Progress Review Report

Progress Review Report

Date:
Name: / Program name:
Reviewed by:
6 month Pre-Staffing other
Date of Annual Review:
Reporting period:
(months reviewed)

Outcome Goals:

Outcome 1:
Baseline:
Criteria for achievement (Objective):
Supports and methods:
Summary of the person’s status and progress:
Jan / Feb / Mar / Q 1 / Apr / May / Jun / Q 2 / Jul / Aug / Sep / Q 3 / Oct / Nov / Dec / Q 4
Baseline / 99
Data / 10 / 12 / 11 / 11 / 2 / 5 / 6 / 5 / 2 / 4 / 6 / 4 / 4 / 6 / 8 / 6
Changing outcome Continuing outcome Discontinue outcome
Rationale / Recommendations for continuing, changing or discontinuing the outcome:
Outcome 2:
Baseline:
Criteria for achievement (Objective):
Supports and methods:
Summary of the person’s status and progress:
Jan / Feb / Mar / Q 1 / Apr / May / Jun / Q 2 / Jul / Aug / Sep / Q 3 / Oct / Nov / Dec / Q 4
Baseline / 12.5
Data / 10 / 12 / 11 / 11 / 2 / 5 / 6 / 5 / 2 / 4 / 6 / 4 / 4 / 6 / 8 / 6
Changing outcome Continuing outcome Discontinue outcome
Rationale / Recommendations for continuing, changing or discontinuing the outcome:
Outcome 3:
Baseline:
Criteria for achievement (Objective):
Supports and methods:
Summary of the person’s status and progress:
Jan / Feb / Mar / Q 1 / Apr / May / Jun / Q 2 / Jul / Aug / Sep / Q 3 / Oct / Nov / Dec / Q 4
Baseline / 12.5
Data / 10 / 12 / 11 / 11 / 2 / 5 / 6 / 5 / 2 / 4 / 6 / 4 / 4 / 6 / 8 / 6
Changing outcome Continuing outcome Discontinue outcome
Rationale / Recommendations for continuing, changing or discontinuing the outcome:
Outcome 4:
Baseline:
Criteria for achievement (Objective):
Supports and methods:
Summary of the person’s status and progress:
Jan / Feb / Mar / Q 1 / Apr / May / Jun / Q 2 / Jul / Aug / Sep / Q 3 / Oct / Nov / Dec / Q 4
Baseline / 12.5
Data / 10 / 12 / 11 / 11 / 2 / 5 / 6 / 5 / 2 / 4 / 6 / 4 / 4 / 6 / 8 / 6
Changing outcome Continuing outcome Discontinue outcome
Rationale / Recommendations for continuing, changing or discontinuing the outcome:
Review of behavioral data (behavior support plan review) NA
Target Behavior:
Objective:
Current rate/Baseline:

Summary and analysis of data:

Jan / Feb / Mar / Q 1 / Apr / May / Jun / Q 2 / Jul / Aug / Sep / Q 3 / Oct / Nov / Dec / Q 4
Baseline / 12.5
Data / 10 / 12 / 11 / 11 / 2 / 5 / 6 / 5 / 2 / 4 / 6 / 4 / 4 / 6 / 8 / 6

Evaluation / Recommendations:

Review of behavioral data (behavior support plan review) NA
Target Behavior:
Objective:
Current rate/Baseline:

Summary and analysis of data:

Jan / Feb / Mar / Q 1 / Apr / May / Jun / Q 2 / Jul / Aug / Sep / Q 3 / Oct / Nov / Dec / Q 4
Baseline / 12.5
Data / 10 / 12 / 11 / 11 / 2 / 5 / 6 / 5 / 2 / 4 / 6 / 4 / 4 / 6 / 8 / 6

Evaluation / Recommendations:

What activities/interests would you like to participate in so that you feel fully included in your community?
DRCC will provide the following supports so that you can be engaged in those activities/interests you choose.
DRCC will provide the following supports to you regarding employment.
Do the current services support 's individual preferences, daily needs and activities, and the accomplishment of 's goals? (Review every six months) yes no comment:
Are services being provided in accordance with the CSSP/CSSP Addendum? yes no comment:
Are changes needed in the CSSP/CSSP Addendum? yes no comment:
As a result of the above review and recommendations, do instructions/training need to be communicated to staff? yes no comment:
When/how will this occur?
Summary of medical appointments/issues for the reporting period:
Were there any medication changes for the reporting period? / yes no If yes, describe/list
Review of incident reports for the reporting period:
Is there a pattern of incidents? / yes no comment:
Is any corrective action necessary? / yes no comment:
Other:

This report was reviewed and approved by:

Program Director/Designated Coordinator / Date

If you have questions you can contact the Program Director at:

Date mailed / Report mailed to: / Title
Person
Legal Representative
Case Manager

Frequency of Progress Reports to be provided:

Semi-Annually / Annually [minimum requirements] / Other: [as requested]

1. The purpose of the service plan review is to determine whether changes are needed to the service plan based on the assessment information, the license holder’s evaluation of progress towards accomplishing outcomes, or other information provided by the support team or expanded support team.

1. This program must give the person or the person's legal representative and case manager an opportunity to participate in the ongoing review and development of the service plan and the methods used to support the person and accomplish outcomes identified in the person’s coordinated service and support plan or coordinated service and support plan addendum.

1. This form must be sent to the person or person legal representative within five working days prior to the review meeting if requested by the team in the coordinated service and support plan or coordinated service support plan addendum.

1. This program must send this report to the person, the person’s legal representative, and the case manager by mail within ten working days of the progress review meeting.

1. Within ten working days of the mailing of this report, dated signatures must be obtained from the person or the person’s legal representative and the case manager to document approval of any changes to the coordinated service and support plan addendum.

1. If dated signatures are not obtained by the person, the person’s legal representative, and case manager within ten working days of submitting this report, or the person, the person’s legal representative, and case manager has not proposed written modifications to this report, this report is deemed approved and effective and will remain in effect until the legal representative or case manager submits a written request to revise this report.

Page 1 of 6 05.05.17