________________________ Plans

These are probably the most common names for service plans.

3
R-09-01-13
Module 5 DSP Notebook Individual Service Plan Development & Implementation

Description of Individual Service Plan for Adults

Although each agency has its own ISP format, there are some basic elements and
information contained in almost all plans as listed in the Appendix of this Module.

Note: Because of their highly individualized nature, not all service plans contain all the
components listed. Some plans may have additional information not listed in the
Appendix.

Life Goals

Individual Service Plans should reflect the goals of the individual

served. Because we are all different and unique people, each person’s
ISP should be unique and address the needs and desires of the person.

To begin the process, we must first learn how a person wants to live.
In your role as a DSP, you can continually encourage people to
experience new things. This enables the person to exercise greater choice in life
because they have the experience to do so. After we learn what a person wants, we can
then decide what needs to be done to help the person move toward that life.

Good plans are rooted in what is important to the person, while taking into account all
the other factors that impact the person’s life.

Life Changes

Just as people change, service plans need to be revised to reflect growth, new interests
and desires. Service plans are reviewed a minimum of once per year at Individual
Service Plan meetings. Sometimes these meetings are called annuals.

More and more, agencies are getting away from that practice and holding meetings to
discuss these plans on an as needed basis.

In a year's time, much in your own life changes. This includes developing new interests
and desires, changing where you live or work, who your friends are, etc.

4
R-09-01-13
Module 5 DSP Notebook Individual Service Plan Development & Implementation

Activity:

On a separate piece of paper, list the changes that have taken place in your own
life in the past year. Include interests, dreams, goals, relationships, births, deaths,
etc. Then we will discuss how you would feel if you had to wait for an annual meeting
to make adjustments to your plans.

_______________________________________________________________________

_______________________________________________________________________

_______________________________________________________________________

_______________________________________________________________________

_______________________________________________________________________

_______________________________________________________________________

_______________________________________________________________________

_______________________________________________________________________

_______________________________________________________________________

_______________________________________________________________________

_______________________________________________________________________

5
R-09-01-13
Module 5 DSP Notebook Individual Service Plan Development & Implementation

ISP Scavenger Hunt

Directions: Work with your assigned group to find the answer to as many of the
following questions as possible.

1. Where is the following information found in the ISP? Use page number(s) to
indicate the location(s). Note - it may be in more than one location.

Assessment results Personal Preferences

Background/Historical Personal Rights

Communication Style Personal Values

Education Personality

Financial Recent Life Changes

Goals Social Relationships

Interests & Activities Strengths & Weaknesses

Learning Style Vision for the Future/dreams

Medical/Dental/Nutritional Vocation

Personal Description

2. How does this person communicate?

3. List one of this individual's favorite activities.

4. List one of this individual's goals.

5. How will this goal be achieved?

6. When is this goal to be met?

7. What responsibility do you as a DSP have in supporting the individual in achieving

this goal?
8. Does this person have a behavior management (intervention) plan? If so, what is
6
R-09-01-13
Module 5 DSP Notebook Individual Service Plan Development & Implementation

your role in implementing it?

9. What is this individual's current medical condition? What can you do to support
his/her health?

10. Name a recent life change.

11. List five things below that you would like to know more about in order to provide
support to this individual:

1.

2.

3.

4.

5.

What Makes A Good Service Plan?

How do you know that the ISP you just reviewed is an accurate reflection of the person?
Things to check for:

C It was unique to this individual

C Focused on abilities
C Showed the person’s choices and preferences
C Was respectful
C People significant to the individual were involved
C Identified social connection
C Maintained confidentiality
C Hopes/Dreams/Goals are a priority to the individual
C Hopes/Dreams/Goals are realistic
C Hopes/Dreams/Goals are precise & measurable
C Hopes/Dreams/Goals state how they are to be met

The plan should include a personalized statement of the person’s expectations for the
future and state who will be responsible for providing the supports and services to reach
those goals. Additionally, the plan should address natural supports and connections for
people with other citizens of the community.

7
R-09-01-13
Module 5 DSP Notebook Individual Service Plan Development & Implementation

What is the IDT?

The Interdisciplinary Team (IDT) consists of at least the person, parents (except
when the person or the person’s guardian does not desire them to participate), the
guardian, as well as representatives of disciplines and services necessary to identify
the person's needs and to design services and alternatives to meet them. At least
one member of the team must be a Qualified Intellectual Disabilities Professional
(QIDP).

The IDT process assesses the strengths and needs of persons with mental
disabilities with input from the person requesting and/or receiving services and
from those providing services. The IDT works to develop and implement the
person’s service plan.

8
R-09-01-13
Module 5 DSP Notebook Individual Service Plan Development & Implementation

Who Makes Up the Interdisciplinary Team?

A number of people are involved in developing the ISP. The most important member of
the team is the person being served and there should never be a meeting without the
person. Its primary purpose is to assist the
individual with developmental disabilities in making
decisions about life goals.

Members:

The person supported and

the team of professionals, who usually include
the following:

C QIDP
C Psychologist/Psychiatrist
C Social Worker
C Doctor/Nurse
C DSP
C Nutritionist
C OT/PT
C Teacher
C Residential Representative
C Day Program Representative
C Vocational Rep/Job Coach

Note: It is usually the DSP who works most closely with the person being
supported. Your role is vital to the team.

Non-Professionals
C Friends
C Family
C Guardians
C Co-Workers

9
R-09-01-13
Module 5 DSP Notebook Individual Service Plan Development & Implementation

The DSP's Role in the Interdisciplinary Team Process (IDT)

Your role with the IDT is to assist the QIDP in determining the best course of action for
the persons you will be supporting. How will you do that? By getting to know the
persons you support and learning their likes and dislikes, documenting your
observations, and making recommendations about what you think should be included in
their plans. You may be asked to document certain behaviors. It will be up to you to
report your observations about the wants and needs of the person. Others can then
develop a plan, with the person’s input, to meet their wants and needs in order to
support change in the person’s behavior. This is not an easy job.

How will you know what supports are needed by the persons with whom you will be
assisting? First, build a relationship with them and get to know them as a person. In
order to do this it is very important to understand that you need to listen to people
objectively, without judgment. This is essential to the service planning process. In fact,
one of the most important roles of the DSP is the day-to-day getting to know the people
they support and what they want, then representing that to other members of the team.
Remember, your role is vital in developing and implementing the ISP.
When implementing the ISP it is important that you…

10
R-09-01-13
Module 5 DSP Notebook Individual Service Plan Development & Implementation

• Be Consistent - Lack of consistency leads to confusion.

• Offer a sufficient number of trials - Individuals may need a lot of practice to

attain their goals. Look for opportunities to practice and reinforce learning in
natural settings and across environments. (E.g., Spending and counting money
at Wal-Mart; using a napkin at McDonalds; etc.)

• Understand the ISP - You need to understand your role in each area of the
ISP.

• Implement the ISP in positive manner - Offer praise and encourage the
individual using positive body language and tone. Treat the individual with dignity
and in a non-condescending manner. Explain rather than demand or threaten.
Support the individual in achieving his/her goals.

• Document all required behaviors, successes and concerns related to the

ISP B The ISP is constantly changing to meet the needs, goals and desires of the
individual for whom it is written. Documentation will help identify those areas
that need adjustment.

NOTE: Be sure to communicate with your supervisor

when a goal is not working, or you are having a
difficult time with the implementation of a goal.

11
R-09-01-13
Module 5 DSP Notebook Individual Service Plan Development & Implementation

Family Involvement

Don't underestimate the importance of family involvement.

Family members can provide a wealth of information useful in
the planning process. Also, they act as a natural support system
for the individual and give meaning to his/her life. We should
respect and use them as resources.

At times, family members may not acknowledge their relatives as

adults or may resist implementing portions of the service plan. The more involvement
they have in the planning process, the less likely this will be a concern for them.

Your responsibilities include helping family members:

C see their relative as a person with dreams, hopes, and skills;

C understand the individual's strengths aptitudes, and competencies;
C identify how they can serve as resources and supports for the individual’s active
participation in community life; and
C respect the person's life goals and achievements.

People should be selected for the team based on their expertise, interest, connection,
and respect for the person for whom the planning is intended.

Information from the team members can be in the form of assessments, reports,
anecdotes or test results.

The person with a developmental disability is by far the most

important member of the IDT.

12
R-09-01-13
Module 5 DSP Notebook Individual Service Plan Development & Implementation

What Is Person-Centered Planning?

Person-Centered Planning is a set of approaches designed to assist someone to plan

their life and supports. It is used most often as a life planning model to enable
individuals with disabilities, or otherwise requiring support to increase their personal self-
determination and improve their own independence.

It is important to remember that a person-centered plan is a means not an end. The

person-centered plan is a process, not a piece of paper.
The life that a person wants is the outcome, not the plan
that describes it. Person-centered planning is a written
planning tool giving a description of where the person
wants their life to go and what needs to be done to get
there.

We’ve talked a bit about what person-centered planning is,

but sometimes knowing what it isn’t makes things even
clearer. A person-centered plan isn’t:

Stagnant (it must be revisited and re-evaluated)

Limited to available services

Unrealistic

A written plan, separate from a process

A mystical quick or easy process.

Person-centered planning involves: keeping the focus on the person and his/her
abilities. Person-centered planning means individually tailoring things for the person.

It starts with the person at the center and grows outward. It utilizes available
resources to assist the person in obtaining his/her goals and objectives. It incorporates
what is important to the person. It focuses on the strengths of the person, not the
person's deficits or limitations or those of the system.

At all times we should demonstrate respect and dignity in all that we do to support a
person with a developmental disability. `This includes protecting the person’s
confidentiality.

13
R-09-01-13
Module 5 DSP Notebook Individual Service Plan Development & Implementation

QUIZ - What Is Person-Centered Planning?

(Fill in the blanks with the information from the previous page.)

Person-centered planning involves:

C keeping the focus always on the ______________________ and his/her

abilities.

C _______________________ tailoring things to the person.

C planning for the person utilizing available ______________________ to

assist the person in obtaining his/her goals and objectives.

C incorporating what is important to the person. It focuses on the

_______________________ of a person, not the deficits or limitations,
nor those of the system.

C demonstrating _________________ and ___________________ in all

that we do to support a person with a developmental disability.

C protecting the person's __________________________.

Remember what we learned about people first language. The way we speak shows
respect or a lack of respect for an individual. We should focus on an individual's
strengths, not their problems. Our words should reflect this focus. The ISP should also
reflect this and be written in people first language.

Individual First,
Disability Last!

14
R-09-01-13
Module 5 DSP Notebook Individual Service Plan Development & Implementation

Definitions
Age-appropriate - programs, possessions, settings and activities which are appropriate
for a person’s chronological age.
Age Appropriate Activities include:
• Preparing Meals

• Reading newspaper

• Completing crossword

• Playing checkers

• Listening to music

Choice - exposing the individual to an assortment of experiences that could serve as a

basis for decision making. (John is given a chance to taste whole wheat bread as well
as white bread and then make a choice.)

Preference - an individual's personal choice after being exposed to an assortment of

things or experiences. (John indicates he prefers whole wheat bread to white bread.
How does he know? Because he has tasted both.)

15
R-09-01-13
Module 5 DSP Notebook Individual Service Plan Development & Implementation

Natural Rhythm of Life

In our society the majority of people typically go to work or school during the week with
weekend activities more relaxed and focused on leisure and social activities. For most
people, this is the natural rhythm of life. People with disabilities should be offered the
same conditions as are offered to other citizens to live as normal a life as possible.
Rhythm of life includes natural rhythm of a day, a week, a year and the life cycle itself.
Included in this natural rhythm of life are certain life conditions such as housing,
employment, exercise, recreation and freedom of choice.

As part of this natural rhythm of life, people with disabilities should be:

• Enjoying meals with others in restaurants and at picnics

• Working in regular industries
• Supported in regular homes and apartments
• Seen moving almost everywhere in our neighborhoods
• Worshipping in regular churches, synagogues, and mosques
• Cheering for their favorite local athletic teams
• Going on vacations to break up routines

16
R-09-01-13
Module 5 DSP Notebook Individual Service Plan Development & Implementation

Community Inclusion
Community inclusion is an integrated setting where people of all abilities and
backgrounds work, live, go to school, or play together. Community inclusion includes at
least six components: Presence, choice, competence, respect, participation and
belonging.

Presence - Persons participate in all settings where people without disabilities are
present, including classrooms, planning meetings, businesses, neighborhoods, and
community events.

Choice - Persons will have multiple life experiences from which to draw.
These various experiences will help him/her make decisions on what
activities he/she wants to participate in as well as choose who will
participate with them in those activities.

Competence - Persons are recognized for their strengths, contributions

and, thus, have additional opportunities from which to learn.

Respect and Valued Roles: People are seen as a person--as well as a being valued
by others, not seen as a bother.

Participation – Persons engaging with others, having a wide variety of relationships,

being known and knowing others, being part of the event--not just an observer.

Belonging – People's feelings are valued by others. For example, when others call just
to talk or invite him/her to go to a party, out to eat, to the movies, or to just "hang out."

Inclusion is NOT:
• When volunteers spend time with people out of pity or charity.
• "Special" activities or programs only for people with similar disabilities.
• Going on a series of unrelated activities, just to get out.
• Going everywhere (work, shopping, out for a walk) in groups.
• Only going places with other people with similar disabilities.
• Only interacting with people who are paid to take care of you (staff) or people
with whom you do not choose to be with.

17
R-09-01-13
Module 5 DSP Notebook Individual Service Plan Development & Implementation

The Benefits of Inclusion

Some of the benefits to persons served and their families include:
• Better health.
• Increased feelings of well-being.
• Psychosocial development
• Improved esteem.
• More opportunities and access to resources.
• The protection of being known by other people. (Others are
more likely to report or check on problems and become
involved.)
• Greater life experience.
• Greater variety of relationships.
• Incentive to learn appropriate social behavior.

The Role of the DSP in Supporting Community Inclusion

Residential staff can support inclusion by:

• Offering choices.
• Providing training to develop the person’s skills for future inclusionary activities.
• Supporting people’s participation at actual community and social events. As much
as possible, try to promote people’s individual participation in community activities
rather than as part of a group. People may have trouble making new friends and
being looked at as an individual if they arrive in a group.
• Researching information about community resources and sharing this information
with persons served.
• Helping people learn social skills and other skills as needed.
• Analyzing inclusion barriers and helping the person overcome these barriers.
• Using a respectful tone of voice and friendly words when addressing individuals in
public.
• Not speaking for or about the person. Problem behaviors should be dealt with as
discretely as possible.
• Being prepared for questions about the person’s disability. Plan ahead and
discuss how the person would like information shared, if at all. Each person has a
different “comfort level” regarding privacy. Pay particular attention to, and do
your best to support, each person’s unique needs and expectations.

18
R-09-01-13
Module 5 DSP Notebook Individual Service Plan Development & Implementation

• Trying to help people fit in with others by assisting them in their dressing,
grooming and communication skills.
• Making sure the person has the training and skills necessary to become
independent. For instance, training the person how to use the bus can pay off in
a lifetime of inclusion and freedom from relying on staff for every transportation
need.
• Being prepared to advocate for and educate others about the benefits of
inclusion.
• Understanding when to get involved and when to stay out of the person’s
relationships. Instead of sheltering people from potential dangers by isolating
them, support staff should help the person manage risks in real and sometimes
complex situations.
• Teaching daily living, vocational, and educational skills in natural settings in a
functional and empowering way.
• Networking to find contacts and allies in the community who may have
information about social or vocational opportunities.
• Developing strategies to minimize persons’ risks and barriers and help the person
understand the importance of making good choices that will reduce such risk.
• Ask individuals to go with you to any community group speaking engagements
you may present at. Individuals can explain what his/her life was like before
coming to the community program they participate in and how the program has
impacted his/her life.
• Allow individuals to order their own food, etc. when in public.
• Ensure that the people have access to opportunities and education to facilitate
building and maintaining relationships.

• Provide information about human, legal, civil rights and other resources and assist
individuals to use information for self-advocacy and decision-making about living,
working, and social relationships.

19
R-09-01-13
Module 5 DSP Notebook Individual Service Plan Development & Implementation

Resources Available for Vocational Opportunities

In your role as DSP, you may be asked to assist with vocational opportunities. DSPs can
support people who are seeking vocational opportunities by first helping them research
community resources that could provide those vocational opportunities. When these are
identified, DSPs can assist with the application process.

Tips for researching community resources:

• Look in the local newspaper or weekly shopper

• Contact the Chamber of Commerce for a list of organizations, groups and clubs
and contact those

• Contact the local tourism office

• Look in the yellow pages

• Ask family, friends and co-workers

• Contact the local community education office

• Search the Internet

• Contact the local library

• Contact out the local park and recreation office

• Check out local volunteer agencies

• Check with public schools and colleges

20
R-09-01-13
Module 5 DSP Notebook Individual Service Plan Development & Implementation

Teaching Functional Skills

Functional Skills are those tasks that most people do on a regular basis as part of their
daily living routine. If a person is unable to perform these tasks, someone would
probably need to do it for him or her. Consider all the things that must be done for the
person served and find ways to get them more involved, even if initially it is only a small
part of the task. This type of teaching is sometimes called “Active Treatment”. The
types of skills that need to be taught depend on each individual’s needs and wants. The
skills may range from teaching someone to brush their teeth or make their own
breakfast to learning how to search for and find a job or use public transportation. The
goal of teaching is to add skills that will improve the person’s independence and quality
of life. In order to determine if your interactions with the individual are “functional”, ask
yourself these questions:

• Did the person LEARN something as the result of your interactions that will allow
the individual to function more INDEPENDENTLY?

• Did the individual INCREASE HIS/HER SKILLS as a result of the services you
provided?

• Did the activities help PREVENT THE LOSS of skills the person already had?

21
R-09-01-13
Module 5 DSP Notebook Individual Service Plan Development & Implementation

Tips for Teaching Functional Skills

• Encourage the person to do as much as possible for themselves

• Know each person’s goals and objectives and consistently implement formal and
informal training

• “Teach” people rather than “do” for them

• Get people actively involved in the routine of the home (doing chores, making
choices, etc.)

• Do things with people not for them (One noted teacher/author on this subject
jokes that staff fingerprints should never be found within areas where individuals
served receive quality services. That’s because individuals served are
performing all the tasks, not staff, even if they are doing it with hand-over-hand
guidance.)

• Use language stimulation techniques throughout the day

• Offer opportunities for choice

• Be a good role model

• Look at every interaction as an opportunity to teach something

22
R-09-01-13
Module 5 DSP Notebook Individual Service Plan Development & Implementation

Stimulation Activities Compared To Real Activities

Teaching Functional Activities also means assisting people in identifying and
experiencing real activities. Consider how to incorporate real activities into lives of the
people you support. Write your ideas for “real” activities which promote the same
stimulation effects.

Stimulation Activities Real Activities

Smelling different bottled scents.

Touching stuffed animals.

Feeling a soft cloth on your face or

mouth.
A paid staff member talking to you as a
scheduled activity.
Going for a ride in the van with the
group.
Touching a variety of baby toys in a bag.

Catching a ball in the yard at the group

home.
Sorting different shaped blocks.

Walking up and down a hallway.

23
R-09-01-13
Module 5 DSP Notebook Individual Service Plan Development & Implementation

Learning Styles

We all have a preferred way of learning and learn in a variety of ways--by seeing,
hearing, touching, doing, etc. People with developmental disabilities are just like us.
They have preferred ways of learning too. In order for DSPs to identify and use
various instructional strategies, and effective teaching techniques, it is important to
understand different learning styles. Often times we learn using a combination of
ways, although, we usually have one preferred way of learning. In each person’s ISP
you will find information on which learning style is most effective to teach new tasks.
The three primary learning styles are: visual, auditory, and kinesthetic.

Visual learners tend to learn by looking, seeing, viewing, and

watching. Visual learners need to see an instructor’s facial expressions
and body language to fully understand new information. They tend to
sit at the front of the room to avoid visual distractions. They tend to
think in pictures and learn best from visual displays. During a lecture
or discussion, they tend to take detailed notes to absorb information.

Auditory learners tend to learn by listening, hearing, and speaking.

Auditory learners learn best through lectures, discussions, and
brainstorming. They interpret the underlying meaning of speech by
listening to voice tone, pitch, and speed and other speech nuances.
Written information has little meaning to them until they hear it. They
benefit best by reading text out loud and using a tape recorder.

Kinesthetic learners tend to learn by experiencing, moving, and

doing. Kinesthetic learners learn best through a hands-on approach
and actively exploring the physical world around them. They have
difficulty sitting still for long periods of time, and easily become
distracted by their need for activity and exploration.

24
R-09-01-13
Module 5 DSP Notebook Individual Service Plan Development & Implementation

The table below shows some of the methods that appeal to visual, auditory, and
kinesthetic learners. Training should take into account all three styles.

VISUAL AUDITORY KINETHESTIC

PowerPoint slides Lectures Role plays

Videos/Slideshows Group discussions Simulations

Flip charts Informal conversations Practice

demonstrations

Readings Stories and examples Writing/Note taking

Demonstrations Brainstorms Activities

VISUAL

Knowing people's preferred learning style will help us develop appropriate learning
strategies. Let's look more closely at some ways in which we assist people with
developmental disabilities in learning a new task.

25
R-09-01-13
Module 5 DSP Notebook Individual Service Plan Development & Implementation

Task Analysis

Any skill can be thought of as a chain of small steps. These small steps are identified
by completing a Task Analysis. Each step, or link in the chain, serves as a cue to
do the next step. Sometimes a task an individual is learning is too complicated for
the person to learn all at once (e.g., brushing your teeth).
Therefore, we break the task down into teachable steps.
This allows the learner to develop multi-step, complex skills
that would otherwise be difficult to acquire. Identifying the
step-by-step sequence does this. This requires a task
analysis.

How Does Task Analysis Work?

• Determine what task you want the student to perform.

• Figure out what steps will be required to complete the task.

• Teach the student one step until the student displays mastery of it.

• Decide what order to teach the steps in. You might want the person to master
the last step, then second to last and so on until the entire task can be done
independently. Or vice versa, you can work from the first step to the last. This is
known as chaining. We will learn more about this later.

• As each part of the process is learned, add it to the chain until the task can be
completed independently.

You should note that much of our own learning is

done in steps. Many of the things we learn,
remember, and do are done in this process.

26
R-09-01-13
Module 5 DSP Notebook Individual Service Plan Development & Implementation

For example, the Task Analysis for teaching someone how to eat with utensils might
look something like this:
1) Sit in seat at table
2) Identify fork and knife
3) Pick up fork with less dominant hand
4) Pick up knife with dominant hand
5) Put fork into meat or other food to hold in place
6) Use knife to cut meat or other food into bite-sized pieces
7) Remove fork from food
8) Put knife down on plate
9) Pick up fork with dominant hand
10) Use fork to pick up one piece of bite-sized food
11) Raise fork with food on it to mouth
12) Open mouth
13) Put food into mouth
14) Close mouth
15) Put fork down onto plate
16) Chew food
17) Swallow food
18) Start process again.

Author: Tom McIntyre at www.BehaviorAdvisor.com; Retrieved June 27, 2011

27
R-09-01-13
Module 5 DSP Notebook Individual Service Plan Development & Implementation

Task Analysis Activity

Your instructor will guide you through the next activity. After
completion, please consider the following questions:

1. What happens when each staff does a task differently when helping a person with
a developmental disability learn to do a task?

2. Why is it important to do a program plan the way it is written?

3. What should staff do if the program plan doesn’t seem to be working?

Also consider. . .

C Is there more than one way to do the same thing?

C What happens if each of you does a task differently with an individual?

C Why is it important to implement an individual's training plan the way it is written?

28
R-09-01-13
Module 5 DSP Notebook Individual Service Plan Development & Implementation

Techniques for Teaching New Skills

By building one step onto another learned step in the sequence, a strong chain can
be created. This is called CHAINING. There are two kinds of chaining, forwards and
backwards. You’ll learn more about these later.

Shaping

Shaping is a way of adding behaviors to a person’s repertoire. Shaping is used

when the target behavior does not yet exist. In shaping, what is reinforced is some
approximation of the target behavior.

For example: In playing the game “Hot & Cold,” you hide a prize and then
reinforce any movement that takes the player closer to the prize. Each of those
successive movements is a closer approximation of the desired behavior. If the
prize is under the couch and the player is moving toward the couch, every time the
player takes a step toward the couch, you are yelling “hotter,” and you are
reinforcing the behavior. If the player moves away from the couch, you would yell
“colder” (non-reinforcing).

Chaining

Chaining is the process of working forward or backward, step-by-step, to accomplish

a task. For example:
• Forward chaining is a procedure that teaches a task from start to finish. It
involves teaching people one step at a time, working forward step by step to
accomplish a simple task.
• Backward chaining involves teaching the last step first.

29
R-09-01-13
Module 5 DSP Notebook Individual Service Plan Development & Implementation

Modeling

Modeling is a training method in which the individual learns by observing another

perform the behavior that is to be learned.

Prompting

Prompts are signals or cues to perform in a specified manner.

• Verbal prompts use words to initiate, continue or complete a task

• Gestural prompts use a hint or suggestion without using physical
contact
• Physical prompts use physical touch to initiate, continue or complete
the task
• Hand-Over-Hand is a physical prompt that involves actual physical
guidance

Fading

Fading involves reducing the amount of information given in order to decrease

dependence.

Remember, as staff members you are always teaching, whether it is by active

involvement with the individual or by modeling appropriate behavior with staff and/or
individuals. (Dale DiLeo, Enhancing the Lives of Adults with Disabilities.)

30
R-09-01-13
Module 5 DSP Notebook Individual Service Plan Development & Implementation

Discovering Reinforcers
A reinforcer is any stimulus or event that when it follows a behavior, increases the
probability that the behavior will occur again. Positive and personal reinforcers include
actions, consequences, or rewards that can cause an increase in desired behavior.
Activities or incentives can be used, for example, to promote lifestyle changes such as
increased exercise in free-time activities; healthy snacks, etc. When choosing personal
reinforcers, it is important to:

• Get to know the person well

• Ask the person to help choose the type of reinforcers he would
like to earn
• Observe what the person enjoys doing

Positive Reinforcement

A stimulus that, when added to the environment as a consequence of a behavior, results

in an increase (frequency, duration, or intensity or maintenance) of that behavior.

Effective Reinforcers

• Are age-appropriate and are provided immediately after the behavior has
occurred
• Are paired with a clear verbal description of the behavior
• Are varied enough to maintain interest.

Types of Reinforcers

• Primary (substances that sustain life - food, water, etc.)

• Secondary/Social (conditioned reinforcers that are generalized from primary
reinforcers - money, social interactions, tokens, etc.)

A smile, comment and/or compliment can go a long way toward

increasing or maintaining positive behavior!

31
R-09-01-13
Module 5 DSP Notebook Individual Service Plan Development & Implementation

Negative Reinforcement

A behavior is more likely to occur again because the behavior allows a person to stop
something that the person dislikes or finds unpleasant. A negative reinforcement is
anything that, when taken away contingent on a response, tends to increase the
probability or rate of that response.

For Example: Driving in heavy traffic is a negative condition for most

of us. You leave home earlier than usual one morning and don't run
into heavy traffic. You leave home earlier again the next morning and
again you avoid heavy traffic. Your behavior of leaving home earlier is
strengthened by the consequence of the avoidance of heavy traffic.

PERSONAL REINFORCERS EXERCISE

Identify 3 items that are usually primary reinforcers for you:

1. _____________________________________

2. _____________________________________

3. _____________________________________

Identify 3 secondary/social reinforcers for you:

1. _____________________________________

2. _____________________________________

3. _____________________________________

32
R-09-01-13
Module 5 DSP Notebook Individual Service Plan Development & Implementation

Documentation
Documentation means “Providing a written record of an action, event, item, issue, or
thought that is important or meaningful.”

It is important to remember that the things you record are legal documents!

The following tips can help you document important information so that it will be
accurate and meaningful to those who may need it now, or later.

• Do not sign a document that has inaccurate information.

• If two people witnessed an incident, each person should make separate reports or
entries. You should never document for another person or from another person’s
perspective.

• Always include the date (day, month, and year) on all documents.

• Always include the time of day on all documents using a.m. or p.m. for all times.

• Be careful about using abbreviations or acronyms that some people may not
understand.

• Ensure the privacy of people on all documents. When referring to another person
in an individual’s document you may want to describe the relationship to the
person (e.g., coworker, roommate, another staff person, cousin, sister) and the
person’s initials.

• Always use your signature.

Completing Documentation in a Timely Manner

It is important to document events as soon as possible after things happen so you can
remember all the details of what occurred. Your recollection of the events that
happened will not be as clear and accurate if you wait even a day or two after the
occurrence. This also results in poor communication with co-workers, family members
or guardians, and the people you support.

If there is no documentation about a situation, other people providing supports may not
have all the necessary information needed to make the best decisions when handling the
situation afterwards.

If you forget to document something on the day it happened, it is important to begin

your documentation with a statement that indicates your entry was made some time
after the event occurred. This is usually called a “late entry.”

33
R-09-01-13
Module 5 DSP Notebook Individual Service Plan Development & Implementation

The Benefits of Good Documentation

Keep in mind that the report you are writing may later be read by people who do not
know the persons involved. They should be able to easily understand the situation
despite the fact that they do not know the people involved.

Examples of OBJECTIVE Documentation:

• He was crying and his hands were visibly trembling afterwards.
• She stated that she didn’t know what to do.
• I have never encountered a similar situation while working with this individual.

Examples of SUBJECTIVE Documentation:

• He was so upset afterwards.
• She didn’t know what to do.
• Something funny was going on.

34
R-09-01-13
Module 5 DSP Notebook Individual Service Plan Development & Implementation

Always include the four W's:

NOTE: The examples used here are for reporting suspected abuse, neglect and
exploitation.
• Who - This includes everyone involved.
• What - Start at the beginning and explain step by step until the end of the
incident.
• When - Note the exact time, day/month/year and hour including a.m. or p.m.
• Where - The exact location, address, inside or outside, what room?

WHO?
• Who is the suspected perpetrator?
WHO?
• Who is the suspected victim of abuse, neglect, or exploitation?
• Who are the individuals that witnessed the incident?
• Who else may have been involved in the incident?

WHAT?

Document what happened step-by-step. Start at the beginning of the

incident and include all details until the end of the incident. Report only the
facts and write an objective description of your observations in your report. WHAT?
Do not write your feelings, opinions, and attitudes. Also do not make
judgments about the situation.

Here is an example:

December 9, 2010. At 9:00AM this morning, I heard a sound from the back bedroom.
I went to the back room and knocked on the door. The staff person said, “We are OK,
don’t worry.” I asked if I could come in. The staff person said, “yes.” I opened the
door and saw Amy sitting on the floor on the right side of her bed. Amy was crying
and holding her wrist. I asked Amy if she was OK. Amy stated, “My wrist hurts.” I
then examined Amy’s wrist. There were no visible signs of injury. Two hours later, I
examined Amy’s wrist and there was visible bruising about 2 inches in diameter.'’

• Report only the facts and objective descriptions of your observations in your
report.

35
R-09-01-13
Module 5 DSP Notebook Individual Service Plan Development & Implementation

• Do not write feelings, opinion, attitudes or judgments. Include any other

important statements and details, such as your relationship to the victim.

WHEN?

Note the exact time of the incident, including the month, day, year, and WHEN?
time of day with a.m. or p.m. noted.

WHERE?
• Note where the incident occurred
WHERE?
• Outside or inside
• The address of the place of the incident
• The exact room the incident took place
• The exact place in the room where the incident took place

Types of Documentation
Depending on the situation, agency procedures, and local and state laws, you may need
to document for any number of reasons. Here are some possible types of documentation
you will be doing:

• Health related documentation

• Personal goals and individual program documentation

• Behavioral support plan documentation

• Incident and accident documentation

You may also be required to provide verbal reports or faxed or e-mailed copies of
reports to certain external agencies or people. It is important for you to be familiar
with the right place to document and report these types of incidents.

36
R-09-01-13
Module 5 DSP Notebook Individual Service Plan Development & Implementation

Ensure people’s privacy in documents. Refer to their relationship

with the person such as, “coworker,” “roommate,” etc., and then
use initials to identify them.

Things not to document are:

• Complaints about other staff
• Disagreements you have with agency policy
• Your own personal problems
• Negative comments made by other co-workers
• Negative comments about people served

37
R-09-01-13
Module 5 DSP Notebook Individual Service Plan Development & Implementation

Documentation Scenario

You are a DSP working the afternoon shift at one of the CILA homes. You are
working alone on this particular day. You have assisted the 3 women with the
evening meal and now it’s time to clean up the kitchen. One of the women, Linda,
begins to wash the dishes and Marley begins drying the dishes. The other lady
wants to go watch TV. You went into the other room to turn down the volume of the
TV. Marley starts telling Linda that she does not know how to do dishes. While you
were out of the room you heard arguing and loud voices in the kitchen. As you walk
into the kitchen to see what’s happening, you see Linda slap Marley and Marley drops
the dish. Marley begins to cry and calls Linda a “Stupid jerk.” You separate the
women, help them to calm down and help get the kitchen cleaned up. Now it’s time
to write the progress/service notes on this situation.

Linda’s file:
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________

Marley’s file:
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________

38
R-09-01-13
Module 5 DSP Notebook Individual Service Plan Development & Implementation

A Penny Is...............?

39
R-09-01-13
Module 5 DSP Notebook Individual Service Plan Development & Implementation

Martin Luther King said:

“I have a dream.”

He didn’t say:

“I have an annual plan with

quarterly goals and objectives.”

Inclusion News, 1997-1998

40
R-09-01-13
Module 5 DSP Notebook Individual Service Plan Development & Implementation

Sections of the Service Plan

Most service plans contain the following information:

Personal Description- This section describes the person. It goes beyond the old
way of describing a person (e.g., 25-yr. old black male with Down syndrome).

Medical/Dental/Nutritional- This section contains a summary of significant

medical issues. This includes any medication the person takes and the reasons.
There may be nutritional information mentioned here, as well.

Background/Historical- This is a summary of significant events that have

happened in the individual's life. These events may be a clue as to what shaped who
the person is today.

Social Relationships- Here is where details of the person's social life are outlined.
Important people are mentioned, as well as all types of relationships (e.g., family,
friends, work, staff members). Some of these relationships may be positive and
others not. Sometimes we draw maps to show how these people are related. These
show graphically, the connections between people. This area would indicate whether
the person prefers to be with people or by himself/herself.

Goals/Objectives- This section identifies the areas targeted for development. The
information for this section is gathered through interviews, assessments, and on-
going interactions with the person. Goals can be from any area, but they need to be
important to the person, not necessarily the staff providing input into the plan. We
must set goals in various areas to obtain funding. This includes economic self-
sufficiency, daily living skills, and community integration. We look at what the person
wants to learn and prioritize short and long-term goals based on the person's
preferences.

Interests and Activities- This is where we learn what interests the person outside
of work and home responsibilities. Leisure activities, hobbies, sports, or just about
any other interest can be listed in this section.

Personal Values- This section makes a statement about what is important to the
person. This is useful to know because often times we are motivated by what we
value the most.

Personality, Feelings, & Emotions- We need to know these things about the
person in order to develop a supportive environment. Therefore, getting to know the
person is essential.

41
R-09-01-13
Module 5 DSP Notebook Individual Service Plan Development & Implementation

Sources of Comfort and Discomfort- This section will outline what things provide
comfort as well as, discomfort to the person. You may want to remember that we
can never know everything about a person. So, this section may have information
only known to the staff who wrote it. Further, as people grow and change, this area
of the plan may have to undergo change. Again, you will learn much about the
person as you interact with him/her.

Assessments- The results of assessments or tests may be included here. For

example, PT/OT, IQ, speech and language, etc.

Strengths and Needs- Here we learn about the abilities as well as areas which
require support.

Vocation- This section will describe the kinds of work the individual likes to do or
would like to do.

Education- A summary of the person's educational background as well educational

goals.

Financial - This area discusses financial information about the person including
sources of income and needs for the future.

Communication Style- The best way to communicate with the person would be
spelled out here. People can and do communicate in a variety of ways and it is
important for you to understand how to communicate with each person you will be
working with.

Learning Style- How the person learns is outlined. This includes strategies you can
use to work most effectively given the person's specific situation.

Personal Rights- In this area, we would learn which rights are most important to
the person. Also, what, if any, rights restrictions might be in place and details of the
situation.

Recent Life Changes- Anything that has recently occurred in a person's life which
may have an effect on his/her day-to-day functioning should be noted here. This is
another area that would be updated continually.

Vision for the Future- Just as we have dreams and hopes for the future, so do
people we support in our programs. You need to get to know the person. This will
assist you in identifying his/her hopes and dreams. Then you can assist the person
in realizing them.

42
R-09-01-13
Module 5 DSP Notebook Individual Service Plan Development & Implementation

Each ISP is tailored to the individual. Therefore, not all

service plans contain all of these components. Some
plans may have additional information not listed here.

Additional Information: Service Plans are developed and signed by the individual or
guardian, the QIDP, and all service providers. Service Plans explain significant
changes in services or providers and indicate that the individual, family members and
Service Facilitator participated in the decision process regarding these changes.

Service Plans contain at least one measurable goal. Service Plans contain an
explanation of instructional methods for assisting the individual in moving toward
accomplishment of his/her goal(s) and a way to monitor the individual’s progress in
achieving the goal. It also contains the name(s) or role(s) of the person(s)
responsible for assisting the individual in achieving the goal.

43
R-09-01-13