Downloading a Form to Your Computer
Fillable forms cannot be viewed on mobile or tablet devices. Follow the steps below to download and view the form on a desktop PC or Mac.
- Right Click for PC or Ctrl + Click for Mac on the PDF link and click “Save link as” from the menu.
- Select the folder you want to save the file in and then click "Save."
- Navigate to the folder you saved the file in and Right Click for PC or Ctrl + Click for Mac, then select "Open With" from the menu and select Adobe Acrobat Reader DC.
Note: Open the PDF file from your desktop or Adobe Acrobat Reader DC. Do not click on the downloaded file at the bottom of the browser since it will not open the PDF in Adobe Acrobat Reader DC. It will try to open the file in the browser that results in the same browser error message.
If still having trouble viewing or downloading a form, click here.
When to Prepare
The Local Intellectual and Developmental Disability Authority (LIDDA) must conduct the permanency plan within 20 days starting the first business day after:
- notification of the individual's admittance by the facility; or
- the individual's name appears on Client Assignment and Registration (CARE) System Xporter Report HC021395 (Permanency Plan Reviews Needed) and Report HC021395 (PPRS Status By Consumer).
Subsequent permanency plan reviews must be completed within six months of the previous review.
Transmittal and Responsibilities
Initial permanency plans are to be completed and entered into CARE within 10 days after meeting with the individual and family or legally authorized representative (LAR). Permanency planning review information is to be entered into CARE within 10 days after the review date.
Responsibilities of the permanency planner include (but are not limited to):
- Waiver interest lists. Ensure the child or young adult’s name is on appropriate waiver interest lists.
- Documents to families/LARs. Provide the LAR with a series of informational materials.
- Distribution of copies. Provide copies of the permanency plan to the individual and family or LAR and the facility.
- Submit plans for children under age 10 to LocalAuthoritiesCAO@hhsc.state.tx.us for review and approval.
A. Type of Review (choose one) – Select initial or six month.
B. Identifying Information
Individual's Name – Enter the individual’s first, middle and last name.
Medicaid No. (Client ID) – Enter the individual’s Medicaid number.
Individual’s Social Security No. – Enter the individual’s Social Security number.
Date of Birth – Enter the individual’s date of birth.
Individual’s Age – Enter the individual’s age.
Facility Admission Date – Enter the date the individual was admitted to the current facility (i.e., intermediate care facility for individuals with an intellectual disability or related conditions (ICF/IID), state supported living center (SSLC), nursing facility, or Home and Community-based Services (HCS) supervised living or residential support).
Local Intellectual and Developmental Disability Authority (LIDDA) Comp Code (Component) – Enter the component code for the LIDDA.
Local Case No. – Enter the individual’s unique local case number assigned by the LIDDA.
Review Date – Enter the date of the permanency planning meeting.
Facility Name – Enter the facility name.
Facility Physical Address – Enter the facility street address, city, state and ZIP code.
Name of Facility Contact – Enter the facility contact’s name.
Facility Contact Area Code and Phone No. – Enter the facility contact’s area code and phone number.
Family/Legally Authorized Representative (LAR) Name – Enter the name of a family member or LAR.
Family/LAR Area Code and Phone No. – Enter the family member’s or LAR’s area code and phone number.
Family/LAR Mailing Address and Physical Address (if different) – Enter the address for the family member or LAR.
C. Permanency Planning Instrument (PPI) completed based on (mark all that apply) – Check all boxes indicating applicable sources of information used in developing the plan.
D. PPI Completed By – Enter the name, agency/affiliation, email address, and area code and phone number of the person completing the form.
E. Information about the Individual
- Describe the individual, including his or her personality characteristics, attributes, likes, dislikes, behavior and reaction to others. Do not use jargon, technical terms, or acronyms. –Provide a narrative documenting direct observations, paraphrases and quotes of informants, and facts from records. Include personal observations of the child or young adult and comments by him or her and others who provided information. Address each of the following:
- Description – Include age, sex, ethnicity, physical appearance, communication methods and mobility methods.
- Personality characteristics and attributes – Include descriptors of general disposition, temperament, activity level and alertness to environment.
- Likes and dislikes – Include what the individual identifies, other indicators and the source (e.g., informants’ reports), and what is evident from observations of the individual and his or her environment.
- Behavior and reactions to others – Include how the individual interacts with others generally, and under unusual circumstances, or particularly pleasant or stressful situations.
- Level of intellectual disability (choose one) – Check the appropriate box.
- Sensory impairments (mark all that apply) – Check vision or hearing, or both.
- Related condition diagnosed by a licensed physician, if applicable – Enter a diagnosis by a licensed physician based on documentation attesting that the condition occurred before age 22 and that it resulted in substantial functional limitations in at least three of six major life skill areas. (For more information, refer to the Approved Diagnostic Codes for Persons with Related Conditions.)
- Personal care needs – Identify the level of independence or assistance needed for activities of daily living, such as eating, dressing, grooming and toileting.
- Communication methods – Identify the means of communication used (e.g., verbal, facial expressions, gestures, signs, use of devices), fluency, and levels of comprehension by persons both familiar and unfamiliar with the individual.
- Mobility methods – Identify the means of mobility, level of assistance needed, use of devices, and circumstances where devices or assistance are needed.
- Ability to self-direct – Identify the level of ability of the individual to understand his or her own needs, express wishes, and execute or direct others to execute preferences and choices.
F. Physical Health
- Height – Enter the individual’s height.
- Weight – Enter the individual’s weight.
- Individual has a feeding tube – Select Yes or No.
- Individual is ventilator dependent – Select Yes or No.
G. Current Physical Health Conditions – Enter the diagnoses for all current health conditions and check Yes for any that require medication or professional evaluation, treatment, medical judgment or monitoring. In additional information, briefly describe the interventions in everyday language (e.g., type of treatment or medical equipment, positioning device, therapy). Do not use abbreviations without explanations.
H. Current Behavioral Health Conditions – Describe the mental health diagnoses or behavioral needs and select Yes for any that require medication or professional evaluation, treatment, behavioral support strategies, counseling, therapy or monitoring. In additional information, describe the nature of the needed interventions in everyday language (e.g., type of therapy, clinical treatment, or behavioral supports).
I. Medical History – Describe any other health information or history not covered elsewhere on the form that should be known and discussed before an individual moves out of the facility.
J. Individual’s Pre-placement History
- Describe the circumstances that first prompted the family to seek a living situation for the individual outside the family home. – Provide details about the family’s or LAR’s situation when placement out of the family or LAR home was sought. The circumstances should include those related to the individual’s disability (e.g., housing that could not accommodate a wheelchair, family discomfort with medical or mental health needs), as well as any unrelated to the disability but which may have affected caring for the child (e.g., poverty, rural location, number or age of other siblings, parent illness or disability).
- What help and support did the family receive in caring for the individual at home and who provided the help? What did and did not work? – Provide details about the services and supports that the family or LAR needed when the child or young adult was living with his or her family or LAR and of those, which were and were not received.
- Reasons that led to the individual’s initial facility placement (mark all that apply) – Check the boxes as appropriate to the child or young adult’s history.
- Beginning with the first out-of-home placement, list all placement settings in chronological order. Include any interim placements in foster care or the family home.
- Placement Setting – Enter the name of the facility, agency or provider, if applicable.
- Dates Placement Began and Ended – Indicate the actual dates of admission and discharge, if known. If unknown, indicate the closest approximation. Ensure the dates cover all time periods following the first out-of-home placement to present.
- Type of Facility Identify the setting as an ICF/IID, SSLC, nursing facility, HCS supported living arrangement, foster home, residential treatment setting, Child Protective Services facility, or other residential facility. Temporary hospitalizations (both medical and psychiatric) are not considered residences, but may be noted if the individual had an extended stay (e.g., 30 days) and lost residential placement during the hospitalization.
- Reason Placement Ended Provide a brief explanation for movement.
K. Individual’s Relationships with Family or LAR and Significant Others
- If the individual has been living outside the family home, what has been the family’s pattern of interaction with the individual (e.g., number of visits to the facility and back home, outings, letters and phone calls)? – Identify interactions, participation, and availability of the responsible decision-maker, as well as family members and significant others.
Pattern of interaction – Describe the extent of the family's or LAR's interaction with the individual in the current facility. Identify impediments to the family's or LAR's interaction including distance from the facility or transportation problems. Provide details about the level and frequency of interaction over the past six months.
- Contact frequency by family or LAR (e.g., new admission, daily, weekly, monthly, one to three times per quarter, or none);
- Number of visits by the family or LAR during the last six months;
- Number of visits by the individual to the family’s or LAR’s home during the last six months;
- The family’s or LAR's expectations for ongoing interaction; and
- Any discrepancies between the family’s or LAR’s report of visits and the facility’s report of visits.
Participation in permanency and service planning – Describe the extent of participation in service planning by the family or LAR within the past six months, including participation in meetings in person, by phone, via email or through another means of communication. Provide details about the frequency and types of participation in planning. Indicate:
- Family or LAR participation in the development of a service plan within the past six months;
- Family or LAR participation in permanency planning;
- Whether the family has been able to be located in the last six months;
- Whether the family or LAR responded in the last six months to requests for participation in permanency planning, annual meetings to discuss the plan of care, or when medical consents were needed;
- The family’s or LAR's expectations for participation; and
- The family’s or LAR's participation in any prior residential settings.
Available to the facility – Describe the extent to which the family or LAR has been responsive to the facility. Responsive means the family or LAR responded in a timely manner to the facility’s requests and provided input either verbally or in writing.
- If the family or LAR has not visited, provide details about any factors that may contribute to the lack of visits, such as distance, lack of reliable transportation or inability to afford transportation. Where distance is a factor, identify the miles from the family’s or LAR’s home to the facility and the time it would take to travel.
- If the family or LAR indicates unwillingness to participate in permanency planning, provide details.
- If the family or LAR is unavailable to the facility, indicate the steps taken to follow reporting requirements.
- Has the family participated in service planning with the facility within the past year and been available to the facility when they were needed for medical or other decisions? – Check Yes or No.
- Identify the people in the individual's life, including current and past caregivers, service providers or others, with whom he/she has (or has had) a significant relationship of affection and attachment. Describe the nature, duration and continuity of each relationship and potential for sustaining each relationship. – Identify relationships with family members, including immediate family as well as extended family. Identify relationships with significant others, including people who are currently part of the individual’s life as well as those who have been important in the past. Be alert to relationships with caregivers or service providers, both current and past, that have extended beyond employment responsibilities, especially those that provide an opportunity to become an alternate family. Identify how the individual knows the identified person (e.g., is a blood or step relative, through a previous placement or service), how long the relationship has existed, and whether the relationship has been continuous or has been interrupted by periods without contact.
L. Goals for the Future
- Choose one – Select the goal preferred by the family or LAR (Goal 1: Return home or move to own home with access to needed services, or Goal 2: Family based alternate with access to needed services). If neither goal is preferred, select the “best fit” permanency goal the system can work toward on behalf of the individual.
- Do the LAR and family support accomplishing Goal 1 or 2 within the next year? – Check Yes or No. Family or LAR support of the goal should be interpreted as support for achieving the goal within one year. If the family or LAR is not supportive of movement to one of the two family options within the next year, the answer should be No and their views explained in the summary section. The summary section should indicate if there is agreement with a family-based goal but with a longer time frame, or indicate the nature of their lack of agreement with the goal. In the case of a young adult without a guardian, his or her preference should guide the selection of a goal and his or her agreement with the goal of a family option should be used to answer the question about support of the goal. For a young adult with a guardian, the guardian’s preference should guide the selection of a goal and the extent of support of a family-based goal. In either case, both party’s preferences should be noted in the summary section.
- Do the LAR and family acknowledge an understanding that their legal rights are not lost or negatively affected by choosing a family-based alternative? – Check Yes or No.
- Summarize the discussion with LAR and family. Include the LAR’s and family’s level of support for the selected goal; all information on family-based options provided to the LAR and family; family-based options the LAR and family visited or expressed interest in visiting; and any issues, concerns, and questions identified by the LAR and family. – Provide details about discussions with the individual and family or LAR and describe your understanding of their perspectives. Be sure to address all prompts.
M. Supports Needed to Accomplish Goal 1 or 2 – Mark all that apply and explain each marked item. In identifying supports needed for the individual to live successfully in a family or on his own, do not limit the selection to only services for which there is known funding, existing programs or current availability. Support needs are to be identified whether or not they represent services provided under Medicaid or a waiver program. Include a brief description that is unique to the individual’s need for each identified support that indicates why it is needed. Refer to the CARE instructions for definitions of the support categories.
N. Waiver Program Options – Check all boxes that apply and enter the waiver program name, if applicable.
O. Action Plan for Next Six Months to Achieve Goal – Enter the task and responsible participant. Actions should reflect steps to achieve movement to a family living arrangement. Actions should take into account the level of agreement of the family or LAR with family-based options and the supports needed for the individual to live with family or in his or her own home, if an adult. If a goal for family life is not preferred at this time, actions may reflect ways to increase support of the family and LAR with that possibility in the future. Actions may also reflect ways to assist the family or significant others to remain actively engaged while the individual remains in the facility. Identify specific activities regarding:
- Movement to a preferred family option (return home or move to an alternate family);
- Continuing or increasing interaction between the individual and family members or significant others;
- Any other action that will further achievement of a permanency goal; and
- Referrals to achieve a preferred living arrangement other than a family option.
P. Permanency Plan Contributors – Identify all persons who participated in the permanency plan and the person responsible for taking each identified action. Indicate participants in the planning process by entering names and titles or relationships to the individual for whom the permanency plan is written. Enter the method(s) and date(s) of each person’s participation.