Section 472-1-A-XII - INDIVIDUALIZED SUPPORT PLANSA. Recipients hive the right to an individualized support plan which shall be coordinated and monitored by a community support worker.B. These plans shall be developed based upon consideration of the recipient's housing, financial, social, recreational, transportation, medical, dental, emotional and psychiatric and/or psychological strengths and needs as well as his or her potential need for crisis intervention services. The plan shall reflect full consideration of the least restrictive appropriate treatment and related services taking into account factors that are supportive of each recipient's exercise of his or her basic rights, consistent with each individual's strengths, needs and treatment requirements pursuant to this section. Such considerations shall include accommodation of particular needs involving communication and physical accessibility to all treatment programs.C. The recipient and the legally responsible parent, guardian or custodian shall be notified of all ISP meetings, and shall be actively encouraged to attend. If the recipient and/or the legally responsible parent, guardian or custodian does not attend an ISP meeting, the Community Support Worker shall relay their views to other members of the team. The legally responsible parent, guardian or custodian may invite other persons to ISP meetings. Persons unable to attend the meeting shall be notified that they may submit information in writing for consideration at the meeting.D. ISP's shall be developed in a timely manner and shall be reviewed and revised no less frequently than every 90 days. Plans may be reviewed more frequently as necessary to address substantial changes in the recipient's life, such as hospitalization.E. The ISP shall be developed by a team consisting of the recipient, the legally responsible parent, guardian or custodian, and others among whom there exists the authorization to exchange information and who are needed to ensure that the recipient's needs are adequately assessed and that appropriate recommendations are made, based upon a comprehensive assessment of the recipient The plan shall contain but not be limited to:(1) A statement of the recipient's specific strengths and treatment needs. a. The ISP should include a description of any physical handicap and any accommodations necessary to provide the same or equal services and benefits as those afforded non-disabled individuals.(2) A description of services to assist the recipient in meeting identified needs. Goals shall be written for each service. Short-range objectives shall be stated such that their achievement leads to the attainment of overall goals. Objectives shall be stated in terms which allow objective measurement of progress and which the recipient, to the maximum extent possible, both understands and adopts.a. The description of services shall be based upon the actual needs of the recipient rather than on what services are currently available. If at the time of the meeting, members know on the basis of reliable information that the needed services are unavailable, they shall note them as "unmet service needs" on the ISP based upon available services which meet, as nearly as possible, the actual needs of the recipient.(3) A description of the manner of delivery of each service to be provided. The manner of delivery shall be one which maximizes the recipient's strengths, independence and integration into the community.(4) A statement of the rationale or reason for specifying certain treatment or services to meet identified goals.(5) A specification of treatment responsibility, including the responsibility and involvement of staff, recipient and parent or guardian to attain treatment goals.F. Within one week of the meeting, the recipient and his or her parent, custodian or guardian shall be offered a written copy of the [SP. The recipient shall also be notified, by means he or she will most likely understand, of the right to file a grievance should he or she disagree with any aspect of the plan or the assessments upon which the Wan is based, or later be dissatisfied with the plan's implementation.G. All agencies providing Community Support Worker services shall maintain specific written guidelines describing their practices concerning development of ISP's.H. The legally responsible parents, guardians or custodians shall be actively involved in individualized support planning, to the maximum extent possible. The Department of Human Services acting as legal custodian has an affirmative duty to be fully and actively involved in individualized support planning.14- 472 C.M.R. ch. 1, § A-XII