INDIVIDUAL SUPPORT PLAN
Person’s legal name: Fitzwilliam Bennet
One Page Profile for:
Preferred name: Fitz
Plan effective dates:
9/1/15- 8/31/16
Home
What people like and admire about Fitz
Fitz is fun loving and laughs/smiles all the time.
Fitz is always helpful. He likes to help with chores or bring in the groceries when he sees you struggling.
Fits makes model planes with his brother and they look so great displayed in his room. They are very detailed.
How to best support Fitz
Fitz has a great mustache. He is very talented with trimming scissors.
Fitz is really good at cards.
Be patient. Let Fitz have time to feel comfortable with
the things he is asked to do or with supports provided.
What is important to Fitz
Reassure Fitz that you will not make him do anything he
doesn't want to do. Tell him you will stay with him until
he is ready, will bring him home if today isn't a good
day, or leave him alone if he is home and needs some
space.
His brother (Bill) and sister-in-islaw (Kathy)--spending time with them
Use a soft voice with Fitz.
Having people around him who make him feel safe
Talk to him about things like doctor appointments and
taking his meds in a way that lets him know it will be
o.k. and he will be safe and won't be alone.
Having fun with his friends at Do Your Thing
Going to his old job and spending time with his friends there.
His model planes--making them and showing them to others.
Spend time with Fitz doing the things he likes to do, like
reading and playing games (especially card games).
His books--all of them in his collection.
Learn Fitz's communication style. Listen to him closely
and ask him a lot of questions to find out who he is and
what he likes or doesn't like.
Being clean and having his clothes clean.
Fitz likes to get up early and spend time in the quiet before anyone else is up.
Refer to Communication Chart as needed and
Know Fitz's protocols and behavior support plan
Person Receiving Services:
Fitzwilliam Bennet
Effective Dates:
9/1/15-8/31/16
Page 1 of 12
Individual Support Plan – ODDS 6.18.2015
Desired Outcomes
Desired Outcome
What is the desired result?
Fitz takes a vacation to the Grand
Canyon this year with Trips
Inc.(Vacation Organization)
Fitz owns fish and cares for them.
Person Receiving Services:
Key steps to work toward
the outcome
Is there a paid service that
supports this outcome? If
so, what is it?
Who is
responsible?
Work with providers and Rep
Payee to budget and plan the
trip (apply with Trips Inc.).
Work with Foster providers and
Rep Payee to budget for, buy
fish, and care for fish.
Natural Supports and
Adult Foster Services
Fitz, Foster
Provider, and Rep
Payee, Trips. Inc.
Fitz, Foster
Provider, and Rep
Payee
Fitzwilliam Bennet
Natural Supports and
Adult Foster Services
Plan Effective Dates:
Timelines
Frequency or
by when?
By September
2015
By October 2015
9/1/15-8/31/16
Where to
record
progress
Note if written
implementation
strategies are
expected
Progress notes
of SC and
Provider
Progress notes
of SC and
Provider
Action Plan
No Action Plan
needed. Provider
understands steps
to achieve.
Page 2 of 12
Individual Support Plan – ODDS 6.18.2015
Career Development Plan (CDP)
Education level completed: Unknown
Students (age 16-20)
Expected date of exit from school:
Date by which CDP will be completed:
Attending school and wants to work now.
Attending school and receiving employment supports elsewhere.
Has an IEP Post-Secondary Goal with employment or training focus.
Attending school and not receiving any employment supports.
Status with Vocational Rehabilitation (VR) (age 16 and up)
Currently receiving VR services
Other/Not applicable, explain:
Want a referral to VR
Working age adults (age 21-60) must choose one of the following statements:
Oregon is an “Employment First” state.
We believe that each person:
 can work and there is a job for everyone.
 has something to contribute and needs to
contribute.
 has the right to a competitive job in a
typical community work setting, including
self-employment, making comparative
wages with sufficient hours to make a
difference.
 may identify the direction of his/her
employment based on skills, interests, and
strengths.
 has a right to be informed about the
employment services options that are
available to him/her.
To receive an employment service, you must
have a goal of pursuing individual, integrated
employment.
If the person is at least 18 years old and has exited school, complete this section instead of the
“Students (age 16-20)” section.
Employed in integrated employment and chooses to: Check all that apply.
Retain current job.
Advance in current job (more hours, raise, new skills, promotion, etc.)
Get a new job.
Get an additional job.
Retire – is at least 60 or will be this ISP year. Employment Outcomes are not required.
No longer continue in integrated employment at this time. Complete Decision Not to Explore Employment section.
Currently not working in integrated employment and chooses to: Check all that apply.
Get integrated employment.
Explore interests in integrated employment through an Employment Path, Discovery, or other time-limited service.
Retire – is at least 60 or will be this ISP year. Employment Outcomes are not required.
Not explore integrated employment at this time. Complete Decision Not to Explore Employment section.
Potential barriers to working in an individualized, integrated job
How will this obstacle be addressed?
N/A
N/A
Person Receiving Services:
Fitzwilliam Bennet
Plan Effective Dates:
9/1/15-8/31/16
Page 3 of 12
Individual Support Plan – ODDS 6.18.2015
Decision Not To Explore Employment *** Not applicable; Decision not to work section removed. ***
Desired Employment Outcomes
Desired Outcome
What is the desired result?
Key steps to work toward
the outcome
N/A
Person Receiving Services:
Is there a paid service that
supports this outcome? If
so, what is it?
Who is
responsible?
Timelines
Frequency or
by when?
Where to
record
progress
Note if written
implementation
strategies are
expected
---
Fitzwilliam Bennet
Plan Effective Dates:
9/1/15-8/31/16
Page 4 of 12
Individual Support Plan – ODDS 6.18.2015
Risk Management Plan
Emergency preparedness (natural disasters, power
outages, community disasters, etc.)
Preventing abuse (physical, emotional, financial,
sexual, neglect)
What happens if the person can’t be reached?
(timelines for notifying others, who to contact, etc.)
Fitz has an emergency plan for home.
Fitz has a rep payee who is also his guardian. Fitz
is never alone at home or in the community.
If Fitz cannot be reached/is missing for any length of
time, look for him for up to 5 minutes then call 911.
Risk
X if
High
risk
How is the risk addressed?
Choking
Aspiration/Choking Protocol
Complications of Diabetes
Hyper and Hypoglycemic Protocol
Unreported pain or illness
Safety Plan
Water temperature safety
Safety covers on all faucets. Water temp is controlled by providers.
Fire evacuation safety
Safety Plan
Vehicle safety
Safety lock in vehicle and reminders to not take off seat belt
Street safety
All providers stay at arm’s length and give reminders to stay close around streets and parking lots
Refusing medical care
Extreme food seeking
behavior
Unsafe social behavior
Behavior Support Plan
All providers give reminders to Fitz if he gets too close to someone or pokes them. He is reminded to step back and not to
poke.
Financial Plan. Rep Payee (Bill Bennet).
Potential for financial abuse
Does this person have a Nursing Care Plan?
No
Needed
Yes, where found:
Home:
In medical section of
book
Work:
Back-up Plans, in the event that primary support is not available
Home
Work/School/Day Supports
Other:
Other:
Person Receiving Services:
Fitzwilliam Bennet
Plan Effective Dates:
9/1/15-8/31/16
Page 5 of 12
Individual Support Plan – ODDS 6.18.2015
Chosen Case Management Services
Type: Waiver Case Management
Chosen provider: Wonder County CDDP
Prime number: XOXOXOXO
Authorized dates:
Plan year
Start and end, if not same as plan year:
Required frequency of case management monitoring: Monthly case management monitoring
Case management comments/descriptors of anticipated case management services during the year: SC will coordinate planning each year. Fitz has many risks and
SC will check in on Fitz monthly to monitor how the effectiveness of supports in place to manage these risks. SC will monitor to see how the BSP is working when Fitz is at his
brother and sister-in-law's home. If the BSP continues to not work as well when Fitz is at their home, more conversation will happen among team members and Fitz's Behavior
Support Specialist. SC will communicate monthly with Fitz's nurse to monitor how his nursing plan is working. SC will revise the plan as needed to meet Fitz needs and changes in
desired outcomes.
Person’s preference on how case management is provided: Fitz likes to have his meeting at home where it is quiet and familiar. He prefers to have information given to him
in person. He wants to have his brother with him at most meetings.
Natural Supports, Community Resources, and Other Voluntary Services and Supports
Describe chosen services/supports
Provided by
Fitz needs support to take part in activities he does during holidays and on the weekends (every
Family (brother, Bill, and sister-in-law, Kathy)
other weekend) he is with his family. Fitz needs assistance with bathing (getting in and out of tub
safely and using the right amount of soap and cleaning well, as well as adjusting the water temp
to a comfortable level), toileting (wiping well and cleaning up after, as well as cleaning up after
accidents), oral hygiene (reminders to brush teeth and cues to brush well), dressing and haircare
(wearing appropriate clothes for weather, support with buttoning, and support to comb his hair
and mustache the way he prefers), full physical assistance with shaving his face and trimming his
mustache, support with receptive and expressive communication (complicated info must be
explained in a way that makes sense to him and he needs support expressing himself to those
who do not understand his communication style-i.e. his speech is difficult to understand for those
who do not know him well), safety (e.g. using chemicals, sharp items, and appliances safely), fire
evac.(cues to evacuate and move to a safe area), medication management (taking meds on time
and in the proper amount), health management (expressing pain, daily checks for any signs of
illness or injury, making and keeping appointments and following through with doctors’ orders),
intermittent nighttime supports (support for any daytime support needs that come up at night),
supervision within visual and hearing distance, support to access the community (transportation to
all the places he needs to go, as well as reminders to not take off the seat belt or open the car
door while in motion), support to take part in community activities and events (finding activities of
interest and providing all support needs during activity including communicating effectively and
making monetary exchanges), and support to socialize appropriately and safely (e.g. not poking
Person Receiving Services:
Fitzwilliam Bennet
Plan Effective Dates:
9/1/15-8/31/16
Page 6 of 12
Individual Support Plan – ODDS 6.18.2015
at others or getting too close to others when it is not appropriate to do so).
Fitz needs his support needs (see above) while on vacation to the Grand Canyon with Trips Inc.
Trips Inc. (private pay)
Fitz needs new eyeglasses, but his insurance will not pay for them.
Clear Vision Works (local non-profit that helps people get their
eyeglasses at a much discounted price) Fitz brother will pay for
the difference.
Lions Club
Fitz needs to have an eye exam this year. His insurance would not pay for it, so he received his
eye exam from a local nonprofit.
Chosen State Plan Personal Care (SPPC) services
*** Not applicable; SPPC section removed. ***
Chosen K Plan Services
*** Not applicable; Chosen K Plan services section removed. ***
Chosen Waiver Services
*** Not applicable; Chosen Waiver services section removed. ***
Chosen K Plan Residential Service -----Complete the following only if the person chooses RESIDENTIAL services:
Person Receiving Services:
Fitzwilliam Bennet
Plan Effective Dates:
9/1/15-8/31/16
Page 7 of 12
Individual Support Plan – ODDS 6.18.2015
Service setting: Non-relative Foster Care - Adults DD 58
Chosen provider: Beth and Charlotte Luca Foster Home
Start and end, if not same as plan year: --Authorized dates: ☒Plan year
The K Plan services already included in residential services:
Additional K Plan services included in residential services:
☒ Attendant care – ADL / IADL ☒ Skill training ☒ Community Transportation
☐ Behavior supports ☐ Nursing supports
List identified needs that this service will address:
 Fitz needs assistance with bathing (getting in and out of tub safely and using the right amount of soap and cleaning well, as well as adjusting the water temp to a
comfortable level).
 Toileting (wiping well and cleaning up after, as well as cleaning up after accidents)
 Oral hygiene (reminders to brush teeth and cues to brush well)
 Dressing and haircare (wearing appropriate clothes for weather, support with buttoning, and support to comb his hair and mustache the way he prefers)
 Full physical assistance with shaving his face and trimming his mustache
 Support with receptive and expressive communication (complicated info must be explained in a way that makes sense to him and he needs support expressing himself
to those who do not understand his communication style-i.e. his speech is difficult to understand for those who do not know him well)
 Safety (e.g. using chemicals, sharp items, and appliances safely), fire evacuation (cues to evacuate and move to a safe area)
 Medication management (taking meds on time and in the proper amount)
 Health management (expressing pain, daily checks for any signs of illness or injury, making and keeping appointments and following through with doctors’ orders)
 Intermittent nighttime supports (support for any daytime support needs that come up at night)
 Supervision within visual and hearing distance
 Support to access the community (transportation to all the places he needs to go, finding the destination he needs to get to, reading all the street signs, as well as
reminders to not take off the seat belt or open the car door while in motion)
 Support to take part in community activities and events (finding activities of interest and providing all support needs during activity including communicating effectively
and making monetary exchanges).
 Support to socialize appropriately and safely (e.g. not poking at others or getting too close to others when it is not appropriate to do so).
Person’s preference on how this service is delivered:
 Give privacy and modesty around all supports. (i.e. provide supports like helping with going to the bathroom, bathing in his bathroom, and dressing and changing in his
room)
 Tell Fitz what you are going to do to help him before you do it. Ask him for permission.
 Fitz likes to have his face shaved twice a day. (keep the mustache)
 Fitz wants juice with his medication.
Chosen K Plan Community Transportation Service Specific to travel to and from vocational program. Complete DD 53 budget.
Transportation type
-------
Person Receiving Services:
Plan
year
☐
☐
Authorized dates
Start and end, if not same as
plan year
-----
Fitzwilliam Bennet
Chosen provider type or description of service
-----
Plan Effective Dates:
9/1/15-8/31/16
Page 8 of 12
Individual Support Plan – ODDS 6.18.2015
----
☐
---
---
Additional Chosen Services
Use to record General Fund services as well as overflow for any of the above Chosen Services.
Describe service setting, service code, # units, frequency,
List identified needs that this service will
authorized dates, and chosen provider type as applicable
address
Community Nursing Services/MMIS
1 event per week for plan year
Carol Dorn, RN
Person’s preference on how this service is
delivered
Fitz has diabetes and the nurse comes in once
a week to work with him on managing his
diabetes, checking blood sugars, talking about
his diet, and checking his feet for any problems.
Fitz likes the nurse who comes to the house.
He wants to be poked for testing on the first two
fingers on his left hand and not touched with
cold hands.
Differences
Note any differences between the contents of this plan and what the person wants.
None
Note any differences between the contents of this plan and what any other ISP contributor wants.
Bill and Kathy have been noticing that Fritz is having more instances of poking and talking very loudly to strangers when they are in the community, as well as leaving the area
they are in and trying to walk off on his own. When they attempt to follow the BSP and redirect Fritz accordingly it doesn't work as well as they feel it did in the past. Fitz became
angry with Bill when he tried to redirect Fitz on two occasions. Foster providers have not noticed a change. For now, Bill and Kathy are willing to see how things go over the next
few months, but would like to look into making sure the BSP is still working or if Fritz needs to meet with the Behavior Support specialist to see if there is something new going on
with Fritz. The team decided to start by having Fritz see the doctor to make sure there isn't anything medical causing a change in Fritz's behavior. SC will follow up after the
medical appointment.
Legal Relationships
Parent(s) of minor child who retain parental rights: N/A
Legal Representative/Guardian(s), if any: William Bennet
Scope of authority: Full
Designated Representative(s) for service planning, if any: N/A
Designated Representative(s) for employer representative/employer of record issues, if any:
Self-Appointed
Health Care Representative, if any: N/A
Appointment Date: N/A
Person Receiving Services:
Fitzwilliam Bennet
Plan Effective Dates:
9/1/15-8/31/16
ISP Team Appointed
Page 9 of 12
Individual Support Plan – ODDS 6.18.2015
Representative Payee(s), if any: William Bennet
Conservator(s), if any:
Any other Legal Documents on file limiting personal decision making: N/A
Person Receiving Services:
Fitzwilliam Bennet
Plan Effective Dates:
N/A
9/1/15-8/31/16
Page 10 of 12
Individual Support Plan – ODDS 6.18.2015
Acknowledgments
Describe the supports the person needs to understand his/her rights or to understand this plan, if any:
Check here if no
support is needed
Brother Bill, sister-in-law, Kathy, and Foster providers will help to advocate for Fitz and make informed decisions in Fitz's best interest. They will continue to look for what works and
doesn't work for Fitz, along with asking him about preferences to determine what services will work best for him
Person Receiving Services
Does this ISP reflect the services the person chooses and the outcomes the person wants to work toward?
Has the person been provided information about the planning process and how to request changes and
updates to the ISP?
Did the person choose the location of their ISP meeting?
Yes
No
Declined
Did the person choose who participated in their ISP development?
Did the SC/PA review the services that are available to the person?
Did the person receive notification of his/her DHS rights?
Families and/or Guardian who provide support
Yes
No
N/A
Yes
No
Does this ISP reflect what is needed for the family to effectively provide supports?
ISP Team – Does this ISP reflect…
Independence: Having control and choice over one’s own life.
Integration: Living near and using the same community resources and participating in the same activities as,
and together with, people without disabilities.
Productivity: Engaging in contributions to a household or community; or engaging in income-producing work
that is measured through improvements in income level, employment status, or job advancement.
Describe the reason for any question above remaining “no” and the plan to address it:
N/A
Person Receiving Services:
Fitzwilliam Bennet
Plan Effective Dates:
9/1/15-8/31/16
Page 11 of 12
Individual Support Plan – ODDS 6.18.2015
Agreement to this Plan
These people agree to this plan and associated documents as reflecting the person’s strengths and preferences, support needs as identified by an
assessment, and the services and supports that will assist the person to achieve identified desired outcomes.


Services Coordinator/Personal Agent/ODDS Residential Specialist: Ensure the plan meets the person’s current service needs and complies with
requirements for the chosen service setting(s) and associated funding.
Providers: Agree to implement and provide the supports that have been designated as their responsibility in this ISP. A signed contract, job description,
or service agreement may be used in lieu of this signature page.
Relationship to this
person
Present at
meeting?
Self / Person Receiving Services
Yes
Services Coordinator
Yes
Bill Bennet
Legal Guardian
Yes
Beth Lucas
Foster Provider
Yes
Charlotte Lucas
Foster Provider
Yes
Name
Fitzwilliam Bennet
Jane Bingley
Person Receiving Services:
Fitzwilliam Bennet
Signature
Plan Effective Dates:
Date
9/1/15-8/31/16
Comments
Page 12 of 12