South Dakota Home Care Plan: How the Individual Support Plan Works

Once your parent qualifies for the HOPE waiver, the next step isn't just "getting services." It's building the plan that determines exactly which services, how many hours, through which providers, and on what schedule. In South Dakota, this document is the Individual Support Plan (ISP), and it's the operational blueprint for your parent's home care.

What the ISP Contains

The Individual Support Plan is developed by your parent's assigned LTSS Specialist from the Division of Long Term Services and Supports. It's a person-centered document, meaning it's supposed to reflect your parent's actual preferences, routines, and goals — not just a standard checklist of services.

A typical ISP for a HOPE waiver participant includes:

• Authorized services and hours — personal care assistance, homemaker services, companion care, adult day services, respite, PERS, environmental modifications
• Service schedule — which days and times aides come, how hours are distributed across the week
• Provider assignments — which agency or agencies deliver each service
• Goals and outcomes — specific, measurable care objectives (maintain mobility, prevent falls, manage medications safely, preserve social engagement)
• Emergency backup plan — what happens if the regular aide doesn't show up, or if the primary caregiver is unavailable
• Risk assessment — identified safety concerns and mitigation strategies (fall history, wandering, medication errors, nutritional risk)

How the Plan Gets Built

The ISP isn't handed to you as a finished document. It's developed through a planning meeting that includes your parent (to the extent they can participate), the LTSS Specialist, the family caregiver or authorized representative, and sometimes the provider agency. Your input matters here — you know your parent's daily routines, what frustrates them, what time they're most alert, and what they'll resist.

The LTSS Specialist uses data from the InterRAI clinical assessment (the same tool that determined HOPE waiver eligibility) to inform service recommendations. The RUG score helps inform the level and amount of care the waiver may authorize.

If you disagree with the proposed plan — you think the hours are too few, a specific service was left out, or the schedule doesn't match your parent's needs — say so during the planning meeting. The ISP should be a negotiation, not a take-it-or-leave-it prescription.

Annual Reviews and Reassessments

The ISP isn't permanent. South Dakota requires an annual reassessment of every HOPE waiver participant, which includes a new clinical evaluation and a review of the current care plan. If your parent's condition has declined — more falls, increased confusion, new medical diagnoses — the reassessment can increase authorized hours or add services.

You don't have to wait for the annual review. If your parent's needs change significantly between reviews, contact the LTSS Specialist and request a plan modification. Common triggers:

• A hospitalization or ER visit
• A noticeable decline in cognitive function
• A change in the primary caregiver's availability (the daughter who was providing evening care got a new job, for example)
• A fall or safety incident
• A new medical diagnosis that affects daily functioning

Document the change before you call — specific dates, incidents, and observable differences in function give the LTSS Specialist the evidence they need to justify a plan update.

What Happens If Services Aren't Delivered

The ISP is an authorization, not a guarantee that every service will be delivered as planned. Provider staffing shortages — especially in rural South Dakota — can mean cancelled visits, late arrivals, or substitute aides who don't know your parent's routine.

If this happens regularly, escalate through two channels:

1. The provider agency — document missed or late visits and request a written staffing plan
2. Your LTSS Specialist — if the agency consistently can't deliver authorized services, the Specialist can help you switch providers or restructure the plan to use a different service mix (for example, shifting from agency personal care to Structured Family Caregiving)

For a waiver delivery concern, contact your LTSS Specialist or DHS/LTSS. The Long-Term Care Ombudsman is specifically a resource for facility-resident rights and quality-of-care complaints.

The South Dakota Home Care Navigator includes a care plan preparation worksheet that helps families organize their priorities, daily routine preferences, and non-negotiables before the ISP planning meeting — so you walk in ready to advocate effectively.

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