7000, Implementation Plan and Service Backup Plan

7100 Implementation Plan Overview

Revision 21-2; Effective November 8, 2021

The Implementation Plan (IP) is developed by the individual, the individual’s legally authorized representative (LAR) and the program provider. The IP addresses every Home and Community-based Services (HCS) service the individual receives through the program provider.

The program provider is not required to develop an IP for an HCS service provided though the Consumer Directed Services (CDS) Option. Developing an IP for HCS program services delivered through the CDS Option is a responsibility of the CDS employer.

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

An HCS provider may use Form 2125, Implementation Plan - HSC/TxHmL/CFC, or another document that includes the same elements in Form 2125. A nursing care plan, a behavior support plan or other plans completed by HCS service providers may serve as the IP if those plans include all required elements of the IP as defined in 40 Texas Administrative Code §9.153(51).

 

7200 Implementation Plan Elements

Revision 21-2; Effective November 8, 2021

 

7210 Desired Outcome(s)

Revision 21-2; Effective November 8, 2021

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

 

7220 Conversation, Observation and Formal Assessment

Revision 21-2; Effective November 8, 2021

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

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

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

 

7230 Implementation Strategies

Revision 21-2; Effective November 8, 2021

The implementation strategies are individualized and allow for evaluation of progress in achieving each desired outcome. Strategies are the steps that contribute to reaching desired outcomes. Depending on the outcome, the IP may contain one or more strategies that lead to the individual's acquisition of additional skills or describe actions to be completed by paid supports to achieve an outcome. There is no prescribed number of strategies for each outcome. Strategies are written in observable, measurable or outcome-oriented terms. Measurable means a person can consistently and reliably determine whether an action or event has occurred. Observable means the action or event can be detected using one or more of the five senses: sight, hearing, touch, taste or smell. Outcome-oriented means that it can be determined when a desired result has been achieved.

 

7240 Signing the Implementation Plan (IP)

Revision 21-2; Effective November 8, 2021

Once the IP has been developed, the IP must be signed and dated by the individual, LAR and the program provider to verify that they have participated in the development of the IP.

 

7300 Provider Monitoring of Service Delivery

Revision 21-2; Effective November 8, 2021

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

The program provider must document services provided as specified in the implementation plan and verify the requirements for reimbursement, as defined in the HCS Program Billing Requirements, have been met. The IP and documentation related to service delivery may also be used by HHSC utilization review staff when determining whether to authorize the Individual Plan of Care (IPC).

 

7310 Example of Documenting Observable Strategies

Revision 21-2; Effective November 8, 2021

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

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

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

This example indicates that Johnny appropriately performed many of the steps associated with making a purchase, but he continues to require assistance with determining the total dollar amount to complete the purchase. The program provider is responsible for reviewing staff documentation to determine Johnny’s progress or lack of progress in reaching the desired outcome.

 

7320 Example of Measurable Strategies

Revision 21-2; Effective November 8, 2021

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

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

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

Note: When using data sheets for measuring progress, be sure that the criteria does not “lock” the individual into a perpetual loop. The individual should be provided with the adequate support to reach their desired outcomes and strategies should be adjusted to assist the individual to do so. When success is not occurring, staff should note their observations on the data sheet and the program provider should assess whether the strategies remain effective.

Example: Staff documented that Johnny does not appear to be motivated to use his walker inside the house. However, Johnny expressed to staff that he enjoys checking the mailbox at the end of the driveway. Staff observed that he consistently uses his walker when he is provided the opportunity to complete this task.

 

7330 Example of Documenting Outcome Oriented Strategies

Revision 21-2; Effective November 8, 2021

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

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

Staff Documentation: Staff took Johnny to the American Cancer Society today so that he could sign up to participate in the annual cancer research walk/run.

 

7400 Revising the Implementation Plan

Revision 21-2; Effective November 8, 2021

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

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

 

7500 Service Backup Plan

Revision 21-2; Effective November 8, 2021

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

  • contain the name of the critical service;
  • specify the period of time in which an interruption to the critical service would result in an adverse effect to the individual’s health or safety; and
  • describe the actions the program provider will take to ensure the individual’s health and safety in the event of an interruption to the critical service.

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

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

7100, Implementation Plan Overview

Revision 21-2; Effective November 8, 2021

The Implementation Plan (IP) is developed by the individual, the individual’s legally authorized representative (LAR) and the program provider. The IP addresses every Home and Community-based Services (HCS) service the individual receives through the program provider.

The program provider is not required to develop an IP for an HCS service provided though the Consumer Directed Services (CDS) Option. Developing an IP for HCS program services delivered through the CDS Option is a responsibility of the CDS employer.

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

An HCS provider may use Form 2125, Implementation Plan - HSC/TxHmL/CFC, or another document that includes the same elements in Form 2125. A nursing care plan, a behavior support plan or other plans completed by HCS service providers may serve as the IP if those plans include all required elements of the IP as defined in 40 Texas Administrative Code §9.153(51).

7200, Implementation Plan Elements

7210 Desired Outcome(s)

Revision 21-2; Effective November 8, 2021

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

 

7220 Conversation, Observation and Formal Assessment

Revision 21-2; Effective November 8, 2021

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

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

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

 

7230 Implementation Strategies

Revision 21-2; Effective November 8, 2021

The implementation strategies are individualized and allow for evaluation of progress in achieving each desired outcome. Strategies are the steps that contribute to reaching desired outcomes. Depending on the outcome, the IP may contain one or more strategies that lead to the individual's acquisition of additional skills or describe actions to be completed by paid supports to achieve an outcome. There is no prescribed number of strategies for each outcome. Strategies are written in observable, measurable or outcome-oriented terms. Measurable means a person can consistently and reliably determine whether an action or event has occurred. Observable means the action or event can be detected using one or more of the five senses: sight, hearing, touch, taste or smell. Outcome-oriented means that it can be determined when a desired result has been achieved.

 

7240 Signing the Implementation Plan (IP)

Revision 21-2; Effective November 8, 2021

Once the IP has been developed, the IP must be signed and dated by the individual, LAR and the program provider to verify that they have participated in the development of the IP.

7300, Provider Monitoring of Service Delivery

Revision 21-2; Effective November 8, 2021

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

The program provider must document services provided as specified in the implementation plan and verify the requirements for reimbursement, as defined in the HCS Program Billing Requirements, have been met. The IP and documentation related to service delivery may also be used by HHSC utilization review staff when determining whether to authorize the Individual Plan of Care (IPC).

 

7310 Example of Documenting Observable Strategies

Revision 21-2; Effective November 8, 2021

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

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

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

This example indicates that Johnny appropriately performed many of the steps associated with making a purchase, but he continues to require assistance with determining the total dollar amount to complete the purchase. The program provider is responsible for reviewing staff documentation to determine Johnny’s progress or lack of progress in reaching the desired outcome.

 

7320 Example of Measurable Strategies

Revision 21-2; Effective November 8, 2021

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

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

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

Note: When using data sheets for measuring progress, be sure that the criteria does not “lock” the individual into a perpetual loop. The individual should be provided with the adequate support to reach their desired outcomes and strategies should be adjusted to assist the individual to do so. When success is not occurring, staff should note their observations on the data sheet and the program provider should assess whether the strategies remain effective.

Example: Staff documented that Johnny does not appear to be motivated to use his walker inside the house. However, Johnny expressed to staff that he enjoys checking the mailbox at the end of the driveway. Staff observed that he consistently uses his walker when he is provided the opportunity to complete this task.

 

7330 Example of Documenting Outcome Oriented Strategies

Revision 21-2; Effective November 8, 2021

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

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

Staff Documentation: Staff took Johnny to the American Cancer Society today so that he could sign up to participate in the annual cancer research walk/run.

7400, Revising the Implementation Plan

Revision 21-2; Effective November 8, 2021

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

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

7500, Service Backup Plan

Revision 21-2; Effective November 8, 2021

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

  • contain the name of the critical service;
  • specify the period of time in which an interruption to the critical service would result in an adverse effect to the individual’s health or safety; and
  • describe the actions the program provider will take to ensure the individual’s health and safety in the event of an interruption to the critical service.

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

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