← Back to Demo Binder

INDIVIDUALIZED SERVICE PLAN

CARF Standard 2.B · CLBC Community Living BC

Person Served

Jamie R. (Demo)

Plan Date

April 01, 2026

Review Date

October 01, 2026 (Quarterly)

Review Frequency

Quarterly (every 3 months)

MY INVOLVEMENT IN THIS PLAN

"I was involved in making this plan from the start. My support worker sat down with me over coffee on March 15th and we talked about what I want to work on. I said what matters to me and picked my own goals. My family came to the meeting on March 22nd and we all talked about how I am doing and what help I need. I agreed to everything in this plan and I know I can change it anytime."

GOAL 1: I WANT TO GET OUT INTO THE COMMUNITY MORE ON MY OWN

MY GOAL (in my own words)

"I want to get out into the community more on my own"

WHY THIS MATTERS TO ME

I like being around people and doing things outside the house. Going out makes me feel good about myself and I have been telling my support worker I want more independence.

WHAT I WILL DO

I will attend at least 2 community activities per month on my own or with minimal support, building on my growing confidence with public transit.

HOW I WILL DO IT

STEP 1: I will learn the bus route to the community centre with my support worker beside me (2 trips) How: Practice trips on Route 25 during low-traffic hours (Tues/Thurs 10am) Who helps: Support Worker (S. Thompson)
STEP 2: I will ride the bus with my support worker nearby but not sitting with me (2 trips) How: Support worker rides same bus but sits separately, available if I need help Who helps: Support Worker (S. Thompson)
STEP 3: I will ride the bus on my own with a check-in call when I arrive (3 trips) How: I text or call when I get on and when I arrive; support worker on standby Who helps: On-call Staff
STEP 4: I will go to community activities on my own without check-ins (ongoing) How: Full independence; I tell staff my plans at morning routine Who helps: House Staff (awareness only)

WHO WILL HELP ME

S. Thompson (Demo) — Support Worker, transit training lead
Community Centre Staff — Activity registration and orientation
L. Rivera (Demo) — Family Representative, encouragement and planning

WHEN WE WILL CHECK MY PROGRESS

Quarterly. We will talk about:

Which steps I have completed
Any problems I am having
Whether I want to change anything
If I need more help or if I am ready to move faster

GAS (Goal Attainment Scaling)

Level	Description
-2	Unable to attend community activities even with full staff escort and planning
-1	Can attend 1 activity/month with full staff accompaniment ← Baseline
0	Can attend 2+ activities/month with transit training support Target
+1	Can attend 3+ activities/month using public transit with minimal check-ins ✓ Current
+2	Can plan and attend activities independently, helps orient new residents

Weight 1.0

Baseline -1

Target 0

Current +1

GOAL 2: I WANT TO STAY HEALTHY AND KEEP WALKING EVERY DAY

MY GOAL (in my own words)

"I want to stay healthy and keep walking every day"

WHY THIS MATTERS TO ME

I feel better when I am active. Walking in the park is my favourite part of the day and my doctor says it is good for me. I also like eating well because I enjoy cooking shows and knowing about food.

WHAT I WILL DO

I will maintain my weight within 5% of my baseline (72 kg) by walking daily and making balanced meal choices with verbal support.

HOW I WILL DO IT

STEP 1: I will walk for at least 20 minutes each day with a companion How: Daily park walk after lunch with familiar companion Who helps: Support Worker (rotating)
STEP 2: I will help choose balanced meals at dinner prep with verbal prompts How: Visual meal planner on fridge; I pick from healthy options Who helps: Kitchen Support Worker
STEP 3: I will go to my weight check every month and talk about how I am doing How: Monthly weigh-in recorded in health log; reviewed with me Who helps: Health Coordinator

WHO WILL HELP ME

Support Workers (rotating) — Daily walk companions
Kitchen Support Worker — Meal choice guidance
Health Coordinator — Monthly weigh-in and health review

WHEN WE WILL CHECK MY PROGRESS

Quarterly. We will talk about:

Which steps I have completed
Any problems I am having
Whether I want to change anything
If I need more help or if I am ready to move faster

GAS (Goal Attainment Scaling)

Level	Description
-2	Weight fluctuating >10% with no engagement in nutrition planning
-1	Weight fluctuating 5-10%, participates in meal planning when prompted ← Baseline
0	Weight stable within 5% of baseline, engages in weekly walks and meal choices Target ✓ Current
+1	Weight stable, independently initiates physical activity 3x/week
+2	Mentors peers in healthy choices, self-manages dietary needs completely

Weight 1.5

Baseline -1

Target 0

Current 0

GOAL 3: I WANT TO MAKE MY OWN LUNCH

MY GOAL (in my own words)

"I want to make my own lunch"

WHY THIS MATTERS TO ME

I love cooking shows and I know a lot about food. I want to make my own sandwiches and salads so I do not always have to wait for someone to help me. It makes me feel proud when I do things in the kitchen.

WHAT I WILL DO

I will prepare a simple meal (sandwich, salad) with verbal prompts only, at least 3 times per week, within 6 months.

HOW I WILL DO IT

STEP 1: I will learn to make a sandwich with staff helping me through each step (2 attempts) How: Laminated visual recipe card; staff guides each step hands-on Who helps: Support Worker (S. Thompson)
STEP 2: I will make a sandwich with staff nearby for questions only (2 attempts) How: Visual card on counter; staff present but only answers if I ask Who helps: Support Worker (S. Thompson)
STEP 3: I will make lunch with only verbal prompts — no hands-on help (3 attempts) How: Staff gives reminders ("What comes next?") but does not touch food/tools Who helps: Any on-shift Support Worker
STEP 4: I will make lunch fully on my own (ongoing, 3x/week target) How: I tell staff I am making lunch; they check in afterward Who helps: On-shift Support Worker (check-in only)

WHO WILL HELP ME

S. Thompson (Demo) — Primary skill-building support
On-shift Support Workers — Verbal prompts and check-ins
L. Rivera (Demo) — Family Representative, practice at home visits

WHEN WE WILL CHECK MY PROGRESS

Quarterly. We will talk about:

Which steps I have completed
Any problems I am having
Whether I want to change anything
If I need more help or if I am ready to move faster

GAS (Goal Attainment Scaling)

Level	Description
-2	Requires full physical assistance for all meal preparation ← Baseline
-1	Can prepare simple items (sandwich, cereal) with verbal prompts + visual guide ✓ Current
0	Can prepare simple meals with verbal prompts only, 3x per week Target
+1	Can prepare simple meals independently, follows written recipes
+2	Can plan a weekly menu, shop for ingredients, and prepare meals independently

Weight 1.0

Baseline -2

Target 0

Current -1

COMPOSITE GAS T-SCORE SUMMARY

T = 50 + 10 × (Σ(w_i × x_i) / √(Σ(w_i²))) — where w = weight, x = current level. T = 50 means meeting all expected outcomes.

Goal	Weight (w)	Current Level (x)	Weighted Score (w × x)
1. Community Participation	1.0	+1	1.0
2. Health & Wellness	1.5	0	0.0
3. Daily Living Skills — Meal Prep	1.0	-1	-1.0
Σ Totals	Σ(w²) = 4.25	—	Σ(wx) = 0.0

Calculation: Σ(w_i × x_i) = 1.0 + 0.0 + (-1.0) = 0.0
Σ(w_i²) = 1.0² + 1.5² + 1.0² = 1.0 + 2.25 + 1.0 = 4.25
T = 50 + 10 × (0.0 / √4.25) = 50 + 10 × 0.0 = 50.0

T = 50.0

Composite GAS T-Score (range: 30–70)

Interpretation: Meeting expected outcomes overall. Goal 1 (Community Participation) is exceeding target at +1 — Jamie is now attending 3+ activities/month with minimal check-ins. Goal 2 (Health & Wellness) is at target (0) — weight stable, engaging in walks and meal choices. Goal 3 (Meal Prep) is progressing but below target at -1 — Jamie can prepare simple items with visual guides but has not yet reached verbal-prompts-only independence.

OVERALL REVIEW SCHEDULE

Review Frequency

Quarterly (every 3 months)

Next Review

October 01, 2026

Major Plan Review

April 01, 2027 (every 6 months)

SIGNATURES

Jamie R. (Demo)

Person Served

March 29, 2026

Date

S. Thompson (Demo)

Support Worker

March 28, 2026

Date

L. Rivera (Demo)

Family Representative

March 29, 2026

Date

REVISION HISTORY

Date	Revision	Reason
April 01, 2026	Initial plan created	Annual ISP development meeting with Jamie and family
March 22, 2026	Draft goals reviewed	Family consultation — L. Rivera confirmed goal priorities
March 15, 2026	Goal extraction session	S. Thompson met with Jamie to identify goals using "I" language

CARF STANDARD 2.B.5 COMPLIANCE CHECKLIST

Standard	Requirement	Validated
2.B.5.a	Person was involved in developing the plan; plan written in "I" language	Yes
2.B.5.b	Goals are based on identified strengths, needs, abilities, and preferences	Yes
2.B.5.c	Objectives are measurable (SMART format with GAS scale)	Yes
2.B.5.d	Methods and responsible parties identified for each step	Yes
2.B.5.e	Timeline for achieving objectives is specified	Yes
2.B.5.f	Schedule for reviewing the plan is documented	Yes
2.B.6.a	Consent obtained from person served (signature)	Yes
2.B.6.b	Copy of plan available to person served and authorized parties	Yes
2.B.9	Plan is reviewed and updated at established intervals	Due Oct 2026

Generated by CHAI (Care Home Assistive Intelligence)
Using: Goal Extraction, SMART Objective Generation, Person-Centered Language
Output format: service_plan_generator.py:generate_plan_document() · Deterministic (zero-token) · CARF 2.B compliant