PART 1 - GENERAL INFORMATION
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Required identifying information - 4 points a. Focus person’s pseudonym or initials b. Focus person’s age (1 point for A-D) c. Referral source & contacts d. Facilitator name e Focus person’s gender identification f. Focus person’s preferred pronouns are noted (1 point for E-H) g. Focus person’s person first or identity first language is honored as observed with the team h. Legal authorization to make their own decisions is explained (i.e. supported decision maker, legal guardian, person makes own decisions) i. The focus person’s preferred method of communication is documented. (1)
PART 2 - PERSON'S HISTORY AND CURRENT INFORMATION 2. Focus person’s strengths: What others like and admire about the person - 2 points a. Includes person's strengths, including skills (1) b. Describes the person's personality characteristics (1) 3. Brief history of the focus person’s life - 12 points a.1 Current residence is described (1) a.2 Past residences are described. Indicates if there are no past residences. (1) b. Biological family history and current status is described (1) c. Educational history is described (1) d. Previous support services are documented (1) e.1 Dream statement is included in plan (1 point) and focus person's involvement in the statement (1 point) is described (2) e.2 How the person’s life lines up with what they want life to be like (dream statement) is explained. (1) f.1 History of person's social life and community connections are described (1) f.2 History of daytime engagement is described (1) g. Adaptive equipment and necessary accommodations are described. (1) h. Person's culture/heritage is described. (1) 4. Person centered tools and approaches This section is about explaining what is Important To/For the person, plus at least 3 additional person-centered approaches are conducted with the team and outcome is documented. (Donut, 4+1, Good Day/Bad Day, Reputations/Reframing, two-minute drill, what’s working/Not working, relationship mapping, Learning log, Rituals and Routines, communication chart, matching staff, MAPS, PATH, CtLC, etc.) - 12 points a. What is important to (1 point) and for (1 point) the person is described. A description of how important to and for are currently balanced is included. (1 point) (3) b. Person Centered approach #1: The tool, (1 point) how it was used (1 point) , and the result of using the approach (1 point) are described (3) c. Person Centered approach #2: The tool, (1 point) how it was used (1 point) , and the how (1 point) are described (3) d. Person Centered approach #3: The tool, (1 point) how it was used (1 point) , and the result of using the approach (1 point) are described (3) 5. Current Important places and people for the focus person - 3 points a. Important places during person's daytime engagement, e.g. school, work, are described. If the person has no daytime engagement, that is indicated (1) b. Important places in the community for the focus person are described (1) c. Important people for the focus person and opportunities to interact are described (1) 6. Preference assessment information - 3 points a. How the person enjoys spending their time is described (1) b. The method of gathering preference information is described (1) c. The results of a preference assessment are described (1) 7. Opportunities for choice in the focus person’s current environment are described [1] 8. Issues of focus person’s control over their current environment are documented [1] 9. Health and physiology issues - 7 points a. Childhood health and development is discussed. It is noted if childhood information is not available (1) b. Etiology (if appropriate) and diagnoses or absence of diagnosis of physical health are described (1) c. Etiology (if appropriate) and diagnoses or absence of diagnosis of mental health are described (1) d. The plan includes a description of how the focus person’s health influences their current life (1) e. Medications are listed (If applicable. If no medications are used, it should be noted) (1 point) and their intended purpose (1 point) (2) f. Potential effects of medication influencing behavior are described. If no medications or side effects are evident, it should be noted (1) 10. Trauma - 2 points a. The plan documents whether the person has experienced trauma. If the person did not experience trauma, it is noted (1) b. How trauma impacts the focus person’s behavior is documented. If trauma does not impact behavior, it is noted (1) 11. Mobility - 2 points a. The person’s ability to move around is described (1) b. The person’s transportation access is discussed (1) 12. Current Weekly Schedule - 5 points a. The plan describes a weekly schedule of what the person does daily (1 point) and the times of day the events occur (1 point) (2) b. The plan includes the focus person's comments and/or participation regarding their current activities (1) c. The plan documents the focus person’s perspective on whether they want to continue to participate in current activities (1) d. The plan describes the predictability of the focus person’s schedule (1) 15. Reason For Referral - 4 points a. The reason why PBS services are being requested is documented (1) b. Behavior of concern is described (1) c. Impact of the behavior on the focus person’s (1 point) and team’s (1 point) day -to-day life is described (2) 16. Positive Behavior Support Team - 12 points a. Focus person’s choice of team participants is described (1) b. Roles of team members are described (excluding PBS Facilitator) (1) c. Team’s positive characteristics are described (1) d. Strategies to address team’s challenges and obstacles are described (1) e. Strategies used to give the focus person control in team meetings are described (1) f. Prior to the design of the intervention, the plan includes a description of team’s agreement (1 point), focus person’s agreement (1 point) on behavior of concern, and commitment to address it by signed consent (1 point) (3) g. The risks (1 point) and benefits of services(1 point) are described (2) h. The plan describes the role of the PBS Facilitator (1 point) (1) i. The plan documents whether needed accommodations were provided for team members (1)
PART 3 – ASSESSMENT 17. Functional Behavior Assessment 2 points a It is documented that FBA was conducted in location where person uses services (1) b. The plan documents that the FBA is within 6 months of current date (1) 18. Indirect assessment - 4 points a. The plan describes that record reviews were conducted. (1) b. The plan describes that support team was interviewed (1) c. The plan describes the focus persons's involvement in the interview (1) d. The plan documents lists what assessment tools were used. (1) 19. Direct Assessment from observations - 3 points a. Direct assessments are described in the plan. (1) b. Raw data are included in the plan. (1) c. Method of measurement of behavior is documented and explained in plan. (1) 20. Operational Definition of the Behavior of concern - 6 points a. Behavior (s) of concern’s definition in operational terms (1) b. Includes method of measurement for behavior(s) (1) c. Intensity is described (1) d. Risks and negative outcomes are described (1) e. Examples of the behavior are included (1) f. Non examples of the behavior are included (1) 21. Items included in Functional Behavior Assessment (FBA) - 5 points a. Setting events/motivating operations for each behavior are described (1) b. Antecedents are described for each behavior (1) c. Consequences are described for each behavior (1) d. Description of the functions of the behavior match to accepted operant functions (1) e. Description if there are non-operant conditions that influence behavior. Note if non-operant conditions are not present. (1) 22. Baseline data are clearly graphed - 3 points a. Graph axes are labeled (1) b. Graph is titled (1) c. Behavior(s) of concern are identified by legend or otherwise (1)
PART 4 – INTERVENTIONS AND SUPPORTS 23. Function Based Interventions - 5 points a. Rationales for intervention design are stated (1) b. Hypothesis statement contains setting event/motivating operation (1) c. Hypothesis statement contains antecedent (1) d. Hypothesis statement contains behavior (1) e. Hypothesis statement contains consequence (1) 24. Methods to cope/address trauma are included if necessary. If not necessary, plan notes that past trauma has not been identified [1] 25. Criteria for success and goals for the intervention are described 3 points a Goals for the intervention are described (1) b. Team input for establishing criteria is documented - What does the team determine as a successful outcome? (1) c. Focus person’s agreement for criteria is documented. What does the focus person determine as a successful outcome? (1) 26. Replacement Behaviors - Targets for Increase - 6 points a. Provides description of how the replacement behavior addresses the function of the behavior (1) b. Replacement behavior(s) are operationally defined (1) c. Replacement behavior includes method of measurement (1) d. Includes examples (1 point)/non-examples (1 point) of replacement behaviors (2) e. Method for how the replacement behavior is taught to the focus person is described (1) 27. System Change - Description of recommended environmental and/or system changes are noted in the plan. If no changes need to be made, it is noted. [1] 28. Antecedent Interventions - 6 points a. Antecedent interventions describe stimuli that should (1 point) and should not be present (1 point) (2) b. Antecedent interventions address motivating operations/setting events for the behavior (1) c. Calming strategies that address precursors of a behavior are addressed as an antecedent intervention i.e. How will the focus person be guided to cope with identified triggers for the behavior? (1) d. Environmental interventions that address schedule predictability are addressed (1) e. Environmental intervention that addresses good match of staff/family/peer interactions is provided (1) 29. Consequence Intervention - 7 points a. Plan incorporates a function-based intervention for each of the behaviors of concern (1) b. Plan addresses the least restrictive consequence and incorporates natural consequences, if appropriate (1) c. Types of reinforcers are described (1) d. Strategies to make reinforcers as effective as possible (immediate, preferred, and specific, for example) (1) e. Schedule of positive or negative reinforcement is described (1) f. Team input for establishing criteria is documented- What did the team determine as a successful outctome? (2) 30. Data Collection/ Training Others - 2 points a. Team’s input and approval regarding measurement strategy and data collection is documented (1) b. Outcomes of data and effects of intervention are described. (1) 31. Training Support Staff/Family Members- Plan for training others incorporates a BST (Behavior Skills Training) approach, with the following described: 5 points a. verbal and/or written instruction (1) b. modeling (1) c. roleplay or rehearsal (1) d. feedback (1) e. Includes short version of the plan that was given to direct care staff for quick reference (1) 32. Graph of Intervention Data - 7 points a. Baseline and intervention(s) data delineated for behavior of concern and phase condition changes lines are noted with arrows, text boxes etc. (1) b. Replacement behavior is graphed (1) c. Graph x (1 point) and y axes (1 point) are labeled accurately (2) d. Graph is titled (1) e. Behavior of concern and replacement behavior are identified by legend or otherwise (1) 33. A statement regarding the effectiveness of interventions is made [1] 34. Resources needed are described (1 point), including time requirements for implementation (1 point) [2] 35. Financial costs related to interventions are addressed [1] 36. Date of initial plan is included [1] 37. After the intervention has been designed, the focus person (1 point) and team (1 pont) agree to implement the plan. Signatures of person and guardian and date are included. If person is unable to sign, their participation is indicated. Signatures of the team are included. [2]
PART 5– FOLLOW-UP 38. Follow up and Continuous Evaluation - 7 points a. Timeline for follow up meetings is provided (1) b. Tasks to be done are listed with descriptions (1) c. Person responsible for carrying out task is listed (1) d. Measures to be gathered for continued evaluation are described (1) e Direct evaluation measures are described (1) f. Indirect evaluation measures are described (1) g As the result of the intervention, differences that may have occurred in removing inequities, power imbalances, biases, barriers in systems, practices, policies and settings are described.It is noted if there are not any changes in these areas. (1) 39. Sustainability - 3 points a. Plan for transitions or a major change in setting events is stated (1) b. After initial training of existing staff has occurred, a description of how new staff or care giver will be trained is provided (1) c. Strategy and criteria for thinning reinforcement is addressed (1) 40. Person Centered terms are used to reflect the focus person throughout the document - 1 point [1]
PART 6 – ATTACHMENTS 41. All pertinent supporting materials are included with the report including: 5 points a. Raw data sheets (1) b. Meeting notes (1) c. Questionnaires/Assessments (1) d. Person Centered Tools (1) e. Teaching log/instructional program for sharing plan with support staff or family members (1) Total possible points: 155