Form 1063, Individual Profile – Nursing Facility

Instructions

Updated: 7/2019

Purpose

Form 1063 is used by local intellectual and developmental disability authorities (LIDDAs), specifically maintained by the habilitation coordinator (HC), and dispersed to all members of the Service Planning Team (SPT). Form 1063 acts as a comprehensive profile of key information on individuals in the Preadmission Screening and Resident Review (PASRR) program through the LIDDA. It will accompany Form 1057, Habilitation Service Plan (HSP), Form 1054, Community Living Options, and the Transition Plan.

When to Prepare

The HC at the LIDDA, using the discovery process as the basis for collecting information, develops information on Form 1063 with the individual/legally authorized representative (LAR) and members of the service planning team (SPT). Form 1063 is completed at the time of the initial/annual SPT and maintained with the individual’s record. It is reviewed at least quarterly and revised as necessary when the individual’s information changes. It is not necessary to submit a copy of Form 1063 to SPT members every time Form 1057, Form 1054 or Form 1053 is updated, unless the information on Form 1063 has changed. SPT members will receive a copy of Form 1063 with Form 1057 when the individual first enters the nursing facility following the initial SPT, when the information on Form 1063 is updated, with Form 1057 annually following the SPT meeting, and with Form 1053.

Detailed Instructions

HSP Year

• Begin Date — Enter the date of the initial or annual interdisciplinary team (IDT)/SPT meeting.
• End Date — Enter the date that is the 365th day following the begin date (or the 366th day in a leap year).
• Plan Date — Enter the date Form 1063 was initially developed or subsequently revised.

Section 1, Individual’s Information — Enter all of the data elements in the section for the individual and LAR. Enter N/A for those data elements that do not apply to the individual/LAR.

Section 2, Nursing Facility LIDDA Information — Enter all the data elements in the section for nursing facility and the LIDDA. Enter N/A for those data elements that do not apply to the LIDDA.

Section 3, People Important to the Individual — List the people who are close to the individual and who know and care about him/her. This will help members of the SPT in determining who to speak with in certain situations. It will also help to ensure that the individual does not lose contact with important people in his/her life. (Additional rows may be added, if necessary.) Enter the names, relationships, telephone numbers, addresses, email addresses and the reason the individual/LAR has identified this person as being important to list on this form. Examples of “Important Because” are:

• He visits the individual often.
• She is a friend the individual calls every weekend.
• He stays with the individual until his mom comes home from work.
• She is the individual’s favorite teacher and helps tutor on weekends.
• He takes the individual to Special Olympics practices and out to eat.
• The individual visits with him during the holidays.

Section 4, Profile Information — Enter the individual’s name.

These are my strengths and what people like and admire about me — Using the discovery process, summarize the individual’s strengths. Enter a descriptive narrative about what you have learned through the discovery process about what strengths and admirable qualities the individual has.

These are my preferences and what is important to me — Enter what you have learned through the discovery process about what is important to the individual. “Important to me” reflects what is important from the individual’s perspective and is based on the individual’s words and behavior. When words or behavior are in conflict, listen to the behavior. The information might include important relationships, how the individual prefers to interact, things the individual likes to do or not do, preferred routines, relevant background information that may affect how services should be delivered and what the individual wants to do in the future. Remember the individual’s response is limited to the knowledge and experiences he/she has experienced to date. Additional efforts should be explored to increase his/her awareness of additional possibilities and experiences to increase his/her options of choice. This section could also include personal preferences (e.g., sleep with the light on, blackout curtains needed on windows, baths in the evenings only).

This is what others need to know and do to support me in the following areas — Include what you have learned through the discovery process of what is important for the individual, as identified by the individual and those who know him/her best. “Support me” reflects information that is important for members of the SPT to know and understand about the individual. Include information in all the areas listed and be specific about health needs, supervision requirements, specific behavioral needs and special instructions for those who support the individual.

• Communication — Enter important information you have learned through the discovery process about how the individual communicates and how to best communicate with him/her. List the individual’s communication-related needs. For instance, what is the individual’s primary or preferred method of communication? How does the individual communicate or express a need (gestures, sounds, facial expressions, adaptive equipment, etc.)? What is the best way to determine if the individual is expressing satisfaction, happiness, comfort or agreement, as opposed to dissatisfaction, unhappiness, discomfort and disagreement? Among those who know the individual best, who seems better able to interpret what the individual is trying to communicate? What is the best way for others to learn how to communicate effectively with the individual?
• Nursing Care — Describe the individual’s nursing-related needs, such as assistance taking medication, suctioning, wound care and oxygen. Describe how staff should attend to the individual’s nursing needs.
• Clinical — Describe the individual’s behavioral and mental health-related needs. What kinds of behavioral supports does the individual need? Does the individual need counseling services or psychiatric services for medication management?
• Medical and Dental — Describe all medical and dental concerns, diagnoses and routine procedures (e.g., medication management, blood work, history of constipation, dental cleaning, x-ray or sedation needs).
• Adaptive Aids and Medical Supplies — Describe the adaptive aids (e.g., wheelchair, walker, shower chair) and medical supplies (e.g., briefs, test strips) needed by the individual and how are they funded (e.g., Medicaid, personal funds) or obtained (e.g., leased, purchased).
• Nutritional Management — Describe the individual’s nutritional-related needs (e.g., thickened, pureed, textured, use of supplements, food allergies or restrictions, choking risk).
• Supervision Needs — Describe the individual’s supervision needs. Consider if there are any personal issues that might present risk for harm in the individual’s living arrangement (e.g., daily rituals, threats of suicide or physical harm to self or others, inability to handle a personal crisis). Describe the supports needed to address any risks, such as line of sight, one-to-one, limited proximity or door alarm. Is the individual currently receiving these supports?
• Other things people need to know about me — Enter pertinent information not otherwise captured in the other areas (e.g., triggers, preferences).
• Risk factors not otherwise addressed above — Describe any risk factors not otherwise covered in the other areas (e.g., risk of financial exploitation, factors surrounding abuse, neglect and exploitation).

Historical Information — Enter historical or background information that continues to significantly affect the individual or his/her services.