Tammy’s Story - ISP Review Checklist Example
Tammy is 35 years old and has lived at home with her mother for her whole life. Tammy
enjoys music, watching reality television, and shopping in her community. Tammy’s mother recently
passed away and she was Tammy’s primary caregiver. Tammy has a lot to say about her life and is an
active member of her planning team. The ISP team is called to action to help plan for Tammy’s health
and safety needs due to this new life situation.
In beginning to plan for Tammy, the team considers her personal, medical, and emotional
history. She is diagnosed with a Borderline Personality Disorder and is at risk of running away. Tammy
doesn’t sleep well at night. She bangs her head when she is upset and at times has seriously hurt
herself. This was documented in a behavior support plan for Tammy. Throughout her life, Tammy has
not identified herself as having an intellectual disability and does not get along with people who have
an intellectual disability. Tammy has Type 2 diabetes, needs to take daily insulin, and needs help with
maintaining a healthy diet.
Tammy previously attended a day program but often hurt other people so she could no longer
attend. When she left the day program, she began receiving 16 hours of Home and CommunityBased Habilitation during the day. Tammy also receives eight hours of Companion Services and
Behavior Support services. She is enrolled in the Consolidated Waiver.
Since her mother died, Tammy has become more aggressive toward others and is restless and
constantly moving or talking. Recently she was taken to the hospital to try to get help with her
emotional issues. The hospital did not know what to do and was going to put Tammy in a taxi and
send her to the ODP regional office.
The ISP team, including Tammy, her brother, aunt, and longtime neighbor, met to begin to
plan to address Tammy’s needs. Throughout the years of her living with her mother, the family
provided support by taking Tammy shopping and doing things that she enjoys to do in the
community. In the Know and Do section of Tammy’s ISP, it states that Tammy needs to be involved in
decisions affecting her life. It is important to Tammy that she has choice and control in her life. This is
especially true during this difficult time and her team closely works together to ensure that this is
present.
In thinking about where Tammy could live, Lifesharing options were discussed first. However,
Tammy gets upset when talking about moving in with another family because she does not want her
family to be replaced. With Lifesharing ruled out, the team used Section A of the ISP Review Checklist
to discuss general ISP requirements and Section B of the Checklist as a guide in their discussion to
determine the need for residential habilitation services.
Office of Developmental Programs, ISP Review Checklist Training – 2013
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Tammy’s Story - ISP Review Checklist Example
The following information was discussed that helped answer the questions in Sections A & B:
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Tammy’s brother has a wife and children and her aunt and neighbor are elderly. They are not
able or willing to provide supports but are interested in continuing to be actively involved in
Tammy’s life.
Tammy needs ongoing support to assure her health, safety, and welfare.
o Her mom, Tammy, and the team received mental health support to work to decrease
Tammy’s aggressive behaviors
o On her own, Tammy does not take her medication regularly
Tammy was assessed using the SIS and PA Plus.
o The assessment indicated that she needs frequent support in activities of daily living.
o The Behavioral Supports Needed section indicates that she requires extensive supports
in multiple areas.
o Her ISP reflects the results of her assessment.
Considering her aggression toward herself and others, Tammy’s health and safety would be at
risk if not supported in a residential habilitation setting.
After it was determined that residential habilitation service was appropriate, referrals were made
to three willing and qualified providers. Two of the three providers thought they could support
Tammy; however, because Tammy met the criteria identified in Section C of the ISP Review Checklist,
the team determined that Tammy would be best supported in a licensed one-person home. The
team used Section C of the Checklist to assess that a one-person home is the least restrictive
environment for Tammy.
The team determined that a licensed one-person home currently meets Tammy’s needs. At the
same time, they developed a plan to monitor Tammy’s progress and to be able to identify when a
licensed one-person home is no longer the least restrictive environment. Tammy’s behavior support
plan was updated to include a fading plan to eliminate the need for a one-person home when
appropriate.
The process for completing the ISP Review Checklist began with the chosen Provider who
completed the Provider Sections at the beginning of the Checklist indicating the service need and
type of support that staff will be providing to Tammy. This includes activities, programming, and
training that will be provided to staff. Staff responsibilities include assuring that Tammy doesn’t run
away, especially at night since she doesn’t sleep through the night. Day staff will help Tammy engage
in activities that are interesting to her and chosen by her and address her assessed needs.
Staff will also offer new opportunities such as volunteering. Staff members are responsible to
monitor Tammy’s diet and assure that her blood sugar is tested and she takes her medication
according to doctor’s orders. Staff will review her behavior plan and attempt to anticipate situations
that may cause Tammy to be physically aggressive toward herself and others and redirect her to
activities that she enjoys. In addition, staff will keep track of Tammy’s behaviors as identified in her
behavior support plan, and communicate any changes to their supervisor.
Office of Developmental Programs, ISP Review Checklist Training – 2013
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