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This form is used by local intellectual and developmental disability authorities (LIDDAs) when assisting an individual with remaining in the community when they may be at risk for nursing facility (NF) or other institutional admission.
When to Prepare
The form is filled out by the service coordinator (SC) when an individual receives a Home and Community-based Services (HCS) slot as an NF diversion or a crisis diversion. The form is updated as necessary.
Plan Date — Enter the date the form is developed or revised.
Date HCS slot authorized by HHSC — Enter the date HHSC notified the LIDDA that the slot was authorized.
Date enrollment to be completed by — Enter the date by which enrollment must be completed. This date is communicated to the LIDDA via the slot notification email.
Section 1, Individual Information
Name of Individual — Enter the name of the individual.
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.
Individual’s Address — Enter the individual’s current physical address.
Area Code and Telephone No. — Enter the individual’s area code and telephone number.
Nursing Facility Diversion or Crisis Diversion — Check the appropriate box.
Section 2, Profile Information
____________’s Profile — Enter the individual’s name.
These are my strengths and what people like and admire about me — Enter the individual’s unique strengths and the characteristics others admire about them.
These are my preferences and what is important to me — Enter the individual’s preferences that are unique to them and what they consider to be important to them.
This is what others need to know and do to support me in the following areas — Enter information important and unique to the individual’s needs as they relate to the bulleted items.
Historical Information — Enter background information that continues to significantly affect the individual or his/her services and is not reflected elsewhere in this document.
Section 3, Service Planning Team (SPT) Meeting Summaries
Date — Enter the date of the SPT meeting.
Service Coordinator — Enter the name of the SC facilitating the SPT meeting.
Summary of SPT Meeting — Enter a summary of the SPT’s discussions and decisions.
Section 4, Service Coordination Plan
The individual will receive service coordination throughout the HCS enrollment process. The SC will meet face-to-face with the individual at least monthly.
List all activities to be coordinated and monitored by the service coordinator during the diversion process — List all activities to be coordinated and monitored by the SC throughout the diversion process.
Section 5, Identified Supports
Description of Support/Comments — Next to each support, provide details about the support required by the individual to remain in the community. If a listed support is not necessary, then enter “none” or “n/a.” For NF diversion only, refer to the individual’s latest Form 1054, Community Living Options, when completing this section.
Essential Support — Check the box if the support has been identified as essential and needing to be in place prior to the Individual Plan of Care (IPC) begin date.
Due Date — For supports that are identified as essential, enter the same date as the projected IPC begin date as identified in Section 6. For all other supports required by the individual, enter the date the support needs to be in place.
Name of Person Responsible for Arranging Support — Enter the name of the person who will arrange the identified support.
Section 6, Diverting to HCS
The individual/LAR has selected _______________ (provider) as the individual's HCS program provider. — Enter the name of the HCS program provider selected by the individual or legally authorized representative (LAR) in the blank.
The SPT, which now includes the provider, agrees that all identified essential supports are necessary for the individual to remain in the community. The essential supports and the following pre-move preparations must be in place prior to the IPC begin date, which is projected to be: — Enter the projected IPC begin date.
The SPT agrees the following pre-move preparations must be arranged before the IPC begin date — Complete the list of items that must be arranged prior to the IPC begin date. Note that specific numeric amounts can be filled in for the daily supply of medication, nutritional and dietary products, and medical supplies (this may not apply if the individual is remaining in their own home/family home). List any adaptive/assistive/protective equipment that will accompany the individual and describe anything else that must be arranged in “Other.” Enter “n/a” or “none” if the item is not applicable.
Responsible Party — Enter the name of the person who will arrange for each item listed.
Section 7, Diversion Plan Disposition
Enrolled in HCS with Diversion slot on, Declined HCS Diversion slot on, Other, explain — Check the appropriate box and enter a date.
Comments — Enter any additional comments related to the disposition of the diversion plan.
Section 8, Post-Move Monitoring Dates
1-7 calendar days, 8-45 calendar days, 46-90 calendar days — Dates will auto-populate based on the projected move date from Section 6.
Section 9, Service Coordinator Signature
The SC’s signature in this section affirms that the development of this diversion plan was based on decisions by the SPT.
Name of Service Coordinator — Enter the name of the SC.
Signature of Service Coordinator — The SC signs the form.
Date — Enter the date the SC signed the form.