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).