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Effective Date: 
5/2015

Documents

Instructions

Updated: 5/2015

Purpose

This form is used to document the service backup plans developed by Home and Community-based Services (HCS) and Texas Home Living (TxHmL) program providers.

A program provider must develop a written backup plan for a waiver or Community First Choice (CFC) service identified on the Person Directed Plan (PDP) as a critical service that is necessary to meet the needs to ensure the individual’s health and safety. A backup plan must:

  • contain the name of the critical service;
  • specify the amount of time an interruption may occur before the individual’s health or safety begin to be effected; and
  • describe the actions the program provider will take to ensure the individual's health and safety in the event of an interruption to the critical service.

Procedure

When to Prepare

The program provider completes this form for each service requiring a backup plan:

  • annually; and
  • any time a revision to the service backup plan is needed, based on problems with implementation of the plan or changes in the resources required to carry out the plan.

Detailed Instructions

Name of Individual — Enter the name of the individual receiving services.

Client Assisgnment and Registration (CARE) CARE ID. — Enter the CARE identification number (ID) of the individual receiving services.

Effective Date of Service Backup Plan — Enter the date the service backup plan will be effective. The effective date of the enrollment/renewal backup plan should correspond with the effective date of the enrollment/renewal individual plan of care (IPC). The effective date of a revision to the backup plan is determined by the program provider.

Name of Program Provider — Enter the name of the program provider.

Component Code — Enter the component code for the program provider.

Contract Number — Enter the contract number for the program provider.

Service Type — Check the appropriate program box: Home and Community-based Services (HCS), Texas Home Living (TxHmL) or Community First Choice (CFC).

Type of Service Backup Plan — Check the type of service backup plan as applicable:  Enrollment/Renewal Backup Plan or Revision to Backup Plan.

Program Service — Enter the service that the backup plan is for.

Backup Plan Strategies — Enter each strategy that will be implemented to ensure the delivery of the service when the individual's normal service delivery is interrupted. The plan may include the use of paid service providers; unpaid service providers, such as family members, friends or non-program services; or respite, if included in the authorized IPC.

Period of Time Before Health and Safety Begins to Be Effected — Specify the allowable amount of time an interruption may occur before the individual’s health and safety begins to be effected.

Specific Action(s) to be Taken in Absence of Service Delivery — Enter the steps that will be followed in order to implement each service backup plan strategy.

Resource Person — Enter the name, telephone number and any other contact information of the resource person to be contacted when a backup plan strategy must be implemented. Indicate if the person will be a service provider (paid) or a natural support (unpaid).

Acknowledgement — Check the appropriate boxes to acknowledge who received copies of the backup plan: The individual receiving services, legally authorized representative (LAR), if applicable, and the resource person(s).

  • Check the box to acknowledge that all service providers indicated in the plan have received a copy of pertinent information, is/are able to meet the needs of the individual; is/are able to protect the individual’s health and safety; meet(s) provider qualifications; are not listed on the Employee Misconduct Registry or the Nurses Aid Registry; and do not have any bars to employment as indicated by current criminal history background check.
  • Check the box to acknowledge that all natural supports indicated in this plan have received a copy of pertinent information and is/are able to meet the needs of the individual, and is/are able to protect the individual’s health and safety.

Program Provider Representative Signature and Date — The program provider representative signs and dates the form.

Individual/LAR Signature and Date — The individual or LAR signs and dates the form.