MILESTONE, INC.
ENVIRONMENTAL RISK BENEFIT ASSESSMENT
Name of Individual: / Date Completed:Name/Title of Staff Completing Assessment:
Directions: At the ISP planning meeting, use the grid to facilitate open discussion, analysis, brainstorming and planning in order to:
- Identify all risks recorded on the Risk Issues Identification Tools by the planning participants
- Identify the recommendations associated with each risk-related issue identified
- Identification of the final actions, supports, and services for addressing the risk
- Whether or not actions, strategies, support or services should be included in the Plan and Recommendations of the person’s ISP
- Prioritize identified needs
Identify Risk Issues
Community Safety(Situations, communication, community circumstances that create the potential for risk)
Yes / No / Risk Issue / Prioritizing Needs / Acceptable Risk / Training objective / Addressed in ISP
1)Can communicate wants and needs using verbal, sign, or body language.
2)Can identify the difference between friend, family, stranger or acquaintance.
3) Can independently & appropriately interact w/community members & follow normal social rules / boundaries.
4) Can access neighborhood, community and natural supports (family or friends) independently.
5) Cansafely carry and keep track of personal identification.
6) Stays with a group when in the community.
7) Canprotect self in unsafe situation (yell, say “no”, tell others).
8) Canidentify common safety signs or symbols in the community, work or school.
9) Cannavigate safely in the community.
10) Canaccess community resources; grocery store, bank, doctor, pharmacy, police, or other resources as needed.
11) Canmake and keep appointments in the community.
12) Knows how & when to seek help from others in the community.
13) Canuse public transportation .
14) Cancommunicate phone number and address.
15) Does not require line of sight supervision in community.
16) Free from risk of legal involvement in the community.
Comments:
The following risks are acceptable risks due to 24 hour staff supervision______
Name of Individual:______
Safety in the Home Environment(Environmental issues that create the potential for risk)
Yes / No / Risk Issue / Prioritizing Needs / Acceptable Risk / Training objective / Addressed in ISP
1) Has ability to protect self from others.
2) Has ability to safely store and use chemicals in home.
3) Has ability to stay alone in the home.
4) Has ability to dial a telephone
5) Has ability to call for help / call Poison Control / call 911 for emergency.
6) Has abilityto use a cell phone
7) Has abilityto independently identify and use phone numbers
8) Has abilityto respond to alarms and safety drills: fire, tornado, power outage.
9) Has ability to recognize safe water temperature when bathing.
10) Has abilityto properly adjust water temperature to avoid scalding.
11) Has ability to choose and wear appropriate clothing for weather and activity.
12) Has ability to keep personal valuables safe.
13) Has abilityto locate and use fire extinguisher.
14) Has ability to recognize electrical hazards.
15) Has ability to use major appliances safely.
16) Has ability to use sharp knives safely.
17) Aware of safe kitchen practices / safe cooking skills.
18) Has ability to identify safety risks in home: ie- wet floor
19) Has ability to recognize, use, and keep track of a key/key card.
20) Has knowledge of correct response for visitors coming to home.
21) Has abilityto understand safety risks when using the internet or phone.
Comments:
The following risks are acceptable risks due to 24 hour staff supervision______
Name of Individual:______
Safety in the Work / School Environment(Environmental issues that create the potential for risk)
Yes / No / Risk Issue / Prioritizing Needs / Acceptable Risk / Training objective / Addressed in ISP
1) Understands safety procedures with chemicals, cleaning supplies, etc.
2) Safely uses tools, equipment, & supplies.
3)Canrecognize & avoid potential hazards.
4)Can appropriately respond to emergencies (fire, tornado).
5)Can handle conflict resolution in the workplace / school.
6)Complies w/wearing uniform, protective equipment, follows dress code.
7)Remains in designated work area / classroom.
8)Can follow established social rules at work / school.
9)Compliant with transportation.
10) Has the ability to keep personal valuables safe at work / school.
11) Has the ability to protect self from others at work / school.
Comments:
The following risks are acceptable risks due to 24 hour staff supervision______
Name of Individual:______
Health and Medical Safety(Health Related risks)
Yes / No / Risk Issue / Prioritizing Needs / Acceptable Risk / Training objective / Addressed in ISP
1) Allergy free
2) Is cooperative with taking medication(s)
3) Can identify basic information relating to medication(s) (ie-color, dose, name)
4) Can identify side effects of medications
5) Free from any significant chronic medical or dental condition./Endentulous (ie- cardiac, respiratory)
6) Has stable health and mental status
7) Able to attend medical / dental appointments &/or procedure(s) without restriction(s) &/or sedation
8) Ambulates without falls
9) Seizure activity controlled
10) Dietary Needs (ie-weight control, exercise) controlled
*Indicate if N/A for #10 here ______
11) Free from aspiration
12) Has ability to eat without choking
13) Eats at a normal rate of pace
14) Free from vision or hearing impairments
15) Has good skin integrity &/or has ability to reposition self independently
16) Able to communicate illness, pain, or inform of abnormal changes
17) Has knowledge of basic first aid
18) Treatment unnecessary for constipation
19) Agrees with and follows through with physician recommendations
20) Makes healthylifestyle choices (i.e. refrains from tobacco use, drinking)
21) Has ability to receive adequate nutrition & take meds by mouth without the assistance of a feeding tube
22) Uses medical equipment safely (ie- diabetic testing supplies) *Indicate if N/A for #22 here ______
23) Has the ability to keep feeding tube intact without the use of an abdominal binder
Comments:
The following risks are acceptable risks due to 24 hour staff supervision______
Name of Individual:______
Behavioral and Relationship Safety(Personal behaviors that are considered dangerous or potentially dangerous to self or pose a risk to others)
Yes / No / Risk Issue / Prioritizing Needs / Acceptable Risk / Training objective / Addressed in ISP
1) Psychotropic medication free
2) Can identify emotions of others and/or self
3) Can understand consequences of displaying inappropriate or maladaptive behavior
4) Compliance with treatments or supports
5) Cooperative with services offered (programming)
6) Respects others property (does not steal)
7) Seeks attention from others appropriately (enjoys the company of others)
8) Able to act appropriately without displaying physical aggression towards others
9) Able to act appropriately without displayingverbal aggression towards others
10) Has knowledge of &/or practices safe sex
11) Displays sexually appropriate behavior / appropriate locations
12) Free from self-injurious behavior (past or present)
13) Free from displaying PICA behavior (past or present)
14) Free from displaying fire setting behavior (past or present)
15) Free fromdisplaying drug and/or alcohol abuse (past or present)
16) Free from a mental health diagnosis
17)Free from environmental factors which may affect behavior (loss of family, home, pet, fears). (Past or Present)
18) Free from threats of aggressive actions to self or others
19) Free from elopement issues (past or present)
20) Displays functional communication skills
21) Free from health conditions that cause chronic pain
22) Refrains fromusing or accessing weapons
23) Free from current and past involvement with officers of the law (Not on probation/parole/incarceration)
Comments:
The following risks are acceptable risks due to 24 hour staff supervision______
Name of Individual:______
Financial Safety(Mismanagement of finances by self or others or loss of income)
Yes / No / Risk Issue / Prioritizing Needs / Acceptable Risk / Training objective / Addressed in ISP
1) Can understand the value of money
2) Knows to wait for change if applicable when making a purchase
3) Can identify different money denominations
4) Can identify if they receive the correct change back
5) Can independently use vending machine to make purchase
6) Can independently carry money in community, work or school
7) Can budget money for expenses
8) Can understand contracts and written documents
9) Can be assertive to tell solicitors and others who
ask for money or personal items “No”
10) Can fill out forms and entitlements to maintain services
11) Has legal mark / signature
12) Has the ability to manage finances and conduct banking
13) Has the ability to pay bills
14) Has the ability to prioritize needs from wants
15) Can use credit card / banking card safely
16) Can communicate financial concerns to appropriate personnel
17) Understand the value of a check and how to exchange it for currency.
18) Is attentive of notices for benefits review, reductions, need for signature(s)
Comments:
The following risks are acceptable risks due to 24 hour staff supervision______
Name of Individual:______
Other risks (identified risks not otherwise mentioned above)Yes / No / Risk Issue / Prioritizing Needs / Acceptable Risk / Training objective / Addressed in ISP
1)
2)
3)
4)
5)
6)
7)
8)
Comments:
Check Box / The following people help me to address and reduce my risks and provide me with support and advocacy.
Residential Staff Support
Developmental Training Staff Support
Nursing Staff Support
School Staff Support
Access Services
Natural Supports, family or friends
Other
Name of Individual:______
Home / Work / Community / Defined Level of Supervision in Home, Work and CommunityIndependent in the community without restriction
Requiring intermittent staff support with specific frequency or to meet specified support needs
Requiring 24 hour staff supervision
Requiring 24 hour on site nursing support
Requiring line of sight monitoring
Semi- independent to specified locations or for specified activities;
Time unsupervised in community ______
Time unsupervised in home ______
______
QIDP Signature Date Initiated
AS.405/09/14
1