SPR (Non-Foothold)

Service Plan Review (Non-Foothold)

Haypath CR, MHANC CLP

Consumer: ______________________________

SPR Date: __________

 Date of the change in service plan periods; the end of the current period and the start of
the next period.

2 weeks prior to SPR date:

1. For the Collateral Contact part within each Goal section: Make contact with one of the
resident’s treatment team members for his or her opinion regarding the appropriateness of
any new, proposed goals, as well as any suggestions or recommendations for goals.
2. Meet with the resident to provide his or her input, to discuss, determine and agree on any
new, proposed goals, objectives and services.

Target Date of Objectives: __________

 For new or continued objectives; 90 days from the SPR date (above). To determine this
date, see the “Service Plan Periods” post in the office or see Foothold’s SPR schedule:
Foothold>Charts>Services-Individual>Service Plans>(Select Consumer)>Continue>
Update Schedule (near the bottom of the page)>(Find the date that is next after, below,
the present SPR’s date).

Strengths:
 Consumer’s mental health and wellness strengths and other internal attributes including
abilities, skills, knowledge, motivation, positive habits, healthy coping tools, religious
faith, positive personality traits, positive characteristics, etc.
 Consumer’s assets, external resources and anything else that benefits or helps the
consumer, e.g., social resources (e.g., family, friends, etc.), owning a car (can be utilized
to seek, gain and maintain employment), having significant monetary savings (can be
utilized for supplemental treatment, recreation, etc.), having specific opportunities, etc.
 It is helpful to briefly assess the consumer’s strengths and assets relevant to each of the
Medicaid 595 Restorative Services (ASA, CIR, DLS, HS, MMT, (PT if applicable), RC,
SDS, SO, (SA if applicable), SM).
 E.g., “CONSUMER is respectful, polite, generous, self-confident, has close ties with his
family and is motivated to pursue employment. He exhibits somewhat strong
assertiveness and self-advocacy capabilities. He exhibits appropriate capabilities and
motivation for community integration and resource development. He exhibits strong and
appropriate daily living skills. He exhibits strong awareness of and motivation to
maintain or improve his health. He exhibits somewhat clear rehabilitation directions or
goals. He exhibits some basic capabilities required for employment. He exhibits some
socialization. He exhibits abstinence from mind-altering substances. He somewhat
exhibits a general maintenance of his mental health and well-being.”

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SPR (Non-Foothold)

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Limitations:
 *Must include mention of what each of the 5 upcoming service plan objectives focus on,
e.g., medication noncompliance, poor hygiene, poor social skills, lack of applying daily
living skills, unwillingness or inability to perform responsibilities, (e.g., scheduling
appointments, ordering refills, budgeting, etc.), having an unhealthy diet, etc.
 That which the consumer needs help with, has difficulty doing, is unable or refuses to do.
 That which limits the consumer from mental health progress, housing progression,
developing independence, etc.
 Negative characteristics, behaviors, thinking patterns, etc.
 Deficiencies in mental health, behaviors, knowledge or resources, e.g., deficiency in
abilities such as memory or speech, in skills such as cooking or bathing, in knowledge
such as with regard to his or her medication regimen, in resources such as family, peer
support or care coordination, in coping tools or strategies, in characteristics such as
patience or self-confidence, etc.
 It is helpful to briefly assess the consumer’s needs, limitations or deficiencies relevant to
each of the Medicaid 595 Restorative Services (ASA, CIR, DLS, HS, MMT, (PT), RC,
SDS, SO, (SA), SM).
 E.g., “CONSUMER is occasionally temperamental, suspicious and distrustful of others,
he exhibits distorted thinking patterns and he sometimes experiences mood swings. He
does not exhibit knowledge or application of a diverse skill set of wellness or coping
tools. He exhibits slightly limited assertiveness and self-advocacy capabilities. He
exhibits slightly limited capabilities for community integration and resource
development. He exhibits limited insight and motivation to maintain a diet that promotes
good health. He does not participate in the management of his medication supplies. He
exhibits slightly limited rehabilitation directions or goals. He has slightly limited
capability of identifying obstacles to his rehabilitation directions or goals. He exhibits
limitations to capabilities required for employment or educational opportunities. He
exhibits slightly limited socialization capabilities. He has expressed a relatively recent
personal history of mind-altering substance use. He exhibits limited symptom
management capabilities when faced with distressful circumstances.”

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SPR (Non-Foothold)

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Goals

Goal:
 *Must begin with “CONSUMER wants…”
 Relevant to the consumer’s needs and fit to the consumer’s level of capability.
 Broad, unspecific, not time-bound.
 E.g., “CONSUMER wants to participate in the management of his medication supply.”

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Rationale for Goal, Assessment Statement:

 Briefly explain the rationale for the goal and describe an assessment of the consumer with
relevance to the goal.
 Describe the relevance to the consumer’s particular need or relevant limitation.
 Relay the consumer’s capacity to pursue the goal; describe the capabilities, skills,
knowledge and other characteristics the consumer possesses that are required to pursue
the goal.
 Describe any relevant history or experience related to the goal.
 Describe how the goal can benefit the consumer or improve the consumer’s capabilities,
skills, knowledge or other characteristics, e.g., memory, communication skills, social
skills, mental health, well-being, self-efficacy, self-confidence, patience, motivation, etc.
 Relay how the goal is relevant to the two general goals of Haypath CR, i.e., to improve
the independence or autonomy of consumers and to improve the capacity of consumers to
graduate into a more independent level of housing.
 E.g., “CONSUMER does not participate in the management of his medication supply. He
does not order medication refills for himself. With assistance, he is capable and skilled
enough to participate in the management of his medication supply; he has sufficient
communication skills and sufficient memory and motivation. He managed his medication
supply about one year ago when he self-administered his medications independently,
without staff supervision. Pursuing this goal can improve his organization and
communication skills, his self-efficacy, self-confidence, autonomy and can improve his
capacity to graduate into a more independent level of housing.”

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SPR (Non-Foothold)

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Collateral Contact (Psychiatric Treatment Team):

 2 weeks prior to the SPR date, make contact with a treatment team member for his or her
opinion regarding the appropriateness of any new, proposed goals, as well as any
suggestions or recommendations for goals.
 Briefly describe the collateral contact made in reference to the goal.
 Relay the treatment team’s agreement on the goal’s appropriateness for the consumer.
 E.g., “Staff spoke with CONSUMER’s [PROS advisor, social worker, psychiatrist, etc.]
who agreed that this goal is appropriate for CONSUMER.”

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Review of Goal:
 *Must begin with a summation of progress, or lack thereof, toward the goal or relays the
attainment of the goal; beginning with the consumer’s name, including the past tense of
the verb from the goal, e.g., “CONSUMER [somewhat participated, did not participate,
minimally participated, adequately participated, greatly participated, enthusiastically
participated, etc.] in the management of his medication supply.”
 *Must end with “This goal will be [continued/discontinued/revised].”
 Relay if a relevant need, deficiency or limitation has changed. Relay if the consumer
maintained the same degree of the need, deficiency or limitation.
 E.g., “CONSUMER somewhat participated in the management of his medication supply.
He continues to require prompting to order refills of his medications. With much
prompting, he only occasionally orders refills of his medications. This goal will be
continued.”

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SPR (Non-Foothold)

New or Revised Goal:

 *Must begin with “CONSUMER wants…”
 Relevant to the consumer’s needs and fit to the consumer’s level of capability.
 Broad, unspecific, not time-bound.
 E.g., “CONSUMER wants to participate in the management of his medication supply.”

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Objectives & Services

Objective:
 *Must begin with “CONSUMER wants…”
 *Must end with “… within the next three months.” This excludes the Admission Note (a
1-month period) and the Initial Service Plan (a 2-month period).
 SMART: Specific, measurable, attainable, relevant, time-bound (three months). Entails
only one type of activity, not more than one. Relevant to the related goal, to the
consumer’s needs and fits to the consumer’s level of capability.
 E.g., “CONSUMER wants to order a medication refill six times, within the next three
months.”

Service Type: __________

Service:
 *Each sentence must begin with “Staff will…”
 *Must end with “CONSUMER will attain this objective when he [present tense of the
objective] [the time-bound aspect], e.g., “CONSUMER will attain this objective when he
orders a medication refill six times, within the next three months.”
 *Must include the basic aspects of what residence staff should do with regard to assisting
the consumer to make progress toward the objective, e.g., for objectives related to
medication, the service must include points such as “Staff will review with CONSUMER
his medication regimen” and “Staff will provide CONSUMER with his detailed
medication list.”
 *Must include descriptions of how staff will assist the consumer in various aspects and
phases of progress toward the objective, e.g., comprehension and review of the objective,
learning what’s necessary to make progress toward the objective, developing plans,
implementing plans, rehearsing or practicing, applying plans outside of goal sessions (if
appropriate), reviewing progress and attempts, identifying obstacles, developing plans to
overcome obstacles, etc.

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SPR (Non-Foothold)

 E.g., “Staff will review CONSUMER’S medication regimen with him. Staff will provide
him with his detailed medication list. Staff will present him with his medication supply.
Staff will facilitate his surveying of his medication supplies in order to assist him in
identifying which medications of his need to be refilled. Staff will prompt him to
memorize or write down which medications need to be refilled. Staff will facilitate his
rehearsal of ordering a medication refill via phone. Staff will facilitate role play to
facilitate his rehearsal of ordering medication refills, as needed. Staff will direct him to
where he can find the phone number to his pharmacy. Staff will encourage him to save
his pharmacy’s phone number. Staff will encourage him to survey his medication
supplies daily, when he takes his medications, in order to determine which ones need to
be refilled. Staff will encourage him to order medication refills independently. Staff will
reinforce his behavior or progress. Staff will explore any obstacles to this objective that
he may experience. Staff will assist him in developing strategies to overcome any
obstacles to this objective. CONSUMER will attain this objective when he orders a
medication refill six times, within the next three months.”

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Review of Objective & Service:

 *Must begin with a summation of the objective, beginning with the consumer’s name,
including the past tense of the verb from the objective, and excluding the time-bound
aspect, e.g., “CONSUMER ordered a medication refill two times.”
 *Must end with “This objective will be [continued/discontinued/revised].”
 *If the objective was attained, relay so.
 *Must review the services provided in the related goal sessions. Review the related goal
session progress notes to discover what services to describe.
 Generally, you may copy and paste the service and put it in past tense, e.g., “Staff
reviewed CONSUMER’S medication regimen with him. Staff provided him with his
detailed medication list. Staff presented him with his medication supply…” (each “will”
from the service is deleted).

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SPR (Non-Foothold)

 E.g., “CONSUMER ordered a medication refill two times. Staff reviewed his medication
regimen with him. Staff provided him with his detailed medication list. Staff presented
him with his medication supply. Staff facilitated his surveying of his medication supplies
in order to assist him in identifying which medications of his need to be refilled. Staff
prompted him to memorize or write down which medications need to be refilled. Staff
facilitated his rehearsal of ordering a medication refill via phone. Staff facilitated role
play to facilitate his rehearsal of ordering medication refills, as needed. Staff directed him
to where he can find the phone number to his pharmacy. Staff encouraged him to save his
pharmacy’s phone number. Staff encouraged him to survey his medication supplies daily,
when he takes his medications, in order to determine which ones need to be refilled. Staff
encouraged him to order medication refills independently. Staff reinforced his behavior
or progress. Staff explored any obstacles to this objective that he may experience. Staff
assisted him in developing strategies to overcome any obstacles to this objective. This
objective will be continued.”

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New or Revised Objective (See “Objective” guidelines):

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New or Revised Service (See “Service” guidelines):

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File Location: F:(MHACOMMON)\CLP Forms\Cushman-Haypath House\Service Plan Review (Non-Foothold)