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Effective Date: 
6/2016

Documents

Instructions

Updated: 6/2016

 

PURPOSE

To develop the Person-Directed Plan (PDP) for an individual to participate in the Home and Community-based Services (HCS) Program, Texas Home Living (TxHmL) Program, and Community First Choice (CFC) and update the plan, as needed, in accordance with the person-directed planning process and the rules governing the Programs (40 Texas Administrative Code, Chapter 9, Subchapters D and N).

 

INTRODUCTION

The service coordinator (SC) at the local intellectual and developmental disabilities authority (LIDDA), using the discovery process as the basis for collecting information, develops the PDP with the individual, legally authorized representative (LAR) and others, as requested by the individual or LAR.

The person-directed planning process:

  • identifies existing supports and services necessary to achieve the individual's desired outcomes;
  • identifies natural supports available to the individual and negotiates needed service system supports;
  • occurs with the support of a group of people chosen by the individual (and the LAR on the individual's behalf); and
  • accommodates the individual's style of interaction and preferences regarding time and setting.

Additional guidance and information about person-directed planning can be found at https://www.dads.state.tx.us/providers/LA/PersonDirectedPlanningGuidelines.pdf and http://www.learningcommunity.us.

Examples of the discovery process include, but are not limited to:

  • conversations with the individual, LAR and those who know the individual best, such as a provider staff, caregiver, family member and friend;
  • a method called Planning Alternative Tomorrows with Hope (PATH);
  • methods taught by The Learning Community for Person Centered Practices (TLCPCP);
  • use of activities and tools from Person Centered Planning; and
  • prompts from the Discovery Guide.

In addition to understanding person-directed planning, the SC must understand the HCS Program Billing Guidelines, TxHmL Billing Guidelines and CFC Program Billing Guidelines to facilitate the gathering of outcome information necessary for justifying support and services to be provided through the HCS program.

 

PROCEDURE

Following the discovery process and before developing the PDP, the SC assists the individual and LAR to designate members of the individual’s service planning team (SPT). The SC should discuss with the individual and LAR the importance of including the HCS/TxHmL/CFC provider when the individual discusses his/her preferences and goals. Since the provider will be responsible for designing and providing the services to the individual, understanding the individual’s strengths, capabilities and desires is critical to providing services that are meaningful to the individual. The SC should request permission from the individual/LAR to invite the HCS/TxHmL/CFC provider to the planning meeting to develop the PDP. The SC should also ask the individual/LAR to invite anyone else, such as a family member or friend, to participate in the service planning process.

 

DETAILED INSTRUCTIONS

Plan Date – The date a meeting is held to discuss the PDP.

Enter the later of the date of the meeting to discuss the PDP:

  • first is developed; or
  • is updated during the individual plan of care (IPC) year; or
  • is updated prior to the latest IPC renewal.

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.

Provider Agency Information – Enter all of the data elements in the section for the provider agency. Enter N/A for those data elements that do not apply to the provider.

Financial Management Services Agency (FMSA) — Enter the FMSA's information if the individual has selected to self-direct his/her supported home living, CFC personal assistance services/habilitation (PAS/HAB) or respite services. If Consumer Directed Services (CDS) is chosen, enter the date the SC provided a list of FMSA providers to the individual or LAR. (This date will remain the same until a new list of FMSA providers is given to the individual or LAR.)

Local Intellectual and Development Disabilities Authority (LISSA) Information – Enter the data elements in the LIDDA section.

List the discovery process(es) and participant(s) used to obtain information about the individual.

Describe how information was gathered Describe all the ways information was gathered to discover the individual’s desires and preferences. Examples include, but are not limited to: conversations with the individual/LAR and those who know the individual best, such as a provider staff, caregiver, family member and friend;

  • a method called PATH;
  • methods taught by TLCPCP;
  • use of activities and tools from Person Centered Planning; and
  • prompts from the Discovery Guide.

This information may change for PDP updates.

Participants Enter the names of all who participated in the discovery process including the individual/LAR. The names may change when the PDP is updated and new information is gathered.

Plan Summary Enter the Plan date for which the plan summary is being added, the SC’s name and a brief summary of relevant information discussed about the individual's preferences and needs during the meeting that support the PDP. The summary of a subsequent Plan meeting during the IPC year is added above the summary of the previous meeting and is identified as a subsequent Plan meeting by entering the new Plan Date of the subsequent meeting, and the SC’s name and title and the summary of the meeting. 

One Page ProfileThe format of this “One-Page Profile” is based on work by TLCPCP.

____________'s One Page Profile Enter the individual's name.

Insert Photo Here Insert one or two recent photos of the individual or photos of people, places or things that are important to the individual, if available.

What people like and admire about me Enter a descriptive narrative including what you have learned through the discovery process that others like and admire about the individual.

What's important to me Enter what you have learned through the discovery process that is important to the individual. “Important to” 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 the service 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 to date. Additional efforts should be explored to increase his/her awareness of additional possibilities and experiences to increase his/her options of choice.

What others need to know and do to support me Enter important information you have learned through the discovery process about the individual such as how the individual communicates and how to best communicate with him or her.  Include what you have learned through the discovery process that is important for the individual, as identified by those who know him/her best. “Important for” reflects information that is important for the service provider to know and understand about the individual. This information should be related to health, safety and any supports regarded as necessary to enhance the individual to be a valued member of the community. Enter information such as health needs, supervision requirements, specific behavioral needs and special instructions for those who support the individual. This section includes contraindications and special justifications for deviating from typical routines or activities (for example, school-age children should be in educational services five days a week, six hours a day, unless contraindicated). This section can identify a non-HCS/TxHmL/CFC service that is supported by a desired HCS/TxHmL/CFC service. For example, transportation provided through supported home living may be necessary for the individual’s supported employment activities. List any barriers that could prevent the outcomes/purposes from being achieved. Things identified as “important for” are not usually included as “important to” the individual. 

Date Completed – Enter the date that information was added or changed on this page.

Historical Information – Enter historical or background information that continues to significantly affect the individual or his/her services. Do not repeat information that is contained on the One Page Profile or elsewhere in the PDP.

People in____________’s Life – Enter the individual’s name.

List the people who are close to the individual and who know and care about the individual. – List the people who are close to the individual and who know and care about him/her. This will help the provider 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 takes the individual to work.
  • She is a friend the individual calls every weekend.
  • He stays with the individual until 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 stays with him during the holidays.

SERVICES– The first portion of the section is the SC’s attestation about the HCS/TxHmL/CFC services included on the individual’s PDP. The next portion of the section serves to meet the requirement of the service coordination rule by identifying the frequency and duration based on the individual’s preference and needs. Frequency is determined by completing Form 8647, Service Coordination Assessment – Intellectual Disability Services, for the individual. Once Form 8647 has been completed, enter how often the SC will have face-to-face contact with the individual (must be at least every 90 calendar days).

Non-HCS/TxHmL/CFC services– List all non-HCS/TxHmL/CFC services provided by family and/or other funding sources to be coordinated and/or monitored by the SC.

Identify type of non-HCS/TxHmL/CFC service and enter what the individual wants from this service – Enter the type of non-HCS/TxHmL/CFC service and describe the outcome/purpose of the service. Examples of non-HCS/TxHmL/CFC services are education services provided by an independent school district (ISD), attendant care, transportation, mental health services, counseling or supported employment. 

Person, specialty, or agency providing services – Enter the name of the person, specialty, or agency that will be providing this service. Examples of a person, specialty, or agency providing a non-HCS/TxHmL/CFC service are: ISD, Personal Assistance Services (PAS) through the Health and Human Services Commission (HHSC), family member (include name and relationship), neurologist (name optional) private psychiatrist (name optional) and community resources, such as a church (include name of church) or a non-profit organization (include name of non-profit organization).

HCS/TxHmL/CFC services that will be used to support the individual to access this non-HCS/TxHmL/CFC service, if any — Enter the HCS/TxHmL/CFC service that will be used in conjunction with the non-HCS/TxHmL/CFC service. An example could be that the individual is receiving supported employment (type of non-HCS/TxHmL/CFC service) through (person or agency providing services) and CFC PAS/HAB (HCS/TxHmL/CFC services that will be used to support the individual to access this non-HCS/TxHmL/CFC service, if any) will be used to provide transportation to and from the office and to the individual’s work site. If an HCS/TxHmL/CFC service is identified in this section, documentation must be made in the area of “important to” or “important for” of the Action Plan for that service to describe how the service will be provided in conjunction with the non-HCS/TxHmL/CFC service.

Service Coordinator's Follow-up Responsibilities– The SC documents actions the SC will take to facilitate non-waiver services, such as making a referral, scheduling an intake or assisting with an application.

Action Plan – These sections identify the HCS/TxHmL/CFC service components necessary to assist the individual to achieve his/her desired outcome(s). Complete an Action Plan for each HCS/TxHmL/CFC service the individual will be receiving during the IPC year. Organize the individual’s “important to” and “important for” items into an action plan that the program provider can use to begin service provision, and as a starting point for the development of the Implementation Plan (IP).

Individual's Name– Enter the individual's name.

Client Assignment and Registration (CARE) System ID – Enter the individual's CARE System identification (ID).

PDP Date – Enter the PDP date for which this action plan was developed. This date will change to a new PDP date when a PDP meeting is held that affects any section of this action plan.

Desired ServiceEnter the HCS/TxHmL/CFC service that this action plan will address.

Does this service require a backup plan? Mark only one box based on the SPT’s decision on a need for a service backup plan. (A service backup plan must be recommended by the SPT for any HCS/TxHmL/CFC service identified as critical for the individual. Service backup plans are not limited to CDS delivered services only.)

Service Delivery Option Mark only one box based on the individual's preference of service deliver option for allowable CDS option services.

Support Management Voluntary training with selecting, managing and dismissing attendants. Individuals can elect this benefit by indicating yes on the PDP.

Outcome/PurposeEnter what the individual wants from this service. There may be one or more outcomes/purposes that the individual/LAR has identified. Outcome/Purpose can be specific or general depending on the request of the individual/LAR and his/her specific needs.

Pertinent Information – Enter information identified by the individual and/or the SPT as needs, requests, or considerations specific to the identified services for this Action Plan. This information is necessary for the service provider to know in order to support the individual in achieving his/her outcomes. Specific preferences related to how the individual wants the service delivered are important to include, if known. This could be a preference for a specific gender of service provider or special preferences for a morning or evening routine. State an individual’s particular fears or concerns about the delivery of services that would be helpful to the service provider. This section may change and grow as the SC has more conversations and interactions with the individual/LAR and as additional information about the individual’s needs and preferences are discovered.

For update purposes during the IPC year only This section is to be completed any time information for this Action Plan changes or when a new Action Plan is added or discontinued during the IPC year. Once the Action Plan is revised, the SC enters the date, prints his/her name and signs the Action Plan. The SC will submit to the provider a copy of only the page(s) of the PDP that were revised.

The information for this service was changed or added for this Plan date and will be implemented on Check the appropriate box to indicate if a change, such as revising an outcome or new information on how the individual wants his/her services delivered, was made to an existing service or if adding a new service. Insert the Plan date from the front page of the PDP. This should be the same date that the Plan meeting was held that supported the changes identified in the Action Plan. A summary should also be included on the first page with the same date. Insert the date the provider has agreed that the changed or new service will be implemented. The implemented date cannot be a date prior to the Plan date. 

Decision to discontinue this service occurred on this Plan date Insert the date the SPT decided a service would be discontinued based on the individual's needs or preferences.  

Service Coordinator's printed name and signature Insert the printed name of the SC who facilitated the plan meeting and an approved electronic signature, or the SC can sign the Action Plan. 

ADDITIONAL INFORMATION

Process for PDP Updates for an IPC Revision

The PDP may be updated at any time during the IPC year based on the individual’s needs and desires. After the SPT has met and discussed the need to update the PDP, the SC will revise the PDP as appropriate and complete the Plan Summary. Note: The summary of a subsequent PDP update meeting during the IPC year is added above the summary of the previous meeting and is identified as a subsequent PDP update meeting by entering “PDP Update,” the date of the subsequent meeting, and the SC’s name and title.  This will make it easier to find the new information during the IPC year. This process will also provide information on when and by whom the additional information was added.

Process for Annual PDP Update for an IPC Renewal

The PDP may be updated at any time during the IPC year based on the individual’s needs and desires. After the SPT has met and discussed the need to update the PDP, the SC will revise the PDP as appropriate and complete the Plan Summary. Note: The summary of a subsequent Plan date during the IPC year is added above the summary of the previous Plan date and is identified as a subsequent Plan meeting by entering the new Plan date of the subsequent meeting, the SC’s name and title and the meeting summary.  This will make it easier to find the new information during the IPC year. This process will also provide information on when and by whom the additional information was added.

  • A new Plan Date on the first page of the PDP and all Action Plan pages. Note: The Action Plan will not contain anything in the box at the bottom of the page titled, “For update purposes during the IPC year only.” All Action Plans, even if continued from the previous PDP will be represented as a new Action Plan for the annually updated PDP. The annual updated PDP will not contain any Action Plan for services that have been discontinued from a previous year.
  • A Planning Meeting Summary about the PDP meeting. Note: Because it is a new PDP year, this will be the only summary in this section. Any subsequent planning meeting summaries will be included as they take place throughout the IPC year.

Signatures — All people involved in the PDP process, including the individual, must sign the signature page (if able), state the relationship to the individual and include the date.