Revision 19-0; Effective July 7, 2019

 

5100 Required Face-to-Face Visits

Revision 19-0; Effective July 7, 2019

 

An HC meets face-to-face with an individual monthly, or more frequently if needed, unless the only specialized service the individual is receiving is habilitation coordination, in which case the HC meets face-to-face with the individual at least quarterly. Based on these requirements, the SPT determines the frequency of face-to-face visits. A face-to-face meeting with the individual must include the provision of at least one of the habilitation coordination activities described in this section.

 

5200 Assess/Reassess Habilitative Needs

Revision 19-0; Effective July 7, 2019

 

An HC must assess and periodically reassess an individual’s habilitative service needs by gathering information from the individual and other appropriate sources, such as the LAR, family members, social workers and service providers, to determine the individual’s habilitative needs and the specialized services that will address those needs.

An HC must complete Form 1064, Habilitative Assessment, for the individual:

  • within 75 days following the initial IDT; and
  • no earlier than 60 days before the scheduled annual IDT.

The HC will ensure the completed assessment is sent to each SPT member at least 10 business days before the first quarterly SPT meeting following the initial IDT/SPT meeting and before the annual IDT/SPT.

Based on formal and informal assessments, the SPT determines if an individual’s current specialized services need to be discontinued or if a new specialized service needs to be added.

 

5210 Reviewing Assessments

Revision 19-0; Effective July 7, 2019

 

An HC reviews all applicable and available assessments and makes available copies of the assessments to each member of the SPT for review. If an assessment indicates:

  • the individual can benefit from the specialized service,* the HC will monitor to determine that the service begins in the amount, frequency and duration identified on the assessment;
  • the individual cannot benefit from the specialized service, the HC will convene the SPT to discuss how the identified outcome can be met; and
  • an outcome or goal that was not previously identified, the HC will convene the SPT to discuss the newly identified outcome or goal.

*An individual can benefit from a specialized service if the service will help the individual acquire new skills, maintain skills, or delay or slow the loss of skills or functioning.

Reviewing assessments provides a more comprehensive understanding of an individual’s strengths, preferences and service needs, and helps SPT members outline services to meet the individual’s identified goals and objectives. As the facilitator of the SPT meeting, the HC must ensure the needs identified in all assessments are addressed.

HHSC encourages the HC to bring copies of all current assessments to the SPT meeting, so that the SPT can review and discuss recommendations. The HC must provide copies of assessments to the NF. It is recommended for assessments to be grouped together to make maximum use of the quarterly SPT for review and discussion.

Functional assessments to consider as part of Form 1057, Habilitation Service Plan (HSP), and the NF comprehensive care planning process include, but are not limited to:

  • PE or resident review;
  • MDS assessment;
  • Form 1064, Habilitative Assessment;
  • Therapy assessments;
  • Psychiatric assessments;
  • Behavior support assessments;
  • Community participation and independent living skills training assessments;
  • Medical and other clinical assessments; and
  • Assessments conducted prior to admission to an NF, if still applicable (e.g., CFC PAS/HAB assessment).

 

5300 SPT Meetings

Revision 19-0; Effective July 7, 2019

 

An HC must convene and facilitate SPT meetings as described in this section for an individual receiving habilitation coordination.

By facilitating the SPT meeting, the HC assists SPT members to accomplish their responsibilities, which are to:

  • ensure that the individual, regardless of whether he or she has an LAR, participates in the SPT to the fullest extent possible and receives the support necessary to do so, including communication supports;
  • review all available assessments to determine the individual’s need for specialized services;
  • develop Form 1057, Habilitation Service Plan (HSP), for the individual;
  • review and monitor identified risk factors, such as choking, falling and skin breakdown, and report to the proper authority (e.g., HHS Complaint and Incident Intake) if they are not addressed;
  • make timely referrals, service changes, and revisions to Form 1057, as needed; and
  • considering the individual’s preferences, monitor to determine if the individual is provided opportunities for engaging in integrated activities:
    • with residents of the NF who do not have ID or DD; and
    • in community settings with people who do not have a disability.

For an SPT meeting convened by the HC, the HC must ensure a sign-in sheet is provided to document the attendance of each participant, as well as the meeting date. If an SPT member participated by phone, the HC must ensure the member’s name is included on the sign-in sheet. The HC must maintain all sign-in sheets.

 

5310 First SPT Meeting

Revision 19-0; Effective July 7, 2019

 

See Section 4500, Developing Individual Profile and Habilitation Service Plan at First SPT Meeting.

 

5320 Quarterly SPT Meetings

Revision 19-0; Effective July 7, 2019

 

A quarterly SPT meeting should take place three months after the first SPT meeting or the previous quarterly SPT meeting, no more than two weeks before or after the three-month mark.

The HC must maintain the every-three-month base schedule even if a particular quarterly SPT meeting takes place within two weeks before or after the three-month mark. HHSC permits an HC to revise an individual’s schedule for quarterly SPT meetings to accommodate alignment with the NF’s service planning schedule. Revising an individual’s schedule for quarterly SPT meetings requires detailed documentation in the HC’s progress notes. The HC is responsible for coordinating with the NF so that the quarterly SPT meetings coincide with the NF’s quarterly service planning schedule.

 

5320.1 Required Activities during a Quarterly SPT Meeting

Revision 19-0; Effective July 7, 2019

 

During each quarterly SPT meeting, the SPT must:

  • review all assessments conducted since the last SPT meeting to determine:
    • whether the individual is receiving all necessary specialized services and in the appropriate amount, frequency and duration; and
    • if all identified outcomes are being addressed;
  • review each specialized service being provided to the individual to evaluate the effectiveness and adequacy of specialized services, including reviewing the written reports submitted by SPT members that are providers of specialized services as required by Section 5350, SPT Member that is a Provider of a Specialized Service;
  • discuss the progress, or lack of progress, in achieving all outcomes identified on Form 1057, Habilitation Service Plan (HSP), including whether the individual is maintaining progress toward outcomes; and
  • if CLO was conducted since the last quarterly SPT meeting, review and discuss the individual’s completed Form 1054, Community Living Options, including addressing barriers to transitioning to the community or selecting a community program, if identified in Sections 6 or 7 of Form 1054 or by the SPT.

If Form 1057 requires revisions based on the quarterly SPT meeting, the HC must revise Form 1057 as needed within 10 days after the meeting.

 

5320.2 Documenting Summary of Quarterly SPT Meeting

Revision 19-0; Effective July 7, 2019

 

The HC must summarize the SPT discussions and decisions at a quarterly SPT meeting in a progress note.

 

5320.3 Documenting Specialized Services in the LTC Online Portal

Revision 19-0; Effective July 7, 2019

 

Within five days after a quarterly SPT meeting, the HC will enter in the LTC online portal all required information on the PASRR Comprehensive Service Plan (PCSP) form.

 

5330 Update SPT Meetings

Revision 19-0; Effective July 7, 2019

 

An HC must convene an update SPT meeting between quarterly SPT meetings when necessary, such as when there is a change in the individual’s service needs, medical condition, or if requested by the individual or LAR.

 

5330.1 Update SPT Meeting Because of a Change in Medical Condition or a Change in Service

Revision 19-0; Effective July 7, 2019

 

An HC must convene an update SPT meeting if:

  • the individual experiences a change in medical condition that will affect the individual’s specialized services;
  • a change in the individual’s specialized services are necessary; or
  • a recent assessment shows:
    • the individual cannot benefit from a specialized service; or
    • an outcome or goal that was not previously identified.

The HC must summarize the SPT discussions and decisions at an update SPT meeting in a progress note.

If Form 1057, Habilitation Service Plan (HSP), or Form 1063, Individual Profile – Nursing Facility, requires revisions based on the update SPT meeting, the HC must revise Form 1057 or Form 1063, as needed, within 10 days after the meeting.

Within five days after an update SPT meeting is held per the information in this section, the HC enters in the LTC online portal all required information on the PCSP form.

 

5330.2 Update SPT Meeting for an Issue Not Addressed in Section 5330.1

Revision 19-0; Effective July 7, 2019

 

An HC convenes an update SPT meeting to address any outstanding issue that is unrelated to an issue identified in Section 5330.1, Update SPT Meeting Because of a Change in Medical Condition or a Change in Service.

The HC must summarize the SPT discussions and decisions at an update SPT meeting in a progress note.

If Form 1057, Habilitation Service Plan (HSP), or Form 1063, Individual Profile – Nursing Facility, requires revisions based on the update SPT meeting, the HC must revise Form 1057 or Form 1063, as needed, within 10 days after the meeting.

A PCSP form is not required for an update SPT meeting held per the information in this section.

 

5340 Annual IDT/SPT Meeting

Revision 19-0; Effective July 7, 2019

 

 

 

5340.1 Annual IDT/SPT Meeting

Revision 19-0; Effective July 7, 2019

 

An annual IDT/SPT meeting is held for an individual regardless of whether the individual is receiving habilitation coordination or any other specialized service. The HC is responsible for inviting all SPT members to the annual IDT/SPT meeting.

Note: If the individual has refused habilitation coordination, then there is no SPT for that individual, but the HC still must attend the annual IDT meeting.

The IDT/SPT members will discuss Form 1064, Habilitative Assessment, conducted by the HC and all recommended specialized services and decide:

  • the specialized services the individual (or LAR on the individual’s behalf) want to receive;
  • whether the individual is best served in the NF or the community; and
  • whether the individual wants to transition to the community.

The HC must confirm the annual IDT/SPT meeting information in the LTC online portal on the PCSP form in accordance with Section 2520, Confirmation of IDT/SPT Meeting Information.

 

5340.2 HC Preparation for Annual IDT/SPT Meeting

Revision 19-0; Effective July 7, 2019

 

An HC must complete Form 1064, Habilitative Assessment, for the individual no earlier than 60 days before the scheduled annual IDT/SPT meeting regardless of whether the individual is receiving habilitation coordination or any other specialized service. The HC provides a copy of the completed Form 1064 to all IDT/SPT members at least 10 business days before the annual IDT/SPT meeting.

 

5340.3 IDT Agrees to Habilitation Coordination

Revision 19-0; Effective July 7, 2019

 

If the IDT agrees to the provision of habilitation coordination for the individual, the HC requests a renewal authorization for habilitation coordination in accordance with the Habilitation Coordination Billing Guidelines.

 

5340.4 Refusal of Habilitation Coordination

Revision 19-0; Effective July 7, 2019

 

If an eligible individual/LAR does not want habilitation coordination:

  • the HC requests authorization for habilitation coordination in accordance with the Habilitation Coordination Billing Guidelines to fund the habilitation coordinator’s attendance at the IDT meeting; and
  • the HC uses Form 1044, Refusal of Habilitation Coordination, to document the refusal of habilitation coordination, obtains necessary signatures, provides the individual/LAR a copy of the completed form and maintains the original completed form in the individual’s record.

 

5340.5 Annual SPT Meeting

Revision 19-0; Effective July 7, 2019

 

If the IDT agrees to the provision of habilitation coordination for an individual, the HC convenes the annual SPT meeting immediately following the annual IDT meeting. An annual SPT meeting is conducted as described in Section 5320, Quarterly SPT Meetings.

 

5350 SPT Member that is a Provider of a Specialized Service

Revision 19-0; Effective July 7, 2019

 

Each SPT member that is a provider of specialized services must:

  • submit to the HC a copy of all assessments of the individual that were completed by the provider;
  • at least five days before a quarterly or annual SPT meeting, submit to the HC a written report describing the individual’s progress or lack of progress;
  • provide the HC with a copy of the provider’s implementation plan for the individual’s specialized service if requested; and
  • actively participate in an SPT meeting, in person or by phone, unless the HC determines active participation by the provider is not necessary. (See Section 5360, Determination that Participation in SPT Meeting is Not Necessary, below.)

 

5360 Determination that Participation in SPT Meeting is Not Necessary

Revision 19-0; Effective July 7, 2019

 

If an HC determines active participation by a provider of a specialized service is not necessary, as described above in Section 5350, SPT Member that is a Provider of a Specialized Service, the HC must:

  • base the determination on:
    • the information in the written report submitted in accordance with Section 5350 above; and
    • the needs of the SPT; and
  • document the reasons for exempting participation.

 

5370 Guidance for Convening SPT Meeting When an Individual or LAR Does Not Want to Attend

Revision 19-0; Effective July 7, 2019

 

This section provides guidance when an HC receives information from an individual or LAR that they will not attend a scheduled SPT meeting.

  • Offer to reschedule the SPT meeting. Ask the individual or LAR for a date and time that is preferable for them and work with them to reschedule.
  • Provide adequate notice of the meeting. “Adequate notice” may mean something different to each individual/LAR. An LAR may need several weeks’ notice. For an individual who is disturbed by SPT meeting preparations, one hour may be adequate notice.
  • Offer to change the location of the SPT meeting. An individual may prefer the meeting in their room instead of a conference room.
  • Offer the individual or LAR the opportunity to participate by phone.
  • Offer to have other SPT members participate by phone if the meeting is too crowded for the individual or LAR. Note that a provider agency representative may attend on behalf of two or more service providers if the representative is knowledgeable about the individual’s services, implementation plans, progress or lack of progress, and satisfaction with services.
  • If an individual or LAR states that the SPT meeting should proceed without him or her, the HC must find out what topics he or she wants discussed at the meeting and afterward share with the individual or LAR a summary of the discussion and the results of meeting.
  • If an individual absolutely refuses to attend or participate in SPT meetings, the HC must initiate an SPT discussion about why the individual refuses to attend or participate. The SPT members must attempt to identify and resolve barriers.

 

5400 Develop and Revise Habilitation Service Plan and Individual Profile

Revision 19-0; Effective July 7, 2019

 

An HC must develop and revise, as needed, an individual’s Form 1057, Habilitation Service Plan (HSP), and Form 1063, Individual Profile – Nursing Facility, with the SPT. Form 1057 and Form 1063 are individualized and developed through a person-centered process using ongoing discovery in accordance with each form’s instructions.

 

5410 Person-centered Planning

Revision 19-0; Effective July 7, 2019

 

Person-centered planning helps an individual figure out and describe what they need from services and from the service provider. The goal is to improve the individual’s quality of life by making sure their preferences are articulated and honored. This includes convening an SPT meeting at a time that is convenient for the individual and the individual’s LAR.

For more information about person-centered planning, including training, see HHS website.

 

5420 Discovery Process

Revision 19-0; Effective July 7, 2019

 

Discovery is the process of listening to people and learning about what they want from their lives. It is getting to know people so that their personal outcomes, preferences, choices and abilities are understood, documented and to form the foundation for planning their services and supports. Discovery is the basis for person-centered planning and service delivery. It is an ongoing process that occurs each time the HC talks to the individual or those who know the individual best. It is necessary to record the information learned so that it can be used when developing or updating Form 1057, Habilitation Service Plan (HSP). An HC leads the discovery process, advocating on behalf of the individual whose services and supports are being planned.

 

5430 Developing Habilitation Service Plan and Individual Profile

Revision 19-0; Effective July 7, 2019

 

Form 1057, Habilitation Service Plan (HSP), and Form 1063, Individual Profile – Nursing Facility, identify an individual’s strengths, preferences, medical, nursing, nutritional management and clinical needs, and support needs and desired outcomes. This information is gathered through discovery and through other sources, such as:

  • the PE;
  • records from the NF and previous providers;
  • CARE (e.g., diagnostic data, previous LIDDA services); and
  • previous individual service plans (ISPs) and HSPs.

The HSP also address barriers to transitioning to the community or selecting a community program. These barriers are identified in Sections 6 or 7 of the most recent Form 1054, Community Living Options. The SPT may also identify and address barriers.

The HSP identifies the services and supports that are needed to meet the individual’s needs, achieve the desired outcomes, and maximize the individual’s ability to live successfully in the most integrated setting possible. The HSP must include all specialized services (including habilitation coordination) agreed upon during an IDT meeting or an SPT meeting within the HSP year, including the individual’s desired outcomes.

The HSP year:

  • begin date is the date of the initial IDT/SPT meeting; and
  • end date is the 365th day following the begin date or 366th day in a leap year.

At a minimum, for each specialized service agreed upon during the IDT meeting, the HSP must indicate either:

  • an assessment will be conducted; or
  • the amount, frequency and duration of the specialized service to be provided.

 

5430.1 Specialized Services Requiring an Assessment

Revision 19-0; Effective July 7, 2019

 

An assessment is required for:

  • all NF specialized services; and
  • the following IDD habilitative specialized services:
    • behavioral support;
    • employment assistance; and
    • supported employment.

The HSP must state an outcome that supports initiating an assessment.

 

5430.2 Specialized Services that Do Not Require an Assessment

Revision 19-0; Effective July 7, 2019

 

For independent living skills training and day habilitation, the SPT identifies for inclusion in Section 5 of the HSP:

  • the outcome(s); and
  • the amount, frequency and duration based on the individual’s identified needs, interest and desired outcomes.

 

5430.3 Frequency and Duration of Habilitation Coordination

Revision 19-0; Effective July 7, 2019

 

The duration for habilitation coordination is “while the individual is residing in the nursing facility,” which is pre-printed on Form 1057, Habilitation Service Plan (HSP). The frequency of habilitation coordination is determined by the SPT in accordance with the requirements in rule and Section 5100, Required Face-to-Face Visits.

 

5430.4 Barriers to Transitioning to the Community or Selecting a Community Program Identified During CLO

Revision 19-0; Effective July 7, 2019

 

If barriers are identified during CLO and described in Sections 6 or 7 of Form 1054, Community Living Options, the HC initiates as a topic of discussion at an SPT meeting about the possible solutions to the barriers, how the SPT can implement the solutions and any follow-up activities. If the SPT identifies an additional barrier to the individual transitioning to the community, the SPT must identify possible solutions to the barrier, how the SPT can implement the solutions (including who and when) and any follow-up activities.

Solutions to a barrier can include the provision of a specialized service or an additional outcome for an existing specialized service. For example, if a barrier to an individual’s transition to the community is an inability to navigate public transportation, then the individual may benefit from receiving independent living skills training with an outcome of learning how to use the public bus system.

The HC documents all identified barriers (i.e., from Sections 6 or 7 of Form 1054 and barriers identified by the SPT) and the solutions and follow-up actions for implementation in Section 7 of Form 1057, Habilitation Service Plan (HSP).

 

5440 Revising the Habilitation Service Plan and Individual Profile

Revision 19-0; Effective July 7, 2019

 

Form 1057, Habilitation Service Plan (HSP), and Form 1063, Individual Profile – Nursing Facility, are reviewed at least quarterly and revised as necessary. Revisions to Form 1057 or Form 1063 must be completed within 10 days following the SPT meeting in which the revisions were agreed upon.

 

5440.1 Revising the HSP Because an Assessment for an NF Specialized Service is Completed

Revision 19-0; Effective July 7, 2019

 

An assessment must be conducted for all NF specialized services. The results of an assessment are reflected in Section 6 of Form 1057, Habilitation Service Plan (HSP) as follows.

  • If the individual can benefit from the service, the HSP includes:
    • the amount, frequency and duration from the assessment, except for CMWC or DME; and
    • the goal(s) from the assessment.
  • If the individual cannot benefit from the service, the HSP will indicate “discontinued.”

Note: The assessment results may impact the provision of an IDD habilitative specialized service. For example, if the individual is receiving day habilitation five days per week and a therapy assessment shows he or she needs therapy two days per week, then the amount or frequency of day habilitation may need to be reduced to allow for the provision of therapy.

A copy of all assessments for NF specialized services must be maintained in the individual’s record.

 

5440.2 Revising the HSP Because an Assessment for an IDD Habilitative Specialized Service is Completed

Revision 19-0; Effective July 7, 2019

 

An assessment must be conducted for behavioral support, employment assistance and supported employment. The information included in a completed assessment indicates whether the individual can benefit from the specialized service, and if so, should identify the necessary amount, frequency and duration for the service.

The results of an assessment are reflected in Section 5 of Form 1057, Habilitation Service Plan (HSP) in the appropriate outcome action plan as follows.

  • If the individual can benefit from the service, the HSP includes the amount, frequency and duration. If the assessment identifies an additional outcome, then the additional outcome is included in Section 5 of the HSP as an additional outcome action plan if agreed to by the SPT.
  • If the individual cannot benefit from the specialized service, the assessment should state why. This information is included in Section 5 of the HSP in the appropriate outcome action plan, and the HSP will indicate “discontinue.”
  • Assessment results may impact the provision of another IDD habilitative specialized service. Additionally, following delivery of an IDD habilitative specialized service, the SPT may revise the amount, frequency and duration to better reflect the individual’s identified needs, interest and desired outcomes.

A copy of all assessments for behavioral support, employment assistance and supported employment must be maintained in the individual’s record.

 

5440.3 Revising the HSP to Address Barriers Identified During CLO

Revision 19-0; Effective July 7, 2019

 

If barriers are identified during CLO and described in Sections 6 or 7 of Form 1054, Community Living Options, the HC initiates at an SPT meeting a discussion of the possible solutions to the barriers, how the SPT can implement the solutions and any follow-up activities. If the SPT identifies an additional barrier to the individual transitioning to the community, the SPT must identify possible solutions to the barrier, how the SPT can implement the solutions (including who and when) and any follow-up activities.

Solutions to a barrier can include the provision of a specialized service or an additional outcome for an existing specialized service. For example, if a barrier to an individual’s transition to the community is an inability to navigate public transportation, then the individual may benefit from receiving independent living skills training with an outcome of learning how to use the public bus system.

The HC documents all identified barriers (i.e., from Sections 6 or 7 of Form 1054 as well as barriers identified by the SPT) and the solutions and follow-up actions for implementation in Section 7 of Form 1057, Habilitation Service Plan (HSP).

 

5450 New Habilitation Service Plan for Next HSP Year

Revision 19-0; Effective July 7, 2019

 

Following an annual SPT meeting, an HC must complete a new Form 1057, Habilitation Service Plan (HSP), for the next HSP year that includes all new and ongoing information, such as:

  • outcomes and the specialized services and natural supports that help the individual achieve the outcomes, including amount, frequency and duration;
  • NF and MI specialized services, including amount, frequency and duration;
  • barriers preventing transition to the community or selection of a community program identified during a CLO or by the SPT; and
  • informational and educational opportunities that have been offered to the individual/LAR but have not yet occurred.

Discontinued specialized services and barriers that have been resolved are not included in the new HSP for the next HSP year.

The new HSP year:

  • begin date is the date of the annual IDT/SPT meeting; and
  • end date is the 365th day following the begin date or 366th day in a leap year.

Note: It is unlikely the annual IDT/SPT meeting date will occur exactly 12 months after the initial or previous annual IDT/SPT meeting date. The LTC online portal allows for an annual IDT/SPT meeting to take place as early as 344 days after the initial or previous annual IDT/SPT meeting. This means the HSP year will not always be a full 12-month period.

 

5460 Documents in an Individual’s Habilitation Packet

Revision 19-0; Effective July 7, 2019

 

A complete habilitation packet for an individual has:

  • Form 1063, Individual Profile – Nursing Facility (see Section 5460.1, Individual Profile, below);
  • Form 1057, Habilitation Service Plan (HSP) (see Section 5460.2, Habilitation Service Plan); and
  • the following attachments:
    • the most current Form 1054, Community Living Options; and
    • the most current NF comprehensive care plan.

 

5460.1 Individual Profile

Revision 19-0; Effective July 7, 2019

 

Information documented on Form 1063, Individual Profile – Nursing Facility.

Section 1, Individual’s Information — This section gathers identifying information about an individual as well as contact information for the individual, LAR and primary contact, if any, and information about an individual’s language preferences, ambulation abilities and accommodation needs.

Section 2, Nursing Facility and LIDDA Information — This section gathers name and contact information for NF and LIDDA staff.

Section 3, People Important to the Individual — The section identifies the important people in the individual’s life and who can provide information about the individual, such as family, friends, mentor and clergy.

Section 4, Profile Information — This section provides an overall profile of an individual’s strengths, preferences and needs, learned during the discovery process.

These are my strengths and what people like and admire about me: A descriptive narrative about the individual’s strengths and what others like and admire about the individual.

These are my preferences and what is important to me: A descriptive narrative about what 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 services 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 or she has to date. Additional efforts should be explored to increase his or her awareness of additional possibilities and experiences to increase his or her options of choice. This section could also include personal preferences (e.g., sleep with the light on, blackout curtains needed on windows, baths in the evenings only).

This is what others need to know and do to support me in the following areas: A descriptive narrative about what is important for the individual, as identified by those who know him or her best. “Support me” reflects information that is important for the service provider to know and understand about the individual. All specific areas listed below must be addressed and include specificity about health needs, risk factors and special instructions for those who support the individual. See Appendix IV, Risk Factors, for more information about identifying risks.

  • Communication — A descriptive narrative about how the individual communicates and how to best communicate with the individual. Describe the individual’s communication-related needs. For instance, what is the individual’s primary or preferred method of communication? How does the individual communicate or express a need (gestures, sounds, facial expressions, adaptive equipment, etc.)? What is the best way to determine if the individual is expressing satisfaction, happiness, comfort or agreement, as opposed to dissatisfaction, unhappiness, discomfort or disagreement? Among those who know the individual best, who seems better able to interpret what the individual is trying to communicate? What is the best way for others to learn how to communicate effectively with the individual?
  • Nursing Care — A description of the individual’s nursing-related needs, such as assistance taking medication, suctioning, wound care and oxygen. Describe how staff should attend to the individual’s nursing needs.
  • Clinical (Behavioral/Mental Health) — A description of the individual’s behavioral health and mental health-related needs. What kind of behavior supports does the individual need? Does the individual need counseling services or psychiatric services for medication management?
  • Medical and Dental — A description of all medical and dental concerns, diagnoses and routine procedures (e.g., medication management, blood work, history of constipation, dental cleaning, x-ray or sedation needs).
  • Adaptive Aids and Medical Supplies — A description of the adaptive aids (e.g., wheelchair, walker, shower chair) and medical supplies (e.g., briefs, test strips) needed by the individual and how they are funded (e.g., Medicaid, personal funds) or obtained (e.g., leased, purchased).
  • Nutrition Management — A description of the individual’s nutritional-related needs (e.g., thickened, pureed, textured, use of supplements, food allergies or restrictions, choking risk).
  • Supervision Needs — A description of the individual’s supervision needs. Consider if there are any personal issues that might present risk for harm in the individual’s living arrangement (e.g., daily rituals, threats of suicide or physical harm to self or others, inability to handle a personal crisis). Describe the supports needed to address any risks, such as line of sight, one-to-one, limited proximity or door alarm. Is the individual currently receiving these supports?
  • Other things people need to know about me, if any.
  • Risk factors not otherwise addressed above, such as those related to safety or exploitation.

Historical information: Include background information that continues to significantly affect the individual or his or her services.

 

5460.2 Habilitation Service Plan

Revision 19-0; Effective July 7, 2019

 

Information documented on Form 1057, Habilitation Service Plan (HSP).

Section 1, Individual Information — This section gathers identifying information about an individual and identifies the HSP year and plan date.

Section 2, Discovery — This section describes all the ways information was gathered to discover an individual’s desires and preferences, such as observation of the individual and conversations with the individual/LAR and those who know the individual best, such as an NF staff, caregiver, family member or friend.

Section 3, Changes Made to the HSP — This section is where changes to the HSP made within the previous 12 months are described.

Section 4, Habilitation Coordination Plan — This section describes the habilitation coordination plan, including duration and frequency of face-to-face meetings between the individual and the HC. The duration of habilitation coordination while the individual is residing in the NF and is pre-printed on the form. The frequency of face-to-face visits is determined by the SPT within the constraints of Section 5100, Required Face-to-Face Visits, and which may be either at least monthly or at least quarterly.

This section also lists all the activities to be coordinated and monitored by the HC. The first two activities are pre-printed because they are mandatory. If the NF agreed to provide NF PASRR support activities, then each support activity to be provided by the NF must be listed as an activity that will be monitored by the HC. The PASRR rules provide a definition of “nursing facility PASRR support activities” and includes the following examples of support activities:

  • arranging transportation for [an individual] to participate in an IDD habilitative specialized service or a MI specialized service outside the [NF];
  • sending an individual to a scheduled IDD habilitative specialized service or MI specialized service with food and medications required by the individual; and
  • stating in the comprehensive care plan an agreement to avoid, when possible, scheduling NF services at times that conflict with IDD habilitative specialized services or MI specialized services.

Note: The examples above are not all inclusive. A support activity can be any type of activity that supports the individual to receive specialized services.

Section 5, Outcome Action Plan — A separate outcome action plan is needed for each identified outcome. An outcome identifies what the individual wants to do, achieve, change, maintain or experience. For an identified outcome, the outcome action plan must identify all specialized services and other resources and natural supports the individual receives that will help the individual achieve the outcome. Each outcome action plan provides space to identify IDD habilitative specialized services, NF specialized services, MI specialized services and other resources/natural supports, as necessary and unique to the outcome. For each specialized service and resources/natural support listed, a description is necessary of how the specialized service or resource/natural support helps the individual achieve the outcome.

Note: While an NF specialized service or MI specialized service may be listed in a particular outcome action plan, all NF specialized services and MI specialized services for the individual must be included in Section 6 of the HSP.

Section 6, NF Specialized Services to be Monitored by the SPT — This section is for recording all NF specialized services and MI specialized services provided to the individual during the HSP year, including:

  • the goal(s) for the service as identified by the licensed therapist on the therapy assessment or as identified by the LMHA/LBHA staff;
  • the amount, frequency and duration of the service; and
  • whether the service was discontinued during the HSP year, and if so the date of discontinuance.

The form allows the user to add lines for more than one NF specialized service and MI specialized service.

Section 7, Preference Regarding Transitioning — Each time an HC presents CLO to the individual/LAR during the HSP year, the CLO date is included in this section of the HSP. Also included in this section are barriers to preventing a transition to the community from Section 6 of Form 1054, Community Living Options, or barriers to selecting a community program from Section 7 of Form 1504, if any. If there are barriers, the SPT’s proposed solutions and follow-up activities are also included in this section of the HSP. The SPT may identify additional barriers.

Section 8, Educational Activities — This section is used to describe all CLO educational, informational, and support activities offered to the individual/LAR and actively involved people. If an offered activity was attended, the information about attendance is also included in this section.

Section 9, Documentation of Exploration of Community Programs — This section is used to describe the community living settings for which a visit is planned or has occurred. When the visit has occurred, a summary of the outcome of the visit is included in this section.

Section 10, HC Signature — This section is for the HC to affirm that the HSP was developed based on IDT or SPT decisions and includes the HC’s printed name, signature and date.

 

5470 Sharing the Habilitation Service Plan, Individual Profile and Habilitation Packet

Revision 19-0; Effective July 7, 2019

 

An HC is responsible for providing a copy of the current Form 1057, Habilitation Service Plan (HSP), and Form 1063, Individual Profile – Nursing Facility, to all SPT members when they are developed and whenever they are revised.

An HC must share an individual’s habilitation packet with an SPT member upon request.

 

5480 SPT Member Believes HSP or Individual Profile Does Not Accurately Reflect SPT Decisions or Information about the Individual

Revision 19-0; Effective July 7, 2019

 

If an SPT member believes Form 1057, Habilitation Service Plan (HSP), or Form 1063, Individual Profile – Nursing Facility, does not accurately reflect an SPT decision or information about the individual, then:

  • if the HC agrees with the SPT member, the HC corrects Form 1057 or Form 1063 to accurately reflect the SPT decision or individual’s information; or
  • if the HC does not agree with the SPT member, the HC presents the issue to the SPT to resolve the discrepancy.

 

5500 Assisting with Access to Needed Specialized Services

Revision 19-0; Effective July 7, 2019

 

 

 

5510 Initiating IDD Habilitative Specialized Services

Revision 19-0; Effective July 7, 2019

 

An HC is responsible for initiating IDD habilitative specialized services identified on an individual’s Form 1057, Habilitation Service Plan (HSP), within 20 business days after the date of an IDT meeting or SPT meeting of any kind. “Initiating” means to take necessary action that will result in the individual receiving specialized services in a timely manner.

Note: The NF is responsible for requesting NF specialized services in the LTC online portal within 20 business days after the date of an IDT meeting or SPT meeting.

 

5520 Monitoring the Initiation and Delivery of all Specialized Services

Revision 19-0; Effective July 7, 2019

 

An HC must document the initiation and delivery of all specialized services agreed upon in an IDT meeting or an SPT meeting.

The HC must report to Complaint and Incident Intake (800-458-9858) a noncompliant entity (i.e., LIDDA, NF or LMHA/LBHA) if the entity fails to:

  • initiate or request a specialized service by the 20th business day after the service was agreed to in an IDT meeting or SPT meeting; or
  • deliver a specialized service:
    • for NF therapy services — within three business days after receiving approval from HHSC in the LTC online portal;
    • for behavioral support, employment assistance and supported employment — within three business days after the HC receives the completed assessment; and
    • for independent living skills training and day habilitation — within 20 business days after the service was agreed to in an IDT meeting or SPT meeting.

Note: In addition to a report to Complaint and Incident Intake for a noncompliant entity, as noted above, a LIDDA is responsible for submitting monthly noncompliance reports to HHSC in accordance with the performance contract.

 

5530 Accessing Other Habilitative Programs

Revision 19-0; Effective July 7, 2019

 

An HC must assist an individual to access needed specialized services and other habilitative programs and services that can provide services to address the individual’s needs and achieve outcomes identified in the HSP.

 

5540 Assisting Individual/LAR with Requesting a Fair Hearing for Denial of NF Specialized Services

Revision 19-0; Effective July 7, 2019

 

If an individual is denied a specialized service and the individual/LAR wants to appeal the denial, the HC is responsible for assisting the individual/LAR with completing Form 2361, PASRR Specialized Services Fair Hearing Request, to request a fair hearing.

 

5600 Coordination

Revision 19-0; Effective July 7, 2019

 

An HC is responsible for:

  • coordinating with other habilitative programs and services that can address needs and achieve outcomes identified in Form 1057, Habilitation Service Plan (HSP);
  • facilitating the coordination of an individual’s HSP and the NF comprehensive care plan; and
  • coordinating with the NF in accessing medical, social, educational and other appropriate services and supports that will help an individual achieve a quality of life acceptable to the individual and LAR on the individual's behalf.

 

5700 Monitoring and Follow-up Activities

Revision 19-0; Effective July 7, 2019

 

An HC must provide monitoring and follow-up activities to determine:

  • whether an individual receives the specialized services agreed upon in an IDT or SPT meeting and follow up when delays occur;
  • whether an individual’s Form 1057, Habilitation Service Plan (HSP), is fully implemented;
  • an individual’s and LAR’s satisfaction with all specialized services; and
  • an individual’s progress or lack of progress toward achieving goals and outcomes identified in Form 1057.

Monitoring may be accomplished through a combination of:

  • observation of the individual receiving services;
  • conversations with the individual, LAR, NF staff or provider; or
  • review of documentation, service delivery logs or written reports from a provider.

The HC must share with the SPT the results of the HC’s monitoring and follow-up activities.

 

5800 Community Living Options (CLO), Visits to Community Programs, and Educational Opportunities

Revision 19-0; Effective July 7, 2019

 

 

 

5810 Presenting CLO

Revision 19-0; Effective July 7, 2019

 

An HC provides information and discusses with an individual and LAR about the range of community living services, supports and alternatives, identifying the services and supports the individual will need to live in the community (whether or not the individual/LAR has chosen to transition to community living) and identifying and addressing barriers to community living. This activity is referred to as “CLO.”

CLO must be presented in a manner that allows the person and his or her LAR to fully understand the options available. Therefore, CLO duration may vary but should last as long as needed to completely and meaningfully present all available community living options. If there are barriers to the individual’s or LAR’s full understanding of CLO, the HC must document these barriers in Form 1054, Community Living Options, and how they will be addressed in Form 1057, Habilitation Service Plan (HSP).

 

5810.1 When CLO is Presented

Revision 19-0; Effective July 7, 2019

 

CLO is presented at the following times regardless of whether the individual is receiving or has refused habilitation coordination:

  • six months after the initial CLO (which was presented during the PE) and at least every six months thereafter, but no more than 30 days before the scheduled second quarterly SPT meeting or annual IDT/SPT meeting;
  • when requested by the individual or LAR;
  • when the HC is notified or becomes aware that the individual, or the LAR on the individual’s behalf, is interested in speaking with someone about transitioning to the community; and
  • when notified by HHSC that the individual’s response in Section Q of the MDS assessment indicates the individual is interested in speaking with someone about transitioning to the community.

Note: CLO is presented anytime a PE is completed, including for a resident review or Change of Ownership (CHOW).

 

5810.2 Six-Month Base Schedule

Revision 19-0; Effective July 7, 2019

 

The HC presents CLO to the individual/LAR six months after the initial CLO and at least every six months thereafter while the individual continues to reside in the NF. The HC must ensure the CLO presentation occurs no more than 30 days before the scheduled second quarterly SPT or annual IDT/SPT, so that it can be discussed during the meeting. The HC must maintain the every-six-month base schedule beginning with the initial CLO, even if an additional CLO was presented before the next six-month CLO is due.

 

5810.3 CLO Materials Provided to Individual/LAR

Revision 19-0; Effective July 7, 2019

 

The HC uses the following materials to present CLO and explains each of the materials using the person’s preferred method of communication, taking the time necessary to ensure that the individual and his or her LAR fully understand the materials and each of the individual’s community options:

*CLO booklets are available by ordering from Pinnacle Cart.

 

5820 Documenting CLO

Revision 19-0; Effective July 7, 2019

 

The HC documents the CLO presentation and discussion on Form 1054, Community Living Options.

Note: The HC also documents barriers from Sections 6 or 7 of Form 1054 in Section 7 of Form 1057, Habilitation Service Plan (HSP). See Section 5460.2, Habilitation Service Plan.

 

5830 HC Actions Following CLO

Revision 19-0; Effective July 7, 2019

 

The HC complies with the requirements in this section following:

  • the HC’s receipt of CLO information from the PE evaluator in accordance with Section 2430.5, Presenting Information about Community Services as Part of the PE; and
  • the HC’s presentation of CLO to the individual/LAR.

 

5830.1 Individual/LAR Wants to Transition and has Selected a Community Program

Revision 19-0; Effective July 7, 2019

 

If an individual wants to transition to the community and has selected a community program, the HC must, within three business days after receipt of CLO information from the PE evaluator or within three business days after the HC’s presentation of CLO,

  • send a referral using Form 1579, Referral for Relocation Services, to the individual’s MCO (see Appendix II, MCO Contact Information) so that a relocation specialist (RS) can be assigned and an assessment and evaluation completed within 14 days; and
  • notify the appropriate LIDDA staff to assign a service coordinator (SC) or an enhanced community coordinator (ECC) to begin transition planning with the individual and LAR.

The HC must:

  • ensure receipt of the RS’s assessment and evaluation;
  • review the RS’s assessment and evaluation to determine if specialized services can assist the individual with transitioning to the community and, if so, follow up with an SPT meeting to discuss the issue;
  • ensure the assigned SC/ECC receives a copy of the RS’s assessment and evaluation;
  • share a copy of the individual’s habilitation packet with the RS and SC/ECC; and
  • inform the RS of the name and contact information of the SC/ECC who will be facilitating transition planning for the individual.

 

5830.2 Individual/LAR Wants to Transition, but has NOT Selected Community Program

Revision 19-0; Effective July 7, 2019

 

If an individual wants to transition to the community, but has not selected the community program to pursue, the HC must, within three business days after receipt of CLO information from the PE evaluator or after the HC’s presentation of CLO, send a referral, using Form 1579, Referral for Relocation Services, to the individual’s MCO (see Appendix II, MCO Contact Information) so that an RS can be assigned and an assessment and evaluation completed within 14 days.

The HC must:

  • ensure receipt of the RS’s assessment and evaluation;
  • review the RS’s assessment and evaluation to determine if specialized services can assist the individual with transitioning to the community and, if so, follow up with an SPT meeting to discuss the issue;
  • share a copy of the individual’s habilitation packet with the RS;
  • work with the RS to assist the individual and LAR in selecting a community program that best suits the individual’s needs (Note: Waiver comparison chart is available here); and

if the individual has not refused habilitation coordination, ensure that if barriers to selecting a community program are identified in Section 7 of the completed Form 1054, Community Living Options, they are included in Section 7 of Form 1057, Habilitation Service Plan (HSP) for SPT discussion.

When the individual/LAR has selected a community program, the HC must:

  • notify the appropriate LIDDA staff to assign an SC or an ECC to begin transition planning with the individual and LAR;
  • share with the SC/ECC:
    • a copy of the RS’s assessment and evaluation; and
    • a copy of the individual’s habilitation packet; and
  • inform the RS of the name and contact information of the SC/ECC who will be facilitating transition planning for the individual.

 

5830.3 Individual/LAR Does Not Want to Transition, is Undecided or Desire of Individual/LAR Cannot be Determined

Revision 19-0; Effective July 7, 2019

 

For an individual who has not refused habilitation coordination, if the individual/LAR does not want to transition, is undecided or the desire of the individual/LAR cannot be determined, the HC must:

  • ensure that if barriers preventing a transition to the community are identified in Section 6 of Form 1054, Community Living Options, they are included in Section 7 of Form 1057, Habilitation Service Plan (HSP);
  • ensure the barriers are discussed at the next quarterly SPT meeting with the SPT identifying possible solutions to the barriers, how the SPT can implement the solutions and any needed follow-up activities; and
  • document the resolutions and actions for implementation in Section 7 of Form 1057.

 

5840 Exploring Community Programs

Revision 19-0; Effective July 7, 2019

 

An HC arranges exploratory visits to community programs for an individual, if requested, and addresses concerns about community living from the individual and LAR. Additionally, the HC may assist an individual and LAR with exploring different types of community programs using print and digital media, such as brochures, magazines, DVDs, virtual visit apps and virtual tours.

 

5850 Educational Opportunities

Revision 19-0; Effective July 7, 2019

 

An HC offers an individual and LAR the educational and informational opportunities that are required to be arranged by the LIDDA semiannually pursuant to the performance contract. An HC must document that the offer was made, including the specific educational or informational opportunity (i.e., description, location, date and time).

 

5900 Explanation of Rights

Revision 19-0; Effective July 7, 2019

 

An HC must initially, and annually thereafter, provide an individual and LAR an oral and written explanation of the individual’s rights contained in the “Your Rights in Local Authority Services” booklet.