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Effective Date: 
7/2019

Documents

 

Instructions

Updated: 7/2019

 

Purpose

To document the person’s preferences/needs and identify specialized services to support those preferences/needs based on specific life domains. It is used to document the person’s preferred living option and the legally authorized representative’s (LAR’s) preferred living situation for the person, if applicable. It is to be shared with the Service Planning Team (SPT) to help guide the decisions identifying which specialized services are best to support the person in accomplishing his or her outcomes and is completed by the habilitation coordinator (HC) and maintained in the local intellectual and developmental disability authority’s (LIDDA’s) records.

During the development of the habilitative assessment, the HC gathers information from the person and LAR about the person’s likes, dislikes, needs, and desires and discusses and identifies specialize services in each area.

 

Procedure

When to Prepare

Form 1064 is developed and maintained by the assigned HC:

  • within 75 days after the initial Interdisciplinary Team (IDT)/SPT meeting;
  • no earlier than 60 days before the annual IDT/SPT for persons with and without an assigned HC; and
  • updated throughout the habilitation plan year as new information is discovered during any face-to-face visits, quarterly and  SPT meetings.

 

Form Retention

Form 1064 must be kept in the individual’s record until notified otherwise by HHSC Legal Services.

 

Detailed Instructions

I. Person Information and Purpose

Name of Person — Enter the person’s first and last name.

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

Medicaid Number — Enter the person’s assigned Medicaid number, if known.

Date form was completed — Enter the date the HC gathered the information to complete the form. This date will be revised each time the HC makes changes to the form based on additional information discovered throughout the habilitation plan year.

 

II. Resources for Support Planning and Service Provision

1. Participants/Service Planning Team(SPT) — This entire section is to document information gathered about whom the person/LAR wishes to be directly involve in support planning. Note: This section can be anyone, including staff.

Name — Enter the names of the people identified by the person/LAR who will be involved in the person’s service planning.

Relationship to Person — Enter the type of relationship the names identified have with the person. This can be any type of relationship.

Contact Address and Phone — Enter the contact address and phone number for each name.

Preferred Method for SPT Member to Participate in the Person’s Planning (personal availability, phone availability, etc.) — Enter the preferred method the person/LAR wants the names listed to participate in the person’s service planning meetings.

2. SPT Involvement — This section is to document information gathered about what the person’s preference for the way other team members not listed above participate in the SPT meeting. This can include face-to-face, by phone, or by other means of remote methods that include both audio and visual methods.

3. Habilitation Coordinator Involvement — This section documents the person’s preferences regarding methods used by the HC to gather information from others about the person. For instance, the person may express his/her desire to be present when the HC is interacting with others, or the person may not wish to be present at all. Another example could be that the person wishes for the HC to share all information with the person after they have met with others.

4. Places — This section is to document information gathered about the location in which the person is most comfortable when participating in planning activities such as the Habilitation Service Plan (HSP). What would the person’s/LAR’s preference be as an alternate or backup location should the first preference not be available.

5. Times — This section is to document information gathered about the person’s/LAR’s preference regarding the time of day that he or she wants to participate in the planning activities. This is to ensure his or her personal activities are not imposed upon and causing a disruption in those activities. A person is less likely to want to participate in a meeting held at the same time as an activity he or she enjoys and looks forward to doing. Be sure to scheduling meetings at times all SPT members, especially family members, can attend.

 

III. Nutritional and Medical Treatment

Domain 1 and Domain 2 — This section is to document information gathered about the person’s ability to self-monitor nutritional needs and self-monitor coordination of medical treatments. This section provides the SPT with additional guidance regarding possible benefits the identified specialized service can contribute toward the person’s habilitation and accomplishment of personal outcomes.

1. What is the person’s/LAR’s preferences regarding the management of his or her personal health? — Describe what the person’s/LAR’s preferences are for the way his or her personal health issues are managed.

  • The person may be able to manage their health issues and does not want any additional assistance.
  • The person may be happy with the current support they are receiving to manage their health issues and is not seeking a change now.
  • The person may want more control over their health issues and is requesting assistance to do so.

2. What issues impact the person’s ability to self-monitor and coordinate his or her medical treatments (e.g., does not understand most medical issues and required interventions, is afraid of professionals, is combative during medical procedures, or is uncooperative with taking medications as prescribed)? — Describe the person’s ability to self-monitor and coordinate his or her medical treatments.

  • The person may be able to monitor and coordinate their medical treatments and does not want any additional assistance.
  • The person may be happy with the current support they are receiving to monitor and coordinate their medical treatments and is not seeking a change now.
  • The person may not understand most medical issues and required interventions, is afraid of professionals, is combative during medical procedures, is uncooperative with taking medications as prescribed, or just wants more control over monitoring and coordinating their medical treatments and is requesting or needing assistance to do so.

3. How does the person indicate physical distress or illness (e.g., verbally, gestures, will not indicate physical destress or illness)? — Describe how the person indicates physical distress or illness.

  • The person may be able to verbally or physically indicate when they feel ill or in distress and does not want any additional assistance.
  • The person may have others who can identify when he or she is ill or in physical distress and is happy with the process. He or she may not be seeking a change now.
  • The person may not be able to indicate physical distress or illness or just want more control over how others are determining these symptoms and is requesting assistance to do so.

4. Is the person/LAR satisfied with his or her current management of health and nutritional needs? — Describe the person’s/LAR’s preference regarding the person’s/LAR’s satisfaction with the management of the person’s health and nutritional needs. If the person/LAR displays dissatisfaction with the management of the person’s health or nutritional needs, the HC will discuss the specialized services and supports to determine which one best supports the person’s/LAR’s desire to improve the current situation.

5. What change does the person/LAR wish to make to any of the current services for nutritional or medical treatments? — Describe changes the person/LAR wishes to make to the current services for nutritional and medical treatments the person is currently receiving.

6. If the person takes medication, what level of assistance is required? — Describe the level of assistance the person may require if taking medication. If the person/LAR takes medications and requires assistance, the amount and frequency must be determined, and the HC will discuss the specialized services and supports to determine which one best supports the person’s/LAR’s desire as they relate to assistance with medications.

7. If the person requires other interventions (e.g., positioning, nutritional management.), what assistance is required? — Describe the level of assistance the person may require with other interventions. If the person/LAR requires assistance, the amount and frequency must be determined, and the HC will discuss the specialized services and supports to determine which one best supports the person’s/LAR’s desire as they relate to assistance with other interventions.

8. Does the person require medically necessary supplies? What and how are they obtained? — Describe if the person requires medically necessary supplies and if so, document what supplies are utilized and how they are acquired. Describe if the person/LAR is satisfied with the current process or they would like supports to change the current process. The HC will discuss the specialized services and supports to determine which one best supports the person’s/LAR’s desire to improve the current situation.

9. Is the person interested in acquiring additional knowledge, skills, and abilities that facilitate increased choice and control in meeting physical/emotional/behavioral health needs? — Describe the person’s/LAR’s preference regarding the person’s interest in acquiring additional knowledge, skills, and abilities that facilitate increased choice and control in meeting physical/emotional/behavioral health needs. If the person/LAR displays an interest, the HC will discuss the specialized services and supports to determine which one best supports the person’s/LAR’s desire to improve the person’s abilities.

 

Specialized Services Section for Domain 1 and Domain 2

This section contains the Preadmission Screening and Resident Review (PASRR) specialized services that could support the person’s desires and needs identified by the information collected from asking the specific questions listed in Section III, Nutritional and Medical Treatment.

The HC will check the appropriate box next to the selected specialized services identified by the HC and the person/LAR during the development of this form.

 

IV. Social Development and Relationships

Domain 3 — This section is to document information gathered about the person’s social development to include social/recreational activities or relationships with others.

1. Does the person have close relationships in his or her life (who is the person(s), what is the nature of the relationship(s), how often does the person’s wish to see the person(s), etc.). How do you know? — Describe the person’s relationships.

  • The person may be content with their current relationships including frequency of contact and does not want any additional relationships.
  • The person may be happy with their current relationships but may want to increase the contact with the person or change the way contact is being made.
  • The person may want to develop relationships or additional relationships and is requesting assistance to do so.

The HC will discuss the specialized services and supports to determine which one best supports the person’s desire.

2. Who are the person’s friends? How often does the person wish to see his or her friends? How do you know? — Describe the person’s friends and frequency and type of contact they have.

  • The person may be content with their current friends and frequency of contact with them and does not want any additional assistance.
  • The person may be happy with the current number of friends but is requesting additional assistance to increase or decrease the frequency of contact.
  • The person may not have any friends and has a desire to build skills to develop a relationship and increase their number of friends.

The HC will discuss the specialized services and supports to determine which one best supports the person’s desire.

3. Is the person satisfied with the number and types of relationships in his/her life? How do you know? — Describe the person’s satisfaction with the number and types of relationships in their life.

4. Is the person satisfied with the type and frequency of contact with friends and family? How do you know? — Describe the person’s satisfaction with the type and frequency of contact with friends and family. If the person/LAR displays dissatisfaction with the type and frequency of contact with friends and family, the HC will discuss the specialized services and supports to determine which one best supports the person’s/LAR’s desire to improve the current situation.

5. In what new types of relationships is the person interested in exploring? — Describe the person’s/LAR’s interest in exploring new types of relationships. If the person displays an interest in exploring new types of relationships, the HC will discuss the specialized services and supports to determine which one best supports the person’s/LAR’s desire.

6. Is the person interested in acquiring additional knowledge, skills, or abilities to increase control and choice regarding relationships? Describe what the person is most interested in acquiring. — Describe the person’s interest in acquiring additional knowledge, skills, or abilities to increase control and choice regarding relationships. If the person/LAR displays an interest, the HC will discuss the specialized services and supports to determine which one best supports the person’s desire.

7. What type of social/recreational activities does the person participate in? — Describe the type of social and recreational activities the person participates in. Document all activities.

8. Is the person’s involvement in social/recreational activities meeting his or her needs and desires? — Describe the person’s preference regarding involvement in social/recreational activities and if these activities meet his or her needs and desires. If the person/LAR displays dissatisfaction in the current involvement in social or recreational activities, the HC will discuss the specialized services and supports to determine which one best supports the person’s/LAR’s desire to improve the current situation.

9. If no, what additional involvement would the person like to see change? — Describe the person’s/LAR’s preference regarding additional involvement in social or recreational activities. The HC will discuss the specialized services and supports to determine which one best supports the person’s/LAR’s desire to improve the current situation.

 

Specialized Services Section for Domain 3

This section contains the PASRR specialized services that could support the person’s desires and needs identified by the information collected from asking the specific questions listed in Section IV, Social Development and Relationships.

The HC will check the appropriate box next to the selected specialized services identified by the HC and the person/LAR during the development of this form.

 

V. Independent Decisions and Judgments

Domain 5 — This section is to document information gathered about the person’s ability to express interests and emotions, make personal judgments about their life, or make independent decisions.

1. What rights does the person exercise (e.g., freedom of movement, accessibility, opening mail, privacy, phone calls, personal possessions, voting, exercising chosen religion)? — Describe the person’s knowledge and ability to exercise their rights.

  • The person may be aware of and able to exercise their rights and does not want any additional assistance.
  • The person may be aware of some of their rights but is unable to exercise those rights.
  • The person may want more education on their rights.
  • The person may want assistance with rights.

The HC will discuss the specialized services and supports to determine which one best supports the person’s desire.

2. What rights are not exercised? What are the reasons? — This section is to document information gathered about what rights the person is not exercising and the reasons why.

Is the person choosing not to exercise those rights? How do you know? — Describe in detail.

If the right is being limited by someone else, describe the reason for the limitation(s). — Describe in detail.

Has there been discussion concerning the limitation(s) to find what is necessary to protect the person? — Describe in detail.

If there are limitations, describe the plans that are in place/necessary to restore the person’s rights. — Describe in detail.

Does the person need help to exercise his or her rights (guardian, power of attorney, advocate, etc.)? If applicable, who is responsible for helping? — Describe in detail.

3. Describe the person’s ability and desire to advocate for himself or herself. — Describe the person’s ability and desire to advocate for himself or herself.

  • The person may be able to verbally or physically advocate for himself or herself and does not want any additional assistance.
  • The person may already have others who advocate for him or her and may not be seeking a change now.
  • The person may not be able to advocate for himself or herself and just wants more ability to advocate for himself or herself and is requesting assistance to do so.

The HC will discuss the specialized services and supports to determine which one best supports the person’s desire.

4. Would the person like to learn more about self-advocacy? What supports are in place/necessary to help the person learn? — Describe the person’s desire to learn more about self-advocacy and what supports are necessary to assist the person to learn. If the person/LAR displays a desire to learn more about self-advocacy, the HC will discuss the specialized services and supports to determine which one best supports the person’s/LAR’s desire.

5. Does the person feel he or she has been abused, neglected, or exploited? What is occurring to address this? — Describe the person’s feeling of been abused, neglected or exploited. If the person/LAR indicates a feeling of being abused, neglected or exploited, the HC files a report with the Texas Department of Family and Protective Services (DFPS) at 1-800-252-5400. The HC will also discuss the specialized services and supports to determine which one best supports the person’s/LAR’s desire to improve the current situation.

6. If the person is still experiencing personal distress from a previous occurrence of abuse, neglect or exploitation, describe the supports the person is receiving (or needs/wants) to cope with the distress. — Describe the person’s/LAR’s preference regarding the person’s need for supports to cope with the distress from a previous occurrence of abuse, neglect or exploitation. If the person/LAR is experiencing distress from a previous occurrence of abuse, neglect or exploitation, the HC will discuss the specialized services and supports to determine which one best supports the person’s/LAR’s desire.

7. Is there any information regarding the person’s vulnerability to abuse, neglect or exploitation that should be shared with staff supporting the person? — Describe the person’s vulnerability to abuse, neglect or exploitation. If the person/LAR provides evidence regarding their vulnerability to abuse, neglect or exploitation, this information needs to be discussed with the SPT. The HC will discuss the specialized services and supports to determine which one best protects the person.

8. Is the person interested in obtaining new knowledge, skills, or abilities related to exercising rights or preventing abuse, neglect or exploitation? Fully describe what the person is most interested in acquiring. — Describe the person’s/LAR’s preference regarding obtaining new knowledge, skills, or abilities related to exercising rights or preventing abuse, neglect or exploitation. If the person/LAR displays an interest, the HC will discuss the specialized services and supports to determine which one best supports the person’s/LAR’s desire.

 

Specialized Services Section for Domain 5

This section contains the PASRR specialized services that could support the person’s desires and needs identified by the information collected from asking the specific questions listed in Section V, Independent Decisions and Judgments.

The HC will check the appropriate box next to the selected specialized services identified by the HC and the person/LAR during the development of this form.

 

VI. Academic and Vocational Development

Domain 4 and Domain 7 — This section is to document information gathered about the person’s preference for academic/educational development, including functional learning skills and the person’s preference for vocational developmental.

1. What are the person’s preferences regarding work, education and volunteer opportunities in the community? —- Describe the person’s preference regarding work, education and volunteer opportunities in the community, and if the person expresses an interest, the HC will discuss the specialized services and supports to determine which one best supports the person’s desire.

2. For a person who is 21 years of age or older, are educational/school services being provided and where? What prioritized supports are being provided by the school? (Note: The person’s parent, teacher and person education plan are excellent resources.) Are the school’s services reflecting the person’s/LAR’s priorities? — Describe the person 21 years of age or older and their educational/school services.

  • Where does the person receive educational/school services?
  • What prioritized supports are being provided by the school?
  • Are the school’s services reflecting the person’s/LAR’s priorities?

3. For a person not school age, what does the person do during the day (work, adult learning, etc.)? — Describe the person who is not school age and what the person does during the day. If the person/LAR displays dissatisfaction with their activity, the HC will discuss the specialized services and supports to determine which one best supports the person’s/LAR’s desire.

4. What is the person’s understanding of available options in the community to address his/her preferences for work or education? — Describe the person’s/LAR’s knowledge regarding options in the community to address preferences for work or education. If the person/LAR displays interest in understanding more about the availability of options in the community, the HC will discuss the specialized services and supports to determine which one best supports the person’s/LAR’s desire.

5. If the person expresses a preference, does the person currently possess the necessary skills, knowledge and abilities to address preferences? If not, what does the person require? — Describe the person’s/LAR’s preference regarding options in the community for work or education and current skill, knowledge and abilities to address that preference. If the person/LAR displays interest in increasing skills, knowledge and/or abilities for work or education, the HC will discuss the specialized services and supports to determine which one best supports the person’s/LAR’s desire.

6. If the person is not interested in volunteering, working or going to school, describe what the person would like to do? — Describe the person’s preference for daily activities if they are not interested in volunteering, working or going to school. The HC will discuss the specialized services and supports to determine which one best supports the person’s desire.

 

Specialized Services Section for Domain 4

This section contains the PASRR specialized services that could support the person’s desires and needs identified by the information collected from asking the specific questions listed in Section VI, Academic and Vocational Development.

The HC will check the appropriate box next to the selected specialized services identified by the HC and the person/LAR during the development of this form.

 

Specialized Services Section for Domain 7

This section contains the PASRR specialized services that could support the person’s desires and needs identified by the information collected from asking the specific questions listed in Section VI, Academic and Vocational Development.

The HC will check the appropriate box next to the selected specialized services identified by the HC and the person/LAR during the development of this form.

 

VII. Person’s Preferences for Specialized Supports with Daily Living

Domain 6, Domain 9, Domain 10 and Domain 11 — This section is to document information gathered about the person’s preference for academic/educational development, including functional learning skills and his or her preference for vocational developmental, including current vocational skills.

1. What supports are necessary to assist the person in meeting physical needs (oral hygiene, physical hygiene, using the bathroom, eating assistance, positioning, shopping, cooking, etc.)? — Describe the supports necessary to assist the person in meeting their physical needs.

  • The person may be able to manage their physical needs and does not want any additional assistance.
  • The person may be happy with the current support they are receiving to manage their physical needs and is not seeking a change now.
  • The person may want more control over their physical needs and is requesting assistance to do so.

The HC will discuss the specialized services and supports to determine which one best supports the person’s desire.

2. Supports are necessary to assist the person in maintaining possessions in the living environment (household tasks such as house cleaning, laundry, maintaining adaptive equipment, etc.)? — Describe the supports necessary to assist the person in maintaining possessions in their living environment.

  • The person may be able to maintain their current living environment and does not want any additional assistance.
  • The person may be happy with the current support they receive to maintain their medical living environment and is not seeking a change now.
  • The person may not be able to maintain their current living environment or just wants more control over it and is requesting or needing assistance to do so.

The HC will discuss the specialized services and supports to determine which one best supports the person’s desire.

3. What are the person’s preferences for his/her daily routine (the activities he/she does and the times in which he/she does those activities, the food he/she eats, etc.)? — Describe the person’s preferences for their daily routine.

  • The person may be able to verbally or physically manage their daily routine and does not want any additional assistance.
  • The person may have others who assist their daily routine and is happy with the process. He or she may not be seeking a change now.
  • The person may not be able to manage their daily routine or just wants more control over decisions being made and is requesting assistance to support him or her.

The HC will discuss the specialized services and supports to determine which one best supports the person’s desire.

4. Is the person interested in acquiring additional knowledge, skills, and abilities to increase control and choice regarding daily living? In which area is he/she most interested? — Describe the person’s interest in acquiring additional knowledge, skills, and abilities to increase control and choice regarding daily living. If the person/LAR displays interest, the HC will discuss the specialized services and supports to determine which one best supports the person’s desire.

5. What financial resources are accessible to the person (review assets, sources of income as well as insurance coverage)? — Describe what financial resources are accessible to the person.

6. Does the person have adequate financial resources to meet his/her priority needs and preferences (food, shelter, medical and prioritized leisure activities)? — Describe the person’s financial resources and if they adequately meet the person’s priority needs and preferences.

7. What support does the person receive in managing his/her financial resources (e.g., parent/other serves as representative payee, a guardian appointed to manage financial affairs)? — Describe supports the person receives in managing financial resources.

8. Describe any additional supports necessary to assist the person in addressing financial security/obligations. — Describe the person’s/LAR’s preference for any additional supports to assist in addressing financial security/obligations. If the person/LAR displays interest in obtaining additional supports to assist with financial security or obligations, the HC will discuss the specialized services and supports to determine which one best supports the person’s/LAR’s desire.

9. Is the person interested in acquiring additional knowledge, skills or abilities to increase control and choice regarding financial security? In which areas is he/she most interested? — Describe the person’s/LAR’s preference regarding acquiring additional knowledge, skills or abilities to increase control and choice regarding financial security. If the person/LAR displays interest, the HC will discuss the specialized services and supports to determine which one best supports the person’s/LAR’s desire.

 

Specialized Services Section for Domain 6

This section contains the PASRR specialized services that could support the person’s desires and needs identified by the information collected from asking the specific questions listed in Section VII, Person’s Preferences for Specialized Supports with Daily Living.

The HC will check the appropriate box next to the selected specialized services identified by the HC and the person/LAR during the development of this form.

 

Specialized Services Section for Domain 9

This section contains the PASRR specialized services that could support the person’s desires and needs identified by the information collected from asking the specific questions listed in Section VII, Person’s Preferences for Specialized Supports with Daily Living.

The HC will check the appropriate box next to the selected specialized services identified by the HC and the person/LAR during the development of this form.

 

Specialized Services Section for Domain 10

This section contains the PASRR specialized services that could support the person’s desires and needs identified by the information collected from asking the specific questions listed in Section VII, Person’s Preferences for Specialized Supports with Daily Living.

The HC will check the appropriate box next to the selected specialized services identified by the HC and the person/LAR during the development of this form.

 

Specialized Services Section for Domain 11

This section contains the PASRR specialized services that could support the person’s desires and needs identified by the information collected from asking the specific questions listed in Section VII, Person’s Preferences for Specialized Supports with Daily Living.

The HC will check the appropriate box next to the selected specialized services identified by the HC and the person/LAR during the development of this form.

 

VIII. Social Inclusion

Domain 8 — This section is to document information gathered about the person’s preference for academic/educational development, including functional learning skills and their preference for social developmental, including their current social skills.

1. Is the person aware of available community-based activities? If not, describe how the person could become more aware of options. — Describe the person’s knowledge of available community activities. If the person is unaware of any available community activities, the HC will discuss the specialized services and supports to determine which one best supports the person to explore community activities the person may be interested in.

2. In what community-based activities does the person actively participate (going to movies, church, festivals, or participating in clubs or other community-based organizations)? — Describe the person’s active participation in community activities. List all activities the person is currently participating in.

3. Is the person satisfied with his or her participation in community-based activities? What other activities would the person like to do? — Describe the person’s level of satisfaction with his or her participation in community activities. Document any additional activities the person would like to participate in. The HC will discuss the specialized services and supports to determine which one best supports the person.

4. What activities does the person specifically dislike? — Describe the person’s/LAR’s preference regarding the person’s dislike of current activities. If the person/LAR displays dissatisfaction with any current activities, the HC will discuss the specialized services and supports to determine which one best supports the person’s/LAR’s desire for preferred activities.

5. Is transportation a barrier to the person’s participation in community activities? What resources are available to assist the person with transportation? — Describe the person’s/LAR’s availability of transportation. If no transportation is available, does this create a barrier? If the person/LAR indicates a need for transportation but it is currently unavailable, the HC will discuss the specialized services and supports to determine which one best supports the person’s/LAR’s desire to improve the current situation.

6. What supports would the person require to participate in community-based activities to his/her satisfaction? — Describe the person’s/LAR’s preference regarding satisfaction with the management of community activities. If the person/LAR displays dissatisfaction with the management of community activities, the HC will discuss the specialized services and supports to determine which one best supports the person’s/LAR’s desire to improve the current situation.

7. Is the person interested in obtaining new knowledge, skills, or abilities related to social inclusion? Describe what the person is most interested in acquiring. — Describe the person’s interest in obtaining new knowledge, skills or abilities related to social inclusion. If the person/LAR displays a desire to obtain new knowledge or to increase skill or abilities related to social inclusion, the HC will discuss the specialized services and supports to determine which one best supports the person.

 

Specialized Services Section for Domain 8

This section contains the PASRR specialized services that could support the person’s desires and needs identified by the information collected from asking the specific questions listed in Section VIII, Social Inclusion.

The HC will check the appropriate box next to the selected specialized services identified by the HC and the person/LAR during the development of this form.

 

IX. Speech and Language (Communication)

Domain 12 — This section is to document information gathered about the person’s preference for speech and language (communication) development, such as expressive language (verbal and nonverbal) and receptive language (verbal and nonverbal).

1. How does the person communicate (words, gestures, sounds, facial expressions, adaptive equipment, etc.)? What is the best way to determine if the person is expressing satisfaction/happiness/comfort/agreement as opposed to dissatisfaction/unhappiness, discomfort/disagreement? — Describe how the person communicates with others. Document if the person can communicate expression of satisfaction or dissatisfaction, happiness or unhappiness, comfort or discomfort, agreement or disagreement verbally or through gestures, sounds, facial expressions, adaptive equipment, etc. Is the person’s ability to communicate meeting their needs? If not, does the person wish to improve their communication skills? The HC will discuss the specialized services and supports to determine which one best supports the person.

2. Among those who know the person best, who seems able to interpret what the person is trying to communicate? — Describe the people who know the person best and who know how to interpret what the person is trying to communicate. If no supports are currently in place, specialized supports maybe necessary to support the person in making their needs known.

3. What is the best way for others to learn how to communicate effectively with the person? — Describe the best way for others to learn how to communicate effectively with the person. This information can be obtained from the person, LAR or others who know the person best.

4. Does the person want to increase his or her ability to communicate effectively to others? — Describe how the person communicates with others. Document the person’s/LAR’s preference regarding the person’s ability to communicate effectively. If the person/LAR displays a desire to increase their ability to communicate effectively, the HC will discuss the specialized services and supports to determine which one best supports the person to improve their current abilities.

5. If so, how does he or she want to accomplish this? — Describe how to accomplish the person’s desire to increase their ability to communicate effectively.

 

Specialized Services Section for Domain 12

This section contains the PASRR specialized services that could support the person’s desires and needs identified by the information collected from asking the specific questions in Section IX, Speech and Language (Communication).

The HC will check the appropriate box next to the selected specialized services identified by the HC and the person/LAR during the development of this form.

 

Summary of Specialized Services

Specialized services are defined as support services in addition to nursing facility services that are identified through the habilitative assessment, discussed and agreed to during the IDT/SPT meetings, and documented on the PASRR Comprehensive Service Plan (PCSP). As indicated above, they are provided to persons who have Medicaid eligibility at the time of the meeting and are 21 years of age or older.

This section will auto populate the specialized services identified to support the person based on the selections made in Sections III – IX on the previous pages. The specialized services will be summarized below each title of Sections III – IX.

All services indicated on Form 1064 must be discussed at the SPT meetings.

These nursing facility and intellectual and developmental disability specialized services will auto populate from the selections made in the previous sections below the title of the section where the specialized service was checked.

  • Customized Manual Wheelchair (CMWC)
  • Specialized Occupational Therapy (OT) Assessment
  • Specialized Physical Therapy (PT) Assessment
  • Specialized Speech Therapy (ST) Assessment
  • Specialized Occupational Therapy (OT)
  • Specialized Physical Therapy (PT)
  • Specialized Speech Therapy (ST)
  • Service Coordinator (SC)
  • Habilitation Coordinator (HC)
  • Behavioral Support (BS)
  • Day Habilitation (DH)
  • Supported Employment (SE)
  • Durable Medical Equipment (DME)
  • Independent Living Skills Training (ILST)

Durable Medical Equipment (DME): (These items must be manually selected based on the decision made by the team when DME has been selected.)

  • Gait Trainer
  • Orthotic Device
  • Positioning Wedge
  • Prosthetic Device
  • Special Needs Car Seat or Travel Restraint
  • Specialized or Treated Pressure-Reducing Support Surface Mattress
  • Standing Board/Frame