5100, Required Face-to-Face Visits

Revision 22-1; Effective Nov. 28, 2022

The habilitation coordinator meets face-to-face* with a person monthly, or more frequently if needed, unless the only specialized service the person receives is habilitation coordination. In this case the habilitation coordinator meets face-to-face with the person  at least quarterly. Based on these requirements, the service planning team (SPT) determines the frequency of face-to-face visits. A face-to-face meeting with the person must include the provision of at least one of the habilitation coordination activities described in this section.

*HHSC may waive the face-to-face requirement for habilitation coordination in extenuating circumstances including natural disasters, pandemics, or other declared emergencies. HHSC will provide policy guidance about face-to-face flexibilities through rule making, broadcasts, information letters or other communications.

5200, Assess or Reassess Habilitative Needs

Revision 22-1; Effective Nov. 28, 2022

The habilitation coordinator must assess and periodically reassess a person’s habilitative service needs by gathering information from the person and other appropriate sources, such as the legally authorized representative (LAR), family members, social workers and service providers. This will determine the person’s habilitative needs and the specialized services that will address those needs.

The habilitation coordinator must complete Form 1064, Habilitative Assessment, for the person, whether or not the he or she  will receive or has refused habilitation coordination:

  • within 75 calendar days following the initial interdisciplinary team (IDT) meeting; and
  • between 10 and 60 calendar days before the scheduled annual IDT meeting.

The habilitation coordinator ensures the completed assessment is sent to each SPT member at least 10 business days before the first quarterly SPT meeting after the initial IDT and SPT meeting and before the annual IDT and SPT meeting. 

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

5210 Reviewing Assessments

Revision 22-1; Effective Nov. 28, 2022

The habilitation coordinator 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 person can benefit from the specialized service,* the habilitation coordinator  monitors to determine that the service begins in the amount, frequency and duration identified on the assessment;
  • the person cannot benefit from the specialized service, the habilitation coordinator convenes the SPT to discuss how the identified outcome can be met; and
  • an outcome or goal that was not previously identified, the habilitation coordinator convenes the SPT to discuss the newly identified outcome or goal.

*A person can benefit from a specialized service if the service will help the person acquire new skills, maintain skills, or delay or slow the loss of skills or functioning.
Reviewing assessments provides a more comprehensive understanding of a person’s strengths, preferences and service needs, and helps SPT members outline services to meet the person’s identified goals and objectives. As the facilitator of the SPT meeting, the habilitation coordinator must ensure the needs identified in all assessments are addressed.
HHSC encourages the habilitation coordinator to bring copies of all current assessments to the SPT meeting, so that the SPT can review and discuss recommendations. The habilitation coordinator must provide copies of assessments to the nursing facility (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:

  • PASRR Evaluation (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 before admission to an NF, if still applicable (e.g., CFC Personal Assistance Services/Habilitation (PAS/HAB) assessment).

5300, SPT Meetings

Revision 22-1; Effective Nov. 28, 2022

The habilitation coordinator must convene and facilitate SPT meetings as described in this section for a person receiving habilitation coordination.

The habilitation coordinator must ensure that all members of the SPT receive sufficient notice to participate in the SPT meeting (at least 10 business days before the scheduled SPT meeting).

By facilitating the SPT meeting, the habilitation coordinator helps SPT members accomplish their responsibilities, which are to:

  • ensure that the person, whether or not they have 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 person’s need for specialized services;
  • develop Form 1057, Habilitation Service Plan (HSP), for the person;
  • 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 person’s preferences, monitor to determine if he or she is given 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 habilitation coordinator, the habilitation coordinator 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 habilitation coordinator must ensure the member’s name is included on the sign-in sheet. The habilitation coordinator must maintain all sign-in sheets.

5310 First SPT Meeting

Revision 22-1; Effective Nov. 28, 2022

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

5320 Quarterly SPT Meetings

Revision 22-1; Effective Nov. 28, 2022

The initial or annual SPT meeting date sets the base schedule for the quarterly SPT meetings held between it and the next annual SPT meeting. 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 two weeks after the three-month mark, as set by the base schedule. Note that the base schedule only resets annually and does not reset with each quarterly SPT meeting.

The habilitation coordinator must maintain the every-three-month base schedule regardless of when a particular quarterly SPT meeting takes place. HHSC permits a habilitation coordinator to revise a person’s schedule for quarterly SPT meetings to accommodate alignment with the NF’s care plan meeting schedule, if the new date is within two weeks of the base schedule. Revising a person’s schedule for quarterly SPT meetings requires detailed documentation in the habilitation coordinator’s progress notes. The habilitation coordinator 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 22-1; Effective Nov. 28, 2022

During each quarterly SPT meeting, the SPT must:

  • review all assessments conducted since the last SPT meeting to determine:
    • if the person 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 person to evaluate the effectiveness and adequacy of specialized services, including reviewing the written reports submitted by SPT members that are providers 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 if the person is maintaining progress toward outcomes; and
  • if CLO was conducted since the last quarterly SPT meeting, review and discuss the person’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 or Form 1063, Individual Profile – Nursing Facility requires revisions based on the quarterly SPT meeting, the habilitation coordinator must revise Form 1057 or Form 1063 as needed and send it to the SPT members. They must do this within 10 calendar days after the meeting.

5320.2 Documenting Summary of Quarterly SPT Meeting

Revision 22-1; Effective Nov. 28, 2022

The habilitation coordinator 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 22-1; Effective Nov. 28, 2022

Within five calendar days after a quarterly SPT meeting, the habilitation coordinator enters in the Long-Term Care (LTC) online portal all required information on the PASRR Comprehensive Service Plan (PCSP) form.

5330 Update SPT Meetings

Revision 22-1; Effective Nov. 28, 2022

The habilitation coordinator must convene an update SPT meeting: 

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

The habilitation coordinator 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 habilitation coordinator must revise Form 1057 or Form 1063, as needed, and send it to the SPT members, within 10 calendar days after the meeting.
Within five calendar days after an update SPT meeting is held per the information in this section, the habilitation coordinator enters in the LTC online portal all required information on the PCSP form.

5340 Annual IDT and SPT Meeting

Revision 22-1; Effective Nov. 28, 2022

5340.1 Annual IDT/SPT Meeting

Revision 22-1; Effective Nov. 28, 2022

An annual IDT and SPT meeting is held for a person even if the person is receiving habilitation coordination or any other specialized service. The habilitation coordinator is responsible for inviting all SPT members to the annual IDT and SPT meeting.

Note: If the person has refused habilitation coordination, then there is no SPT for them, but the habilitation coordinator still must attend the annual IDT meeting. The NF is responsible for inviting IDT members to the annual IDT meeting.  
The IDT and SPT members must discuss Form 1064, Habilitative Assessment, conducted by the habilitation coordinator and all recommended specialized services and decide:

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

The habilitation coordinator must confirm the annual IDT and SPT meeting information in the LTC online portal on the PCSP form per Section 2520, Confirmation of IDT and SPT Meeting Information.

5340.2 Preparation for Annual IDT and SPT Meeting

Revision 22-1; Effective Nov. 28, 2022

The habilitation coordinator must complete Form 1064, Habilitative Assessment, for the person between 10 and 60 calendar days before the scheduled annual IDT and SPT meeting regardless of if the person is receiving habilitation coordination or any other specialized service. The habilitation coordinator provides a copy of the completed Form 1064 to all IDT and SPT members at least 10 business days before the annual IDT and SPT meeting.

5340.3 IDT Agrees to Habilitation Coordination

Revision 22-1; Effective Nov. 28, 2022

If the IDT agrees to the provision of habilitation coordination for the person, the habilitation coordinator requests a renewal authorization for habilitation coordination per the Habilitation Coordination Billing Guidelines.

5340.4 Refusal of Habilitation Coordination

Revision 22-1; Effective Nov. 28, 2022

If an eligible person or LAR does not want habilitation coordination:

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

5340.5 Annual SPT Meeting

Revision 22-1; Effective Nov. 28, 2022

If the IDT agrees to the provision of habilitation coordination for an person, the habilitation coordinator convenes the annual SPT meeting immediately after 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 22-1; Effective Nov. 28, 2022

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

  • submit to the habilitation coordinator a copy of all assessments of the person completed by the provider;
  • at least five calendar days before a quarterly or annual SPT meeting, submit to the habilitation coordinator a written report describing the person’s progress or lack of progress;
  • provide the habilitation coordinator with a copy of the provider’s implementation plan for the person’s specialized service if requested; and
  • actively participate in an SPT meeting, in person or by phone, unless the habilitation coordinator 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 22-1; Effective Nov. 28, 2022

If the habilitation coordinator 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 habilitation coordinator must:

  • base the determination on:
    • the information in the written report submitted per 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 22-1; Effective Nov. 28, 2022

This section gives guidance when the habilitation coordinator receives information from a person or LAR that they will not attend a scheduled SPT meeting.

  • Offer to reschedule the SPT meeting. Ask the person or LAR for a date and time they prefer and work with them to reschedule.
  • Provide adequate notice of the meeting. “Adequate notice” may mean something different to each person or LAR. An LAR may need several weeks’ notice. For a person who is disturbed by SPT meeting preparations, one hour may be adequate notice.
  • Offer to change the location of the SPT meeting. A person may prefer the meeting in their room instead of a conference room.
  • Offer the person 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 person or LAR. Note that a provider agency representative may attend for two or more service providers if the representative is knowledgeable about the person’s services, implementation plans, progress or lack of progress, and satisfaction with services.
  • If a person or LAR states that the SPT meeting should proceed without them, the habilitation coordinator must find out what topics they want discussed at the meeting and afterward share with the person or LAR a summary of the discussion and the results of the SPT meeting.
  • If a person absolutely refuses to attend or participate in SPT meetings, the habilitation coordinator must initiate an SPT discussion about why the person 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 22-1; Effective Nov. 28, 2022

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

5410 Person-Centered Planning

Revision 22-1; Effective Nov. 28, 2022

Person-centered planning helps a person discover and describe what they need from services and from the service provider. The goal is to improve the person’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 person and the LAR.

See the HHS website for more information about person-centered planning, including training.

5420 Discovery Process

Revision 22-1; Effective Nov. 28, 2022

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  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 habilitation coordinator talks to the person or those who know the person best. The habilitation coordinator  leads the discovery process, advocating on behalf of the person whose services and supports are being planned, and records the information learned so that it can be used when developing or updating Form 1057, Habilitation Service Plan (HSP).

5430 Developing Habilitation Service Plan and Individual Profile

Revision 22-1; Effective Nov. 28, 2022

Form 1057, Habilitation Service Plan (HSP), and Form 1063, Individual Profile – Nursing Facility, identify a person’s strengths, preferences, psychiatric, behavioral, nutritional management 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;
  • Client Assignment and Registration system (CARE) (e.g., diagnostic data, previous local intellectual and developmental disability (LIDDA) services); and
  • previous 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 person’s needs, achieve the desired outcomes, and maximize the person’s ability to live successfully in the most integrated setting appropriate to their needs. 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 person’s desired outcomes.

The HSP year:

  • begin date is the date of the initial IDT and 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 22-1; Effective Nov. 28, 2022

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 22-1; Effective Nov. 28, 2022

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 person's identified needs, interest and desired outcomes.

5430.3 Frequency and Duration of Habilitation Coordination

Revision 22-1; Effective Nov. 28, 2022

The duration for habilitation coordination is “while the person 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 per  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 22-1; Effective Nov. 28, 2022

If barriers are identified during CLO and described in Sections 6 or 7 of Form 1054, Community Living Options, the habilitation coordinator initiates at an SPT meeting a discussion of  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 person’s 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 a person’s transition to the community is an inability to navigate public transportation, then the person may benefit from receiving independent living skills training with an outcome of learning how to use the public bus system.

The habilitation coordinator 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 22-1; Effective Nov. 28, 2022

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 and sent to the SPT members within 10 calendar days following the SPT meeting in which the revisions were agreed upon.

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

Revision 22-1; Effective Nov. 28, 2022

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 person can benefit from the service, the HSP includes:
    • the amount, frequency and duration from the assessment, except for CMWC or DME; and
    • the goals from the assessment.
  • If the person 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 person is receiving day habilitation five days per week and a therapy assessment shows they need 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 person's record.

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

Revision 22-1; Effective Nov. 28, 2022

An assessment must be conducted for behavioral support, employment assistance and supported employment. The information included in a completed assessment indicates whether the person 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 person can benefit from the service, the HSP includes the amount, frequency and duration. If the assessment identifies an additional outcome, include the additional outcome in Section 5 of the HSP as an additional outcome action plan if agreed to by the SPT.
  • If the person 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 person’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 person's record.

5440.3 Revising the HSP to Address Barriers Identified During CLO

Revision 22-1; Effective Nov. 28, 2022

If barriers are during CLO and described in Sections 6 or 7 of Form 1054, Community Living Options, the habilitation coordinator initiates at an SPT meeting a discussion of  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 person 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 a person’s transition to the community is an inability to navigate public transportation, then the person may benefit from receiving independent living skills training with an outcome of learning how to use the public bus system.

The habilitation coordinator 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 22-1; Effective Nov. 28, 2022

Following an annual SPT meeting, the habilitation coordinator 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 person 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 person and 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 and 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 and 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 and SPT meeting to take place as early as 334 calendar days after the initial or previous annual IDT and 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 22-1; Effective Nov. 28, 2022

A complete habilitation packet for a person 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  NF baseline care plan or comprehensive care plan, whichever is most current.

5460.1 Individual Profile

Revision 22-1; Effective Nov. 28, 2022

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

Section 1, Individual’s Information — This section gathers identifying information about a person as well as contact information for the person, LAR and primary contact, if any, and information about a person’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 person’s life and who can provide information about the person, such as family, friends, mentor and clergy.

Section 4, Profile Information — This section provides an overall profile of a person’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 person’s strengths and what others like and admire about the person.

These are my preferences and what is important to me: A descriptive narrative about what is important to the person. “Important to” reflects what is important from the person’s perspective and is based on the person’s words and behavior. When words or behavior are in conflict, listen to the behavior. The information might include important relationships, how the person prefers to interact, things the person likes to do or not do, preferred routines, relevant background information that may affect how services should be delivered and what the person wants to do in the future. Remember, the person’s response is limited to the knowledge and experiences they have to date. Additional efforts should be explored to increase awareness of o possibilities and experiences to increase  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 person, 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 person. All specific areas listed below must be addressed and include specificity about health needs, risk factors and special instructions for those who support the person. See Appendix IV, Risk Factors, for more information about identifying risks.

  • Communication — A descriptive narrative about how the person communicates and how to best communicate with the person. Describe the person’s communication-related needs. For instance, what is the person’s primary or preferred method of communication? How does the person communicate or express a need (gestures, sounds, facial expressions, adaptive equipment, etc.)? What is the best way to determine if the person is expressing satisfaction, happiness, comfort or agreement, as opposed to dissatisfaction, unhappiness, discomfort or disagreement? Among those who know the person best, who seems better able to interpret what the person is trying to communicate? What is the best way for others to learn how to communicate effectively with the person?
  • Nursing Care — A description of the person’s nursing-related needs, such as assistance taking medication, suctioning, wound care and oxygen. Describe how staff should attend to the person’s nursing needs.
  • Clinical (Behavioral/Mental Health) — A description of the person’s behavioral health and mental health-related needs. What kind of behavior supports does the person need? Does the person 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 person and how they are funded (e.g., Medicaid, personal funds) or obtained (e.g., leased, purchased).
  • Nutrition Management — A description of the person’s nutritional-related needs (e.g., thickened, pureed, textured, use of supplements, food allergies or restrictions, choking risk).
  • Supervision Needs — A description of the person’s supervision needs. Consider if there are any personal issues that might present risk for harm in the person’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 person 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 person or their services.

5460.2 Habilitation Service Plan

Revision 22-1; Effective Nov. 28, 2022

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

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

Section 2, Discovery — This section describes all the ways information was gathered to discover a person’s desires and preferences, such as observation of the person and conversations with the person or LAR and those who know the person best, such as a 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 person and the habilitation coordinator. The duration of habilitation coordination is while the person is living 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  may be either at least monthly or at least quarterly.

This section also lists all the activities to be coordinated and monitored by the habilitation coordinator. 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 habilitation coordinator. The PASRR rules provide a definition of “NF PASRR support activities” and includes the following examples of support activities:

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

Note: The examples above are not all inclusive. A support activity can be any type of activity that supports the person 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 person 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 person receives that will help the person 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 or natural support listed, a description is necessary of how the specialized service or resource or natural support helps the person achieve the outcome.

Note: While a 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 person 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 person during the HSP year, including:

  • the goals for the service as identified by the licensed therapist on the therapy assessment or as identified by the LMHA or LBHA staff;
  • the amount, frequency and duration of the service; and
  • if 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 the habilitation coordinator presents CLO to the person or 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 person, 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 where 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 habilitation coordinator to affirm that the HSP was developed based on IDT or SPT decisions and includes the habilitation coordinator’s printed name, signature and date.

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

Revision 22-1; Effective Nov. 28, 2022

The habilitation coordinator 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 within 10 calendar days after the SPT meeting during which they were developed  or revised.

The habilitation coordinator must share a person’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 22-1; Effective Nov. 28, 2022

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 person, then:

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

5500, Assisting with Access to Needed Specialized Services

Revision 22-1; Effective Nov. 28, 2022

5510 Initiating IDD Habilitative Specialized Services

Revision 22-1; Effective Nov. 28, 2022

The habilitation coordinator is responsible for initiating IDD habilitative specialized services identified on a person’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 person 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 22-1; Effective Nov. 28, 2022

The habilitation coordinator must document the initiation and delivery of all specialized services agreed upon in an IDT meeting or an SPT meeting.

The habilitation coordinator 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 habilitation coordinator 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 per the performance contract.

5530 Accessing Other Habilitative Programs

Revision 22-1; Effective Nov. 28, 2022

The habilitation coordinator must help a person access needed specialized services and other habilitative programs and services that can provide services to address the person’s needs and achieve outcomes identified in the HSP.

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

Revision 22-1; Effective Nov. 28, 2022

If a person is denied a specialized service and the person or LAR wants to appeal the denial, the habilitation coordinator is responsible for helping the person or LAR with requesting a fair hearing. Form 2361, PASRR Specialized Services Fair Hearing Request may be used for this purpose.

5600, Coordination

Revision 22-1; Effective Nov. 28, 2022

The habilitation coordinator 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 a person’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 a person achieve a quality of life acceptable to the person and LAR .

5700, Monitoring and Follow-up Activities

Revision 22-1; Effective Nov. 28, 2022

The habilitation coordinator must provide monitoring and follow-up activities to determine:

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

Monitoring  is accomplished through a combination of:

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

When monitoring progress or lack of progress and satisfaction, the habilitation coordinator must be sure to include the perspective of the person and LAR.

The habilitation coordinator must share the results of the habilitation coordinator’s monitoring and follow-up activities with the STP .

5800, Community Living Options, Visits to Community Programs, and Educational Opportunities

Revision 22-1; Effective Nov. 28, 2022

5810 Presenting CLO

Revision 22-1; Effective Nov. 28, 2022

The habilitation coordinator provides information and discusses with a person and LAR the range of community living services, supports and alternatives. They identify the services and supports the person will need to live in the community, if the person or LAR has chosen to transition to community living, and identify and address barriers to community living. This activity is referred to as “CLO.”

Present CLO in a manner that allows the person and 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 person’s or LAR’s full understanding of CLO, the habilitation coordinator 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 22-1; Effective Nov. 28, 2022

CLO is presented at the following times regardless of whether the person 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. HHSC recommends that CLO be completed no more than 30 days before the scheduled second quarterly SPT meeting or annual IDT and SPT meeting, so that it can be discussed during the meeting.
  • When requested by the person or LAR.
  • When the habilitation coordinator is notified or becomes aware that the person or LAR is interested in speaking with someone about transitioning to the community.
  • When notified by HHSC that the person’s response in Section Q of the MDS assessment indicates the person 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.

*Some people and LARs who have refused habilitation coordination or are not interested in transitioning to the community may be reluctant to receive CLO every six months. As part of a person-centered approach, the habilitation coordinator should remain sensitive to the person’s or LAR’s preferences, ensure the person and LAR understand the importance of presenting CLO, and conduct CLO activities in a way that is responsive to the person’s or LAR’s concerns.

5810.2 Six-month Base Schedule

Revision 22-1; Effective Nov. 28, 2022

The habilitation coordinator presents CLO to the person or LAR six months after the initial CLO and at least every six months thereafter while the person continues to reside in the NF. The habilitation coordinator 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 or LAR

Revision 22-1; Effective Nov. 28, 2022

The habilitation coordinator 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 person and  LAR fully understand the materials and each of the person’s community options:

*CLO booklets are available by ordering from Pinnacle Cart.

5820 Documenting CLO

Revision 22-1; Effective Nov. 28, 2022

The HC documents the CLO presentation and discussion on Form 1054, Community Living Options. The habilitation coordinator must fill out Section 4 on Form 1054 whether the person is interested in transitioning to the community or not.

Note: The habilitation coordinator 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 Habilitation Coordinator Actions Following CLO

Revision 22-1; Effective Nov. 28, 2022

The habilitation coordinator complies with the requirements in this section following:

  • the habilitation coordinator’s receipt of CLO information from the PE evaluator per Section 2430.5, Presenting Information about Community Services as Part of the PE; and
  • the habilitation coordinator’s presentation of CLO to the person or LAR.

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

Revision 22-1; Effective Nov. 28, 2022

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

  • send a referral using Form 1579, Referral for Relocation Services, to the person’s  managed care organization (MCO) (see Appendix II, MCO Contact Information) so that a relocation specialist (RS) can be assigned and an assessment and evaluation completed within 14 calendar 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 person and LAR.

The habilitation coordinator must:

  • ensure receipt of the RS’s assessment and evaluation;
  • review the RS’s assessment and evaluation to determine if specialized services can help the person transition 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 person’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 person.

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

Revision 22-1; Effective Nov. 28, 2022

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

  • ensure receipt of the RS’s assessment and evaluation;
  • review the RS’s assessment and evaluation to determine if specialized services can help the person transition to the community and, if so, follow up with an SPT meeting to discuss the issue;
  • share a copy of the person’s habilitation packet with the RS;
  • work with the RS to help the person and LAR in selecting a community program that best suits the person’s needs. Note: Waiver comparison chart is available here; and
  • if the person 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 person or LAR has selected a community program, the habilitation coordinator must:

  • notify the appropriate LIDDA staff to assign an SC or an ECC to begin transition planning with the person and LAR;
  • share with the SC/ECC:
    • a copy of the RS’s assessment and evaluation; and
    • a copy of the person’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 person.

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

Revision 22-1; Effective Nov. 28, 2022

For a person who has not refused habilitation coordination, if the person or LAR does not want to transition, is undecided or the desire of the person or LAR cannot be determined, the habilitation coordinator 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 22-1; Effective Nov. 28, 2022

The habilitation coordinator arranges exploratory visits to community programs for a person, if requested, and addresses concerns about community living from the person and LAR. Additionally, the habilitation coordinator may assist a person 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 22-1; Effective Nov. 28, 2022

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

5900, Additional Habilitation Coordinator Responsibilities

Revision 22-1; Effective Nov. 28, 2022

5910 Explanation of Rights

Revision 22-1; Effective Nov. 28, 2022

The habilitation coordinator must initially, and annually thereafter, provide a person and LAR an oral and written explanation of the person’s rights contained in the “Your Rights in Local Authority Services” booklet.

Rights booklets are available on the HHS website. Rights booklets may also be ordered by sending an email to OmbudsmanIDD@hhs.texas.gov.

The habilitation coordinator must document every time the habilitation coordinator gives the written and oral explanations to the person, LAR, or actively involved person. The documentation must be signed by the person or LAR and the habilitation coordinator.

5920 Activities Related to Guardianship

Revision 22-1; Effective Nov. 28, 2022

5920.1 Individual Has a Guardian

Revision 22-1; Effective Nov. 28, 2022

The habilitation coordinator must determine annually if the letters of guardianship for a person are current. The letter of guardianship is required to be renewed in the county court annually. The habilitation coordinator annually must request the current letter of guardianship and keep a copy in the person’s record.

The habilitation coordinator must document in the HSP whether the letter of guardianship is current.

If the letter of guardianship is not current, the habilitation coordinator must provide a reminder to the guardian that a renewal needs to be completed and document that the guardian was provided this reminder.

5920.2 Individual Does Not Have a Guardian

Revision 22-1; Effective Nov. 28, 2022

If a person does not have a guardian and may benefit from having one, the habilitation coordinator, along with the SPT, must assess if the person needs a guardian or would benefit from a less restrictive alternative to guardianship, and must document this discussion. If the SPT believes guardianship is the least restrictive option, the habilitation coordinator makes appropriate referrals, such as to the local probate court.

See Appendix III, Legal Authority to Make Decisions, for information about types of guardianship and alternatives.