Practical guide · Person-centered planning
ISP goals for adults with disabilities: examples and how to write them.
Published 2026-10-28 · Updated 2026-10-28
An individual support plan (ISP), also called a person-centered plan or individual service plan, sets out what matters to the person, the support they need and the goals they choose. Good goals are the person's own, specific and measurable, so staff know what to support and everyone can see progress. The examples use invented people, and your state's form and terms may differ.
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Key points
The short version.
- Start with the person's own words.
- Separate the outcome, the measurable goal and the support strategy.
- Say what, how often, with what support and by when.
- Record work on each goal in daily notes.
- Review at least every 12 months and when things change.
- Never write a rights restriction as a goal.
01 · Person-centered planning
Start with what the person wants.
Federal rules for Medicaid HCBS waivers (42 CFR 441.301(c)) require the planning process to be led by the person, include people they choose, offer informed choices and happen at times and places convenient to them. The plan must include individually identified goals and desired outcomes, reflect the person's strengths and preferences, and be written in plain language the person can understand.
So a goal starts in the person's own words: "I want a job working with animals," "I want to cook dinner for my sister," "I want to take the bus to church by myself." The planning team's job is to turn that into steps and support, not to choose the goal for them.
- Ask what the person wants more of, less of and to learn.
- Write the goal in a way the person would recognize as theirs.
- Note who the person wants involved.
02 · Person-centered planning
Know the difference between an outcome, a goal and a support strategy.
Plans use different words, but most separate three things. The outcome is what the person wants in their life. The goal or objective is a measurable step toward it. The support strategy is what staff do to help.
Outcome: "Dana wants a paid job at an animal shelter." Goal: "Dana will volunteer at the county animal shelter two mornings a week for three months, completing her task list with no more than one verbal prompt per shift." Support strategy: "Staff ride the bus with Dana for the first four weeks, then meet her at the shelter; staff review her picture task list with her before each shift."
03 · Person-centered planning
Make every goal measurable.
A measurable goal says what the person will do, how often or how well, with what level of support, and by when. Many teams use the SMART test: specific, measurable, achievable, relevant to the person and time-bound.
Weak: "Marcus will improve his cooking skills." Stronger: "By March 31, Marcus will make a breakfast of his choice three mornings a week using his picture recipe, with no more than two verbal prompts, as recorded in daily notes."
- Name the action the person will take.
- Say how it is measured: times per week, percent of opportunities or prompt level.
- Set a review date.
- Say where progress is recorded.
04 · Person-centered planning
Example goals by life area.
These examples use invented people. Adjust them to the person's own priorities, abilities and supports.
- Employment: "Lena will apply for two jobs she chooses each month, using a resume she updates with her job coach, until she is hired."
- Home and daily living: "Marcus will do his own laundry each Saturday, sorting, washing and folding with no more than one gestural prompt, for 10 of 12 weeks."
- Health: "Ruth will take her evening medications at the kitchen counter and tell staff when each one is taken, with verbal reminders only, on 90% of evenings."
- Community: "James will ride the bus to his church and back with staff following in a car, then on his own, within six months."
- Relationships: "Tia will call or video-chat with her brother every Sunday, starting the call herself on the tablet."
- Money: "Andre will pay for his own purchases at the store, counting bills and waiting for change, on four outings a month."
- Communication and self-advocacy: "Sam will use his communication device to choose his weekend activity from three options every Friday."
05 · Person-centered planning
Connect each goal to daily notes.
A goal is only as useful as the record of working on it. Each progress note should name the goal, the support given, the prompt level and how the person responded, so the next review can show real progress instead of a guess.
If staff cannot tell from the goal what to do or what to record, rewrite the goal or the support strategy before the next shift, not at the annual review.
06 · Person-centered planning
Review and change goals.
The same federal rules require the plan to be reviewed and revised at least every 12 months, when the person's circumstances or needs change significantly, and when the person asks.
Look at the data at each review. A goal met should be replaced by the next step the person wants. A goal with no progress usually needs a different support strategy, or it may not be what the person wants anymore. Ask them.
07 · Person-centered planning
Restrictions are not goals.
Limiting a person's rights in a provider-controlled home, such as access to food, visitors, privacy or a lockable door, is not a goal or a house rule. Under the federal HCBS settings rule, a modification must be justified in the plan with eight things documented.
- A specific, individualized assessed need.
- Positive interventions and supports used first.
- Less intrusive methods tried that did not work.
- A clear description of the condition, proportionate to the need.
- Regular collection and review of data on whether it works.
- Time limits for periodic review.
- The person's informed consent.
- An assurance that it will cause no harm.
08 · Person-centered planning
Keep goals where staff document.
Goals written in a binder that staff never see do not get worked on. Put the current goals and support strategies where staff write their notes, so each note can name the goal it supports.
In LunahUP, the person's plan context and goals stay with their record, within reach of the staff documenting support. Staff provide the facts for each note and check any AI-prepared wording before they sign.
Questions people ask
Short answers.
What is the difference between an ISP and a person-centered plan?
States and agencies use different names, such as ISP, individual service plan or person-centered support plan, for the plan required in Medicaid HCBS. The idea is the same: the person's goals, needs and supports in one plan.
Who writes ISP goals?
The person leads, with the planning team they choose. A case manager or support coordinator usually facilitates. Federal conflict-of-interest rules generally keep providers of the person's services from developing the plan.
How many goals should an ISP have?
There is no federal number. Focus on a manageable set the person cares about and staff can actually support and record. Your state's form may set its own expectations.
How often are ISP goals reviewed?
Federal HCBS rules require review at least every 12 months, when needs or circumstances change significantly, and when the person asks. Your state may require more frequent progress reviews.
Can a goal be to maintain a skill?
Yes, if the person wants it. Keeping a job, staying healthy or keeping a skill can be a real outcome. Write how it will be measured, just like any other goal.
Sources
Check the official source.
Requirements change and differ by state. Confirm current rules with your state agencies and payers.
Keep the work connected
Related LunahUP workflows.
Start with one recurring task
Bring the goal your staff struggle to document.
Inspect a fictional person record with plan goals, and a note prepared from staff facts against one of them.
Book a 30-minute compliance demoUse sample data. No patient or employee records needed for the demo. Booking does not create an account or start billing.