Free Template Guide

ISP/PCP Template Guide

Best practices for building person-centered Individual Support Plans that satisfy Virginia DD waiver requirements and genuinely improve outcomes for the individuals you support.

What This Guide Covers

6 sections covering every aspect of ISP development, from person-centered foundations to quarterly review best practices.

Person-Centered Foundation

The ISP starts with the individual, not the service. A strong person-centered plan captures who the individual is beyond their diagnosis.

Document the individual's personal history, preferences, interests, and daily routines in their own words when possible
Identify what matters most to the individual — relationships, activities, independence goals, and quality of life priorities
Document communication style and preferences so all team members interact consistently
Include cultural, spiritual, dietary, and social preferences with specific accommodations
List natural support networks — family, friends, community members — and how they participate in the individual's life
Document the individual's strengths and capabilities, not just needs and deficits

Writing Measurable Goals & Outcomes

DBHDS expects ISP goals that are specific, measurable, and tied to outcomes the individual has identified as important. Vague goals lead to audit findings.

Each goal should answer: What will the individual do? How will progress be measured? By when?
Use action verbs: "will independently prepare," "will attend," "will initiate" — not "will be helped to" or "will try to"
Define the baseline: where is the individual starting? Without a baseline, progress cannot be measured
Set realistic timelines — quarterly milestones for annual goals help track momentum and justify continued services
Include criteria for goal completion: What does "achieved" look like? What percentage or frequency demonstrates mastery?
Tie every goal to an outcome the individual expressed during person-centered planning

Support Strategies & Implementation

Goals without implementation steps are just aspirations. The ISP must define who does what, when, and how — in specific enough detail that any trained DSP can execute the plan.

For each goal, list specific support strategies: what the DSP does, how often, and in what setting
Include prompting hierarchies: independent, verbal prompt, gestural prompt, physical assist — define which level the individual currently needs
Document teaching strategies if the goal involves skill building (modeling, task analysis, backward chaining)
Specify data collection method and frequency: daily tally, weekly narrative, shift-by-shift checklist
Define crisis or regression protocols: what to do if the individual refuses, has a behavioral episode, or regresses significantly
Include generalization strategies — practicing skills across settings, people, and times of day

Team Roles & Responsibilities

List every ISP team member by name, role, and contact information
Document who is responsible for implementing each goal — which staff, which shifts, which locations
Define the Case Manager's monitoring schedule and what they will review at each visit

Quarterly Reviews & Updates

Review each goal individually — document quantitative progress against the baseline and target
If a goal is not progressing, document why and what changes the team is making to the approach
Record the individual's input on their own progress and whether they want to continue, modify, or discontinue the goal

Get the Full ISP Guide

Download all 6 sections with best practices, example language, and a printable ISP development checklist.

Common ISP Mistakes That Trigger Audit Findings

Mistake: Goals written in staff-centered language

Fix: Write goals from the individual's perspective: "I will..." not "Staff will help client to..."

Mistake: No measurable criteria for goal completion

Fix: Define exactly what "achieved" looks like — percentage, frequency, duration, or independence level

Mistake: Quarterly reviews that say "continue goal"

Fix: Document specific data, what is or is not working, and what changes the team is making

Mistake: Missing team member signatures

Fix: Every team member who participated in the ISP meeting must sign and date the document

Mistake: No backup plans for critical supports

Fix: Document what happens when the primary DSP is unavailable for every critical support need

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CareHub's person-centered planning module helps teams build ISPs that meet waiver requirements and actually drive outcomes. Goals, data collection, and quarterly reviews — all in one place.

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