Evergreen s Program Coordinator will ensure that the names of the current and projected Managed Care Organization and Behavioral Health Organization are noted

							                    EVERGREEN PRESBYTERIAN MINISTRIES, INC.
                             TENNESSEE DIVISION
                        POLICY AND PROCEDURE 40.2A-TN


RE:           SUPPORTED LIVING-TRANSITION/INDIVIDUAL SUPPORT PLAN

EFFECTIVE
DATE:     January 1, 1999
          Last Revised: September 26, 2001


POLICY:

It is the policy of Evergreen Presbyterian Ministries, Inc., that the Supported Living services
provided to consumers in Tennessee adhere to the guidelines and regulations as defined by the
Office of Licensure for the Tennessee Department of Mental Health and Mental Retardation and
as outlined in Evergreen's contract with TDMHMR.

PROCEDURE:

A.     Services and Supports

       1.     Evergreen will work with the consumer, the Transition Team, and the Circle of
              Support in determining ways that the consumer should be supported in reaching
              his or her vision as identified in the Individual Support Plan and in maintaining
              optimal health.

       2.     Evergreen will:

              a.     Document how services and supports will be provided.

              b.     Provide staff training on how to implement the activities noted in the
                     Support Plan.

              c.     Document the provision of services and supports.

              d.     Perform monthly reviews of the consumer's progress on his Individual
                     Support Plan, including activities, incidents, social, leisure, vocational,
                     and other aspects of the consumer's program.

              e.     Complete all follow-up activities as noted in the Individual Support Plan.

       3.     Evergreen will provide a written plan that consists of the following:

              a.     A description of actions/efforts of staff.(i.e. strategies).
Supported Living-Transition/Individual Support Plan
Page 2

              b.     A denoting of the frequency of staff actions/efforts.

              c.     A description of the type and format used for documentation of
                     actions/efforts/responses.

       4.     Therapeutic activities will be integrated into all activities during the day,
              including activities in the home, at work, or in the community.

       5.     The monthly reviews will document the following:

              a.     How the services and supports were provided.

              b.     The consumer's response to the activities.

              c.     The need for updates or revisions to the Plan or the Plan's strategies.

              d.     The need for other follow-up activities.

              e.     The Program Coordinator is responsible for the monthly reviews and is
                     also responsible for contacting the Independent Support Coordinator if
                     revisions are needed to the Individual Support Plan.

B. Health and Wellness

       1.     Evergreen will ensure that all consumers will receive the necessary support and
              assistance to select medical providers of choice for preventive health care and
              promotion of wellness, as well as medical treatment.

       2.     Prior to the time a consumer transitions from an institution, Evergreen's Program
              Coordinator will ensure that the names of the current and projected Managed Care
              Organization and Behavioral Health Organization are noted in the file, along with
              the ID numbers for the consumer.

       3.     The Program Coordinator will also ensure that all information on the consumer's
              health and medical care is in the consumer's file and that all staff have been
              trained on this specific information. This will include, but is not limited to,
              medical history, information regarding medications, information on equipment
              and medical supplies or communication devices, and information regarding
              treatment for any special medical conditions and the treatment required.

       4.     Evergreen's Program Coordinator will work with staff at the Developmental
              Center, where the consumer is residing, and with the Transition Team members to
              develop an Emergency Plan specific to the needs of that consumer. This
Supported Living-Transition/Individual Support Plan
Page 3
              Program Coordinator will ensure that a copy of this Plan is sent to the Primary
              Care Physician and all providers involved with the transition of the consumer or
              with the care of the consumer after the transition is completed.

       5.     The Program Coordinator will make an appointment for the consumer with the
              Primary Care Physician in the community for a day during the first week after the
              transition is completed or as soon as possible, but no later than 30 days after the
              move.

       6.     The Program Coordinator will ensure that ongoing healthcare needs as identified
              in the Transition Plan or the Individual Support Plan are addressed and that all
              follow-up care is completed and continued as appropriate. Evergreen will ensure
              that each consumer receives comprehensive health care from a Primary Care
              Physician.

       7.     In case of a consumer's need to be hospitalized, Evergreen will work with the
              consumer's Independent Support Coordinator and with the consumer's family
              members to provide support to the consumer during the hospitalization and
              afterward.

       8.     See also Policy and Procedure 60.2, Health Care Services.