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Effective Date: 
10/2019

Documents

 

Instructions

Effective Date: 7/2019

 

Purpose

Form 1057, Habilitation Service Plan (HSP), is used by local intellectual and developmental disability authorities (LIDDAs) to:

  • describe the desired outcomes of an individual with intellectual disability (ID) or developmental disability (DD) residing in a nursing facility (NF) and identify specialized services provided;
  • document community living educational and exploration activities; and
  • document barriers to transitioning to community living and the solutions to those barriers.

 

When to Prepare

The form is initially completed by the habilitation coordinator (HC) following an individual’s initial interdisciplinary team/service planning team (IDT/SPT) meeting and revised as needed to reflect decisions made by the individual’s SPT.

 

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.

HSP Year

  • Begin Date — Enter the date of the initial or annual IDT/SPT meeting.
  • End Date — Enter the date that is 365th day following the begin date (or the 366th day in a Leap Year).
  • Plan Date — Enter the date the HSP was initially developed or subsequently revised.

 

Section 2, Discovery

Describe how information was gathered. — Describe all the ways information is being 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, assessments, document review, and use of activities and tools from person centered planning.

Participants — List the names of people who provide information as part of the discovery process. New names are added as necessary.

 

Section 3, Changes made to the HSP

Date change was made — Enter the date that a change(s) was made to the form. The date should be the same as the Plan Date in Section 1.

Section number in which change was made — Enter the section number(s) of the form in which a change was made.

Description of Change — Describe the change(s) made to the form.

Insert section for additional changes — If the individual has had more than one change to the HSP, click the box to add each change individually.

 

Section 4, Habilitation Coordination Plan

In accordance with the requirements in the rule and handbook, the SPT has determined the habilitation coordinator (HC) will meet face-to-face with the individual: — Select either “at least monthly” or “at least quarterly.”

List all activities to be coordinated or monitored by the HC, including NF Preadmission Screening and Resident Review (PASRR) support activities. — Specify all activities to be coordinated or monitored by the HC. (Note that two activities are pre-populated.)

Insert line for additional activity — If more lines are needed to list activities, click the box to add activities.

 

Section 5, Outcome Action Plan

A separate outcome action plan is needed for each identified outcome and must identify all specialized services and other resources and natural supports that will help the individual achieve the outcome.

Outcome — Enter a desired outcome of the individual, which should identify what the individual wants to do, achieve, change, maintain or experience. Outcomes must be supported by the discovery process and, as much as possible, should be written using language the individual understands.

Pertinent Information — Describe any need, request or consideration specific to this outcome that is necessary for staff to know when supporting the individual in achieving this outcome.

 

Identify the IDD habilitative specialized service(s)

Name of service — Select the name of the IDD habilitative specialized service from the drop-down list.

Frequency — Indicate how often the person receives the service (e.g., twice a week).

Amount — Indicate the amount of the service the individual is receiving (e.g., two hours).

Duration— Indicate how long the individual will receive the service (e.g., six months).

Discontinued on — If the service was discontinued, enter the date of discontinuation.

How will this IDD habilitative specialized service support achieving this outcome? — Describe how the IDD habilitative specialized service will help the individual achieve the outcome.

Insert additional service — If the individual has more than one IDD habilitative specialized service to help achieve the outcome, click the box to add a service.

 

NF specialized service(s)

Name of service — Select the name of the NF specialized service from the drop-down list. Note: If the individual is receiving an NF specialized service that does not directly support the individual to achieve the outcome, leave this blank but copy the NF specialized service in Section 6.

How will this NF specialized service support achieving this outcome? — Describe how the NF specialized service will help the individual achieve the outcome.

Insert additional service — If the individual has more than one NF specialized service to help achieve the outcome, click the box to add a service.

 

Mental illness (MI) specialized service(s)

Name of service — Enter the name of the MI specialized service that will support the individual to achieve the outcome during an HSP year. Note: If the individual is receiving MI specialized services that do not directly support the individual to achieve the outcome, leave this blank but copy the MI specialized service in Section 6.

How will this MI specialized service support achieving this outcome? — Describe how the MI specialized service will help the individual achieve the outcome.

Insert additional service — If the individual has more than one MI specialized service to help achieve the outcome, click the box to add a service.

 

Other resources and natural supports

Name of resource or natural support — Identify the resource or natural support that will help the individual achieve the outcome.

Responsible party — Enter the name of the person who is responsible for arranging or coordinating the resource or natural support.

Actions to be taken, such as referral and follow-up — Describe what actions will be taken by the responsible party to ensure the individual has access to the resource or natural support to assist with achieving the outcome.

Insert additional resource or support — If the individual has more than one resource or natural support to help achieve the outcome, click the box to add a resource or support.

How will this resource or natural support help support achieving this outcome? — Describe how this resource or support will help the individual achieve the outcome.

Insert additional outcome action plan page — Click the box to add an outcome action plan page for an additional outcome. A separate outcome action plan is needed for each identified outcome.

 

Section 6, NF Specialized Services to be Monitored by the SPT

This section is used to describe each NF and MI specialized service the individual is receiving or has received during the HSP year. Each NF or MI specialized service is entered individually. Copy all NF outcome/goals directly from the LTC Online Portal on the Nursing Facility and Specialized Services form. Copy all MI outcomes/goals exactly as provided by the LMHA or LBHA staff. Use the Insert additional service box, as necessary. Note: All NF and MI specialized services must be included in this section, even if the specialized service is also included in an outcome action plan in Section 5.

 

Section 7, Preference Regarding Transition

Most of the information included in this section of the HSP comes from Form 1054, Community Living Options, in Section 5, Section 6 or Section 7.

CLO Completed On — Enter the date of the most recent CLO presentation.

Describe the individual’s preference on transitioning to the community — Select the item from the drop-down list that is the same item from Section 5 of Form 1054.

  • Wants to transition into the community and has selected a program;
  • Wants to transition into the community but wants more information before selecting a program;
  • Does not want to transition;
  • Undecided; or
  • Unable to determine.

Barrier from the CLO — Select a barrier identified in Section 6 or Section 7 of Form 1054. Use the Insert additional row for CLO Barriers box to add a barrier.

Barrier present for — Select whether the barrier is present for the individual or for the legally authorized representative (LAR).

SPT proposed solutions/follow-up activities — Describe the SPT’s proposed solutions to the barrier and the follow-up activities to implement the solutions and resolve the barriers.

Barrier identified by the SPT — Enter a barrier identified by the SPT that is not otherwise identified on Form 1054. Use the Insert additional row for SPT Barriers box to add a barrier.

Barrier present for — Select whether the barrier is present for the individual or for the LAR.

SPT proposed solutions/follow-up activities — Describe the SPT’s proposed solutions to each barrier and the follow-up activities to implement the solutions and resolve the barriers.

Insert additional Section 7 — Every time the CLO is presented during the HSP year, an additional Section 7 is inserted and completed.

 

Section 8, Educational Activities

Description — Provide a short description of the education, informational, or support activity offered to the individual/LAR and actively involved persons during the HSP year.

Date Offered — Enter the date the information was offered.

Date Attended — Enter the date the activity was attended, if applicable.

Attended by — If “Date Attended” is completed, check the appropriate box to identify who attended: the individual (I), LAR (L) and/or actively involved person (AIP).

 

Section 9, Documentation of Exploration of Community Programs

Description — Provide a short description of a planned visit to a community program.

Target Date — Enter the target date for completing arrangements for the visit. This is not necessarily the date the visit will occur.

Outcome — After the visit has occurred, describe the outcome of the visit, including the attendees’ and program provider’s responses and feedback.

Attended by — Check the appropriate box to identify who visited: the individual (I), LAR (L), and/or actively involved person (AIP).

Insert additional planned visit — Click the box to add a planned visit.

 

Section 10, HC Signature

Name of Habilitation Coordinator — Enter the name of the HC who developed the plan.

Signature of Habilitation Coordinator — The HC signs the form.

Date — Enter the date of the HC signature.