D.C. Mun. Regs. tit. 29, r. 29-7410
The HSS provider shall monitor the individual's progress towards meeting their ISP goals. The ISP shall be reviewed with the individual, as needed or at a minimum frequency defined in the HSS provider's HCA with the Department.
The HSS provider shall make person-centered and strengths-based updates to an individual's ISP as needed. Updates shall be made regarding the individual's needs and shall reflect priorities important to the individual. Any updates establish or further already established appropriate and measurable goals and objectives, desired outcomes, and recommended service interventions that will address the individual's needs and assist the individual in moving toward self-sufficiency and housing stability.
The HSS provider shall make referrals to and partner with other agencies, as necessary and appropriate, to support individual's supportive needs, including behavioral health (e.g., mental health, substance abuse), educational, technical and trade supports, parenting skills and support, legal, financial, family and child support, early intervention, and senior and disability supports.
The HSS provider shall establish referral and follow-up procedures to confirm and track participation in all referrals made to other agencies. Documentation of referrals made, and referral confirmation shall be documented in the Department's case note system.
The HSS provider shall document in the individual's record, existing in the Department's case note system, whether an individual's court-appointed guardian, family, or significant others participated in the development of the ISP.
In situations where the individual does not demonstrate the capacity to sign or does not sign their ISP, the reasons the individual does not sign shall be recorded in the individual's record, existing in the Department's case note system, including each date when obtaining a signature was attempted.
D.C. Mun. Regs. tit. 29, r. 29-7410