Community Living for Individuals with Brain Injury
Devereux PA Adult Services provides
residential supports for individuals with brain injuries and other
cognitive/neurological impairments which facilitates opportunities for
participation in community living and meaningful daily activities with the
needed supports and supervision to ensure the wellbeing of the individual.
The goal of the Community Living
Program for Individuals with Brain Injury (CLIBI) is to empower each person to
discover their innate strengths, unique talents and their potential to live a
meaningful and productive life. Our goal is accomplished by providing each
person we serve with a customized plan of support that focuses on maximizing a
person’s strengths and providing the therapeutic and daily supports to help increase
the individual’s capacities of self-direction, self-management, and potential.
Our comprehensive effort is guided by our Philosophy of Care is which is
comprised of three fundamental principles:
- Positive Approaches - Finding a
Positive way to work through each situation
- Individualized Services - Every Person is Unique
- Effective and Accountable Services - Using data to ensure positive outcomes
CLIBI provides individuals the opportunity to
live in a community setting with help and guidance in finding and retaining a
job, finding a volunteer opportunity or a vocational program, learning how to
arrange for public transportation, planning and arranging for participation in
social and recreational activities, building friendships and relationships and
developing a network of natural supports in the community. CLIBI are shared
living arrangements in comfortably furnished apartments and homes, with
community areas and individual bedrooms for the privacy of each person.
An Individual Support Plan (ISP) or
Treatment Plan is developed for each person. This document is the result of Person
Centered Planning that has usually taken place with the individual, a case
manager from the funding agency, Devereux’s inter-disciplinary team, and the
family/friends/guardian or interested parties. The Plan generally includes the
Developing self-management and
independent living skills by the use of desired and relevant outcomes. Outcomes
are based on the following questions:
Communication-can the individual
communicate effectively? What supports/therapeutic interventions are needed to
Relationships-does the individual have
friends, family, intimate relationships? What can be done to help the
individual to develop or improve relationships?
Recreation/Social Life- does this
person have hobbies, faith based activities, club memberships?
Self-image and esteem-who in this
person’s life makes him/her feel valued and important, what activities and
groups or persons could help this person to feel valued and important? Does
this person work, attend a vocational program or participate in volunteer
Safety-does this person feel safe? Is the
level of supports and supervision adequate for this person? Is the home,
community, work or vocational program safe?
Healthy Living-does the individual have
privacy, dignity and respect? Is the individual aware of their rights? Does the
individual have adequate medical, dental and clinical care and supports?
Decision making and autonomy- Does the
individual make decisions as to who they live with and what they do each day?
Active employment or work training abilities.
areas of the ISP or Plan of Support include:
Individual preferences and interests
Medical and health information –current
doctors, appointments, medication (dose, reason for medication) , diagnosis, history
and current medical issues
Types of services and services provided
–frequency, duration, costs
Satisfaction with services –Is the individual
satisfied with their services? Did the individual participate in their plan? Do
they agree with the plan?
Individual participated in their plan?
Back-up plans in case of emergency.
Other supportive services such as art,
music, speech, occupation or physical therapy, cog rehab.
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Program Costs, Referral and Funding Sources:
Referrals for the CLIBI often come directly
from families, other providers, rehabilitation hospitals, attorneys, insurers,
and public payers such as the Office of Long Term Living’s Support Coordination
The CLIBI per diem rate is based on an
individual’s needs for support, supervision and daily assistance. Devereux accepts HCBS Waivers from
Pennsylvania and other states, commercial insurance, and private funding. The
per diem rate includes the following services.
Support, supervision and care up to
twenty-four hours per day to maintain health, safety and well-being of the
Case management duties performed by a Program
Activities of daily living.
Productive daily activity, based on an
individualized treatment plan.
Organized leisure and recreational programs.
Assistance in obtaining and managing health
and financial benefits.
Transportation to medical appointments, daily
Behavioral Analyst or licensed psychologist.
Furniture –bedroom, shared areas, linens,
Accessible living environment, if needed.
Assistance in locating and enrolling in day
programs, finding employment or community habilitation activities.
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Consultative Services Available on a
Fee for Service Basis:
Services Not Included in Per Diem:
Personal care attendant/One-to-one
Durable medical equipment.
For individuals receiving funding
through a State HCBS Waiver- room and board is paid through a monthly “cost
share” from the individual’s Social Security entitlement benefits.
Personal care/hygiene items.
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Devereux has Admission and Discharge
Polices-please refer to these Policies for more detailed information.
Devereux’s CLIBI Admission criteria include:
- Documented brain injury or other neurologic disorder.
- Eighteen years of age or older.
- Stable physical and mental health-not actively suicidal
or engaging in substance abuse.
- Ability to participate.
- Completion of specialized rehabilitation.
- Confirmation of funding.
- Criminal Background Check documents which confirm that
the individual does not have felony convictions or has been convicted with
offenses under Megan’s Law (this will be reviewed on a case by case basis with
consideration given to situational factors).
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and Transfer Criteria Include:
individual may be transferred or discharged from a Devereux home/program if
his/her Interdisciplinary Team demonstrates that the current program cannot
meet the needs of the individual. Reasons for discharge include:
An individual has met or is not
making progress on their outcomes/goals and needs a less restrictive/more
independent home or an individual requires a higher level of care than is
currently provided in their program.
A change in the availability of
funding, or a lack of funding for services which are critical for the
individual’s well-being, health or safety. A negative balance in a Devereux
Client Account for longer than 3 months.
An individual’s actions jeopardizes
the safety or welfare of herself/himself or others, he/she may be transferred
or discharged from their home/program. This may include fire-setting, sexual
aggression, sexual promiscuity or attempts to engage in any type of sexual
behaviors with children, active suicidal tendencies, substance abuse, explosive
patterns of destruction or aggression, or psychotic behaviors.
An individual or family/guardian’s
refusal to follow a course of treatment prescribed by the individual’s treating
Discharge /Transfer Procedure:
At any time during an individual’s
enrollment at Devereux Pennsylvania Adult Services, the Interdisciplinary team
may recommend a transfer or discharge or the individual may have temporarily or
permanently lost funding or funding eligibility.
The Director of Admissions will notify
the individual, family, and/or agency of the possibility of discharge and will
invite and encourage interested parties to participate in an interdisciplinary
team meeting to discuss available options including discharge. Whenever
possible, family and/or community integration is considered for future
placements. Discharges can be made to settings such as residential treatment
facilities, hospitals, nursing homes, to a family member, to an independent
living arrangement in the community, or to a community-based program with staff
The Admission Department will work
with the Interdisciplinary Teams to transfer the individual to an appropriate
program within Devereux, if available. If there is no home available to meet
the needs of the individual, alternative placement will be sought within the
Devereux Treatment Network. If these options are not available, discharge may
occur outside of Devereux. Devereux will assist with placement and recommend
other providers, whenever possible, however, it is the responsibility of the
individual, family/guardian, and/or agency to arrange placement.
In situations regarding a loss of
funding or eligibility for funding, the Admission Department will make every
effort to reinstate funding eligibility or to secure funding from an alternate
source. In most cases, if health and safety are not at risk for the individual
or others, Devereux will continue to support an individual until another
placement is identified.
Devereux will make every effort to
provide 30-days written notice to an individual and their representatives;
however, this is not always possible if there is an immediate risk to the
safety and well-being of the individual or others, immediate discharge may be
It is the policy of PA Adult Services to practice non-discrimination in
services. All activities with regard to referrals, admissions, placement of
individuals, and provision of services shall be conducted without regard to
race, color, religious creed, ancestry, national origin, sex and sexual
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