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Community Living for Individuals with Brain Injury
Devereux Pennsylvania Adult Services provides residential supports for individuals with brain injuries - and other cognitive/neurological impairments that 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 our Community Living Program for Individuals with Brain Injury (CLIBI) is to empower each individual to discover his or her innate strengths, unique talents and potential to live a meaningful and productive life. This goal is accomplished by providing each individual we serve with a customized plan of support that focuses on maximizing 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 Advanced Philosophy of Care is which is comprised of four fundamental principles:
- Individualized, evidenced-based interventions
- Effective and accountable programs delivered with compassion – Meeting the “Devereux Family Standard”
- System-wide, trauma-informed, data-driven, positive-behavioral approach to care
- Meaningful family engagement and community connection
Program Objectives:
An Individual Support Plan (ISP) or Treatment Plan is developed for each individual. This document is the result of person-centered planning is created by the individual, a case manager from the funding agency, Devereux’s inter-disciplinary team, and the family/friends/guardian or interested parties. The ISP generally includes the following areas:
Developing self-management and
independent living skills by the use of desired and relevant outcomes. Outcomes
are based on the following:
- Communication: Can the individual communicate effectively? What supports/therapeutic interventions are needed to improved communication?
- Relationships: Does the individual have friends, family and/or intimate relationships? What can be done to help the individual develop or improve relationships?
- Recreation/social life: Does the individual have hobbies, faith-based activities, or club memberships?
- Self-image and esteem: Who in this individual’s life makes him/her feel valued and important? What activities and groups or persons could help this individual feel valued and important? Does this individual work, attend a vocational program or participate in volunteer activities?
- Safety: Does this individual feel safe? Is the level of supports and supervision adequate for this individual? Is the home, community, work or vocational program safe?
- Healthy living: Does the individual have privacy, dignity and respect? Is the individual aware of his/her rights? Does the individual have adequate medical, dental and clinical care and supports?
- Decision-making and autonomy: Does the individual make decisions as to whom he/she lives with and what he/she does each day?
- Active employment or work training abilities.
Other
ISP areas of support include:
- Individual preferences and interests
- Transportation
- 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 his/her services? Did the individual participate in the development of his/her plan? Does the individual agree with the plan?
- Back-up plans in case of emergency
Other supportive
services such as art, music, speech, occupation or physical therapy, cognitive-rehabilitation.
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Program Costs, Referral and Funding Sources:
Referrals for the CLIBI program 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
Agencies.
The CLIBI per diem rate is based on an
individual’s needs for support, supervision and daily assistance. Devereux Pennsylvania accepts HCBS Waivers from
Pennsylvania and other states, commercial insurance and private funding. The
per diem rate includes the following services.
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All services as outlined in the proposed
treatment plan or as identified by the interdisciplinary treatment team
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Support, supervision and care up to
24 hours per day to maintain health, safety and well-being of the
client
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Case management duties performed by a program
specialist
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Nursing oversight
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Activities of daily living
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Productive daily activity, based on an
individualized treatment plan
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Organized leisure and recreational programs
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Assistance in obtaining and managing health
and financial benefits
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Transportation to medical appointments, daily
activities
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Behavioral analyst or licensed psychologist
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Furniture – bedroom, shared areas, linens,
towels
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Accessible living environment, if needed
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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:
- Physical therapy
- Occupational therapy
- Speech therapy
- Cognitive Rehabilitation Therapy
- Psychiatric services
- One-to-one supervision
- Supported employment coach
Services Not Included in Per Diem:
- Services/supplies not related to the
brain injury
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Personal care attendant/one-to-one
supervision
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Medications
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Laboratory services/diagnostic
services
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Wheelchair rental/purchase
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Durable medical equipment
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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
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Personal care/hygiene items
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Admission and
Discharge Criteria:
Devereux Pennsylvania 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.
- 18 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 that confirm 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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Discharge
and Transfer Criteria Include:
An
individual may be transferred or discharged from a Devereux Pennsylvania home/program if
his/her interdisciplinary team demonstrates the current program cannot
meet the needs of the individual. Reasons for discharge include:
- An individual has met or is not making progress on various outcomes/goals and needs a less restrictive/more independent home or an individual requires a higher level of care than is currently provided.
- 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 three 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
physician.
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 about 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
supports.
The admissions department will work with the interdisciplinary
teams to transfer the individual to an appropriate Devereux program, 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 admissions 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 his/her
representatives. However, this is not always possible if there is an immediate
risk to the safety and well-being of the individual or others. In these cases,
immediate discharge may be needed.
Non-Discrimination Policy
It is the policy of Devereux Pennsylvania 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
preferences.
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