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Person-centered ALW service plan: the steps to remember

The short step lists from each lesson of Write a person-centered ALW service plan, on one page. Print it for the station or the break room. Each list points back to its lesson, where the sources are linked.

Open the coursePrint a poster with a QR code

Decision guide

Can this limit go in the ISP as a rights modification?

Does the limit touch tenancy, privacy in the unit, the person's schedule or access to food, or visitors?

  • Yes

    Is a specific, individualized assessed need documented, beyond a diagnosis or condition?

    • Yes

      Does the plan show the positive interventions and less intrusive methods tried first, and why they did not work?

      • Yes

        Does the draft describe a limit that fits the need, with data collection, review dates and a no-harm assurance?

        • Yes

          Has the person, or the authorized representative, understood the modification and given informed consent?

          • Yes

            Write the modification into the ISP, summarize it on the Patient's Rights Form, and get the signatures. The provider implements it; you monitor it at monthly visits.

          • No

            Do not add the modification. If the provider is not willing and able to serve the person without it, help the person find a new provider.

        • No

          Narrow the limit to the need, and add who collects what data, review at your monthly visits, a review date and the no-harm assurance.

      • No

        Work with the provider to try and document them first. You may use the setting's own records of its earlier efforts.

    • No

      Do not add the modification yet. Document the specific need first; a diagnosis alone is not enough.

  • No

    This guide does not cover it. Plan the need in the services section, and ask your CCA supervisor or DHCS before the plan limits anything else.

This guide helps you check a draft. The ISP still goes to DHCS with the assessment, and DHCS direction governs where the plan and this guide differ.

Step through it one question at a time: alwbeta.com/training/courses/person-centered-isp#decision-guide

Lesson 1

The participant leads the plan

Before you write a word of the ISP, you decide how the meeting will run: who leads, who comes, where it happens and which choices you lay out. The Individual Service Plan (ISP) is the plan the CCA develops to name a participant's needs and how they will be met. This lesson prepares that setup.

  1. The participant leads; an authorized representative leads with them
  2. Invite who they choose; mark who was chosen and who provides services
  3. Meet when and where it suits the participant
  4. Plain language, accessible, in a language they understand
  5. Record the settings considered and the one chosen; no steering
  6. Tell them how to ask for an update

Lesson: alwbeta.com/training/courses/person-centered-isp#lesson-isp-plan-leads

Lesson 2

Goals, strengths and preferences that belong to the person

The goals section is where an ISP shows whether it is person-centered. On every plan you decide whose goal you are writing down and how it turns into supports. This lesson shows how to draw out strengths, goals and preferences, and how to write them so providers can act on them.

  1. Strengths: from the person, the others present and your observation
  2. The goal is theirs; it may go beyond the waiver
  3. Age or dementia never rules out a goal; break it into steps
  4. Each goal: what success looks like, supports, who provides
  5. Preferences: likes, dislikes, a typical day
  6. No copied wording across plans

Lesson: alwbeta.com/training/courses/person-centered-isp#lesson-isp-goals-and-preferences

Lesson 3

Assessed needs, services and who provides them

The ALW Assessment Tool shows what help the person needs. The ISP has to say how each need will be met, by whom and how often. This lesson prepares you to turn each assessed need into a service a provider can deliver, without leaving a need unaddressed or adding services the person does not need.

  1. Sources: Assessment Tool, clinical records, professional assessments, preferences
  2. Only diagnoses relevant to long-term support needs
  3. For each need: how, when and by whom the person wants help
  4. Every need: service, named provider, frequency, duration
  5. Look past the waiver: Medi-Cal, programs, natural supports, community
  6. No unnecessary or inappropriate services

Lesson: alwbeta.com/training/courses/person-centered-isp#lesson-isp-needs-and-services

Lesson 4

Risks, back-up plans and who monitors the plan

Every ISP names what could harm the person and what will be done about it. On each plan you decide which risks are real for this person, what drives them and what happens in an emergency. This lesson prepares those choices while keeping the person's right to make their own decisions.

  1. Risks: medical, physical, social and emotional
  2. For each risk: contributing factors
  3. Mitigation: strategies, services and supports, waiver or not
  4. Reasonable risk: explain it, respect the choice, document the outcome
  5. Back-up plan: devices, medication timing, cold storage, mobility
  6. Monitoring: CCA monthly visits; contacts and no-contact persons

Lesson: alwbeta.com/training/courses/person-centered-isp#lesson-isp-risks-and-backup

Lesson 5

Modify a setting right, then sign, share and update the plan

Sometimes a provider says it cannot serve a person safely unless a right is limited. You decide whether the plan can carry that limit and what it must show. This lesson covers the rights that may be modified, the required elements, consent, signatures and copies, and when the ISP is reviewed and updated.

  1. Modifiable: tenancy, unit privacy, schedule and food, visitors
  2. A specific assessed need, not a diagnosis alone
  3. Positive interventions and less intrusive methods tried first
  4. Proportionate limit, data, review dates, no-harm assurance
  5. Informed consent, summarized on the Patient's Rights Form
  6. Sign, share copies, review every six months or sooner

Lesson: alwbeta.com/training/courses/person-centered-isp#lesson-isp-rights-modifications

Beta’s ALW team, course version 2026.10.4, text checked against its sources on October 22, 2026. Educational only. Not continuing-education, licensure or regulatory credit. Follow your employer’s current procedure and the person’s current plan. Call 911 for a medical emergency.

Call the ALW teamFit check