Revision 22-1; Effective Nov. 28, 2022

If the IDT agrees to the provision of habilitation coordination for a person, the habilitation coordinator convenes the first SPT meeting immediately after the initial IDT meeting.

At the first SPT meeting, the habilitation coordinator continues the discovery process and develops and uses Form 1063, Individual Profile – Nursing Facility, and Form 1057, Habilitation Service Plan (HSP). This section describes developing an individual profile and an HSP at the first SPT meeting. Although Section 5400, Develop and Revise Habilitation Service Plan and Individual Profile, describes the process for developing and revising an HSP and individual profile, a fully robust HSP and individual profile are not expected by the end of the first SPT meeting.

Information from the following sources is discussed with the SPT and included in the HSP and individual profile where appropriate:

  • the PE or resident review;
  • the CLO that was conducted during the PE;
  • CARE (e.g., diagnostic data, previous LIDDA services);
  • previous service plans; and
  • other available supporting documentation, including previous assessments such as those listed in Section 5210, Reviewing Assessments.

Also included in the HSP are all specialized services, including habilitation coordination, agreed upon during the IDT meeting. 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.

The habilitation coordinator must complete the HSP and individual profile, and send them to the members of the SPT, within 10 calendar days following the first SPT meeting.

The habilitation coordinator should ask the NF to include all PASRR specialized services identified on the HSP in the NF baseline care plan or NF comprehensive care plan, whichever is most current. The habilitation coordinator must request a copy of the NF baseline care plan or comprehensive care plan from the NF.
 

4510 Specialized Services Requiring an Assessment

Revision 22-1; Effective Nov. 28, 2022

An assessment is required for:

  • all NF specialized services; and
  • the following intellectual and developmental disability (IDD) habilitative specialized services:
    • behavioral support;
    • employment assistance; and
    • supported employment.

The HSP must state an outcome that supports starting an assessment.

When there is lack of consensus among all IDT members about whether a person should receive a NF specialized service or an IDD habilitative specialized service (IHSS), then obtaining an assessment for the specialized service is required. The assessment will indicate whether the person can benefit from the specific NF specialized service or IHSS.

An assessment is not completed for a person who refuses specialized services or in cases in which there is no funding for specialized services.
 

4520 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 Form 1057, Habilitation Service Plan (HSP):

  • the outcome(s); and
  • the amount, frequency and duration based on the person's identified needs, interests and desired outcomes.

4530 Frequency and Duration of Habilitation Coordination

Revision 22-1; Effective Nov. 28, 2022

The duration of habilitation coordination is “while the person is living 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.