Section 5000, Habilitation Coordination

Revision 19-0; Effective July 7, 2019

 

5100 Required Face-to-Face Visits

Revision 19-0; Effective July 7, 2019

 

An HC meets face-to-face with an individual monthly, or more frequently if needed, unless the only specialized service the individual is receiving is habilitation coordination, in which case the HC meets face-to-face with the individual at least quarterly. Based on these requirements, the SPT determines the frequency of face-to-face visits. A face-to-face meeting with the individual must include the provision of at least one of the habilitation coordination activities described in this section.

 

5200 Assess/Reassess Habilitative Needs

Revision 19-0; Effective July 7, 2019

 

An HC must assess and periodically reassess an individual’s habilitative service needs by gathering information from the individual and other appropriate sources, such as the LAR, family members, social workers and service providers, to determine the individual’s habilitative needs and the specialized services that will address those needs.

An HC must complete Form 1064, Habilitative Assessment, for the individual:

The HC will ensure the completed assessment is sent to each SPT member at least 10 business days before the first quarterly SPT meeting following the initial IDT/SPT meeting and before the annual IDT/SPT.

Based on formal and informal assessments, the SPT determines if an individual’s current specialized services need to be discontinued or if a new specialized service needs to be added.

 

5210 Reviewing Assessments

Revision 19-0; Effective July 7, 2019

 

An HC reviews all applicable and available assessments and makes available copies of the assessments to each member of the SPT for review. If an assessment indicates:

*An individual can benefit from a specialized service if the service will help the individual acquire new skills, maintain skills, or delay or slow the loss of skills or functioning.

Reviewing assessments provides a more comprehensive understanding of an individual’s strengths, preferences and service needs, and helps SPT members outline services to meet the individual’s identified goals and objectives. As the facilitator of the SPT meeting, the HC must ensure the needs identified in all assessments are addressed.

HHSC encourages the HC to bring copies of all current assessments to the SPT meeting, so that the SPT can review and discuss recommendations. The HC must provide copies of assessments to the NF. It is recommended for assessments to be grouped together to make maximum use of the quarterly SPT for review and discussion.

Functional assessments to consider as part of Form 1057, Habilitation Service Plan (HSP), and the NF comprehensive care planning process include, but are not limited to:

 

5300 SPT Meetings

Revision 19-0; Effective July 7, 2019

 

An HC must convene and facilitate SPT meetings as described in this section for an individual receiving habilitation coordination.

By facilitating the SPT meeting, the HC assists SPT members to accomplish their responsibilities, which are to:

For an SPT meeting convened by the HC, the HC must ensure a sign-in sheet is provided to document the attendance of each participant, as well as the meeting date. If an SPT member participated by phone, the HC must ensure the member’s name is included on the sign-in sheet. The HC must maintain all sign-in sheets.

 

5310 First SPT Meeting

Revision 19-0; Effective July 7, 2019

 

See Section 4500, Developing Individual Profile and Habilitation Service Plan at First SPT Meeting.

 

5320 Quarterly SPT Meetings

Revision 19-0; Effective July 7, 2019

 

A quarterly SPT meeting should take place three months after the first SPT meeting or the previous quarterly SPT meeting, no more than two weeks before or after the three-month mark.

The HC must maintain the every-three-month base schedule even if a particular quarterly SPT meeting takes place within two weeks before or after the three-month mark. HHSC permits an HC to revise an individual’s schedule for quarterly SPT meetings to accommodate alignment with the NF’s service planning schedule. Revising an individual’s schedule for quarterly SPT meetings requires detailed documentation in the HC’s progress notes. The HC is responsible for coordinating with the NF so that the quarterly SPT meetings coincide with the NF’s quarterly service planning schedule.

 

5320.1 Required Activities during a Quarterly SPT Meeting

Revision 19-0; Effective July 7, 2019

 

During each quarterly SPT meeting, the SPT must:

If Form 1057 requires revisions based on the quarterly SPT meeting, the HC must revise Form 1057 as needed within 10 days after the meeting.

 

5320.2 Documenting Summary of Quarterly SPT Meeting

Revision 19-0; Effective July 7, 2019

 

The HC must summarize the SPT discussions and decisions at a quarterly SPT meeting in a progress note.

 

5320.3 Documenting Specialized Services in the LTC Online Portal

Revision 19-0; Effective July 7, 2019

 

Within five days after a quarterly SPT meeting, the HC will enter in the LTC online portal all required information on the PASRR Comprehensive Service Plan (PCSP) form.

 

5330 Update SPT Meetings

Revision 19-0; Effective July 7, 2019

 

An HC must convene an update SPT meeting between quarterly SPT meetings when necessary, such as when there is a change in the individual’s service needs, medical condition, or if requested by the individual or LAR.

 

5330.1 Update SPT Meeting Because of a Change in Medical Condition or a Change in Service

Revision 19-0; Effective July 7, 2019

 

An HC must convene an update SPT meeting if:

The HC must summarize the SPT discussions and decisions at an update SPT meeting in a progress note.

If Form 1057, Habilitation Service Plan (HSP), or Form 1063, Individual Profile – Nursing Facility, requires revisions based on the update SPT meeting, the HC must revise Form 1057 or Form 1063, as needed, within 10 days after the meeting.

Within five days after an update SPT meeting is held per the information in this section, the HC enters in the LTC online portal all required information on the PCSP form.

 

5330.2 Update SPT Meeting for an Issue Not Addressed in Section 5330.1

Revision 19-0; Effective July 7, 2019

 

An HC convenes an update SPT meeting to address any outstanding issue that is unrelated to an issue identified in Section 5330.1, Update SPT Meeting Because of a Change in Medical Condition or a Change in Service.

The HC must summarize the SPT discussions and decisions at an update SPT meeting in a progress note.

If Form 1057, Habilitation Service Plan (HSP), or Form 1063, Individual Profile – Nursing Facility, requires revisions based on the update SPT meeting, the HC must revise Form 1057 or Form 1063, as needed, within 10 days after the meeting.

A PCSP form is not required for an update SPT meeting held per the information in this section.

 

5340 Annual IDT/SPT Meeting

Revision 19-0; Effective July 7, 2019

 

 

 

5340.1 Annual IDT/SPT Meeting

Revision 19-0; Effective July 7, 2019

 

An annual IDT/SPT meeting is held for an individual regardless of whether the individual is receiving habilitation coordination or any other specialized service. The HC is responsible for inviting all SPT members to the annual IDT/SPT meeting.

Note: If the individual has refused habilitation coordination, then there is no SPT for that individual, but the HC still must attend the annual IDT meeting.

The IDT/SPT members will discuss Form 1064, Habilitative Assessment, conducted by the HC and all recommended specialized services and decide:

The HC must confirm the annual IDT/SPT meeting information in the LTC online portal on the PCSP form in accordance with Section 2520, Confirmation of IDT/SPT Meeting Information.

 

5340.2 HC Preparation for Annual IDT/SPT Meeting

Revision 19-0; Effective July 7, 2019

 

An HC must complete Form 1064, Habilitative Assessment, for the individual no earlier than 60 days before the scheduled annual IDT/SPT meeting regardless of whether the individual is receiving habilitation coordination or any other specialized service. The HC provides a copy of the completed Form 1064 to all IDT/SPT members at least 10 business days before the annual IDT/SPT meeting.

 

5340.3 IDT Agrees to Habilitation Coordination

Revision 19-0; Effective July 7, 2019

 

If the IDT agrees to the provision of habilitation coordination for the individual, the HC requests a renewal authorization for habilitation coordination in accordance with the Habilitation Coordination Billing Guidelines.

 

5340.4 Refusal of Habilitation Coordination

Revision 19-0; Effective July 7, 2019

 

If an eligible individual/LAR does not want habilitation coordination:

 

5340.5 Annual SPT Meeting

Revision 19-0; Effective July 7, 2019

 

If the IDT agrees to the provision of habilitation coordination for an individual, the HC convenes the annual SPT meeting immediately following the annual IDT meeting. An annual SPT meeting is conducted as described in Section 5320, Quarterly SPT Meetings.

 

5350 SPT Member that is a Provider of a Specialized Service

Revision 19-0; Effective July 7, 2019

 

Each SPT member that is a provider of specialized services must:

 

5360 Determination that Participation in SPT Meeting is Not Necessary

Revision 19-0; Effective July 7, 2019

 

If an HC determines active participation by a provider of a specialized service is not necessary, as described above in Section 5350, SPT Member that is a Provider of a Specialized Service, the HC must:

 

5370 Guidance for Convening SPT Meeting When an Individual or LAR Does Not Want to Attend

Revision 19-0; Effective July 7, 2019

 

This section provides guidance when an HC receives information from an individual or LAR that they will not attend a scheduled SPT meeting.

 

5400 Develop and Revise Habilitation Service Plan and Individual Profile

Revision 19-0; Effective July 7, 2019

 

An HC must develop and revise, as needed, an individual’s Form 1057, Habilitation Service Plan (HSP), and Form 1063, Individual Profile – Nursing Facility, with the SPT. Form 1057 and Form 1063 are individualized and developed through a person-centered process using ongoing discovery in accordance with each form’s instructions.

 

5410 Person-centered Planning

Revision 19-0; Effective July 7, 2019

 

Person-centered planning helps an individual figure out and describe what they need from services and from the service provider. The goal is to improve the individual’s quality of life by making sure their preferences are articulated and honored. This includes convening an SPT meeting at a time that is convenient for the individual and the individual’s LAR.

For more information about person-centered planning, including training, see HHS website.

 

5420 Discovery Process

Revision 19-0; Effective July 7, 2019

 

Discovery is the process of listening to people and learning about what they want from their lives. It is getting to know people so that their personal outcomes, preferences, choices and abilities are understood, documented and to form the foundation for planning their services and supports. Discovery is the basis for person-centered planning and service delivery. It is an ongoing process that occurs each time the HC talks to the individual or those who know the individual best. It is necessary to record the information learned so that it can be used when developing or updating Form 1057, Habilitation Service Plan (HSP). An HC leads the discovery process, advocating on behalf of the individual whose services and supports are being planned.

 

5430 Developing Habilitation Service Plan and Individual Profile

Revision 19-0; Effective July 7, 2019

 

Form 1057, Habilitation Service Plan (HSP), and Form 1063, Individual Profile – Nursing Facility, identify an individual’s strengths, preferences, medical, nursing, nutritional management and clinical needs, and support needs and desired outcomes. This information is gathered through discovery and through other sources, such as:

The HSP also address barriers to transitioning to the community or selecting a community program. These barriers are identified in Sections 6 or 7 of the most recent Form 1054, Community Living Options. The SPT may also identify and address barriers.

The HSP identifies the services and supports that are needed to meet the individual’s needs, achieve the desired outcomes, and maximize the individual’s ability to live successfully in the most integrated setting possible. The HSP must include all specialized services (including habilitation coordination) agreed upon during an IDT meeting or an SPT meeting within the HSP year, including the individual’s desired outcomes.

The HSP year:

At a minimum, for each specialized service agreed upon during the IDT meeting, the HSP must indicate either:

 

5430.1 Specialized Services Requiring an Assessment

Revision 19-0; Effective July 7, 2019

 

An assessment is required for:

The HSP must state an outcome that supports initiating an assessment.

 

5430.2 Specialized Services that Do Not Require an Assessment

Revision 19-0; Effective July 7, 2019

 

For independent living skills training and day habilitation, the SPT identifies for inclusion in Section 5 of the HSP:

 

5430.3 Frequency and Duration of Habilitation Coordination

Revision 19-0; Effective July 7, 2019

 

The duration for habilitation coordination is “while the individual is residing in the nursing facility,” which is pre-printed on Form 1057, Habilitation Service Plan (HSP). The frequency of habilitation coordination is determined by the SPT in accordance with the requirements in rule and Section 5100, Required Face-to-Face Visits.

 

5430.4 Barriers to Transitioning to the Community or Selecting a Community Program Identified During CLO

Revision 19-0; Effective July 7, 2019

 

If barriers are identified during CLO and described in Sections 6 or 7 of Form 1054, Community Living Options, the HC initiates as a topic of discussion at an SPT meeting about the possible solutions to the barriers, how the SPT can implement the solutions and any follow-up activities. If the SPT identifies an additional barrier to the individual transitioning to the community, the SPT must identify possible solutions to the barrier, how the SPT can implement the solutions (including who and when) and any follow-up activities.

Solutions to a barrier can include the provision of a specialized service or an additional outcome for an existing specialized service. For example, if a barrier to an individual’s transition to the community is an inability to navigate public transportation, then the individual may benefit from receiving independent living skills training with an outcome of learning how to use the public bus system.

The HC documents all identified barriers (i.e., from Sections 6 or 7 of Form 1054 and barriers identified by the SPT) and the solutions and follow-up actions for implementation in Section 7 of Form 1057, Habilitation Service Plan (HSP).

 

5440 Revising the Habilitation Service Plan and Individual Profile

Revision 19-0; Effective July 7, 2019

 

Form 1057, Habilitation Service Plan (HSP), and Form 1063, Individual Profile – Nursing Facility, are reviewed at least quarterly and revised as necessary. Revisions to Form 1057 or Form 1063 must be completed within 10 days following the SPT meeting in which the revisions were agreed upon.

 

5440.1 Revising the HSP Because an Assessment for an NF Specialized Service is Completed

Revision 19-0; Effective July 7, 2019

 

An assessment must be conducted for all NF specialized services. The results of an assessment are reflected in Section 6 of Form 1057, Habilitation Service Plan (HSP) as follows.

Note: The assessment results may impact the provision of an IDD habilitative specialized service. For example, if the individual is receiving day habilitation five days per week and a therapy assessment shows he or she needs therapy two days per week, then the amount or frequency of day habilitation may need to be reduced to allow for the provision of therapy.

A copy of all assessments for NF specialized services must be maintained in the individual’s record.

 

5440.2 Revising the HSP Because an Assessment for an IDD Habilitative Specialized Service is Completed

Revision 19-0; Effective July 7, 2019

 

An assessment must be conducted for behavioral support, employment assistance and supported employment. The information included in a completed assessment indicates whether the individual can benefit from the specialized service, and if so, should identify the necessary amount, frequency and duration for the service.

The results of an assessment are reflected in Section 5 of Form 1057, Habilitation Service Plan (HSP) in the appropriate outcome action plan as follows.

A copy of all assessments for behavioral support, employment assistance and supported employment must be maintained in the individual’s record.

 

5440.3 Revising the HSP to Address Barriers Identified During CLO

Revision 19-0; Effective July 7, 2019

 

If barriers are identified during CLO and described in Sections 6 or 7 of Form 1054, Community Living Options, the HC initiates at an SPT meeting a discussion of the possible solutions to the barriers, how the SPT can implement the solutions and any follow-up activities. If the SPT identifies an additional barrier to the individual transitioning to the community, the SPT must identify possible solutions to the barrier, how the SPT can implement the solutions (including who and when) and any follow-up activities.

Solutions to a barrier can include the provision of a specialized service or an additional outcome for an existing specialized service. For example, if a barrier to an individual’s transition to the community is an inability to navigate public transportation, then the individual may benefit from receiving independent living skills training with an outcome of learning how to use the public bus system.

The HC documents all identified barriers (i.e., from Sections 6 or 7 of Form 1054 as well as barriers identified by the SPT) and the solutions and follow-up actions for implementation in Section 7 of Form 1057, Habilitation Service Plan (HSP).

 

5450 New Habilitation Service Plan for Next HSP Year

Revision 19-0; Effective July 7, 2019

 

Following an annual SPT meeting, an HC must complete a new Form 1057, Habilitation Service Plan (HSP), for the next HSP year that includes all new and ongoing information, such as:

Discontinued specialized services and barriers that have been resolved are not included in the new HSP for the next HSP year.

The new HSP year:

Note: It is unlikely the annual IDT/SPT meeting date will occur exactly 12 months after the initial or previous annual IDT/SPT meeting date. The LTC online portal allows for an annual IDT/SPT meeting to take place as early as 344 days after the initial or previous annual IDT/SPT meeting. This means the HSP year will not always be a full 12-month period.

 

5460 Documents in an Individual’s Habilitation Packet

Revision 19-0; Effective July 7, 2019

 

A complete habilitation packet for an individual has:

 

5460.1 Individual Profile

Revision 19-0; Effective July 7, 2019

 

Information documented on Form 1063, Individual Profile – Nursing Facility.

Section 1, Individual’s Information — This section gathers identifying information about an individual as well as contact information for the individual, LAR and primary contact, if any, and information about an individual’s language preferences, ambulation abilities and accommodation needs.

Section 2, Nursing Facility and LIDDA Information — This section gathers name and contact information for NF and LIDDA staff.

Section 3, People Important to the Individual — The section identifies the important people in the individual’s life and who can provide information about the individual, such as family, friends, mentor and clergy.

Section 4, Profile Information — This section provides an overall profile of an individual’s strengths, preferences and needs, learned during the discovery process.

These are my strengths and what people like and admire about me: A descriptive narrative about the individual’s strengths and what others like and admire about the individual.

These are my preferences and what is important to me: A descriptive narrative about what is important to the individual. “Important to” reflects what is important from the individual’s perspective and is based on the individual’s words and behavior. When words or behavior are in conflict, listen to the behavior. The information might include important relationships, how the individual prefers to interact, things the individual likes to do or not do, preferred routines, relevant background information that may affect how services should be delivered and what the individual wants to do in the future. Remember, the individual’s response is limited to the knowledge and experiences he or she has to date. Additional efforts should be explored to increase his or her awareness of additional possibilities and experiences to increase his or her options of choice. This section could also include personal preferences (e.g., sleep with the light on, blackout curtains needed on windows, baths in the evenings only).

This is what others need to know and do to support me in the following areas: A descriptive narrative about what is important for the individual, as identified by those who know him or her best. “Support me” reflects information that is important for the service provider to know and understand about the individual. All specific areas listed below must be addressed and include specificity about health needs, risk factors and special instructions for those who support the individual. See Appendix IV, Risk Factors, for more information about identifying risks.

Historical information: Include background information that continues to significantly affect the individual or his or her services.

 

5460.2 Habilitation Service Plan

Revision 19-0; Effective July 7, 2019

 

Information documented on Form 1057, Habilitation Service Plan (HSP).

Section 1, Individual Information — This section gathers identifying information about an individual and identifies the HSP year and plan date.

Section 2, Discovery — This section describes all the ways information was gathered to discover an individual’s desires and preferences, such as observation of the individual and conversations with the individual/LAR and those who know the individual best, such as an NF staff, caregiver, family member or friend.

Section 3, Changes Made to the HSP — This section is where changes to the HSP made within the previous 12 months are described.

Section 4, Habilitation Coordination Plan — This section describes the habilitation coordination plan, including duration and frequency of face-to-face meetings between the individual and the HC. The duration of habilitation coordination while the individual is residing in the NF and is pre-printed on the form. The frequency of face-to-face visits is determined by the SPT within the constraints of Section 5100, Required Face-to-Face Visits, and which may be either at least monthly or at least quarterly.

This section also lists all the activities to be coordinated and monitored by the HC. The first two activities are pre-printed because they are mandatory. If the NF agreed to provide NF PASRR support activities, then each support activity to be provided by the NF must be listed as an activity that will be monitored by the HC. The PASRR rules provide a definition of “nursing facility PASRR support activities” and includes the following examples of support activities:

Note: The examples above are not all inclusive. A support activity can be any type of activity that supports the individual to receive specialized services.

Section 5, Outcome Action Plan — A separate outcome action plan is needed for each identified outcome. An outcome identifies what the individual wants to do, achieve, change, maintain or experience. For an identified outcome, the outcome action plan must identify all specialized services and other resources and natural supports the individual receives that will help the individual achieve the outcome. Each outcome action plan provides space to identify IDD habilitative specialized services, NF specialized services, MI specialized services and other resources/natural supports, as necessary and unique to the outcome. For each specialized service and resources/natural support listed, a description is necessary of how the specialized service or resource/natural support helps the individual achieve the outcome.

Note: While an NF specialized service or MI specialized service may be listed in a particular outcome action plan, all NF specialized services and MI specialized services for the individual must be included in Section 6 of the HSP.

Section 6, NF Specialized Services to be Monitored by the SPT — This section is for recording all NF specialized services and MI specialized services provided to the individual during the HSP year, including:

The form allows the user to add lines for more than one NF specialized service and MI specialized service.

Section 7, Preference Regarding Transitioning — Each time an HC presents CLO to the individual/LAR during the HSP year, the CLO date is included in this section of the HSP. Also included in this section are barriers to preventing a transition to the community from Section 6 of Form 1054, Community Living Options, or barriers to selecting a community program from Section 7 of Form 1504, if any. If there are barriers, the SPT’s proposed solutions and follow-up activities are also included in this section of the HSP. The SPT may identify additional barriers.

Section 8, Educational Activities — This section is used to describe all CLO educational, informational, and support activities offered to the individual/LAR and actively involved people. If an offered activity was attended, the information about attendance is also included in this section.

Section 9, Documentation of Exploration of Community Programs — This section is used to describe the community living settings for which a visit is planned or has occurred. When the visit has occurred, a summary of the outcome of the visit is included in this section.

Section 10, HC Signature — This section is for the HC to affirm that the HSP was developed based on IDT or SPT decisions and includes the HC’s printed name, signature and date.

 

5470 Sharing the Habilitation Service Plan, Individual Profile and Habilitation Packet

Revision 19-0; Effective July 7, 2019

 

An HC is responsible for providing a copy of the current Form 1057, Habilitation Service Plan (HSP), and Form 1063, Individual Profile – Nursing Facility, to all SPT members when they are developed and whenever they are revised.

An HC must share an individual’s habilitation packet with an SPT member upon request.

 

5480 SPT Member Believes HSP or Individual Profile Does Not Accurately Reflect SPT Decisions or Information about the Individual

Revision 19-0; Effective July 7, 2019

 

If an SPT member believes Form 1057, Habilitation Service Plan (HSP), or Form 1063, Individual Profile – Nursing Facility, does not accurately reflect an SPT decision or information about the individual, then:

 

5500 Assisting with Access to Needed Specialized Services

Revision 19-0; Effective July 7, 2019

 

 

 

5510 Initiating IDD Habilitative Specialized Services

Revision 19-0; Effective July 7, 2019

 

An HC is responsible for initiating IDD habilitative specialized services identified on an individual’s Form 1057, Habilitation Service Plan (HSP), within 20 business days after the date of an IDT meeting or SPT meeting of any kind. “Initiating” means to take necessary action that will result in the individual receiving specialized services in a timely manner.

Note: The NF is responsible for requesting NF specialized services in the LTC online portal within 20 business days after the date of an IDT meeting or SPT meeting.

 

5520 Monitoring the Initiation and Delivery of all Specialized Services

Revision 19-0; Effective July 7, 2019

 

An HC must document the initiation and delivery of all specialized services agreed upon in an IDT meeting or an SPT meeting.

The HC must report to Complaint and Incident Intake (800-458-9858) a noncompliant entity (i.e., LIDDA, NF or LMHA/LBHA) if the entity fails to:

Note: In addition to a report to Complaint and Incident Intake for a noncompliant entity, as noted above, a LIDDA is responsible for submitting monthly noncompliance reports to HHSC in accordance with the performance contract.

 

5530 Accessing Other Habilitative Programs

Revision 19-0; Effective July 7, 2019

 

An HC must assist an individual to access needed specialized services and other habilitative programs and services that can provide services to address the individual’s needs and achieve outcomes identified in the HSP.

 

5540 Assisting Individual/LAR with Requesting a Fair Hearing for Denial of NF Specialized Services

Revision 19-0; Effective July 7, 2019

 

If an individual is denied a specialized service and the individual/LAR wants to appeal the denial, the HC is responsible for assisting the individual/LAR with completing Form 2361, PASRR Specialized Services Fair Hearing Request, to request a fair hearing.

 

5600 Coordination

Revision 19-0; Effective July 7, 2019

 

An HC is responsible for:

 

5700 Monitoring and Follow-up Activities

Revision 19-0; Effective July 7, 2019

 

An HC must provide monitoring and follow-up activities to determine:

Monitoring may be accomplished through a combination of:

The HC must share with the SPT the results of the HC’s monitoring and follow-up activities.

 

5800 Community Living Options (CLO), Visits to Community Programs, and Educational Opportunities

Revision 19-0; Effective July 7, 2019

 

 

 

5810 Presenting CLO

Revision 19-0; Effective July 7, 2019

 

An HC provides information and discusses with an individual and LAR about the range of community living services, supports and alternatives, identifying the services and supports the individual will need to live in the community (whether or not the individual/LAR has chosen to transition to community living) and identifying and addressing barriers to community living. This activity is referred to as “CLO.”

CLO must be presented in a manner that allows the person and his or her LAR to fully understand the options available. Therefore, CLO duration may vary but should last as long as needed to completely and meaningfully present all available community living options. If there are barriers to the individual’s or LAR’s full understanding of CLO, the HC must document these barriers in Form 1054, Community Living Options, and how they will be addressed in Form 1057, Habilitation Service Plan (HSP).

 

5810.1 When CLO is Presented

Revision 19-0; Effective July 7, 2019

 

CLO is presented at the following times regardless of whether the individual is receiving or has refused habilitation coordination:

Note: CLO is presented anytime a PE is completed, including for a resident review or Change of Ownership (CHOW).

 

5810.2 Six-Month Base Schedule

Revision 19-0; Effective July 7, 2019

 

The HC presents CLO to the individual/LAR six months after the initial CLO and at least every six months thereafter while the individual continues to reside in the NF. The HC must ensure the CLO presentation occurs no more than 30 days before the scheduled second quarterly SPT or annual IDT/SPT, so that it can be discussed during the meeting. The HC must maintain the every-six-month base schedule beginning with the initial CLO, even if an additional CLO was presented before the next six-month CLO is due.

 

5810.3 CLO Materials Provided to Individual/LAR

Revision 19-0; Effective July 7, 2019

 

The HC uses the following materials to present CLO and explains each of the materials using the person’s preferred method of communication, taking the time necessary to ensure that the individual and his or her LAR fully understand the materials and each of the individual’s community options:

*CLO booklets are available by ordering from Pinnacle Cart.

 

5820 Documenting CLO

Revision 19-0; Effective July 7, 2019

 

The HC documents the CLO presentation and discussion on Form 1054, Community Living Options.

Note: The HC also documents barriers from Sections 6 or 7 of Form 1054 in Section 7 of Form 1057, Habilitation Service Plan (HSP). See Section 5460.2, Habilitation Service Plan.

 

5830 HC Actions Following CLO

Revision 19-0; Effective July 7, 2019

 

The HC complies with the requirements in this section following:

 

5830.1 Individual/LAR Wants to Transition and has Selected a Community Program

Revision 19-0; Effective July 7, 2019

 

If an individual wants to transition to the community and has selected a community program, the HC must, within three business days after receipt of CLO information from the PE evaluator or within three business days after the HC’s presentation of CLO,

The HC must:

 

5830.2 Individual/LAR Wants to Transition, but has NOT Selected Community Program

Revision 19-0; Effective July 7, 2019

 

If an individual wants to transition to the community, but has not selected the community program to pursue, the HC must, within three business days after receipt of CLO information from the PE evaluator or after the HC’s presentation of CLO, send a referral, using Form 1579, Referral for Relocation Services, to the individual’s MCO (see Appendix II, MCO Contact Information) so that an RS can be assigned and an assessment and evaluation completed within 14 days.

The HC must:

if the individual has not refused habilitation coordination, ensure that if barriers to selecting a community program are identified in Section 7 of the completed Form 1054, Community Living Options, they are included in Section 7 of Form 1057, Habilitation Service Plan (HSP) for SPT discussion.

When the individual/LAR has selected a community program, the HC must:

 

5830.3 Individual/LAR Does Not Want to Transition, is Undecided or Desire of Individual/LAR Cannot be Determined

Revision 19-0; Effective July 7, 2019

 

For an individual who has not refused habilitation coordination, if the individual/LAR does not want to transition, is undecided or the desire of the individual/LAR cannot be determined, the HC must:

 

5840 Exploring Community Programs

Revision 19-0; Effective July 7, 2019

 

An HC arranges exploratory visits to community programs for an individual, if requested, and addresses concerns about community living from the individual and LAR. Additionally, the HC may assist an individual and LAR with exploring different types of community programs using print and digital media, such as brochures, magazines, DVDs, virtual visit apps and virtual tours.

 

5850 Educational Opportunities

Revision 19-0; Effective July 7, 2019

 

An HC offers an individual and LAR the educational and informational opportunities that are required to be arranged by the LIDDA semiannually pursuant to the performance contract. An HC must document that the offer was made, including the specific educational or informational opportunity (i.e., description, location, date and time).

 

5900 Explanation of Rights

Revision 19-0; Effective July 7, 2019

 

An HC must initially, and annually thereafter, provide an individual and LAR an oral and written explanation of the individual’s rights contained in the “Your Rights in Local Authority Services” booklet.