Revision 20-0; Effective August 25, 2020

 

If the person has expressed an interest in alternative placement, other than the nursing facility (NF), the local mental health authority (LMHA)/local behavioral health authority (LBHA) is responsible for providing information related to the alternative placement. This would include availability, waiting list, accessibility, cost and other pertinent information relative to the requested alternative placement.  

If after receiving information the person wishes to pursue alternative placement, the LMHA/LBHA is responsible for providing the supports necessary to coordinate and assist with the transition. Once the transition is completed, the LMHA/LBHA shall update the uniform assessment (UA) and Person-Centered Recovery Plan (PCRP) to indicate that the person has transferred to alternate placement in the community.  

 

5100 LMHA/LBHA Role in Alternative Placement

Revision 20-0; Effective August 25, 2020

 

Throughout the Preadmission Screening and Resident Review (PASRR) process, the Qualified Mental Health Professional-Community Services (QMHP-CS) shall serve as an advocate for the person’s desires related to community relocation. During completion of the PASRR Level 1 (PL1), the person is given the opportunity to discuss alternatives to an NF placement and the person’s preferences shall be recorded on the PL1.  

During the PASRR Evaluation (PE) process, the person is again given the opportunity to discuss alternatives to NF placement. When the person indicates living somewhere other than an NF, the LMHA/LBHA must complete Section F of the PE. 

Section F of the PE records the individual’s previous community living experiences, alternate placement preferences, alternate placement options, barriers to community living, supports needed for successful community living and referrals made for alternate placement.

To complete Section F of the PE, the LMHA/LBHA must select the program of interest to the person for which they are eligible. 

Following completion of Section F of the PE, the LMHA/LBHA shall make a referral to the program of interest to the person. The LMHA/LBHA must add the date the referral was made, the phone number of the person the referral was made to, and any additional comments relating to the referral. Once these steps are completed, the LMHA/LBHA may submit the PE.

If a person has indicated that they would like to live somewhere other than an NF, and the referral field in Section F is left blank or not fully completed, PASRR staff will contact the LMHA/LBHA to ensure that Section F is completed.

Alternate placement shall also be discussed during the Interdisciplinary Team (IDT) meeting. The results of the discussion shall be recorded on the PASRR Comprehensive Service Plan (PCSP) form. 

The QMHP-CS shall keep the alternative placement option part of ongoing discussions with the person and during all meetings. When a person is ready to begin to pursue alternate placement, the QMHP-CS shall revise the Person-Centered Recovery Plan (PCRP) to include the transition process. The QMHP-CS must also engage the LMHA/LBHA housing resources, if needed, at the point seeking and/or securing alternative housing become part of the PCRP to ensure all potential resources are made available.

 

5110 Completion of PASRR Level 1, Section E, Prior to Transition

Revision 20-0; Effective August 25, 2020

 

Section E of the PASRR Level 1 (PL1) records the disposition of the location where the person went after leaving the NF.  

When an NF informs an LMHA/LBHA a person is leaving the NF, the LMHA/LBHA must complete Section E of the PL1 before the person has been discharged on the PL1.  

When a person left the NF and the LMHA/LBHA was not notified, Section E cannot be completed if the person has been discharged on the PL1. The LMHA/LBHA must add a note to the Form History to record the disposition of the location where the person went. 

If there is no documentation on the PL1 regarding the disposition, PASRR staff will contact the LMHA/LBHA and request this be completed.

 

5120 Transition and Relocation to Community Living

Revision 20-0; Effective August 25, 2020

 

The transition process must include the person, the Legally Authorized Representative (LAR) and others involved in the person’s life who may assist in the transition.

At the time the person is discharged from the NF, the QMHP-CS must conduct an updated UA.  During the process of completing an updated UA, the person’s place of residence must be changed on the PL1 in Section 4, Community Data, from Nursing Home to the correct new residence type.

It is encouraged to admit the person in a high enough level of care (LOC) to ensure adequate support during the first 90 to 180 days. This may require the QMHP-CS to deviate from the recommended LOC to an LOC that will be intense enough to better meet the person’s transition needs. Services must be provided in accordance with Texas Administrative Code 25, Part 1, Chapter 416, Mental Health Community-based Services.

At the point when a person is no longer a resident of the NF, the services provided are no longer PASRR specialized services. They are now community-based Texas Resiliency and Recovery services based on their LOC and the updated PCRP. The transition process will most likely require a transfer to a different QMHP-CS provider. The transition to a new QMHP-CS provider must be completed with minimal confusion or instability.