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Effective Date: 
10/2020

Documents

 

Instructions

Updated:10/2020

 

Purpose

To document the presentation of, and responses to, community living options (CLO) provided to an individual with intellectual or developmental disabilities (IDD) residing in a nursing facility (NF), as well as the individual’s legally authorized representative (LAR) or actively involved person, if any. CLO encourages individuals/LARs to learn about alternative living arrangements in the community which allow the greatest opportunity for the individual to transition from the NF, be integrated into the community, and interact with non-disabled individuals.

The CLO presentation discusses the range of community living services and support options with the individual and LAR in a manner the individual and LAR can easily understand. The summary of information provided, the individual’s/LAR’s awareness of their options, potential barriers to transitioning to the community, and the individual’s and LAR’s preferences for living options are documented on Form 1054.

The results of each CLO presentation are shared with the service planning team (SPT) for discussion and recommendations.

 

Procedure

When to Prepare

The CLO presentation is conducted:

  • six months after the initial CLO (which was presented during the Preadmission Screening and Resident Review (PASRR) Evaluation (PE)) and at least once every six months thereafter while the individual continues to reside in the NF;
  • when the habilitation coordinator (HC) is notified or becomes aware that the individual, or the LAR on the individual’s behalf, is interested in speaking with someone about transitioning to the community;
  • when requested by the individual or LAR; and
  • when notified by HHSC that the individual’s response in Section Q of the Minimum Data Set (MDS) indicates the individual is interested in speaking with someone about transitioning to the community.

The HC presents CLO to the individual/LAR six months after the initial CLO presentation and at least every six months thereafter, but no more than 30 days before the scheduled second quarterly SPT meeting or annual interdisciplinary team (IDT)/SPT meeting, so that CLO can be discussed during these meetings. The HC must maintain the every-six-month base schedule beginning with the initial CLO date, even if an additional CLO was presented before the next six-month CLO is due.

Note: CLO is presented anytime a PE is completed, including for a resident review or Change of Ownership (CHOW).

Form 1054 is used to:

  • document each CLO presentation;
  • record the individual’s and LAR’s current knowledge about community living;
  • record the materials provided to the individual/LAR during the CLO presentation;
  • document when CLO is refused;
  • identify the supports or services that would be needed for the individual to live in the community;
  • record the individual’s and LAR’s preferred living option for the individual;
  • document barriers preventing a transition to the community, if the individual does not want to move, the individual’s LAR does not want the individual to move, or the individual has not selected a community program to transition to;
  • document the barriers to transitioning to the community after the individual has selected a program to transition to; and
  • document comments related to the CLO by the HC or PE evaluator.

 

Form Retention

A copy of the CLO form is maintained by the LIDDA in the individual’s record.

 

Detailed Instructions

PASRR Evaluation CLO Date — Enter the date the initial CLO was presented to the individual and LAR by the PE evaluator. This date will remain the same with each new CLO presentation.

Date of CLO presentation — Enter the date the CLO is being presented to the individual and LAR.

 

Section 1, Individual’s Information

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

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

Medicaid No. — Enter the individual’s nine-digit Medicaid number.

Name of LIDDA — Enter the name of the LIDDA.

Name of Staff Presenting CLO — Enter the name of the staff presenting CLO (i.e., PE evaluator or HC).

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

Address — Enter the address of the NF.

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

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

Relationship to Individual — Enter the LAR’s relationship to the individual.

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

Name of Other Actively Involved Person — Enter the name of 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).

Relationship to Individual — Enter the relationship between the actively involved person and the individual.

Area Code and Telephone No. — Enter the area code and telephone number of the actively involved individual.

Insert Line for Actively Involved Person — Click this button to add a line for another actively involved person, and provide their name, relationship to the individual, and the area code and telephone number. (Insert as many lines as needed to add other actively involved persons.)

 

Section 2, Current Knowledge of Community Living

Describe the individual’s history of community living experiences. — Use this section to provide a summary of the individual’s experiences with living in the community, if any.

Describe what the individual knows about community services, supports, and programs. — Use this section to help assess what, if anything, the individual knows about various programs, supports, and living options available in the community. Options might include, but are not limited to, knowledge of or experience living in a group home or host home, or with receiving community-based supports while living independently or with family. By understanding what the individual knows, the CLO presenter can better explain the programs and CLO that are not as well understood or known.

Describe what the LAR knows about community services, supports, and programs. — Use this section to help assess what, if anything, the LAR knows about various programs and CLO to help an individual to transition. Options might include, but are not limited to, knowledge of programs or experience with the individual living in a group home or host home, or with receiving community-based supports while living independently or with family. By understanding what the LAR already knows, the CLO presenter can better explain the programs and CLO that are not as well understood or known.

 

Section 3, CLO Presentation

On the form, check the box beside each document given to the individual/LAR. A checked box indicates the document was explained to the individual/LAR in a method or language they understand and a copy of the indicated documents was provided to the individual/LAR. (Check all that apply.)

These are the documents used in all CLO presentations:

  • Explanation of Intellectual and Developmental Disability (IDD) Services and Supports
  • HHSC Long Term Services and Supports (Appendix to LIDDA Handbook)
  • Making Informed Choices: Community Living Options for Individuals Residing in Nursing Facilities booklet

In addition to the three documents used in all CLO presentations, this document is also provided to an individual who had a PE that was positive for both mental illness (MI) and IDD:

  • Friends and Family Guide to Adult Mental Health Services, if applicable

In addition to the three documents used in all CLO presentations, this document is also provided to the LAR of an individual, when the individual has an LAR:

  • Making Informed Choices: Community Living Options for Legally Authorized Representatives of Residents in Nursing Facilities booklet, if applicable

 

Section 4, Identifying Supports and Services for Community Living

This section asks the CLO presenter to consider the supports and services needed for the individual to live in the community. Consider each support/service and provide details.

The supports/services to consider and provide details on are:

  • Residential Setting
  • Level of Supervision
  • Architectural Modifications
  • Behavioral Support Services
  • Behavioral/Mental Health Services
  • Durable Medical Equipment
  • In-Home Health Services
  • Day/Vocational Activities
  • Medical Services
  • Personal Assistance with Activities of Daily Living
  • Respite
  • Special Equipment (include Adaptive Aids)
  • Specialized or Professional Therapies
  • Transportation
  • Training for the Caregiver
  • Legal Guardianship/Alternatives to guardianship (See Appendix C)
  • Social Security Office Notified
  • Leisure/Recreational
  • Mobility Issues
  • Safety Considerations
  • Spirituality/Religion
  • Relationships
  • Communication
  • Other: (explain)

Enter “N/A” in the “Provide Details” column for any support or service that is not needed or does not apply to the individual. For all others, provide details about what would be needed.

Insert Additional Line — Click this button to add a line for another “other” support/service that needs details. Insert as many lines as needed to add other supports/services.

 

Section 5, Preference Regarding Transitioning

This section describes the individual’s preference on transitioning to the community.

On the form, check the box beside the option that best describes the individual’s preference.

The choices are:

  • Wants to transition into the community, and has selected a program (Proceed to Section 8, Barriers to Transitioning to a Program)
  • Wants to transition into the community but wants more information before selecting a program (Proceed to Section 7, Wants More Information Before Selecting a Community Program)
  • Does not want to transition (Proceed to Section 6, Barriers Preventing a Transition to the Community)
  • Undecided (Proceed to Section 6, Barriers Preventing a Transition to the Community)
  • Unable to determine (Proceed to Section 6, Barriers Preventing a Transition to the Community)

Does the LAR agree with the individual’s preference on transitioning to the community above? — Check “Yes” if the LAR and individual agree. Check “No” if they do not agree, or check “No LAR” if there is no LAR.

If “Yes” or “No LAR” is checked, proceed to the next section of the form based on the individual’s decision in Section 5.

If “No” is checked, summarize why the LAR disagrees in the space on the form. Then, identify the LAR’s preference in the drop-down box and proceed to the section indicated by the LAR’s preference. The choices are the same as those at the beginning of Section 5.

Note: Only one of Sections 6, 7 or 8 is to be completed.

When the CLO is completed at the time of the PE, all barriers identified during the PE need to be included on the initial CLO form. Copy the barriers identified on the PE into either Section 6, Section 7 or Section 8 of the form, depending on which section best describes the individual’s preference on transitioning.

 

Section 6, Barriers Preventing a Transition to the Community

Section 6 is completed when:

  • the individual/LAR determine that remaining in the NF is the best living option for the individual;
  • the individual/LAR is undecided; or
  • the CLO presenter is unable to determine the individual's/LAR's preference.

Discuss the barriers with the individual/LAR that are preventing the individual from choosing to transition to the community. Check each reason that applies.

These are the reasons on the form:

  • Individual’s reasons that prevent community living:
    • Lack of understanding of community living options
    • Individual has been provided information and exposure to community living options, but is not interested in community living
    • Individual is not interested in being provided information and exposure to community living options
    • Mistrust of providers
    • Prior community living for the individual was unsuccessful or resulted in an adverse experience
  • Legally authorized representative’s reasons that prevent community living:
    • Lack of understanding of community living options
    • LAR has been provided information and exposure to community living options, but is not interested in community living for the individual
    • LAR is not interested in being provided information and exposing individual to community living options
    • Mistrust of providers
    • Prior community living for the individual was unsuccessful or resulted in an adverse experience
  • Behavioral/mental health needs require frequent monitoring by psychiatric/psychology staff and/or enhanced levels of supervision by direct service staff
  • Other (Describe)

All reasons checked in Section 6 need to be copied into Section 7 of Form 1057, Habilitation Service Plan (HSP) for the SPT.

If Section 6 of the CLO form is completed, proceed to Section 9.

 

Section 7, Undecided about Community Program

Section 7 is completed when the individual/LAR wants to transition to the community but is undecided about the community program and wants more information before selecting a program.

Identify the barriers preventing program selection. Check each reason that applies.

These are the reasons on the form:

  • Needs assistance to explore community living options. (e.g., peer to peer, group home tours, invite providers to visit)
  • Individual/LAR wants more information regarding programs
  • Behavioral/mental health needs require frequent monitoring by psychiatric/psychology staff and/or enhanced levels of supervision maintained by direct service staff
  • Other (Describe)

Note: All reasons checked in Section 7 of the form need to be copied into Section 7 of Form 1057, Habilitation Service Plan (HSP).

If Section 7 of the CLO form is completed, proceed to Section 9.

 

Section 8, Barriers to Transitioning to a Program

Section 8 is completed when the individual/LAR wants to transition to the community and has selected a program that will serve them once they transition. This section assists in determining the barriers to the individual’s transition that will need to be addressed in the Transition Plan before the individual can transition.

Discuss the barriers that need to be addressed so the individual can make a successful transition to the community. Check each reason that applies, and provide a short explanation of the barrier.

  • Lack of supports for people with significant challenging behaviors. Explain:
    Example: Availability of trained and qualified professional staff (e.g., behavior analysis to develop and assure appropriate implementation of successful behavior support plans).
  • Lack of specialized behavioral/mental health supports. Explain:
    Example: Need for enhanced levels of supervision.
  • Need for environmental modifications to support the individual. Explain:
    Example: Architectural changes to the living environment are needed.
  • Lack of availability of specialized medical supports. Explain:
    Example: Access to specialty healthcare providers.
  • Lack of availability of specialized therapy supports. Explain:
    Example: Access to specialty therapy providers.
  • Other (Describe)

All reasons checked in Section 8 of the form need to be copied into Section 6 of Form 1053, Transition Plan.

If Section 8 of the form is completed, proceed to Section 9.

 

Section 9, Comments

This section allows the CLO presenter to provide any comments or clarifications about the information discussed during the CLO.

Enter comments from the CLO presenter related to the CLO presentation, including:

  • if CLO was refused, the reason for the refusal and suggestions to encourage participation in future CLO;
  • other pertinent information that may relate to the individual’s/LAR’s exploration of CLO; and
  • any additional comments from the actively involved person.

 

Section 10, CLO Participants

This section captures the participants in the CLO.

Printed Name of CLO Presenter — The CLO presenter enters his/her name.

Signature — The CLO presenter signs the form.

Date — Enter the date the CLO presenter signs the form.

Printed Name of Individual — Enter the name of the individual.

Printed Name of LAR — Enter the name of the LAR, when applicable.

Relationship to Individual — Enter the relationship between the LAR and the individual.

Printed Name of Actively Involved Person — The name of the actively involved person is printed here, if applicable.

Relationship to Individual — Enter the relationship between the actively involved person and the individual.

Insert Line for Another Actively Involved Person — Click this button to add a line to include other actively involved persons. Obtain the name and relationship to the individual for each additional actively involved person.

 

Community Living Options (CLO) CARE Screen 1141

This section is to be completed and its content transferred to CARE screen 1141.

Parts of this section will auto-populate from the above sections; the following fields will not auto-populate and will require data entry:

Comp Code — Enter the LIDDA comp code.

Local Case No. — Enter the individual’s local case number.

Action — Check the appropriate box to add, change or delete.

Type of CLO Presentation — Check the appropriate box.  

Did the individual participate in the CLO discussion? — Check “Yes” or “No.” If ”No” is checked, answer the next question. If ”No” is checked on the second question, answer the third question.

Did the LAR participate in the CLO discussion? — Check “Yes,” “No” or “No LAR.” If ”No” is checked, answer the next question.

Did this CLO presentation result in a new referral for a service coordinator? — Check “Yes” or “No.”

Did this CLO presentation result in a continuation of service coordination services? — Check “Yes,” “No” or “NA.”

Date — Enter the date in which the CARE screen 1141 is entered in CARE.