*Type of report
Intake
45 Day Review
Semi-Annual Review
Annual Review
Discharge/Other
COORDINATED SERVICE AND SUPPORT PLAN (CSSP) ADDENDUM
Name of person served:
Date of Meeting:
Date of CSSP on file:
Name and title of person completing the CSSP Addendum:
Services and Supports
The license holder must provide services in response to the person’s identified needs, interests, preferences, and desired outcomes. Services will
be provided according to MN Statutes, chapter 245D and the applicable waiver plan for the person served. The following information will be
assessed and determined by the person served and/or legal representative and case manager and other members of the support team.
The person’s preferences for how services and supports are provided:
Current Program Plan
Long-range Program Plan:
Center-based program (no work)
Center-based program (no work)
Center-based with work options
Center-based with work options
Center-based with work options &/or mobile work
crew
Center-based with work options &/or mobile
work crew
Mobile Work Crew
Mobile Work Crew
Supportive Employment Services
Supportive Employment Services
Other:
Competitive employment
Other:
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Attendance
Productivity Level
Avg. Wage/Hour
(Voc. Services Only)
Attendance
Average Level
of Productivity
Prevailing Wage
%
%
(Voc Services Only)
Average Hourly
Wage
$
$9.09
SCHEDULED HOURS
(not including transportation)
DAYS
TIMES
MONDAY
TUESDAY
WEDNESDAY
THURSDAY
FRIDAY
The person’s desired outcomes and the methods or actions that will be used to support the person and to accomplish
the service outcomes (Service Outcomes and Supports):
Outcome 1:
Outcome 2:
Outcome 3:
Cultural needs identified by this person:
How does this person define their culture, taking into consideration age, gender, sexual orientation, spiritual beliefs,
socioeconomic status, language, ethnicity/race, etc.?
How can MSS take this person’s culture into consideration when planning/providing their program (dietary restrictions,
interpreter, space for prayer, etc.)?
Describe the general and health-related supports necessary to support this person based upon the Self-Management
Assessment and the requirements of person centered planning and service delivery:
Transportation supports needed:
Eating :
Physical supports needed (mobility, positioning, orthotics, etc.):
Behavior support needs:
Hygiene supports needed (bathroom, hands, clothing, etc.):
Therapy program(s) carry-over needs:
Assistive Technology needs (communication, environmental control, etc.):
Medical concerns (all medical information/supplies must be obtained prior to 1st day):
Community Integration/ Recreation and Leisure (satisfaction and any desired changes):
Reasonable Accommodations/Special Considerations:
Environment:
Any recent or pending changes in life:
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Other items: ( intakes: any info needed prior to 1st day):
Additional Comments from the person served or the support team on the above information:
Areas of Functional Limitations:
1. Mobility: A serious limitation in the ability to move about from place to place without accommodations, due to
physical or psychological impairment
Needs assistance from others or other accommodations to participate in job training and activities
Vocational training or work opportunities are limited to physically accessible sites
Unable to leave home to participate in job training and work activities
Other:
2. Self-direction: A serious limitation in the ability to independently plan, initiate, problem-solve, organize or carry
out work-related or training-related activities
Unable to independently plan, manage, or solve problems during job preparation or employment-related
tasks
Severe difficulty in remaining on-task to complete required training or employment tasks in assigned time
period due to being easily distracted or having short attention span
Requires substantially more supervision than others at work or in training due to disorientation and
confusion
Inability to recognize the consequences of or self-correct inappropriate behaviors in a job search, on the job,
or in training, leading to problems with job retention or job safety
Impairment results in severe difficulty adjusting to new job preparation or employment situations
Other:
3. Self-care: Individual is dependent upon other people, a service, or a device, to manage eating, toileting,
grooming, dressing, money management, health or safety, to participate in training or work activities
Safety or well-being is at risk in vocational training or at work due to poor judgment or disability
management
Significant deficits in grooming or personal hygiene limits access to employment
Poor money management seriously limits the person’s ability to participate in vocational training or work
activities
Needs assistance for personal needs or health care procedures to participate in vocational activities
Other:
4. Interpersonal Skills: A serious limitation in the ability to establish and maintain relationships with others which
limits job preparation, job acquisition, job performance, and/or job security
Inappropriate or disruptive behavior leads to negative consequences in vocational training and/or at work
Severe difficulty understanding acceptable levels and types of relationships negatively affects ability to
prepare for, enter, engage in, or retain employment
Social isolation, withdrawal, or rejection substantially limits vocational opportunities
Work relationships seriously impeded by talking that is excessive, halting, illogical, irrelevant, or of unnatural
volume
Serious problems interpreting and responding appropriately to the behavior and communications of others
in vocational setting or training activities
Other:
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5. Communication: A serious limitation in the ability to effectively give and receive information through spoken
words, writing or listening; or dependent on another person or adaptations in order to communicate (not due to
cultural/language factors)
Requires speech reading, sign language, real-time captioning, language board, written aids, or other visual
cues to participate in conversation needed to prepare for, enter in, or retain employment
Speech is not readily understood by others on first contact, seriously limiting interaction in work or training
Severe difficulty understanding and processing verbal communication needed to successfully prepare for,
enter, engage in, or retain employment
Severe difficulty with functional writing seriously limits ability to write at work, or independently complete
job applications
Lacks functional reading skills sufficient to follow written directions at work or read job applications
Severe difficulty with verbal communication needed to successfully interview or perform vocational activities
Other:
6. Work Tolerance: A serious limitation in capacity and/or endurance due to a physical or psychological
impairment to the extent that the individual requires modification, adaptive technology and/or special
accommodations not typically made for other people
Requires accommodations or modifications for capacity and endurance to prepare for, enter, engage in, or
retain employment
Requires assistive/adaptive technology (ies) for capacity and endurance to prepare for, enter, engage in, or
retain employment
Experience significant episodes functioning which substantially limits ability to work consistently
Other:
7. Work Skills: Serious limitation in the ability to perform specific tasks, or in capacity to benefit from training
required to carry out functions
Impairment limits vocational choices to routine and repetitive job tasks
Impairment seriously limits the development of skills which others of equivalent age and education have
typically developed, and which are necessary to obtain or maintain employment
Severe difficulty in learning, retaining, or integrating new information relevant to employability
Speed or quality of performing entry-level work tasks is below competitive standards
Requires special training, accommodations, or technology to learn and/or perform work skills
Other:
Worksite Modifications
Support Team members have identified the following barriers to employment:
These worksite job modifications will be made to assist in obtaining and maintaining employment (example: assistive
technology, reasonable accommodations, modified scheduled, communication devices, etc.):
Vocational Assessment:

A Becker Worker Adjustment Profile Summary is completed at a 45-day review, annually, and thereafter every 3
years. A copy of the results is available upon request.
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Is the current service setting the most integrated setting available and appropriate for the person?
Yes
No
If yes, please explain how you determined this:
If no, please describe what will be done to address this:
How will services be coordinated across other 245D licensed providers serving this person to ensure continuity of care?
If there is a need for service coordination between providers, include the name of service provider, contact person and
telephone numbers, services being provided, and the names of staff responsible for coordination:
STAFFING/SUPERVISION NEEDS:
Person accesses support as needed
Person requires some services, doesn’t require 24 hour plan of care
Person needs 24 hour plan of care (may not require supervision at all times but there is someone
identified/assigned that is responsible and accessible to the consumer in case of emergency. 24 hour plan of care
required for individuals in ICF-MR and waiver eligible individuals).
Person requires overnight supervision
Person requires 24 hour awake supervision
LEVEL OF SERVICES REQUIRED FOR HEALTH AND SAFETY SUPPORTS (check one):
Current level of services required for health and safety supports (check one):
Full day
Partial day
other (specify other):
Can be without caregiver for
minutes
hours (check one)
Other:
Specific Plan: (Identify in detail any special arrangements which would need to be implemented in order for person
to remain alone or unsupervised or identify where specific plan is located).
LEVEL OF SUPPORT REQUIRED FOR RESIDENTIAL SERVICES:
Support person on premises at all times when individual is home.
Can be unsupervised at home for
minutes
hours (check one)
(Specify details of alone time if there are specific limitations or plans associated with alone time under the specific plan section.)
Can be unsupervised in the community for
minutes
hours (check one)
Specific Plan: (Identify in detail any special arrangements which would need to be implemented in order for person
to remain alone or unsupervised or identify where specific plan is located).
Does the person require a restriction of their rights as determined necessary to ensure the health, safety, and wellbeing of the person?
Yes
No
If yes, indicate what right(s) are restricted:
(Refer to the attached Rights Restrictions form for all additional requirements and documentation.)
Can this person use dangerous items or equipment?
Yes
No
If yes, address any concerns or limitations:
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Has it been determined by the person’s physician or mental health provider to be medically or psychologically
contraindicated to use an emergency use of manual restraint when a person’s conduct poses an imminent risk of
physical harm to self or others and less restrictive strategies would not achieve safety?
Yes
No
Requested but have not yet received
If yes, the company will not allow the use of the behavioral intervention/manual restraint to be used for the person.
Health Needs
Indicate what health service responsibilities are assigned to this license holder and which are consistent with the
person’s health needs. If health service responsibilities are not assigned to this license holder, please state “NA”:






MSS requires that the annual physical exam is documented on the MSS form or medical supplement is
completed annually along with an alternative physical form.
MSS does not schedule or attend appointments for medical, psychiatric, or additional therapies.
MSS does not arrange or provide transportation to/from any appointments.
MSS will provide first aid, emergency CPR/AED care, and utilize EMS (911) as needed.
MSS personnel will meet the EMS at the hospital and stay with the person served until a different member of
the support team arrives at the hospital.
If person served becomes ill during the day, MSS will contact the residence and they will come to pick them up
as soon as possible.
If health service responsibilities are assigned to this license holder, you will be promptly notified of any changes in the
person’s physical and mental health needs affecting the health service needs.
If the license holder is assigned responsibility for medication assistance or medication administration, the license holder
will provide medication administration or assistance (including set up) according to the level indicated here:
Medication assistance
Medication administration
The following information will be reported to the legal representative and case manager as they occur, unless otherwise
indicated here:
 Any report made to the person’s physician or prescriber.
 The person’s refusal or failure to take or receive medication or treatment as prescribed.
 Concerns about the person’s self-administration of medication or treatments.
MSS requests that physical/medical information to be updated annually and as changes occur.
MSS requires that the physical exam is documented on the MSS form or the medical supplement is completed along
with a different physical form.
The current physical on file is date:
The current seizure plan of care is dated:
The list of current medication/ psychotropic med list is dated:
Emergency Medical Information (DNR/DNI):
YES
NO
Emergency Medical Information (DNR/DNI) is dated:
Psychotropic medication monitoring and use
If assigned responsibility for medication administration, the following information will be maintained by the license
holder. Please refer to the Behavior Outcome and Psychotropic Medication Monitoring Data Report for more
information.
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Does the person use prescribed psychotropic medication?
Yes
No
MSS will not be assigned responsibility for Psychotropic medications and their formal monitoring.
MSS will assist or administer any psychotropic medication as prescribed.
MSS will track behaviors related to psychotropic medications and give the data to the assigned person, if requested.
Describe the target symptoms the psychotropic medication is to alleviate:
Indicate what documentation method(s) will be used to monitor and measure changes in the target symptoms:
Permitted actions and procedures
Does the person require the use of permitted actions and procedures or instructional techniques and intervention
procedures on a continuous basis as identified in 245D.06, subdivision 7, paragraphs (b) and (c)?
Yes
No
If yes, please address how these are used as part of service provision according to 245D.07 and 245D.071, Service
Planning and Delivery:
Is a restraint needed as an intervention procedure to position this person due to physical disabilities?
Yes
No
If yes, please specify the manner in which the restraint is/will be used:
What positive support strategies may be attempted as a means to de-escalate the person’s behavior before it poses an
imminent risk of physical harm to self or others?
NA – this person does not have behaviors that would pose an imminent risk of physical harm to others.
Positive support strategies include:
Staff Information
Are any additional requirements requested for staff to have or obtain in order to meet the needs of the person?
Yes
No
If yes, please specify what these requirements are:
Does a staff person who is trained in cardiopulmonary resuscitation (CPR) need to be available when this person is
present and staff are required to be at the site to provide direct service?
Yes
No
Staff ratio:
For facility-based day services only – please indicate the staff ratio required for this person. Additional information on
how this ratio was determined is maintained in the person’s service recipient record:
1:2
1:3
1:4
1:5
1:6
1:7
1:8
1:9
1:10
Other:
Frequency of Reports and Notifications
*Information received regarding the frequency of reports and notifications is completed with the person served and/or
legal representative and case manager.
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1. Frequency of Progress Reports and Recommendations, at a minimum of annually:
Semi-annually
Annually
Other:
2. Frequency of progress review meetings, at a minimum of annually:
Semi-annually
Annually
Other:
3. Frequency of receipt of Psychotropic Medication Monitoring Data Reports, this will be done quarterly unless
otherwise requested:
Semi-annually
Annually
N/A
4. Frequency of medication administration record reviews, this will be done quarterly or more frequently as directed
(for licensed holders when assigned responsibility for medication administration):
Semi-annually
Annually
Available upon request
5. The legal representative and case manager will receive notification within 24 hours of an incident or emergency
occurring while services are being provided or within 24 hours of discovery or receipt of information that an incident
occurred, or as otherwise directed. Please indicate any changes regarding this notification:
6. Frequency of receiving a statement that itemizes receipt and disbursements of funds will be completed as requested
on the Financial Authorization form.
 MSS does not handle any funds or transactions for persons served.
 MSS will disperse bi-monthly paychecks or direct deposit stubs.
Economic Status: (For Employment Program)
Client receives the following in financial assistance:
** Working may affect other benefits you receive, such as Social Security, Minnesota Supplemental Aid, Food Stamps or
subsidized housing. You must report changes in your income to representatives of those programs. .For Further
information, contact your County Case Manager.**
Resource Bulletin Board:
was informed that there was a resource bulletin board located in the center and on this bulletin board they
would find some of the following information regarding community resources:
*Existing opportunities for employment *Employment guidance *Advanced careers *Current Events *Community
Events *Client Resources
Comments/Additional Resources requested (temp. agencies, resume writing services, etc.):
Any additional comments from the person served or the support team regarding this CSSP addendum:
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