Form 3596, PAS/Habilitation Plan – CLASS/DBMD/CFC

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Documents

Effective Date: 7/2015

Instructions

Updated: 5/2015

Purpose

The Habilitation Plan is used to plan, document and justify the amount and frequency of authorized Community Living Assistance and Support Services (CLASS) habilitation services, Deaf Blind with Multiple Disabilities (DBMD) residential habilitation services and Community First Choice (CFC) Personal Assistance Services (PAS)/Habilitation services and PAS consist of at least habilitation/residential habilitation or PAS and may also include:

  • habilitation training;
  • medically related delegated tasks;
  • CLASS Direct Services Agency (DSA) participation on the service planning team (SPT);
  • CLASS prevocational services;
  • DBMD habilitation service provider participation on the SPT;
  • DBMD intervener services; and
  • DBMD day habilitation.

CLASS and DBMD habilitation services support, but do not replace, non-waiver resources.

Procedure

When to Prepare

For CFC:

As part of the functional needs assessment completed by DSAs and case managers, the person-centered plan facilitator determines the individual’s goals, needs and preferences through use of the person-centered plan development process.

For CLASS:

As part of the service planning process, the SPT determines the individual's needs to be documented on this form. When habilitation services will be delivered by the DSA, a DSA representative will document the SPT's deliberations on the form. When habilitation services will be delivered using the Consumer Directed Services (CDS) service delivery option, the case manager will document the SPT's deliberations on the form. This process occurs for development of an initial habilitation plan and is updated at the annual renewal and whenever habilitation tasks or other habilitation services are added or changed in the plan.

The SPT reviews the Habilitation Plan to determine the accuracy of the information included in the plan, including the frequency and duration of habilitation services.

For DBMD:

As part of the service planning process, the SPT determines the individual’s needs and may use the habilitation plan to document these needs at enrollment, when services are revised or upon renewal. This form may be used as a template for residential habilitation or intervener services identified by the SPT. This form may also be used for individuals directing their own services through the CDS option.

Transmittal

For CFC:

Follow the instructions below dependent on which program the individual is enrolled.

For CLASS:

Completed and revised Habilitation Plans are provided to the case manager. The Case Management Agency (CMA) files a completed Form 3596 in the individual's record. A copy is sent to the DSA, if necessary, individual/legally authorized representative (LAR), and the Financial Management Services Agency (FMSA), if applicable. An FMSA employer must maintain the completed Form 3596 in the FMSA record.

For DBMD:

If the SPT utilizes the Habilitation Plan to document the individual’s habilitation needs, the DBMD provider should maintain a copy of the completed Form 3596 in the individual’s record. A copy should be sent to the individual/LAR, and the FMSA, if applicable. An FMSA employer should maintain the completed Form 3596 in the FMSA record.

Form Retention

For CFC, keep this form as instructed below dependent on which program the individual is enrolled.

For CLASS, keep this form according to record retention requirements documented in the CLASS Provider Manual.

For DBMD, keep this form according to the record retention requirements found in Texas Administrative Code, Chapter 49.

Detailed Instructions

Individual Name — Enter the name of the CLASS/DBMD individual.

Date of Birth — Enter the individual's date of birth.

Medicaid No. — Enter the individual's Medicaid number.

Date — Enter the date that the form is being completed.

Money Management Assistance Needed — Check "yes" or "no." If "yes," give the name of the person authorized by the individual/LAR to assist.

IPC Period — Enter the individual plan of care (IPC) period covered by the habilitation plan.

Service Delivery Model — Check Direct Services Agency (DSA), DBMD Provider, or Consumer Directed Services (CDS).

Habilitation Plan — Check one of the following at the time the Habilitation Plan is completed:

  • Enrollment
  • Renewal
  • Revision No. — Indicate the revision number. For example, the first time a revision is made during an IPC period is revision 1. This sequence starts over at the beginning of each IPC period.

    Note: Throughout this form, if the individual does not require assistance with a task, leave the field blank.

I. Habilitation Needs

Sections 1 through 11 –

Time for Activity — Document in minutes the amount of time required to perform each activity.

Frequency — Document the number of times each activity is performed on a daily or weekly basis. For activities that are performed less frequently than daily or weekly, document the frequency by checking weekly and indicating time as a decimal (e.g., activities performed once a month indicate .25, twice a month .5).

Weekly Totals — Calculate the weekly total time spent on each activity by multiplying the Time for Activity by the Frequency (Daily/Weekly). (For example, brushing teeth: 4 minutes x 2 daily x 7 days = 56 total weekly minutes.)

Habilitation Training Needed — For each activity, check the box to indicate if habitation training is needed to enhance the individual's independence.

Subtotal — Add the weekly totals for each activity to determine the subtotal for each habilitation need.

Section 12 – Additional Tasks

Activity — List additional habilitation tasks.

Time for Activity — Document in minutes the amount of time required to perform each activity.

Frequency — Document the number of times each activity is performed on a daily or weekly basis. For activities that are performed less frequently than daily or weekly, document the frequency by checking weekly and indicating time as a decimal (e.g., activities performed once a month indicate .25, twice a month .5).

Weekly Totals — Calculate the weekly total time spent on each activity by multiplying the Time for Activity by the Frequency (Daily/Weekly). (For example, brushing teeth: 4 minutes x 2 daily x 7 days = 56 total weekly minutes.)

Habilitation Training Needed — For each activity, check the box to indicate if habitation training is needed to enhance the individual's independence.

Subtotal — Add the weekly totals for each activity to determine the subtotal for each habilitation need.

Section 13 – Habilitation Training

Time for Activity — Document in minutes the amount of time required to perform each activity.

Frequency — Document the number of times each activity is performed on a daily or weekly basis. For activities that are performed less frequently than daily or weekly, document the frequency by checking weekly and indicating time as a decimal (e.g., activities performed once a month indicate .25, twice a month .5).

Weekly Totals — Calculate the weekly total time spent on each activity by multiplying the Time for Activity by the Frequency (Daily/Weekly). (For example, brushing teeth: 4 minutes x 2 daily x 7 days = 56 total weekly minutes.)

Subtotal — Add the weekly totals for each activity to determine the subtotal for each habilitation need.

Section 14 – Health-Related Tasks

Time for Activity — Document in minutes the amount of time required to perform each activity.

Frequency — Document the number of times each activity is performed on a daily or weekly basis. For activities that are performed less frequently than daily or weekly, document the frequency by checking weekly and indicating time as a decimal (e.g., activities performed once a month indicate .25, twice a month .5).

Indicate Code — Enter appropriate code (F, P, N, D, C, T) to indicate if the health-related task is to be:

  • F – provided by family, friend or other non-waiver resource;
  • P – physician delegated;
  • N – nurse;
  • D – RN delegated; or
  • C – Consumer Directed Services
  • T – Therapist Delegated (only for extension of therapy)

Weekly Totals — Calculate the weekly total time spent on each activity by multiplying the Time for Activity by the Frequency (Daily/Weekly). (For example, brushing teeth: 4 minutes x 2 daily x 7 days = 56 total weekly minutes.)

Habilitation Training Needed — For each activity, check the box to indicate if habitation training is needed to enhance the individual's independence.

Subtotal — Add the weekly totals for each activity to determine the subtotal for each habilitation need.

Section 15 – Justification for Simultaneously-Delivered Services

Explain the rationale for providing habilitation at the same time another service is provided (e.g., two habilitation providers are required to transfer the individual or the habilitation provider performs housekeeping tasks while the individual is receiving therapy or nursing services).

Section 16 – Additional Comments

Document additional information related to the individual's habilitation needs and services.

II. Weekly Schedule

Indicate the start time, end time and days of the week the individual receives services for applicable activities and include weekly total hours by completing the following schedules.

Section 1 – Nursing — Indicate if services are provided through the CLASS or DBMD program or through other resources. If other, specify.

Section 2 – Therapeutic Services — Indicate if services are provided through the CLASS or DBMD program or through other resources. If other, specify.

Section 3 – Day Activity — Indicate if day activity is Day Activity and Health Services (DAHS), CLASS Prevocational, Employment, Employment Assistance, Supported Employment, DBMD Day Habilitation or Other. If other, specify. Indicate the individual’s current employment status.

Section 4 – Education — Indicate if education is through School, Home-Schooled, Higher Education or Other (e.g., day care, or individual receives educational services from the school district in the home). If other, specify. Indicate the individual’s educational status.

Section 5 – Intervener — Complete the time and days of the week for the intervener, and weekly total intervener hours.

III. Non-Waiver Caregiver Support

Section 1 – Living Arrangement — Indicate if the individual lives alone, with parents, spouse/significant other, caregiver or other. If other, specify. Provide relationship, age and presence of a disability for all who reside in the same household as the individual.

Sections 2-4 – Caregiver Schedule — Enter the name and relationship to the individual. Enter the start and completion time for hours spent each day at work and providing unpaid care to the individual.

  • Weekly Work Schedules – Document time the caregiver works.
  • Unpaid Support/Supervision Provided to Individual – Document time spent providing unpaid support/supervision to the individual.

Additional Comments — Provide additional comments relevant to caregiver schedules (e.g., if the individual's unpaid caregiver(s) also provides care and support to others in the home or has other barriers not indicated in this section, document that information.

IV. Individual's CFC PAS/HAB or CLASS habilitation or DBMD residential habilitation schedule

Special Instructions — Document any unique circumstances related to meeting the activities of daily living or training needs of the individual in this section.

Schedule(s) — Enter the program in which the individual is receiving the service (CLASS/DBMD/CFC) in the column titled Type of Service. Enter the scheduled hours for the services to be provided to the individual (e.g., attendant, habilitation training, CFC PAS/HAB, delegated tasks, prevocational, day habilitation or intervener).

Use Schedules 2 and/or 3 if different schedules are necessary to meet the individual's needs (e.g., a school schedule for school-age individuals versus a summer and holiday schedule). If more than three schedules are necessary, use a separate page.

Totals Reflected on IPC (CLASS Only) — Enter the number of covered weeks, weekly total hours and annual total hours for services to be provided by habilitation staff (SVC 10/CDS SVC 10V),  DSA representation (SVC 10), health-related tasks (SVC 10A), CFC PAS/HAB (SVC 10CFC/CDS10CFV) and habilitation training (SVC 10/CDS). Enter the number of covered weeks, weekly total hours and annual total cost for services to be provided for prevocational services (SVC 10B).

Total Reflected on IPC (DBMD Only) — Enter the number of covered weeks, weekly total hours and annual total hours for services to be provided by residential habilitation service providers (SVC 17/CDS SVC 17V), day habilitation (SVC 10), CFC PAS/HAB (SVC 10CFC/ CDS10CFV), supported employment (SVC 37/CDS 37V), intervener (SVC 45, 45A,45B,45C/CDS SVC 45V, 45AV, 45BV, 45CV) and employment assistance (SVC 54/CDS 54V).

Signatures/Dates — The individual/LAR, case manager, DBMD/CFC/CLASS provider representative and all SPT members must review, sign and date the plan.