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.