Effective Date: 
8/2014

Documents

 

Instructions

Updated: 3/2015

 

PURPOSE

To complete Form 1041 for an individual with an intellectual disability or developmental disability (ID/DD) residing in a nursing facility (NF).

Service Planning

The individual’s service planning team (SPT) develops the individual’s service plan from Section 1 through Phase I of Section 9, Transition Plan to the Community. The service coordinator (SC) documents the development of the plan and all revisions on Form 1041. The SPT completes, revises and updates the plan quarterly and as needed, in accordance with Attachment G of the LA Performance Contract.

The SPT includes:

  • the individual with ID/DD residing in an NF;
  • the individual’s legally authorized representative (LAR), if any;
  • the Local Authority (LA) SC;
  • persons providing specialized services for the individual;
  • an NF staff member familiar with the individual’s needs;
  • a representative from a specific alternate placement provider, if one has been selected; and
  • other concerned persons whose inclusion is requested by the individual or the LAR, and, at the discretion of the LA, other persons who are directly involved in the delivery of services to the individual.

The Individual Service Plan (ISP) portion of Form 1041:

  • is individualized and developed through a person-centered process;
  • identifies the individual’s strengths, preferences, medical, nursing, nutritional management, clinical needs, support needs and desired outcomes; and
  • identifies the services and supports that are needed to meet the individual’s needs, achieve the desired outcomes and maximize the person’s ability to live successfully in the most integrated setting possible.

Section 9, Phase I of the transition plan portion describes the individual’s or LAR’s response to the Community Living Options presentation. If the individual or LAR wants to pursue community living, Phases II and III of the transition plan:

  • describe the activities, timetable, responsibilities, services, and supports involved in assisting the individual to consider community living options, choose a provider, and transition from the nursing facility to the community; and
  • specify the frequency of monitoring visits by the SC and identify at least three monitoring visits during the first 90 days following the individual’s move, including one within the first seven days.

When To Prepare

Initial/Annual: Form 1041 is initially completed when the SPT meets for the first time. The form must be completed from Section 1 through Phase I of Section 9, Transition Plan to the Community. If the individual or LAR is interested in pursuing community living, then Phase II of Section 9 must also be completed at the initial SPT meeting. An annual SPT meeting has the same requirements as a quarterly SPT meeting.

Quarterly: Form 1041 is reviewed and revised every three months. A quarterly or annual SPT meeting involves a review and discussion of:

  • all treatment and activities the individual receives from the NF and the LA, including specialized services; and
  • progress or lack of progress in achieving all outcomes identified in the ISP.

Calculating quarterly SPT meeting date: The quarterly SPT meeting should take place three months after the initial SPT meeting or previous quarterly SPT meeting, on the same day of the month or within the same week of that day. Example: If the initial ISP was developed on April 23, the next quarterly SPT meeting should be on, or within the week of, July 23.

Further, a quarterly SPT meeting should not take place earlier than 14 calendar days before the calculated date. Example: If the initial ISP was developed on April 23, the next quarterly SPT meeting should be on, or within the week of, July 23, but should not be earlier than July 10.

HHS permits an LA to revise an individual’s schedule for the quarterly SPT meeting to accommodate certain disruptions, such as alignment with the NF’s service planning schedule or when the individual is unavailable to participate due to hospitalization. HHS allows a schedule revision to result in a quarterly SPT meeting that occurs:

  • more than the 14th calendar day before the calculated date; or
  • up to 30 days after the calculated date.

Revising an individual’s schedule for quarterly SPT meetings requires detailed documentation in the individual’s record, including the reason for revising the schedule.

Update: Form 1041 is updated, as needed, any time between quarterly reviews.

Before entering information on the form, you must:

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

Detailed Instructions

Plan Date— Enter the date an SPT meeting is held to discuss the ISP. This date is changed every time the SPT revises Form 1041.

Section 1

Name of Individual Enter the individual’s name.

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

Medicaid Number Enter the individual’s nine-digit Medicaid number.

Date of Birth Enter the individual’s date of birth.

GenderCheck the appropriate box indicating the individual’s gender.

Street Address Enter the physical street address where the individual resides (i.e., the NF address or the address of the inidividual's residence in the community).

City/State Enter the city and state.

ZIP Code Enter the ZIP code.

Area Code and Telephone No. Enter the area code and telephone number where the individual currently resides.

Marital Status Check the appropriate box to indicate whether the individual is single, married, divorced or widowed.

Legal StatusCheck the appropriate box to indicate the legal status of the individual. If the individual has a guardian, check the appropriate box to indicate if guardianship is current.

Legally Authorized Representative Information

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

Relationship to IndividualEnter the LAR’s relationship to the individual (e.g., mother, father, sibling, or an agency or organization, such as the Texas Health and Human Services and Friends for Life).

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

LAR Address (Street, City, State, ZIP Code) Enter the address for the LAR.

Fax Area Code and No.Enter the area code and fax number for the LAR, if the LAR has a fax.

Area Code and Alternate Telephone No.Enter the area code and alternate telephone number for the LAR.

LAR Email AddressEnter the LAR’s email address.

Alternate Email AddressEnter an alternate email address for the LAR.

Primary Contact Information

Primary Contact if different from LAR NameEnter the name of the individual’s primary contact, if the primary contact is not the LAR.

Relationship to individualEnter the primary contact’s relationship to the individual (e.g., mother, father, sibling or friend).

Area Code and Telephone No.Enter area code and telephone number for the primary contact.

Primary Contact Address (Street, City, State, ZIP Code)Enter the address for the primary contact.

Fax Area Code and No.Enter the area code and fax number for the primary contact.

Area Code and Alternate Telephone No.Enter the area code and alternate telephone number for the primary contact.

Primary Contact Email Address Enter the primary contact’s email address.

Alternate Email AddressEnter an alternate email address for the primary contact.

Alternate Contact

Alternate Contact who is not LAR or Primary Contact Name — Enter the name of the individual’s alternate contact who is not the LAR or primary contact.

Relationship to individualEnter the alternate contact’s relationship to the individual (e.g., mother, father, sibling or friend).

Area Code and Telephone No.Enter the area code and telephone number for the alternate contact.

Alternate Contact Address (Street, City, State, ZIP Code)Enter the address for the alternate contact.

Fax Area Code and No.Enter the area code and fax number for the alternate contact.

Area Code and Alternate Telephone No.Enter the area code and alternate telephone number for the alternate contact.

Alternate Contact Email AddressEnter the alternate contact’s email address.

Alternate Email AddressEnter an alternate email address for the alternate contact.

Section 2

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

Contract Number Enter the contract number of the NF.

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

NF Area Code and Fax No. Enter the area code and fax number for the NF.

NF Staff Contact Enter the first and last name of the NF’s designated staff contact. This could be the Minimum Data Set (MDS) coordinator or the social worker (SW).

Area Code and Telephone No. Enter the area code and telephone number for the NF’s designated staff contact.

Email Address Enter the email address for the NF’s designated staff contact.

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

Address (Street, City, State, ZIP Code) Enter the LA’s complete address.

Service Coordinator (SC) Name Enter the first and last name of the SC assigned to the individual.

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

Alternate Area Code and Telephone No.— Enter the area code and alternate telephone number for the SC.

SC Email Address Enter the SC’s email address.

SC Fax Area Code and No. Enter the area code and fax number for the SC.

Back-Up Contact for SC Enter the first and last name of the back-up contact for the SC.

Area Code and Telephone No. Enter area code and telephone number for the SC’s back-up contact.

Alternate Area Code and Telephone No. Enter the alternate area code and telephone number for the SC’s back-up contact.

Section 3

Language Check the appropriate box to indicate the individual’s primary language, or describe in Other.

Reads EnglishCheck Yes or No to indicate if the individual can read English.

Understands EnglishCheck Yes or No to indicate if the individual understands English.

Ambulation Check the box that applies to the individual’s ambulation. If the individual requires total assistance, please describe.

Community/home SafetyCheck all boxes that apply to the individual’s community/home safety.

Check any that apply Check all boxes that apply to the individual. Describe any additional needs in Other.

Check adaptive aids that apply Check all boxes that apply to the individual. Describe any additional needs in Other.

Section 4

Describe how information was gathered Describe all the ways information was gathered to discover the individual’s desires and preferences. Examples include, but are not limited to:

  • conversations with the individual/LAR and those who know the individual best, such as an NF staff, caregiver, family member and friend;
  • a method called Planning Alternative Tomorrows with Hope (PATH);
  • methods taught by The Learning Community for Person Centered Practices (TLCPCP);
  • use of activities and tools from Person Centered Planning; and
  • prompts from the Discovery Guide and Discovery Tool (see Appendix III, Discovery Guide, and Appendix IV, Discovery Tool, in the Home and Community-based Services Handbook).

Participant(s) Enter the names of all who participated in the discovery process, including the individual/LAR. Make sure to include the title and credentials of all participants, if applicable.

People in Individual’s Life: Family, Friends, Community/Other If applicable, enter the name and corresponding information for people important in the individual’s life. These are individuals who are close to and who know and care about the individual and may already be listed in Section 1. This will help in determining who to speak with in certain situations. It will also help to ensure that the individual does not lose contact with important people in his/her life. Enter the Name, Relationship, Telephone No., Address, City, State, ZIP code, Email and “Important because” reason the individual/LAR has identified this person. Examples of “Important because” are:

  • He takes the individual on outings.
  • She is a friend the individual calls every weekend.
  • He takes the individual to Special Olympics practices and out to eat.
  • The individual stays with her during the holidays.

Section 5

(Individual’s name auto-populates)’s Profile

These are my strengths and what people like and admire about me:Using the discovery process, summarize the individual’s strengths. Enter a descriptive narrative about what you have learned through the discovery process about what others like and admire about the individual.

These are my preferences and what is important to me: Enter what you have learned through the discovery process 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/she has to date. Additional efforts should be explored to increase his/her awareness of additional possibilities and experiences to increase his/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: Include what you have learned through the discovery process of what is important for the individual, as identified by those who know him/her best. “Support me” reflects information that is important for the service provider to know and understand about the individual. Include information in all of the areas listed and be specific about health needs, supervision requirements, specific behavioral needs and special instructions for those who support the individual.

  • Communication Enter important information you have learned through the discovery process about how the individual communicates and how to best communicate with him/her. List the individual’s communication-related needs. For instance, what is the individual’s primary or preferred method of communication? How does the individual communicate or express a need (gestures, sounds, facial expressions, adaptive equipment, etc.)? What is the best way to determine if the individual is expressing satisfaction, happiness, comfort or agreement, as opposed to dissatisfaction, unhappiness, discomfort and disagreement? Among those who know the individual best, who seems better able to interpret what the individual is trying to communicate? What is the best way for others to learn how to communicate effectively with the individual?
  • Nursing care Describe the individual’s nursing-related needs, such as assistance taking medication, suctioning, wound care and oxygen. Describe how staff should attend to the individual’s nursing needs.
  • Clinical Describe the individual’s behavioral- and mental health-related needs. What kinds of behavioral supports does the individual need? Does the individual need counseling services or psychiatric services for medication management?
  • Medical/dental Describe all medical/dental concerns, diagnoses and routine procedures (e.g., medication management, blood work, history of constipation, dental cleaning, x-ray or sedation needs).
  • Adaptive aids and medical supplies Describe the adaptive aids (e.g., wheelchair, walker, shower chair) and medical supplies (e.g., briefs, test strips) needed by the individual and how are they funded (e.g., Medicaid, personal funds) or obtained (e.g., leased, purchased).
  • Nutritional management Describe the individual’s nutritional-related needs (e.g., thickened, pureed, textured, use of supplements, food allergies or restrictions, choking risk).
  • Supervision needs Describe the individual’s supervision needs. Consider if there are any personal issues that might present risk for harm in the individual’s living arrangement (e.g., daily rituals, threats of suicide or physical harm to self or others, inability to handle a personal crisis). Describe the supports needed to address any risks, such as line of sight, one-to-one, limited proximity or door alarm. Is the individual currently receiving these supports?

Date Profile Completed or Revised Enter the date the profile is completed or revised.

Section 6

Service Planning Team (SPT) Meeting SummariesCheck the box that indicates whether the summary is Initial/Annual, Update or Quarterly. Enter the Plan Date, which is the date of the SPT meeting. Enter Service Coordinator’s Name.

Summarize the SPT meeting discussion and decisions. A quarterly or annual SPT meeting summary includes a review and discussion of:

  • all treatment and activities the individual receives from the NF and the LA, including specialized services; and
  • progress or lack of progress in achieving all outcomes identified in the ISP.

Historical Information Enter historical or background information that continues to significantly affect the individual or his/her services. Do not repeat information that is contained on the Profile Page or elsewhere on Form 1041.

Section 7

Individual’s Desired Outcomes —Enter the individual’s desired outcome(s), such as getting a job, living in the community or reconnecting with family members. There may be one or more outcomes that the individual/LAR identifies. An outcome can be specific or general. If the individual/LAR wants to discontinue an outcome or an outcome has been achieved, check the Discontinued box and enter the date the outcome was discontinued.

Service Coordination Plan — Service coordination is provided at least monthly for the duration the individual is residing in a NF and for six months after enrollment in a community based program. Form 8657, Service Coordination Assessment — Intellectual Disability Services, is completed and maintained in the individual’s record.

List all activities to be coordinated or monitored by the SC List the planned activities to be coordinated and monitored by the SC, including those to assist the individual in obtaining his/her desired outcomes. (Progress toward the outcomes is documented in the SC’s progress notes.) The first activity is pre-populated as:

  • While in NF: Monitor the NF plan of care to determine whether the individual's needs are being met as described in the plan.
  • After transition to the community: Monitor the plan of care related to the Medicaid community program for which the individual is enrolled (e.g., for Home and Community-based Services (HCS), the SC will monitor the person directed plan (PDP)).

Note: A copy of the most current plan of care (NF or Medicaid community program) must be attached to Form 1041 and all ongoing treatment and activities discussed at the quarterly and annual SPT meeting.

If an activity is discontinued or completed and no longer being coordinated or monitored, check the Discontinued box and enter the date the activity was discontinued. (Note that the first pre-populated activity may not be discontinued.)

Specialized Services Provided by the NF to be Monitored by the SC

Name of Specialized Service Enter the name of the specialized service being provided by the NF. Examples of specialized services provided by the NF are: Physical Therapy (PT), Occupational Therapy (OT), Speech Therapy (ST) and Durable Medical Equipment (DME).

Outcome/Purpose Describe the purpose or outcome of the service.

Frequency Describe how frequently the service is to be delivered.

Discontinued/Date — If a specialized service is discontinued, check the Discontinued box and enter the date the specialized service was discontinued.

Section 8

Action Plan Enter the Individual’s Name, Plan Date and CARE ID at the top of the page. Identify the general revenue service (e.g., Vocational Training, Behavioral Supports, Community Supports) authorized by the LA. Enter the Name of the Provider, and the amount, frequency and duration of the service.

Outcome —What does the individual want from this service?Enter what the individual wants to achieve from this service. The individual or LAR may identify one or more outcome/purpose. The outcome/purpose can be specific or general, depending on the request of the individual/LAR and his/her specific needs.

Pertinent Information Enter information identified by the individual and/or the SPT as needs, requests and considerations specific to the identified services for this action plan. This information is necessary in order to support the individual in achieving his/her outcome. Specific preferences related to how the individual wants the service delivered are important to include, if known. This could be a preference for a specific gender of service provider or preference for a morning or evening routine. State the individual’s particular fears or concerns about the delivery of services that would be helpful for the provider to know. The information in this section may change and expand as the SC has more conversations and interactions with the individual/LAR and as additional information about the individual’s needs and preferences are discovered.

Attach a copy of the provider’s strategies that implement this service The SC sends the action plan to the provider to develop the implementation strategies. The provider shares a copy of the provider’s implementation strategies with the SC, who includes the strategies in the ISP. The SC monitors the individual’s progress toward meeting his/her desired outcomes through discussions with the provider and the individual/LAR.

The information for this service. . .—The SC checks the appropriate box for “changed” or “added” and enters the implementation date. If the decision is to discontinue, the SC enters the date the service was discontinued. The SC signs the action plan and prints his/her name next to the signature.

Section 9

(Individual’s name auto-populates)’s Transition Plan to the Community

Enter Name of Individual and CARE ID where indicated.

Initially, Phase I of the Transition Plan is completed on the same day as the initial SPT meeting because the initial Community Living Options (CLO) is presented to the individual and LAR on the same day as the meeting, either before or after. The CLO is also presented every six months thereafter, and as requested by the individual/LAR. The CLO presentation must be documented on Phase I every time it is presented.

Note: The CLO worksheet, Form 1039, must also be completed every time the CLO is presented.

The Transition Plan is a living document where the Phases II and III are not necessarily completed at the same time as Phase I, but rather as the SPT progresses through the various phases. The duration of each phase will vary depending on the individual’s or LAR’s preferences and desires and readiness to move forward with community living.

Phase I: Education/Exploration of Community Settings/Community Living Options (CLO)

CLO completed on — Enter the date that CLO was presented to the individual/LAR.

The individual wants to Check the appropriate box regarding whether the individual/LAR chooses to remain in the NF or pursue community living.
If “Pursue community living” is checked, proceed to Phase II of the Transition Plan.
If “Remain in NF” box is checked, state the barriers preventing the individual from living in the community and the possible resolution to the barrier(s). Examples of barriers may include guardianship issues, Power of Attorney, high medical needs or behavioral needs, concerns about lack of supervision.

Transition Plan updateThis portion is completed:

  • When the individual/LAR changes their mind about remaining in the NF or pursing community living; and
  • When the next required CLO is presented. (A CLO presentation is required on the same day as the initial SPT meeting and every six months thereafter for as long as the individual remains in the NF. A CLO is also required when the individual/LAR express an interest in moving to the community.)

The SC summarizes the discussion and prints and signs his/her name.

Phase II: Identifying the Individual’s Needs for Community Living

(Individual’s name auto-populates)’s Transition Plan to the Community
Enter Name of Individual, CARE ID, and Phase II Transition Plan date.

What supports will the individual need to live in the community? Next to each support, provide details for those supports the individual will require in order to transition to and live in the community. If a listed support is not necessary, then enter NA or none in the “Provide Details” area.

Identify the community based waiver program that will be requested Enter the desired program that will be requested, identify the person responsible for requesting the slot, and the projected date that the request will be made.

Summarize plan for interviews and/or trial visits with potential providers Describe the plan for contacting and setting up interviews and arranging trial visits with potential providers. Identify the person responsible for coordinating interviews and trial visits and the projected date of completion.

Transition Plan Update Information about continuing, discontinuing, or changes to Phase II are documented in this box.

Enter the date of SPT meeting in which there was discussion about continuing, discontinuing, or changing Phase II. After the first time Phase II is completed, reflecting the most recent quarterly or annual service planning team meeting, check the appropriate box indicating the decision to continue, discontinue or change the transition plan.

Summarize the SPT’s discussion, including whether the individual/LAR selected a community provider, and any additional information pertaining to this update. SC prints and signs his/her name.

If “discontinue” is checked, identify the barriers preventing the individual from living in the community and the possible resolutions to the barriers.

Phase III. Transitioning from Nursing Facility

This section addresses essential and non-essential supports the individual will need to live in the community after discharge from the nursing facility. At this point, the SPT includes a representative from the selected community provider. The SPT ensures all essential supports identified in Phase III are in place prior to the individual’s projected move date.

Note: During this phase, the SC requests a copy of the individual’s most recent Quarterly Minimum Data Set (MDS) Assessment from the NF. The SC provides a copy of the MDS Assessment to the provider.

(Individual’s name auto-populates)’s Transition Plan to the Community
Enter Name of Individual, CARE ID, and Phase III Transition Plan date.
The individual has selected . . . Enter the name of the community provider selected by the individual/LAR.

The essential supports must be in place prior to the projected move date of Enter the date that the SPT has agreed upon as a projected date the individual will move into the community. This date may change due to unforeseen circumstances and may be updated, if necessary. All essential supports identified in this transition plan must be in place before the projected move date.

Essential Supports related to Health, Safety and Personal needs, Responsible Person and Comments Enter the supports that are necessary for the individual to move into the community. This could include minor home modifications for the bathroom, Hoyer lifts, specialized transportation or a wheelchair. Enter the responsible person for ensuring the support is in place before the projected move date. Provide additional information in the Comments section, as necessary. Any staff training that needs to occur before the individual’s move should also be listed in this section. Include Transition Assistance Services (TAS) items and Transition to Living in the Community (TLC) items, if appropriate.

Note: TAS and TLC assist Medicaid eligible NF residents being discharged to set up a household in the community. Currently, TAS is available the following waiver programs: Community Living Assistance and Support Services (CLASS), Medically Dependent Children Program (MDCP), Deaf Blind with Multiple Disabilities (DBMD) and HCBS STAR+PLUS Waiver (SPW). TAS must be accessed before TLC can be used. For an individual transitioning into one of the Medicaid waiver programs, the SPT, which includes a relocation specialist, coordinates with the case manager of the waiver program to identify the items and activities to be provided by the TAS or TLC provider.

The SPT agrees that the following must be arranged before the day of transition and Responsible Person — Complete the list of items that must be arranged prior to the day of transition. Note that specific numeric amounts can be filled in for the trust fund account, as well as amounts for the daily supply of medication, nutritional and dietary products, and medical supplies. List any adaptive/assistive/protective equipment that will accompany the individual and describe anything else that must be arranged in Other. Enter NA or None if the item is not applicable. Enter the name of the person responsible for arranging for the items listed.

Non-essential Supports, Responsible Person and Due Date Enter the non-essential supports the individual needs to live comfortably in the community. Enter the responsible person for ensuring the support is in place and the due date. Non-essential supports could include referral for speech, occupational or physical therapy, and referral to the Day Activities and Health Services (DAHS).

Note: “Social Security Administration is notified of the individual’s transition from the NF (if applicable)” is pre-populated because it applies to most Medicaid recipients transitioning from an institution into the community.

Post-Move Monitoring Schedule from Date of NF Discharge and Date Monitoring Visit to be Completed By This section auto-populates based on the projected move date entered at the top of Phase III. The dates populated are the deadlines for the service coordinator to conduct the three required post-move monitoring visits.

Section 10

Individual’s Name —Enter the individual’s name.

CARE ID Enter the individual’s CARE identification number.

Phase III Transition Plan Date — Enter the date.

Community Living Data — This section is for listing all community living information, including names, contacts, addresses, and phone numbers. It serves as a quick reference for important information related to serving an individual. Complete the information as it becomes known.

Section 11

Signature Page Enter the required information for each participant. For persons who attended by phone, the SC faxes the completed Form 1041 to sign, date and return.

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