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LIFE PLANS AND
STAFF ACTION PLANS FOR
EMPLOYMENT SERVICES
CHSE
Innovations in
Employment Supports
Innovations in Employment Supports
2019 Employment and Vocational Services
Leadership Conference
September 24, 2019
About today
• Today’s schedule
• Sign in and sign out
• Site details
• Engage!
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• Employment Services Collaboration with Care Managers
• OPWDD Life Plans for Employment Services
• OPWDD Staff Action Plans for Employment Services
• Questions??????
Today we will cover …
EMPLOYMENT SERVICES
COLLABORATION WITH
CARE MANAGERS
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Employment Services Collaborative Role with
Care Managers
1. Participate in person-centered planning with the person, Care Manager,
and care planning team.
2. Identify the vocational or employment service(s) that matches the
individual’s needs related to prior vocational experiences, career
exposure, work experiences, interests, and demonstrated skills.
3. Work collaboratively with the Care Manager to facilitate enrollment in the
programs, services and resources that best meet the individual’s
vocational needs. Care Manager will need Central Office approval
number for Intensive SEMP and Additional Pathway to Employment
service requests.
4. Update and add new services to the Life Plan (Care Manager) and Staff
Action Plans (Provider Agency), as required.
5. Ongoing communication regarding progress, challenges and changes in
the person’s services, status, schedule, etc.
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Choosing Services to Fit the Person’s
Skills, Experience and Support Needs?
OPWDD Career and Employment Services Options
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Why Combine Programs for
Employment Success?
• To address barriers to employment
such as task focus, interpersonal skills,
flexibility, etc.
• To build social and community
relationships outside of work
• To build stamina and healthy habits
• To develop transportation skills
• To build independence and safety
skills
• To gain experience in new career
paths
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OPWDD LIFE PLAN FOR
EMPLOYMENT SERVICES
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Person
Person Centered Planning
I AM,
CAS,
EAA
Life Plans/
Staff Action Plans
Person
and Care
Planning
Team
Feedback
Participation and Valued
Roles in the Community
Services Delivery and
Supports
Review,
Evaluate
& Revise
Plans
Planning
and
Assessment
Tools
Life Planning Process
Life Plan Development
Life Plan Sample
Derived from the “I Am”
assessment and Life Plan
meeting
CQL POMS:
Example: People choose
personal goals
My Goal/Valued Outcome:
Example: Be more
independent
Sample Provider Assigned Goal
Example: (G) Gain
competitive
employment
Staff Action Plan Sample
(G) Gain competitive employment
Add Staff Action(s) with more
detail……
Example: Staff will assist John in
gaining a job that meets his top two
interests (outdoor maintenance or
vehicle repair assistant). See
Discovery packet and Job
Development Plan for specific job
match criteria.
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Life Plan Format
The person, Care Manager, and care planning team work together
to develop the Life Plan using a person-centered planning
process.
The Life Plan is comprised of 5 sections.
I. Assessment Narrative Summary
II. Outcomes and Support Strategies
III. Individual Safeguards/Individual Plan of Protective Oversight
IV. HCBS Waiver Service and Medicaid State Plan Authorized
Services
V. All Supports and Services: Funded and Natural/Community
Resources
VI. IDT Summary, IDT Meetings/Attendance, Member Conditions
and Diagnoses
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Valued Outcomes in the Life Plan
HCBS Waiver Requirements as Listed in Service ADM’s
Service
Valued Outcome/Goals (must closely reference the
specific ADM requirements listed below)
Community Based
Prevocational
Interest in obtaining pre
-employment skills;
preparation for employment or job readiness
Site Based Prevocational
Interest in obtaining pre
-employment skills;
preparation for employment or job readiness
Pathway to Employment
Interest in obtaining pre
-employment skills;
preparation for employment or job readiness
Supported Employment
Interest in competitive employment or self
-
employment
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Valued Outcomes may be listed in either Section(s) I, II and III of the Life Plan.
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Life Plan Section II and III
How are Goals/Valued Outcomes Listed in the Life Plan?
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• POM (Personal Outcome Measure) – Only in Section II - must have
at least 2 POM in the overall Life Plan
• Goal/Valued Outcome – Overarching goals in the Life Plan
• Provider Assigned Goal – More specific
• Provider/Location
• Service Type
• Frequency (relates to implementing goal NOT the service)
• Quantity (relates to implementing goal NOT the service)
• Timeframe (relates to implementing goal NOT the service)
• Special Considerations (may list additional information as needed)
Sample Life Plan Section II or III
Goal/Valued
Outcome
Provider
Assigned Goal
Provider/
Location
Service Type
Frequency
Quantity
Time Frame
Special
Consideration
s
Instructions:
What does the
person want out
of life? What do
they want to
achieve? May be
generated from I
AM or planning
meetings.
Specifies what
the provider is
expected to do
as it relates to
the person’s
goal/valued
outcome.
List the
agency
name
and
location
How
often the
goal or
support
will be
provided
?
Estimate
Within
the
frequency
–
how
often?
Estimate
When the
goal is
expected
to be
achieved.
Estimate
As needed,
list info
regarding
health
/safety
concerns
or other
pertinent
info.
Sample:
I want to
improve or
maintain my
work skills
(G) Teach work
skills
ABC
Agency
As
needed
Ongoing
Ongoing
None
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Life Plan Section IV
HCBS Waiver Services and Medicaid State Plan Authorized Services
How are OPWDD Service Regulations and ADM Requirements
Listed in the Life Plan?
Valued Outcomes as required by specific service ADM’s may be listed in sections I, II,
III. See valued outcomes as listed in service ADM’s chart.
Section IV:
• Effective Dates – Date of the Life Plan or service start date, if in between the Life
Plan effective dates
• Unit = Frequency (as directed in the service-related ADM)
• Duration (as directed in the service-related ADM)
• Total Units – List the number of units listed in the Service Authorization Letter or
99999 if unknown
• Comments – may list additional information as needed
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Supported Employment
Section IV
HCBS Waiver and Medicaid State Plan Authorized Services
Authorized
Service
Provider/
Facility
Effective
Dates
Qty
Unit
Per Total
Units
Comments
SEMP
Name of the
agency or
Fiscal
Intermediary
(FI)
providing
the
service
Effective
date (i.e.
review date)
of the Life
Plan or new
service start
date)
Duration:
Ongoing
This field is
to assist in
calculating
the total
units and
may or may
not be used
by the
CCO.
“Hour”
or
“Hourly”
This field is
to assist in
calculating
the total
units and
may or may
not be used
by the
CCO.
Per
service
Authoriza
tion or
99999 if
unknown
Other required
or pertinent
information.
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Must have at least one goal/valued outcome identified in Sections II or III. If specific
language needed to met regulatory requirements is not included, the Care Manager may
edit the appropriate section OR list in a comments section.
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Prevocational Services
Section IV
HCBS Waiver and Medicaid State Plan Authorized Services
Authorized
Service
Provider/
Facility
Effective
Dates
Qty Unit Per Total Units
Comments
Site Based
Prevocational
Services
(SBPV), if site
based
Community
Based
Prevocational
Services
(CBPV), if
community
based
Name of
the
agency
providing
the service
Effective
date (i.e.
review
date) of
the Life
Plan or
new
service
start date)
Duration:
Ongoing
This field
is to assist
in
calculating
the total
units and
may or
may not
be used
by the
CCO.
SBPC -
“A day”
CBPV
-
“Hour”
or
“hourly
”
This field is
to assist in
calculating
the total units
and may or
may not be
used by the
CCO.
Per service
Authorizatio
n Letter
99999 if
unknown
Other
required or
pertinent
information.
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Must have at least one goal/valued outcome identified in Sections II or III. If specific
language needed to met regulatory requirements is not included, the Care Manager may
edit the appropriate section OR list in a comments section.
Pathway to Employment
Section IV
HCBS Waiver and Medicaid State Plan Authorized Services
Authorized
Service
Provider/
Facility
Effective
Dates
Qty
Unit
Per Total Units
Comments
Pathway to
Employment
Name of
the agency
providing
the service
Effective
date (i.e.
review date)
of the Life
Plan or new
service start
date)
Duration:
Time
Limited
This field is
to assist in
calculating
the total
units and
may or may
not be used
by the
CCO.
Hour
or
hourly
This field
is to assist
in
calculating
the total
units and
may or
may not
be used
by the
CCO.
Per service
Authorization
Letter
99999 if
unknown
Other
required or
pertinent
information.
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Must have at least one goal/valued outcome identified in Sections II or III. If specific language
needed to met regulatory requirements is not included, the Care Manager may edit the
appropriate section OR list in a comments section.
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Life Plan Section V
All Supports and Services; Funded and Natural & Community Resources
Includes OPWDD state-paid services, other Medicaid services not authorized
by OPWDD, health care providers, natural supports, and community
resources.
Examples related to employment services:
• OPWDD state-funded SEMP (individuals are grandfathered prior to 7/1/15)
• ACCES-VR services (Supported Employment, Assessments, Benefits
Advisement, Assistive Technology, Driver Rehabilitation, Post-Secondary
Education Coaching, etc.)
• ETP Wages are 100% OPWDD state-funded. (ETP services are funded by
HCBS Waiver OPWDD SEMP and must be listed in Life Plan Section IV).
• Community transportation provider or supports (taxi, Uber, coworker, etc.)
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Example: How to List the Employment Training Program (ETP)
on the Life Plan
Service
Provider/
Facility
Effective
Dates
Qty
Unit
Per
Total Units
Comments
SEMP
Name of
the agency
FI
providing
the service
Effective
date (i.e.
review
date) of the
Life Plan or
new
service
start date)
Duration:
Ongoing
This field is
to assist in
calculating
the total
units and
may or may
not be used
by the CCO.
“Hour”
or
“Hourly”
This field is to
assist in
calculating
the total units
and may or
may not be
used by the
CCO.
Per service
Authorization
or
99999 if
unknown
Person
currently
participates in
ETP
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ETP/SEMP Services:
ETP Wages:
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OPWDD STAFF ACTION
PLANS FOR
EMPLOYMENT SERVICES
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Staff Action Plans
Staff Action Plans detail the following:
The goal/valued outcomes, goals, and safeguards, as identified in the individual’s
Life Plan.
How the habilitation staff will implement the goal/valued outcomes, goals, and
safeguards.
Ensure that the goal/valued outcomes, habilitative goals, and safeguard needs of
individuals are met by the planning team and service providers.
Staff Action Plans are developed and signed by the habilitation staff and
forwarded to the Care Manager via the CCO’s portal or another agreed upon
mechanism for prompt communication. In addition to Care Managers, the Staff
Action Plans should also be provided to: the individual and his/her representative
and any other parties agreed to by the person and his/her representative. (2018-
ADM-06R)
Staff Action Plans are required for HCBS Waiver services and OPWDD 100% State-
Funded SEMP (individuals who are grandfathered prior to 7/1/15).
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Staff Action Plan Reviews
There must be evidence that the Staff Action Plan was reviewed at least
twice annually.
Evidence of a review may include, but is not limited to a:
• Review sign-in sheet;
• Service note indicating a review took place; and/or
• Revised/updated Staff Action Plan.
Evidence of reviews must include the:
• Individual’s name;
• Habilitation service(s) under review;
• Staff signature(s) from the habilitation service(s);
• Date of the staff signature(s); and
• Date of the review.
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Staff Action Plan Required Sections
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All Goals/Valued Outcomes assigned to the provider must be included in
the Staff Action Plan.
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Staff Action Plans Must Contain the Following
Additionally, habilitation providers are responsible for the documentation standards
outlined in the specific service-related Administrative Memoranda.
• Individual’s name;
• Individual’s Medicaid Client Identification Number (CIN)
• Habilitation service provider’s agency name;
• Name of habilitation service(s) provided (e.g., Community Based Prevocational)
• Date (day, month, and year) the Life Plan meeting, or Staff Action Plan review/developed
• Identification of the Goals/Valued Outcomes (Life Plan Section II);
• Identification of Provider Assigned Habilitative Goals/Safeguards (Life Plan Section III).
• Description of service(s) and support(s) and frequency (as listed in the Life Plan)
• Safeguards listing all supports and services (may also reference guidance documents);
• Printed name(s), signature(s) and title(s) of the staff who wrote the Staff Action Plan;
• Date (day, month, and year) that staff signed the Staff Action Plan; and
• Evidence that Staff Action Plan was distributed no later than 60 days after: start of services;
life plan review date; or revised/updated Staff Action Plan, whichever comes first.
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Staff Action Plan Template
Optional format available on OPWDD website. Agencies may create their own
format with the required elements.
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Provider Assigned Goals in the Life Plan
Action Step Labels
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(T) Tasks as Listed in the Life Plan
(T) Tasks are one-time activities and are NOT billable.
If a (T) Task is listed in the Life Plan but the provider is
working with the individual to achieve this action step
as a (G) Goal or (S) Support, then the Life Plan should
accurately reflect what the provider is actually doing.
An example may be “Assessment of skills and
preferences” (T) or (S)?
Contact the Care Manager in a timely manner if you
need amendments to the Life Plan.
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Staff Action Plan Strategies for Service Delivery
Skill Acquisition/Retention - Staff assess skill levels, identify
methods to teach skills, and identify how to measure
progress. In some instances, retention of skills may be the
goal.
Staff Supports – Staff provide supervision, on-going support,
or oversight when a person is not expected to perform
independently due to disability or health/safety factors.
Exploration of New Experiences – The person learns about
community and forming relationships often by trying new
experiences to determine life directions and to support
greater independence.
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Staff Action Verbs to
Describe Medicaid-Funded
Services
Use language to
justify Medicaid-
funded services.
Avoid passive verbs or
judgmental language.
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Staff Supports
remind, monitor,
provide, prompt,
assist, network,
communicate,
develop, etc.
Exploration of New
Experiences explore,
assess, evaluate,
test, identify, etc.
Skill Acquisition
teach, instruct,
reinforce,
increase,
enhance, role
play, prompt,
fade supports,
etc.
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Staff Action Plans
How are Allowable Services Listed in the Staff Action
Plan?
In order to bill for the range of services
related to specific goals/valued outcomes,
the Staff Action Plan should list all the
allowable services as stated in the
regulations or a general statement such as,
“Staff may provide any of the allowable
services to support this goal.”
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Sample SEMP Staff Action Plan
Outcomes and Support Strategies (Section II)
SEMP Sample 1:
Copied from Life Plan:
My Goal/Valued Outcome: Be more independent
Provider Assigned Goal: Teach work skills (G-Goal)
Frequency: As needed
Add description(s) of staff actions for goal/support implementation:
Staff will teach the person to learn new tasks, as assigned by work
supervisors. Staff will provide instructional supports, communicate regularly
with supervisor, and gradually fade supports, as John meets the business’
standards. To assist John in remembering his tasks, staff will laminate tasks
lists with pictures/symbols, as new tasks are added. Staff may provide any of
the allowable SEMP services to support this goal.
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Sample SEMP Staff Action Plan
Outcomes and Support Strategies (Section II)
SEMP Sample 2:
Copied from Life Plan:
My Goal/Valued Outcome: Be more independent
Provider Assigned Goal: Gain competitive employment (G-Goal)
Frequency: As needed
Add description(s) of staff actions for goal/support implementation:
Staff will assist Francie in finding a job that meets her keyboarding, filing, and
other clerical skill levels within the public transportation range. Francie recently
completed Discovery which recommended clerical work as her preferred career
choice. Francie is currently employed as a cleaner and would like to eventually
move into her preferred career. Staff may provide any of the allowable SEMP
services to support this goal.
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Sample SEMP Staff Action Plan
Individual Safeguards/Individual Plan of Protection (Section III)
SEMP Sample 3:
Copied from Life Plan:
My Goal/Valued Outcome: I want to improve or maintain my work skills
Provider Assigned Goal: Teach work skills (G-Goal)
Frequency: As needed
Add description(s) of staff actions for goal/support implementation: Staff will
teach John to respond to customer requests by looking customers in the eye,
listening fully to requests, and responding appropriately. If John does not know
the answer, he will escort the customer to another customer service associate
for assistance. Staff will provide instructional supports, gradually fading
supports, as John competently responds to customer requests. Staff may
provide any of the allowable SEMP services to support this goal. John will learn
to respond to customer requests appropriately 95% of the time observed and
reported within 1 year.
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Sample SEMP Staff Action Plan
Individual Safeguards/Individual Plan of Protection (Section III)
SEMP Sample 4:
Copied from Life Plan:
My Goal/Valued Outcome: I want to be healthy
Provider Assigned Goal: Teach diabetes self-management training (S-
Support)
Frequency: As needed
Add description(s) of staff actions for goal/support implementation:
Staff will teach Francie which foods are safe to purchase at the company
cafeteria and special events according to her diabetic diet. Staff will contact
the residential nurse monthly for diabetic instructions and updates. As
Francie makes healthy food choices at work, staff will gradually fade supports
but monitor regularly. Staff may provide any of the allowable SEMP services
to support this goal.
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Sample CBPV Staff Action Plan
Outcomes and Support Strategies (Section II)
CBPV Sample 1:
Copied from Life Plan:
My Goal/Valued Outcome: I want to improve or maintain my work skills
Provider Assigned Goal: Teach work habits (G-Goal)
Frequency: Weekly
Add description(s) of staff actions for goal/support implementation:
Staff will teach Francie to stay focused and limit conversation when engaged
in work-related activities. Staff will teach Francie to use self-management
tools to track her progress. As Francie learns to sustain focus, staff will
gradually fade supports. Staff may provide any of the allowable CBPV
services to support this goal. Francie will stay focused when engaging in
activities until completion (or break time) 80% of the time observed within 1
year.
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Sample CBPV Staff Action Plan
Individual Safeguards/Individual Plan of Protection (Section III)
CBPV Sample 2:
Copied from Life Plan:
My Goal/Valued Outcome: I would like to communicate better
Provider Assigned Goal: Teach communication skills (G-Goal)
Frequency: Weekly
Add description(s) of staff actions for goal/support implementation:
Staff will teach Mike to communicate when he needs assistance, instead of
waiting inactively for someone to help him. Staff will role-play with Mike
various scenarios where he needs help and provide sample statements to ask
for help. Staff will provide instruction and gradually fade supports as he
becomes independent. Staff may provide any of the allowable CBPV services
to support this goal. Mike will ask for assistance 90% of the time without staff
assistance, as observed over 6 months.
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Sample CBPV Staff Action Plan
Individual Safeguards/Individual Plan of Protection (Section III)
CBPV Sample 3:
Copied from Life Plan:
My Goal/Valued Outcome: I need supervision in the community
Provider Assigned Goal: Provide supervision in unfamiliar places (S-
Support)
Frequency: Ongoing
Add description(s) of staff actions for goal/support implementation:
Staff will teach Brian safety skills; specifically contacting emergency contacts
and limiting contacts with strangers. When Brian has demonstrated these
safety skills at a specific community location for over 6 months consistently,
staff may fade assistance while still remaining on the premises. Staff will
provide closer supervision in all less familiar community activities. Staff may
provide any of the allowable SEMP services to support this goal.
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Sample Pathway to Employment Staff Action Plan
Outcomes and Support Strategies (Section II)
Pathway to Employment Sample 1:
Copied from Life Plan
My Goal/Valued Outcome: I want a real job
Provider Assigned Goal: Provide assessment of skills and interests (S-
Support)
Frequency: As needed
Add description(s) of staff actions for goal/support implementation:
Miranda has limited work experience in the community. Staff will implement
Discovery activities and develop community work experiences that meet
Miranda’s expressed interests in clerical, child care and stocking. Staff will
evaluate her skill levels and preferences in each community work experience.
Staff may provide any of the allowable Pathway to Employment services to
support this goal.
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Sample Pathway to Employment Staff Action Plan
Outcomes and Support Strategies (Section II)
Pathway to Employment Sample 2:
Copied from Life Plan
My Goal/Valued Outcome: I want to earn more money
Provider Assigned Goal: Teach to use public transportation (G-Goal)
Frequency: As needed
Add description(s) of staff actions for goal/support implementation:
Mike has safety skills and time alone in the community but has not utilized the
public bus system which will be needed for employment. Staff will assess
Mike’s skills and teach him to take the bus to the downtown area. Staff will
provide assistance and supports until Mike has demonstrated independence
and safe travel on the bus, consistently for 6 weeks. Staff may provide any of
the allowable Pathway to Employment services to support this goal.
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Sample Pathway to Employment Staff Action Plan
Individual Safeguards/Individual Plan of Protection (Section III)
Pathway to Employment Sample 3:
Copied from Life Plan
Individual Safeguards (Life Plan Section III): I want to improve or maintain
my work skills
Provider Assigned Goal: Teach safety skills (G-Goal)
Frequency: As needed
Add description(s) of staff actions for goal/support implementation:
Staff will teach Miranda how to call specific emergency contacts. Staff will role
play, gradually fading as Miranda demonstrates the ability to call emergency
contacts independently. Staff may provide any of the allowable Pathway to
Employment services to support this goal. Miranda will respond to various
practice scenarios, calling emergency contacts accurately, 100% for 3 months.
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Life Plan and Staff Action Plan
Training Resources
Life Plan and Staff Action Plan Administrative Memoranda
https://opwdd.ny.gov/opwdd_regulations_guidance/adm_memoranda
Life Plan and Staff Action Plan Resources -
https://opwdd.ny.gov/providers_staff/care_coordination_organizations/msc_
webinars
Staff Action Plan Questions and Answers -
https://opwdd.ny.gov/providers_staff/care_coordination_organizations/provi
ders/staff_action_plan_info
Email questions to Care.c[email protected]y.gov
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Presenters:
Laura McCaffrey
Regional Care Manager Director
Care Design NY
LMcCaf[email protected]
518-573-9972
Julia Kelly, MS. Ed.
DD Policy Development Specialist
OPWDD
[email protected].gov
518-473-7030
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