LON 9 Documentation

The following documents must be submitted to the Health and Human Services Commission to support the Inventory for Client and Agency Planning ratings and increased supports and services being provided to a person in the Intermediate Care Facilities for Individuals with an Intellectual Disability or Related Conditions program, the Home and Community-based Services program or the Texas Home Living* program that warrants an increased level of need due to extremely dangerous or life-threatening behavior.

*All reimbursement for TxHmL is based on LON 5.

Submission Requirements

  • Form 8603, Level of Need (LON) Review/Increase Cover Sheet
  • Cover letter addressing the following:
    • Description of the life-threatening behavior that requires one-to-one staff coverage for at least 16 hours per day
    • Historical information, including the frequency and severity of the life-threatening behaviors
    • Negative outcomes directly related to the behaviors
    • Work schedule and staffing patterns of all 1:1 staff for the person, including day habilitation staff
  • Complete copy of the current ICAP response booklet and computer scoring sheet
  • Complete copy of the previous ICAP response booklet and computer scoring sheet
  • Behavior support plan that meets HHSC criteria and addresses the behavior considered extremely dangerous or life-threatening, including:
    • Operational definition of the behavior
    • Baseline of the frequency and severity of behavior
    • Functional assessment of the targeted behavior
    • Specific objective to decrease or eliminate the targeted behavior
    • Progress notes based on data
    • History of previous interventions
    • Preventive measures
    • Detailed procedures to address the extremely dangerous or life-threatening behavior
    • Plan to fade 1:1 staff; and
    • Appropriate approvals of the behavior support plan — Click here to review BSP requirements and expectations review BSP requirements and expectations.
  • Any of the following that’s relevant and current within the past year: 
    • Progress notes or quarterly monitoring reports of the BSP by appropriate staff, including data on the effectiveness of the program and plans for addressing problems in implementation or effectiveness
    • Behavior tracking logs
    • Incident, injury and restraint reports documenting serious occurrences or attempts to show targeted behavior supporting the frequency and severity of the identified problem behavior and staff interventions
    • Observation notes, progress notes, data sheets or service and summary logs from home, residential or day programs
    • Psychological and psychiatric evaluations or updates
    • Any team or interim meetings along with professional assessments discussing the extremely dangerous or life-threatening behavior, interventions or changes in treatment due to the targeted behavior
    • Any other documents confirming the frequency and severity of the extremely dangerous or life-threatening behavior, such as:
      • Police reports
      • Hospital records related to the behavior
  • Latest annual staffing and individual program plan for the ICF/IID program or the person-directed plan and implementation plan for the HCS or TxHmL programs
  • Time sheets, for at least the previous month, with the names and schedules of the 1:1 staff, which must include:
    • A person’s need for exclusive and constant supervision for all waking hours, at least 16 hours per day
    • Evidence the service provider assigned to supervise the person has no other duties during such assignments
    • Explanation of how breaks, driving and other household activities are completed to allow the 1:1 staff to stay with the person
    • Explanation why less than a month’s worth of time sheets are submitted, if applicable

HHSC does not require supporting documentation for renewal of a previously authorized initial LON increase, but a renewal request is required through electronic submission of the ID/RC Assessment. The supporting documents for the LON increase must be maintained in the person’s record. These records are subject to review during HHSC on-site reviews or upon HHSC request, as described in Information Letter 14-10 (PDF).

HHSC prefers to receive documents through the IDD Operations Portal but submissions can be made by mail or fax.

At enrollment, submit a purpose code 2 Intellectual Disability/Related Condition Assessment and supporting documents to HHSC Intellectual and Developmental Disability Program Eligibility and Support.

Contact Us

IDD Program Eligibility and Support
Mailing Address: 
Texas Health and Human Services Commission
IDD Program Eligibility and Support 
Mail Code: W254
P.O. Box 149030
Austin, TX 78714-9030

Physical Address:
Texas Health and Human Services Commission
IDD Program Eligibility and Support 
Mail Code: W254
701 W. 51st St.
Austin, TX 78751

Fax: 512-438-4249
Do not fax more than 20 pages without prior approval from IDD PES. For questions, call 512-438-2484.

After enrollment, submit a purpose code 3 (renewal) or 4 (revision) ID/RC Assessment and the required supporting documents to HHSC IDD Waivers Utilization Review.

IDD Waivers Utilization Review
Mailing Address: 

Texas Health and Human Services Commission 
IDD Waivers Utilization Review
Mail Code: W551
P.O. Box 149030
Austin, TX 78714-9030

Physical Address:
Texas Health and Human Services Commission 
IDD Waivers Utilization Review
Mail Code: W551
701 W. 51st St.
Austin, TX 78751

Fax: 512-438-4249 
Do not fax more than 20 pages without prior approval from IDD UR. For questions, call 512-438-5055.