Effective Date: 
9/2014

Documents

Instructions

Updated: 9/2014

PURPOSE

To document the provision of and responses to community living options (CLO) presented to an individual with intellectual or developmental disabilities (IDD) residing in a nursing facility (NF) and the individual’s legally authorized representative (LAR) or actively involved person, if any.

The CLO presentation is conducted by the individual’s assigned service coordinator (SC). During the CLO presentation, the SC discusses with the individual and LAR the range of community living services and support options in a manner that the individual and LAR can easily understand. The summary of information provided, educational activities, the individual’s/LAR’s awareness of their options, and the individual’s and LAR’s preferences for living options are documented on Form 1039.

Procedure

The CLO presentation:

  • is conducted by the assigned SC:
    • at the first face-to-face meeting with the individual and LAR following SC assignment;
    • at least every six months thereafter as long as the individual continues to reside at a nursing facility; and
    • at any time the individual/LAR wishes to review community living options; and
  • uses the CLO educational materials developed by the Texas Health and Human Services (HHS).

Form 1039 is:

  • used to document each CLO presentation;
  • used to document when HHS-approved CLO educational materials are provided to the individual and LAR, which is initially and at least annually thereafter;
  • used to document the level of awareness of the individual and LAR regarding the individual’s CLO;
  • used to document the individual’s preferred living option and the LAR’s preferred living situation for the individual; and
  • completed by the SC and maintained in the LA’s records, with copies provided to the individual and LAR.

Before entering information on the form, you must:

  • rename the file using "save as;"
  • close the file; and
  • open the renamed file.

DETAILED INSTRUCTIONS

Date of Presentation — Enter the date of the CLO presentation.

Individual’s Name— Enter the individual’s first and last name.

CARE ID — Enter the individual’s Client Assignment and Registration (CARE) System identification number.

Nursing Facility Name — Enter the name of the NF where the individual resides.

NF Area Code and Telephone No. — Enter the area code and telephone number for the NF.

Local Authority (LA) — Enter the name of the LA.

Assigned Service Coordinator — Enter the name of the assigned SC.

Legally Authorized Representative (LAR) Name — Enter the first and last name of the individual’s LAR, if any.

LAR Area Code and Telephone No. — Enter the LAR’s area code and telephone number.

LAR Address — Enter the physical street address, city, state and ZIP code for the individual’s LAR. If the LAR’s mailing address is different from the street address, also add the mailing address.

Other Actively Involved Person(s) — Enter the names and contact information for anyone maintaining significant and ongoing involvement with the individual (e.g., primary contact, if different from the LAR, or any others who will support the individual’s exploration of CLO).

The following information regarding. . . A hard copy of all documents of the CLO presentation are provided to the individual/LAR at initial contact and at least annually thereafter. Check the box beside each document given to the individual/LAR. Note: All boxes must be checked unless there is no LAR, in which case the last box remains unchecked.

All marked boxes indicate the document was provided on . . . Enter the date the CLO educational materials were provided to the individual/LAR.

Educational Activities - List all CLO education and exploration activities offered to the individual/LAR and actively involved persons.

Description— Enter a description of each education and exploration activity offered to the individual/LAR, including those required to be arranged on a quarterly basis by the LA.

Date offered — Enter the date the activity described was offered to the individual, LAR or actively involved person.

Date attended* Enter the date the activity described was attended by the individual, LAR or actively involved person. (Leave blank if no one attended).

Participants — If a date is entered in “Date attended,” add “I” if attended by individual, add “L” if attended by LAR, and add “AIP” if attended by an actively involved person.

Documentation of Visits - The following CLO were visited by the individual/LAR or actively involved persons.

Description and Outcome — Enter a description of each community living setting visited, including the name of the provider and the address of the setting. Enter a description of the outcome of the visit (e.g., individual’s reaction, significant issues that arose, provider’s reaction).

Date* — Enter the date of the visit.

Attended by — If a date is entered, then add “I” if attended by individual, add “L” if attended by LAR, and add “AIP” if attended by an actively involved person.

List any issues, concerns, and questions identified by the individual and LAR (e.g., individual responded negatively when introduced to a group learning environment; individual is hesitant to leave friends at the NF; or LAR is apprehensive about ability of a provider to ensure the individual’s health and safety). Self explanatory Note: Newly identified needs and preferences need to be documented in discovery information and necessary updates made to the Individual Service Plan (ISP).

Describe how the service coordinator addressed the individual’s or LAR’s issue, concern or question, including how barriers to community living can be eliminated. Self explanatory.

Discussion of the level of awareness of the individual and expectations the individual has about his/her options.The SC documents his/her conclusions regarding the individual’s awareness and expectations related to CLO based on the individual’s experience with, information about and exposure to CLO (including visits).

Discussion of the level of awareness of the LAR and expectations the LAR has about the individual’s options.The SC documents his/her conclusions regarding the LAR’s awareness and expectations related to the individual’s CLO based on the LAR’s experience with, information about and exposure to CLO (including visits).

Describe where the individual prefers to liveEnter where the individual prefers to live (e.g., in the community at a group home, host home, with family, independently or remain in the NF).

Describe where the individual’s LAR prefers the individual to live Enter where the LAR prefers the individual to live (e.g., in the community at a group home, host home, with family, independently or remain in the NF).

LA Service Coordinator’s Comments — Enter comments related to the CLO presentation, including:

  • follow-up actions that may be necessary related to exploration of community living and support options;
  • newly acquired information related to the individual’s preferences or outcomes; and
  • other pertinent information that may relate to the individual’s/LAR’s exploration of CLO.

Printed Name of LA Service Coordinator and Date — The SC prints his/her name and enters the date.

Signature of LA Service Coordinator — The SC signs Form1039.

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