Revision 13-2; Effective September 3, 2013

 

 

7100 Implementation Plan Overview

Revision 13-2; Effective September 3, 2013

 

The Implementation Plan (IP) is developed by the individual, the individual’s legally authorized representative (LAR), members of the individual’s support network and the program provider. The IP addresses every Home and Community-based Services (HCS) service the individual receives through the provider agency service delivery option (see list in paragraph below). An IP is not required for an HCS service provided though the Consumer Directed Services (CDS) service delivery option.

The program provider must develop an IP for each HCS service for which there is an Action Plan on the individual’s Person-Directed Plan (PDP). See the HCS services below for examples of IPs:

The IP clearly illustrates how the individual will be supported in achieving his or her outcomes/purposes identified in the PDP and details how HCS program services will be delivered to achieve the identified outcomes/purposes. The IP describes and directs the delivery of services, including when, where and by whom services will be provided. A copy of the IP is provided to the service coordinator (SC) upon request.

An HCS provider may use Form 2125, Implementation Plan - HSC/TxHmL/CFC, or another document that includes the same elements in Form 2125. A comprehensive nursing plan, a behavior support plan or other assessments/plans completed by HCS service providers may serve as the IP as long as those plans include all required elements.

 

7200 Implementation Plan Elements

Revision 13-2; Effective September 3, 2013

 

 

7210 Desired Outcome(s)/Purposes(s)

Revision 13-2; Effective September 3, 2013

 

The desired outcome(s)/purpose(s) for an HCS service that are included on the IP are taken directly from the PDP.

 

7220 Conversation, Observation and Formal Assessment

Revision 13-2; Effective September 3, 2013

 

In addition to the PDP, the development of implementation strategies may be based on:

  • Conversations with the individual, the individual’s LAR or any member of the individual’s support network, and/or staff who know the individual;
  • Observations; and
  • Formal assessments (including assessments by occupational therapists, physical therapists, nurses, behavioral support specialists, doctors, dentists, teachers, speech therapists, dietitians, job coaches, etc.).

Documentation must be maintained regarding the information gathered through conversation, observation and formal assessments.

 

7230 Implementation Strategies

Revision 13-2; Effective September 3, 2013

 

The implementation strategies are individualized and allow for evaluation of progress in achieving each desired outcome. Strategies are the steps that contribute to reaching desired outcomes. Depending on the outcome, the IP may contain one or more strategies that lead to the individual's acquisition of additional skills or describe actions to be completed by paid supports to achieve an outcome. There is no prescribed number of strategies for each outcome. Strategies are based on conversations, observations and/or formal assessments and are written in observable, measurable or outcome-oriented terms. Measurable means a person can consistently and reliably determine whether or not an action or event has occurred. Observable means the action or event can be detected using one or more of the five senses: sight, hearing, touch, taste or smell. Outcome-oriented means that it can be determined when a desired result has been achieved.

 

7240 Signing the Implementation Plan (IP)

Revision 13-2; Effective September 3, 2013

 

Once the IP has been developed, signatures are obtained from the individual, the individual’s legally authorized representative (LAR) or a member of the individual’s support network, and the individual’s program provider to verify that they have participated in the development of the IP. These signatures may be on a separate signature sheet that is kept on file or may be on the IP itself.

 

7300 Provider Monitoring of Service Delivery

Revision 13-2; Effective September 3, 2013

 

The provider is responsible for ensuring that the IP is effective and services are provided according to the IP. Ongoing communication between the program provider’s staff and the individual and LAR is necessary to ensure that the IP reflects services and approaches that meet the needs and desires of the individual and LAR.

The provider must document services provided as specified in the implementation plan and to verify that the requirements for reimbursement, as defined in the HCS Program Billing Guidelines, have been met. The IP and documentation related to service delivery may also be used by DADS utilization review staff when determining whether to authorize the IPC.

 

HCS Certification Principles references for IP and related documentation:

§9.174

(a) the program provider must:

(13) ensure that HCS Program services identified in the individual's implementation plan are provided in an individualized manner and are based on the results of assessments of the individual's and the family's strengths, the individual's personal goals and the family's goals for the individual, and the individual's needs rather than which services are available;

(14) Ensure that each individual's progress or lack of progress toward desired outcomes is documented in observable, measurable, or outcome-oriented terms;

(26) Ensure that an individual has a current implementation plan;

(46) Maintain a system of delivering HCS Program services that is continuously responsive to changes in the individual's personal goals, condition, abilities, and needs as identified by the service planning team.

Documentation regarding delivery of services defined by the IP must be written to be observable, measurable or outcome oriented.

 

7310 Example of Documenting Observable Strategies

Revision 13-2; Effective September 3, 2013

 

Observable: Staff use one or more of the five senses (sight, hearing, touch, smell or taste) to evaluate performance on implementation strategy.

Example: Johnny will independently select and purchase items using the correct amount at the local convenience store. (Based on the PDP, which reflects that it is important to Johnny to be able to go independently to the store and purchase items of his choice.)

Staff Documentation: I observed Johnny at the 7-11. He selected three items to purchase and approached the register, greeted the cashier and received the total for his purchase. The purchase price was $3.42. Johnny presented the cashier with $3.00. Staff prompted Johnny to give the cashier an additional dollar. The purchase was then complete.

This example indicates that Johnny is able to perform many of the steps associated with making a purchase, but he was not completely independent in making these purchases. The program provider is responsible for comparing staff documentation to determine if Johnny’s abilities have increased and must document progress or lack of progress.

 

7320 Example of Measurable Strategies

Revision 13-2; Effective September 3, 2013

 

Measurable: Calculations are made to determine progress on implementation strategy.

Example: Johnny will use a walker. (Based on the PDP, which reflects that it is important to Johnny to be able to go from place to place without help.)

Staff Documentation: Johnny used his walker to go a total of 25 feet this afternoon.

Note: When using data sheets for measuring progress, be sure that the criteria does not “lock” the individual into a perpetual loop. The individual should be able to celebrate success and strategies should be adjusted to assist the individual to do so. When success is not occurring, staff should note their observations on the data sheet.

Example: Johnny is not motivated to use his walker inside the house (perhaps because of the number of obstacles). He is much more motivated to walk down the driveway, especially if the mail needs to be checked.

 

7330 Example of Documenting Outcome Oriented Strategies

Revision 13-2; Effective September 3, 2013

 

Outcome Oriented: Progress is defined by occurrence of an event identified in the implementation strategy.

Example: Johnny wants to participate in the annual cancer research walk/run. (Based on the PDP, which indicated that Johnny’s sister died from cancer, he wants to help raise money for the cause.)

Staff Documentation: I took Johnny to the American Cancer Society today so that he could sign up to participate in the annual cancer research walk/run. On the way to the car, he convinced his neighbor, Mrs. Olson, to sponsor him by donating $2 for each mile he walks or runs.

 

7400 Revising the Implementation Plan

Revision 13-2; Effective September 3, 2013

 

The program provider is expected to routinely review the services provided to an individual and share information regarding progress or lack of progress on the implementation strategies with the individual and the individual’s LAR, if applicable. Lack of progress on an implementation strategy indicates that the strategy needs to be reviewed to determine if revision is warranted.

The HCS provider revises an individual's IP whenever there is a change in the outcomes/purposes identified in the PDP, or when changes in implementation strategies, or frequency or duration of HCS program services are needed.

 

7500 Service Backup Plan

Revision 13-2; Effective September 3, 2013

 

A program provider must develop a written backup plan for each waiver service identified on the PDP as critical to meeting an individual’s health and safety. HCS providers may use Form 1742, Service Backup Plan for HCS, TxHmL and CFC Services, to develop a service backup plan or may use their own documentation that includes the required elements of a service backup plan. A backup plan must:

  • contain the name of the critical service;
  • specify the period of time in which an interruption to the critical service would result in an adverse effect to the individual’s health or safety; 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.

If a backup plan is implemented, the program provider must document whether the plan was effective. If the program provider determines the plan was ineffective, the program provider must revise the plan.

Note: Because HCS program providers must ensure that trained and qualified staff are available at all times for the provision of residential support and supervised living, a backup plan is not needed for these services. Backup plans for foster/companion care must be documented in the service agreement the foster/companion care provider has with the HCS program provider.