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Effective Date: 
7/2019

Documents

 

Instructions

Updated: 7/2019

 

Purpose

Form 1043 is used by the local intellectual and developmental disability authority (LIDDA) to document a post-move monitoring visit for an individual who has transitioned or been diverted from a nursing facility (NF) or an individual in crisis who has diverted to the Home and Community-based Services (HCS) program. The LIDDA prepares Form 1043 and conducts a post-move monitoring visit at least three times within the first 90 days after the individual transitioned or diverted.

The time frames for conducting post move monitoring visits are:

  • within the first 7 days after the individual transitioned or diverted;
  • between 8 and 45 days after the individual transitioned or diverted; and
  • between 46 and 90 days after the individual transitioned or diverted.

Before Entering Information on the Form

Before entering information on the form, you must:

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

Detailed Instructions

Name of Individual — Enter the name of the individual who transitioned or diverted.

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

Transition/Diversion Date — Enter the date the individual transitioned or diverted.

Review Date — Enter the date the SC conducted the post-move monitoring visit.

Required Post Move Time frame —Check the box with the time frame that reflects the monitoring visit. Check Additional Monitoring if the visit is conducted within the same time frame as a previous monitoring visit.

Community Provider Information

Provider Name — Enter the business name of the community provider the individual has selected.

Contact Name — Enter the first and last name of the contact person at the community provider.

Contact’s Area Code and Telephone No. — Enter the area code and telephone number for the contact person.

Type of Provider — Enter the type of community program provider (for example, HCS or Intermediate Care Facility for Individuals with an Intellectual Disability or Related Conditions (ICF/IID)).

Day Program Address — Enter the address, including the street, city, state and ZIP code for the day program.

Day Program Area Code and Telephone No. — Enter area code and telephone number for the day program.

Type of Residence — Check the appropriate box to indicate which type of residence the individual has selected: Group Home, Host Home, Own Home/Family Home or Other. If Other, describe.

Address of Residence — Enter the address, including the street, city, state and ZIP code for the residence.

Area Code and Telephone No. — Enter area code and telephone number of the residence.

Location Visited — Check the appropriate box to indicate which location was visited: Residence, Day Program/Work or Other site. Note: The LIDDA must conduct post-move monitoring at all sites where essential supports are provided.

Provider Staff or Family Members Interviewed — Enter the first and last names of any provider staff or family members interviewed while conducting the pre-move site review.

Essential Supports

In the first column enter the essential supports that are listed on Section 4 of Form 1053, Transition Plan, or Section 5 of Form 1050, Nursing Facility or Crisis Diversion Plan.

In the second column, enter the evidence that was reviewed to determine whether the support is in place (e.g., if the individual needs a pureed diet, a blender in the kitchen is evidence of the support being in place).

In the third column, check Yes or No to indicate whether the essential support is in place.

If “No” is checked for any essential support listed, explain the provider’s justification for discontinuing the support and whether the lack of support has had an adverse impact on the individual. — Provide an explanation of the provider's justification for discontinuing the support, whether it has had an adverse impact on the individual and, if so, describe the adverse impact.

Non-Essential Supports

In the first column, enter the non-essential supports identified in Section 4 of the Transition Plan or Section 5 of the Nursing Facility or Crisis Diversion Plan. Each item identified is monitored during post-move monitoring visits to ensure each is in place by the specified due date.

In the second column, enter the evidence that was reviewed to determine if the support is in place or was in place by the specified due date. Note: If the due date has not passed and the non-essential support is not in place, enter N/A.

In the third column, enter the due date for the non-essential support identified in the Transition Plan or Nursing Facility or Crisis Diversion Plan.

In the fourth and fifth columns, indicate Yes or No to indicate whether the non-essential support is in place or was in place by the due date. Note: If the due date has not passed and the non-essential support is not in place, do not check Yes or No.

If the due date has passed and “No” is checked, explain the justification for not having the support in place by the specified due date and whether the lack of support has had an adverse impact on the individual. — Provide an explanation of the provider's justification for discontinuing the support, whether it has had an adverse impact on the individual and, if so, describe the adverse impact.

Questions

Since the service coordinator’s last visit . . . — For Questions 1 through 16, check the appropriate box in response to the question. If indicated, provide details as requested.

Post-Move Monitoring Follow-up Activities

Area of Concern —Identify any areas of concern.

Action Taken by Service Coordinator —Describe the action taken or to be taken by the SC to address the area of concern. This includes immediate attempts to remedy the situation during the on-site monitoring visit in response to an adverse impact on the individual because of the lack of an essential or non-essential support.

Additional Comments —Include comments, as necessary.

Printed Name of Service Coordinator —Print the SC's name.

Service Coordinator's Signature and Date —The SC signs and dates the form.