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Effective Date: 
7/2019

Documents

 

Instructions

Updated: 7/2019

 

Purpose

Form 1053 is used by local intellectual and developmental disability authorities (LIDDAs) to describe the activities to transition the individual from the nursing facility (NF) to the community.

 

When to Prepare

This form is completed by the service coordinator (SC) when an individual residing in a nursing facility has chosen to transition to a specific community program, and is also revised as necessary.

 

Detailed Instructions

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 — Enter the date the form is developed or revised.

 

Section 2: Community Program Choice

Identify the community-based program to be pursued — Enter the name of the community program selected by the individual/legally authorized representative (LAR).

Responsible Party — Enter the name of the person responsible for requesting a slot for the identified program (i.e., the diversion coordinator).

Projected Date of Request — Enter the date by which the responsible party will request a slot for the identified program.

 

Section 3: Service Coordination Plan

List all activities to be coordinated and monitored by the service coordinator during the transition process — Enter the planned activities to be coordinated and monitored by the SC, including those to assist the individual in obtaining his/her desired outcomes.

Insert additional rows — Click to add additional activities that will be coordinated and monitored by the SC.

 

Section 4: Identified Supports

Description of Support/Comments — Next to each support, provide details about the support required by the individual to transition to and live in the community. If a listed support is not necessary, then enter “none” or “n/a.”

Essential Support — Check the box if the support has been identified as essential and needs to be in place the day the individual moves into the community.

Does selected program provide this support? — Check the “Yes” or “No” box based upon the selected program’s availability to provide the identified supports.

Due Date —For supports that are identified as “Essential Supports,” enter the same date as the projected move date identified in Section 7. For supports that are not identified as “Essential Supports,” identify the date that the non-essential support needs to be in place.

Name of Person responsible for arranging support — Enter the name of the person who will ensure the provision of the identified support.

Insert additional rows for Other — Click to add additional supports that are not already listed in this section.

 

Section 5: Plan for Choosing a Program Provider

Summarize the plan for interviews and /or trial visits with potential providers — Describe the plan for arranging for interviews and/or trial visits with potential providers.

Responsible Party — Enter the name of the person responsible for making arrangements.

Projected Date of Completion — Enter the projected date that arrangements will be completed.

Insert additional rows — Click to add additional activities with potential providers.

 

Section 6: Barriers to Transitioning to a Program

Barriers from the CLO — Select the barriers that prevent the individual from transitioning into the community. These barriers originate from the Community Living Options form, Section 8.

SPT Proposed Solution/Follow-up Activities — Describe the SPT’s proposed solutions to each barrier and the follow-up activities to implement the solutions.

Insert additional rows for CLO Barriers — Click to add if the individual has additional CLO barriers.

Barriers identified by the SPT— Enter barriers that prevent the individual from transitioning into the community as identified by the SPT.

SPT Proposed Solution/Follow-up Activities — Describe the SPT’s proposed solutions to each barrier and the follow-up activities to implement the solutions.

Insert additional rows for SPT Barriers — Click to add if the individual has additional SPT barriers.

 

Section 7: Transitioning from the Nursing Facility

The individual/LAR has selected — Enter the name of the community program provider selected by the individual/LAR.

The essential supports and the following pre-move preparations 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.

The SPT agrees the following pre-move preparations must be arranged before the day of transition — 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 each item listed.

 

Section 8: Post-Move Monitoring Dates

Time Frame for Monitoring Visit to be Completed — Dates will auto-populate based on the projected move date from Section 7.

 

Section 9: Community Living Data

This section is for listing all community living contact information, including names, addresses and phone numbers. It serves as a quick reference for important information related to serving an individual in the community. Enter the information as it becomes known.

 

Section 10: Agreements

This section describes agreements for certain SPT members.

 

Section 11: Service Coordinator Signature

Name of Service Coordinator — Enter the printed name of the SC who developed the plan.

Signature of Service Coordinator — Enter the signature of the SC who developed the plan.

Date —Enter the date the SC signed the plan.