ࡱ> y DYbjbj 4x{{ jLLLLL```8<`-f44(\\\K UL,,,,,,,/1~,iL5KK55,LL\\U-!!!5FL\L\,!5,!!r"*T"+\V{Fv*,k-0-*1212"+12L"+55!55555,,!555-555512555555555 : PROVIDER REVIEW (Residential / Day / Personal Assistance) FORMTEXT       FORMTEXT  FORMTEXT       FORMTEXT      (Person s Name)(Name of DIDD Provider)(Period Covered by Review)Types of Service Being Reviewed: FORMDROPDOWN  FORMDROPDOWN  FORMDROPDOWN As a result of your agencys overall review and oversight activities this period, have we learned anything new or different about what is important to or important for this person, or what others need to know to support the person? In reviewing the ISP, has anything been learned or discovered that changes or adds significantly to what is important to, or what is important for this person or what others need to know to support the person? Would this new or changed information make a difference in how the person is supported, or in whether he/she has a good or bad day? Consider information from learning logs, daily notes, incident reviews, high risk reviews, healthcare oversight, funds management, reviews of supports, interactions with the family, or the conservator, etc.  FORMCHECKBOX  No changes are needed to the ISP.  FORMCHECKBOX  Yes, weve learned or discovered some new or different information that could make a difference in how this person is supported and we propose updating the ISP as follows: FORMTEXT      How are we doing with implementing Personal Outcomes and providing Supports for Daily Life as stated in the ISP? Report below only on the outcomes under B. 1. Personal Outcomes and/or the activities under B. 2. Supports for Daily Life for which your agency has responsibility in the ISP Action Plan (section B.)What is the Personal Outcome or Support Activity for Daily Life?What Was Tried & Learned? What Did or Did Not Work?Are there any barriers that we need to address or changes needed to the ISP? If yes, describe: FORMTEXT       FORMTEXT       FORMCHECKBOX  No  FORMCHECKBOX  Yes:  FORMTEXT       FORMTEXT       FORMTEXT       FORMCHECKBOX  No  FORMCHECKBOX  Yes:  FORMTEXT       FORMTEXT       FORMTEXT       FORMCHECKBOX  No  FORMCHECKBOX  Yes:  FORMTEXT       FORMTEXT       FORMTEXT       FORMCHECKBOX  No  FORMCHECKBOX  Yes:  FORMTEXT       FORMTEXT       FORMTEXT       FORMCHECKBOX  No  FORMCHECKBOX  Yes:  FORMTEXT      Did the person receive the services from your agency in the amount and frequency as authorized in section C. of the ISP?Type of ServiceAll Authorized Units Provided?If No, What is the Reason for the Units Not Provided?1.  FORMDROPDOWN  FORMCHECKBOX  Yes.  FORMCHECKBOX  No: FORMTEXT  HJtvxɺyn\ynJn#jGh5/h5/OJQJU#jh5/h(OJQJUh5/h(OJQJjh5/h(OJQJU(jh5/h5/OJQJUmHnHu#j]h5/h5/OJQJUh5/h5/OJQJjh5/h5/OJQJUhhh5@ CJaJhhB5@ CJaJh5@CJaJhxO\5@CJaJ tv }llll$d$Ifa$gd 0,$d$Ifa$gd2Nkd$$Ifl44*+ t+644 laf4p yti$d<$Ifa$gd$d$Ifa$gdxO\   . 0 2 L r    ޾uj^VG^<^h5/hH23OJQJjhOJQJUhOJQJjhOJQJUh5/h7CJaJhih7OJQJhih75h5/h(CJaJhB5CJaJh5/h(CJOJQJaJh5/h(5CJaJ h5/h(h5/h(OJQJ(jh5/h5/OJQJUmHnHujh5/h5/OJQJU#jh5/h5/OJQJU  0 2 b d N====$d$Ifa$gd 0,kd3$$Ifl44rjxX f!*1  t+644 laf4p2ytid =,$d$Ifa$gd7kd\$$Ifl44BrjxX f!*1  t+644 laf4p2yti$d$Ifa$gdB   & $ & Fhd$If^ha$gdBOkdG$$Ifl4*+ t+644 laf4p yti      # $ % & ' z   # b o s g 5 6 Ҽwl^R^^whBh25CJaJhBh256CJaJhBhX CJaJhBh+CJaJhBh2CJaJh5/h2CJaJh5/h51K5CJaJh5/h25CJaJh5/h+5CJaJ h5/hH23jhOJQJUh5/hH23OJQJjhOJQJUj1hOJQJUhOJQJ& '  6 k kUChd$If^hgd 0,hdxx$If^hgd 0,m$ & Fd<x$Ifgd7m$kdC $$Ifl4F @*VVW t+6    44 laf4pytB6 7 E F G H ] h k l z { | } :NRTVjlnxz|~埐s^WKh5/h25CJaJ h5/h2(jh5/h2OJQJUmHnHu#j% h5/h2OJQJUh5/h2OJQJjh5/h2OJQJUh2h5/h/CJaJ#jK h5/h2CJUaJh5/h+CJaJhCJaJ#j h5/hPqdCJUaJh5/h2CJaJjh5/h2CJUaJk RT|~;Lkd $$Ifl*+ t+644 lap yt5/hdxx$If^hgd 0,Lkd $$Ifl*+ t+644 lap ytBdx$If^`gd2\`z )Zjwx6:;<LMNO|naTh5/htCJ^JaJh5/h51KCJ^JaJh7h51K>*CJ^JaJh7>*CJaJh5/h+>*CJaJh5/htCJaJh5/h..>*CJaJh5/h51K>*CJaJh5/ht>*CJaJh2hBh25CJaJhBh2>*CJaJhBh2CJaJh5/h25CJaJh5/hWuq5CJaJ~`wxNwwd$$d$Ifa$gd7$$d$Ifa$gdJkd $$Ifl*+ t+644 lap yt($hd<<$If^hgdi$ & Fd<<$IfgdiNO6sscdxx$Ifgddxx$Ifgd 0,|kdS $$Ifl%F\ *  t+6    44 lapyt7OPZ[ $&468TVX^`b~۫۔hY?Y2j7h5/hBCJU^JaJmHnHuhCJ^JaJmHnHu2j h5/hBCJU^JaJmHnHu#h5/hBCJ^JaJmHnHu,jh5/hBCJU^JaJmHnHu.jO h5/htOJQJUmHnHu.j h5/htOJQJUmHnHuh5/htOJQJmHnHu(jh5/htOJQJUmHnHu &(*ʲʫʓ{dR8d2jh5/hBCJU^JaJmHnHu#h5/hBCJ^JaJmHnHu,jh5/hBCJU^JaJmHnHu.j%h5/htOJQJUmHnHu.jh5/htOJQJUmHnHu h5/ht.jh5/htOJQJUmHnHuh5/htOJQJmHnHu(jh5/htOJQJUmHnHuh5/hBOJQJmHnHuuuedxx$Ifgddxx$Ifgd 0,zkd$$IflF\ *  t+6    44 lapyt7*024PRT\^`bvxޝx`xYxAxx.j}h5/htOJQJUmHnHu h5/ht.jh5/hBOJQJUmHnHuh5/htOJQJmHnHu(jh5/htOJQJUmHnHuh5/hBOJQJmHnHu2j h5/hBCJU^JaJmHnHu,jh5/hBCJU^JaJmHnHuhCJ^JaJmHnHu#h5/hBCJ^JaJmHnHuZuuedxx$Ifgddxx$Ifgd 0,zkd$$IflF\ *  t+6    44 lapyt7"$&.024HìqWqGh5/hBOJQJmHnHu2jh5/hBCJU^JaJmHnHuhCJ^JaJmHnHu2jeh5/hBCJU^JaJmHnHu#h5/hBCJ^JaJmHnHu,jh5/hBCJU^JaJmHnHuh5/htOJQJmHnHu(jh5/htOJQJUmHnHu.jh5/htOJQJUmHnHuHJXZ\^rtüäÌucIuc:uchCJ^JaJmHnHu2j;h5/hBCJU^JaJmHnHu#h5/hBCJ^JaJmHnHu,jh5/hBCJU^JaJmHnHu.jh5/htOJQJUmHnHu.jSh5/htOJQJUmHnHu h5/hth5/htOJQJmHnHu(jh5/htOJQJUmHnHu.jMh5/htOJQJUmHnHuZ\,uuedxx$Ifgddxx$Ifgd 0,zkd$$IflF\ *  t+6    44 lapyt7*,.0DFTVXlϽyayZyByy.j)h5/htOJQJUmHnHu h5/ht.j#h5/htOJQJUmHnHuh5/htOJQJmHnHu(jh5/htOJQJUmHnHuh5/hBOJQJmHnHuhCJ^JaJmHnHu#h5/hBCJ^JaJmHnHu,jh5/hBCJU^JaJmHnHu2jh5/hBCJU^JaJmHnHu,.V~uuedxx$Ifgddxx$Ifgd 0,zkd$$IflF\ *  t+6    44 lapyt7ln|~ìqWqG2(jh5/hOJQJUmHnHuh5/hOJQJmHnHu2jh5/hCJU^JaJmHnHuhCJ^JaJmHnHu2jh5/hCJU^JaJmHnHu#h5/hCJ^JaJmHnHu,jh5/hCJU^JaJmHnHuh5/htOJQJmHnHu(jh5/htOJQJUmHnHu.jh5/htOJQJUmHnHu"#Q^xyz²|ug\g\QgQgCh 0,h>*CJ^JaJhb,>*CJ^JaJhN1>*CJ^JaJh 0,hSj>*CJ^JaJ h5/h2h5/h2CJaJh5/h4t5CJaJh5/h25CJaJh5/h?V5CJaJ h5/hth5/htOJQJmHnHu(jh5/hOJQJUmHnHu.jh5/hOJQJUmHnHuh5/hOJQJmHnHuyzn$Jkd $$Ifl*+ t+644 lap yt($ & Fd<<$Ifgdim$zkdm$$IflF\ *  t+6    44 lapyt7zM;$d<<$Ifgdts|kdo$$IflF X*` d? t+6    44 lapytnA$d$Ifgd 0,$$d$Ifa$gdb,$$d$Ifa$gd !"#$./ǶtgXM;#joh5/h'fOJQJUh5/h'fOJQJjh5/h'fOJQJUh)DhSjCJ^JaJh)DhCJ^JaJ'jh)DhN1CJU^JaJ'jh)DhPqdCJU^JaJh)DhN1CJ^JaJ!jh)DhN1CJU^JaJh5/hSjOJQJjhnAOJQJUjhnAOJQJUhnAOJQJhnAhnAOJQJ#RR:RRR\J$d<<$Ifgdts|kd$$IflhF X*` d? t+6    44 lapytnA$d<<$Ifgdi$$d<<$Ifa$gdi     2.  FORMDROPDOWN  FORMCHECKBOX  Yes.  FORMCHECKBOX  No: FORMTEXT      3.  FORMDROPDOWN  FORMCHECKBOX  Yes.  FORMCHECKBOX  No: FORMTEXT      Health & Safety: If any medical or psychiatric consults, hospitalizations, or health-related issues or problems occurred during the review period, is there anything that we need to do, follow-up on, or change in how the person is supported?  FORMCHECKBOX  No action or change needed.  FORMCHECKBOX  Yes, these changes or actions are indicated: FORMTEXT      Name of Person Completing This Review:Job Title / Position: FORMTEXT       FORMTEXT      Signature:Date: FORMTEXT       FORMTEXT      (Please send a copy of this completed review to the person s ISC agency upon completion)     Page  PAGE \* Arabic \* MERGEFORMAT 1 of  NUMPAGES \* Arabic \* MERGEFORMAT 1 /R R RRRRR4R6R8R:Rh)DhSjCJ^JaJh)DhCJ^JaJ'j%h)DhWuqCJU^JaJ'j$h)DhWuqCJU^JaJh)DhWuqCJ^JaJ!jh)DhWuqCJU^JaJj#hnAOJQJUjhnAOJQJUhnAOJQJ h5/hh5/hSjOJQJ#j!h5/hCOJQJUh5/hCOJQJjh5/hCOJQJURRRFSnSs`Pd<<$Ifgdi$d<<$Ifa$gdid<<$Ifgdts|kdi"$$IflhF X*` d? t+6    44 lapytnAFSHS\S^SlSnSpSSSSZTTUNURUTUpUrUtUxUUUUUUU,V.VzhzzVz#j&h5/h+CJUaJ#j&h5/h+CJUaJjh5/h+CJUaJh5/heCJaJh5/h1CJaJh5/h+CJaJh5/h2CJaJh5/he5CJaJ h5/hh5/hSjOJQJ#jw%h5/hCOJQJUh5/hCOJQJjh5/hCOJQJUnSpSSRUU,VlVVV$hd<<$If^hgdi$ & Fd<<$Ifgdim$|kd%$$IflhF X*` d? t+6    44 lapytnA,V.VVVXVZVUE$d$IfgdiLkd?($$Ifl*+ t+644 lap yt1hdxx$If^hgd(Jkdg'$$Ifl*+ t+644 lap yt(.V0VDVFVHVRVTVVVXVZV\VVVVVVVVVVVVWW W W W巫u_uFuu0jh 0,h4tCJOJQJUaJmHnHu+j *h 0,h4tCJOJQJUaJ%jh 0,h4tCJOJQJUaJh 0,h4tCJOJQJaJhi5CJaJh7hiCJaJh7hi5CJaJ h5/hSj(jh5/hSjOJQJUmHnHu#j'h5/hSjOJQJUh5/hSjOJQJjh5/hSjOJQJUZV\V^VVVVV$d$IfgdiOkd($$Ifl4*+ t+644 laf4p ytiVVVW W2W4WP?????$d$Ifa$gdikd($$Ifl4r|)*q{ t+644 laf4p2yt W"W$W.W0W4W6W8WLWPWZW^W`WbWdWxWzW|WWWWWWWWWWWWWֽ֮֮qֽ֮֮[ֽ֮Ph5/hgNCJaJ+j-h 0,h4tCJOJQJUaJ+j-h 0,h4tCJOJQJUaJh7hiCJaJhi5CJaJh7hi5CJaJ h4thh 0,h4tCJOJQJaJ0jh 0,h4tCJOJQJUaJmHnHu%jh 0,h4tCJOJQJUaJ+j*h 0,h4tCJOJQJUaJ4W6W8WNWPW\W^WP@@@@@$d$Ifgdikd*$$Ifl4r|)*q{ t+644 laf4p2yt^W`WbWWWWWUDDDDD$d$Ifa$gdikd,$$Iflr|)*q{ t+644 lap2ytWWjXP?$d$Ifa$gdikd.$$Ifl4r|)*q{ t+644 laf4p2ytWWWXlXnXpXtXvXzX|XXXXXXXXXXXXX6Y8Y:YY@YBYDYǶǶLjhmjhhCJUaJh{5CJaJmHnHuhh5CJaJ jhh5CJUaJhhCJaJhhCJaJh~jh~UhIh5/hgNCJaJhCJaJjXlXnXrXtXxXzX~XXXX>Y@YBYDY  %0*gd dgd dgd7Lkd/$$Ifl*+ t+644 lap yt721h:p/ =!"#$h% [$$If!vh#v+:V l44 t+65+f4p ytivDText29tDText1vDText30vDText31'$$If!vh#v#v#v#v#v1 :V l44 t+6,555551 / / / / / / / f4p2yti$$If!vh#v#v#v#v#v1 :V l44B t+6555551 / / / f4p2ytib$$If!vh#v+:V l4 t+6,5+f4p ytiDfService1 Supported LivingResidential HabilitationMedical ResidentialFamily Model Residential Day ServicesPersonal AssistanceDfService2 Supported LivingResidential HabilitationMedical ResidentialFamily Model Residential Day ServicesPersonal AssistanceDfService3 Supported LivingResidential HabilitationMedical ResidentialFamily Model Residential Day ServicesPersonal Assistance$$If!vh#vV#vW:V l4 t+6,5V5W/ f4pytBtDCheck1tDCheck2d$$If!vh#v+:V l t+65+/ p ytBtDText5d$$If!vh#v+:V l t+65+/ p yt5/R$$If!vh#v+:V l t+65+p yt($$If!vh#v #v#v:V l% t+65 55pyt7tDText6tDText8tDeCheck3tDeCheck4tDText9$$If!vh#v #v#v:V l t+65 55/ pyt7tDText6tDText8tDeCheck3tDeCheck4jD$$If!vh#v #v#v:V l t+65 55/ pyt7tDText6tDText8tDeCheck3tDeCheck4tDText9$$If!vh#v #v#v:V l t+65 55/ pyt7tDText6tDText8tDeCheck3tDeCheck4tDText9$$If!vh#v #v#v:V l t+65 55/ pyt7tDText6tDText8tDeCheck3tDeCheck4tDText9$$If!vh#v #v#v:V l t+65 55/ / pyt7`$$If!vh#v+:V l t+65+/ p yt($$If!vh#v` #vd#v?:V l t+6,5` 5d5?pytnADfService2 Supported LivingResidential HabilitationMedical ResidentialFamily Model Residential Day ServicesPersonal AssistancetDCheck5tDeCheck6vDText28$$If!vh#v` #vd#v?:V lh t+6,5` 5d5?/ pytnADfService2 Supported LivingResidential HabilitationMedical ResidentialFamily Model Residential Day ServicesPersonal AssistancetDeCheck5tDeCheck6vDText28$$If!vh#v` #vd#v?:V lh t+6,5` 5d5?/ pytnADfService2 Supported LivingResidential HabilitationMedical ResidentialFamily Model Residential Day ServicesPersonal AssistancetDeCheck5tDeCheck6vDText28$$If!vh#v` #vd#v?:V lh t+6,5` 5d5?/ / pytnAhDehDe`$$If!vh#v+:V l t+65+/ p yt(vDText20\$$If!vh#v+:V l t+6,5+p yt1\$$If!vh#v+:V l4 t+65+f4p yti$$If!vh#v#vq#v#v{#v:V l4 t+655q55{5/  / /  / / / f4p2ytvDText24vDText25$$If!vh#v#vq#v#v{#v:V l4 t+6,55q55{5/ / / / / / f4p2yt$$If!vh#v#vq#v#v{#v:V l t+655q55{5/  / /  / / / p2ytvDText26vDText27$$If!vh#v#vq#v#v{#v:V l4 t+6,55q55{5/ / / / / / f4p2yt\$$If!vh#v+:V l t+6,5+p yt7j 666666666vvvvvvvvv666666>6666666666666666666666666666666666666666666666666hH6666666666666666666666666666666666666666666666666666666666666666662 0@P`p2( 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p8XV~ OJPJQJ_HmH nH sH tH J`J CNormal dCJ_HaJmH sH tH DA D Default Paragraph FontRi@R 0 Table Normal4 l4a (k ( 0No List tt  Table Grid7:V0 d@@@ sH} List Paragraph ^m$>@> 0HeaderdH$>o!> 0 Header CharOJPJQJ^J> 2> 0FooterdH$>oA> 0 Footer CharOJPJQJ^JR@RR "p0 Balloon Text dCJOJQJ^JaJRoaR "p0Balloon Text CharCJOJPJQJ^JaJPK![Content_Types].xmlN0EH-J@%ǎǢ|ș$زULTB l,3;rØJB+$G]7O٭V$ !)O^rC$y@/yH*񄴽)޵߻UDb`}"qۋJחX^)I`nEp)liV[]1M<OP6r=zgbIguSebORD۫qu gZo~ٺlAplxpT0+[}`jzAV2Fi@qv֬5\|ʜ̭NleXdsjcs7f W+Ն7`g ȘJj|h(KD- dXiJ؇(x$( :;˹! I_TS 1?E??ZBΪmU/?~xY'y5g&΋/ɋ>GMGeD3Vq%'#q$8K)fw9:ĵ x}rxwr:\TZaG*y8IjbRc|XŻǿI u3KGnD1NIBs RuK>V.EL+M2#'fi ~V vl{u8zH *:(W☕ ~JTe\O*tHGHY}KNP*ݾ˦TѼ9/#A7qZ$*c?qUnwN%Oi4 =3N)cbJ uV4(Tn 7_?m-ٛ{UBwznʜ"Z xJZp; {/<P;,)''KQk5qpN8KGbe Sd̛\17 pa>SR! 3K4'+rzQ TTIIvt]Kc⫲K#v5+|D~O@%\w_nN[L9KqgVhn R!y+Un;*&/HrT >>\ t=.Tġ S; Z~!P9giCڧ!# B,;X=ۻ,I2UWV9$lk=Aj;{AP79|s*Y;̠[MCۿhf]o{oY=1kyVV5E8Vk+֜\80X4D)!!?*|fv u"xA@T_q64)kڬuV7 t '%;i9s9x,ڎ-45xd8?ǘd/Y|t &LILJ`& -Gt/PK! ѐ'theme/theme/_rels/themeManager.xml.relsM 0wooӺ&݈Э5 6?$Q ,.aic21h:qm@RN;d`o7gK(M&$R(.1r'JЊT8V"AȻHu}|$b{P8g/]QAsم(#L[PK-![Content_Types].xmlPK-!֧6 0_rels/.relsPK-!kytheme/theme/themeManager.xmlPK-!0C)theme/theme/theme1.xmlPK-! ѐ' theme/theme/_rels/themeManager.xml.relsPK] .x iiiiil 6 O*Hl/RFS.V WWDY !#$'-.036: d & k ~NZ,zRnS,VZVV4W^WWjXDY  "%&(/1245789;;GMNZ[^jps$6Fk{*6<O[acouw !-35AGIY^nu     + 0 @ G S Y ? O Q a i y     ) / ; A 5 E c s     # = I O R ^ d .FFFFS S S G$G$FFFG$G$FFFG$G$FFFG$G$FFFG$G$FFFG$G$FS$G$G$FS$G$G$FS$G$G$FG$G$FFFFF79>dfl!L# @0(  B S  ?Text29Text1Text30Text31Service1Service2Service3Check1Check2Text5Check5Check6Text10Text20Text24Text25Text26Text27<O_t7l+R j  > S / N\q%G|=b z  $ P e / ,/ ,/9;\^qs%&z"#g56Hhhk}'*=xx6:;<OOw !45HI    Z < P Q b i z } ~   - . / B D T U V [ \  3 5 F H H b   $ ' ' ( ( 1 2 8 9 < < = P R e h h u {  */R%)=X 8I*DZd^`o(. ^`hH. pL^p`LhH. @ ^@ `hH. ^`hH. L^`LhH. ^`hH. ^`hH. PL^P`LhH.h^h`5o(.8^8`.L^`L. ^ `. ^ `.xL^x`L.H^H`.^`.L^`L.^`o(. ^`hH. pL^p`LhH. @ ^@ `hH. ^`hH. L^`LhH. ^`hH. ^`hH. PL^P`LhH.^`o(. ^`hH. pL^p`LhH. @ ^@ `hH. ^`hH. L^`LhH. ^`hH. ^`hH. PL^P`LhH.%) 8*DZ          #                          gKCn" X {@!t^f* 7&a=(C*b, 0,l],;$...5/m01H23~6>nABliB)DEF`\GL#J6J51KIFK}K}NWOI(S?VxO\;]AaNbk*dPqd[Ve km"TqWuqts4tsH}#K}I"pSj7\Z/4 '3Vu2N1/<'A&''f{$'(3;Bii7e(T1+gNR2 s*~|8QbC @d\\\ .@ @,@RUnknownG*Ax Times New Roman5Symbol3. *Cx Arial7.@ Calibri5. .[`)TahomaA$BCambria Math"hh &    qr0 OQHP  $Pts*!xx Randy Moore;Elissa S BoltikElissa S Boltik    Oh+'0Hx    (08@Randy Moore;Elissa S BoltikNormalElissa S Boltik2Microsoft Office Word@F#@lIP@tV@tV  ՜.+,0 hp   Microsoft   Title  !"#$%&'()*+,-./0123456789:;<>?@ABCDEFGHIJKLMNOPQRSTVWXYZ[\]^_`abcdefghijklmnpqrstuvxyz{|}~Root Entry F*VData ={/1TableUM2WordDocument 4xSummaryInformation(oDocumentSummaryInformation8wMsoDataStorevVVYWNVAKOAI==2vVVItem  PropertiesUCompObj r   F Microsoft Word 97-2003 Document MSWordDocWord.Document.89q