5400, Develop and Revise Habilitation Service Plan and Individual Profile

Revision 22-1; Effective Nov. 28, 2022

The habilitation coordinator must develop and revise a person’s Form 1057, Habilitation Service Plan (HSP), and Form 1063, Individual Profile – Nursing Facility, with the SPT as needed. Form 1057 and Form 1063 are individualized and developed through a person-centered process using ongoing discovery per each form’s instructions.

5410 Person-Centered Planning

Revision 22-1; Effective Nov. 28, 2022

Person-centered planning helps a person discover and describe what they need from services and from the service provider. The goal is to improve the person’s quality of life by making sure their preferences are articulated and honored. This includes convening an SPT meeting at a time that is convenient for the person and the LAR.

See the HHS website for more information about person-centered planning, including training.

5420 Discovery Process

Revision 22-1; Effective Nov. 28, 2022

Discovery is the process of listening to people and learning about what they want from their lives. It is getting to know people so that their personal outcomes, preferences, choices and abilities are understood, documented and  form the foundation for planning their services and supports. Discovery is the basis for person-centered planning and service delivery. It is an ongoing process that occurs each time the habilitation coordinator talks to the person or those who know the person best. The habilitation coordinator  leads the discovery process, advocating on behalf of the person whose services and supports are being planned, and records the information learned so that it can be used when developing or updating Form 1057, Habilitation Service Plan (HSP).

5430 Developing Habilitation Service Plan and Individual Profile

Revision 22-1; Effective Nov. 28, 2022

Form 1057, Habilitation Service Plan (HSP), and Form 1063, Individual Profile – Nursing Facility, identify a person’s strengths, preferences, psychiatric, behavioral, nutritional management and support needs, and desired outcomes. This information is gathered through discovery and through other sources, such as:

  • the PE;
  • records from the NF and previous providers;
  • Client Assignment and Registration system (CARE) (e.g., diagnostic data, previous local intellectual and developmental disability (LIDDA) services); and
  • previous ISPs and HSPs.

The HSP also address barriers to transitioning to the community or selecting a community program. These barriers are identified in Sections 6 or 7 of the most recent Form 1054, Community Living Options. The SPT may also identify and address barriers.

The HSP identifies the services and supports that are needed to meet the person’s needs, achieve the desired outcomes, and maximize the person’s ability to live successfully in the most integrated setting appropriate to their needs. The HSP must include all specialized services (including habilitation coordination) agreed upon during an IDT meeting or an SPT meeting within the HSP year, including the person’s desired outcomes.

The HSP year:

  • begin date is the date of the initial IDT and SPT meeting; and
  • end date is the 365th day following the begin date or 366th day in a leap year.
  • 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.

5430.1 Specialized Services Requiring an Assessment

Revision 22-1; Effective Nov. 28, 2022

An assessment is required for:

  • all NF specialized services; and
  • the following IDD habilitative specialized services:
    • behavioral support;
    • employment assistance; and
    • supported employment.

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

5430.2 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 the HSP:

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

5430.3 Frequency and Duration of Habilitation Coordination

Revision 22-1; Effective Nov. 28, 2022

The duration for habilitation coordination is “while the person is residing 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.

5430.4 Barriers to Transitioning to the Community or Selecting a Community Program Identified During CLO

Revision 22-1; Effective Nov. 28, 2022

If barriers are identified during CLO and described in Sections 6 or 7 of Form 1054, Community Living Options, the habilitation coordinator initiates at an SPT meeting a discussion of  possible solutions to the barriers, how the SPT can implement the solutions and any follow-up activities. If the SPT identifies an additional barrier to the person’s transitioning to the community, the SPT must identify possible solutions to the barrier, how the SPT can implement the solutions (including who and when) and any follow-up activities.

Solutions to a barrier can include the provision of a specialized service or an additional outcome for an existing specialized service. For example, if a barrier to a person’s transition to the community is an inability to navigate public transportation, then the person may benefit from receiving independent living skills training with an outcome of learning how to use the public bus system.

The habilitation coordinator documents all identified barriers (i.e., from Sections 6 or 7 of Form 1054 and barriers identified by the SPT) and the solutions and follow-up actions for implementation in Section 7 of Form 1057, Habilitation Service Plan (HSP).

5440 Revising the Habilitation Service Plan and Individual Profile

Revision 22-1; Effective Nov. 28, 2022

Form 1057, Habilitation Service Plan (HSP), and Form 1063, Individual Profile – Nursing Facility, are reviewed at least quarterly and revised as necessary. Revisions to Form 1057 or Form 1063 must be completed and sent to the SPT members within 10 calendar days following the SPT meeting in which the revisions were agreed upon.

5440.1 Revising the HSP Because an Assessment for a NF Specialized Service is Completed

Revision 22-1; Effective Nov. 28, 2022

An assessment must be conducted for all NF specialized services. The results of an assessment are reflected in Section 6 of Form 1057, Habilitation Service Plan (HSP) as follows.

  • If the person can benefit from the service, the HSP includes:
    • the amount, frequency and duration from the assessment, except for CMWC or DME; and
    • the goals from the assessment.
  • If the person cannot benefit from the service, the HSP will indicate “discontinued.”

Note: The assessment results may impact the provision of an IDD habilitative specialized service. For example, if the person is receiving day habilitation five days per week and a therapy assessment shows they need therapy two days per week, then the amount or frequency of day habilitation may need to be reduced to allow for the provision of therapy.

A copy of all assessments for NF specialized services must be maintained in the person's record.

5440.2 Revising the HSP Because an Assessment for an IDD Habilitative Specialized Service is Completed

Revision 22-1; Effective Nov. 28, 2022

An assessment must be conducted for behavioral support, employment assistance and supported employment. The information included in a completed assessment indicates whether the person can benefit from the specialized service, and if so, should identify the necessary amount, frequency and duration for the service.

The results of an assessment are reflected in Section 5 of Form 1057, Habilitation Service Plan (HSP) in the appropriate outcome action plan as follows.

  • If the person can benefit from the service, the HSP includes the amount, frequency and duration. If the assessment identifies an additional outcome, include the additional outcome in Section 5 of the HSP as an additional outcome action plan if agreed to by the SPT.
  • If the person cannot benefit from the specialized service, the assessment should state why. This information is included in Section 5 of the HSP in the appropriate outcome action plan, and the HSP will indicate “discontinue.”
  • Assessment results may impact the provision of another IDD habilitative specialized service. Additionally, following delivery of an IDD habilitative specialized service, the SPT may revise the amount, frequency and duration to better reflect the person’s identified needs, interest and desired outcomes.

A copy of all assessments for behavioral support, employment assistance and supported employment must be maintained in the person's record.

5440.3 Revising the HSP to Address Barriers Identified During CLO

Revision 22-1; Effective Nov. 28, 2022

If barriers are during CLO and described in Sections 6 or 7 of Form 1054, Community Living Options, the habilitation coordinator initiates at an SPT meeting a discussion of  possible solutions to the barriers, how the SPT can implement the solutions and any follow-up activities. If the SPT identifies an additional barrier to the person transitioning to the community, the SPT must identify possible solutions to the barrier, how the SPT can implement the solutions (including who and when) and any follow-up activities.

Solutions to a barrier can include the provision of a specialized service or an additional outcome for an existing specialized service. For example, if a barrier to a person’s transition to the community is an inability to navigate public transportation, then the person may benefit from receiving independent living skills training with an outcome of learning how to use the public bus system.

The habilitation coordinator documents all identified barriers (i.e., from Sections 6 or 7 of Form 1054 as well as barriers identified by the SPT) and the solutions and follow-up actions for implementation in Section 7 of Form 1057, Habilitation Service Plan (HSP).

5450 New Habilitation Service Plan for Next HSP Year

Revision 22-1; Effective Nov. 28, 2022

Following an annual SPT meeting, the habilitation coordinator must complete a new Form 1057, Habilitation Service Plan (HSP), for the next HSP year that includes all new and ongoing information, such as:

  • outcomes and the specialized services and natural supports that help the person achieve the outcomes, including amount, frequency and duration;
  • NF and MI specialized services, including amount, frequency and duration;
  • barriers preventing transition to the community or selection of a community program identified during a CLO or by the SPT; and
  • informational and educational opportunities that have been offered to the person and LAR but have not yet occurred.

Discontinued specialized services and barriers that have been resolved are not included in the new HSP for the next HSP year.

The new HSP year:

  • begin date is the date of the annual IDT and SPT meeting; and
  • end date is the 365th day following the begin date or 366th day in a leap year.

Note: It is unlikely the annual IDT and SPT meeting date will occur exactly 12 months after the initial or previous annual IDT/SPT meeting date. The LTC online portal allows for an annual IDT and SPT meeting to take place as early as 334 calendar days after the initial or previous annual IDT and SPT meeting. This means the HSP year will not always be a full 12-month period.

5460 Documents in an Individual’s Habilitation Packet

Revision 22-1; Effective Nov. 28, 2022

A complete habilitation packet for a person has:

  • Form 1063, Individual Profile – Nursing Facility (see Section 5460.1, Individual Profile, below);
  • Form 1057, Habilitation Service Plan (HSP) (see Section 5460.2, Habilitation Service Plan); and
  • the following attachments:
    • the most current Form 1054, Community Living Options; and
    • the  NF baseline care plan or comprehensive care plan, whichever is most current.

5460.1 Individual Profile

Revision 22-1; Effective Nov. 28, 2022

Information documented on Form 1063, Individual Profile – Nursing Facility.

Section 1, Individual’s Information — This section gathers identifying information about a person as well as contact information for the person, LAR and primary contact, if any, and information about a person’s language preferences, ambulation abilities and accommodation needs.

Section 2, Nursing Facility and LIDDA Information — This section gathers name and contact information for NF and LIDDA staff.

Section 3, People Important to the Individual — The section identifies the important people in the person’s life and who can provide information about the person, such as family, friends, mentor and clergy.

Section 4, Profile Information — This section provides an overall profile of a person’s strengths, preferences and needs, learned during the discovery process.

These are my strengths and what people like and admire about me: A descriptive narrative about the person’s strengths and what others like and admire about the person.

These are my preferences and what is important to me: A descriptive narrative about what is important to the person. “Important to” reflects what is important from the person’s perspective and is based on the person’s words and behavior. When words or behavior are in conflict, listen to the behavior. The information might include important relationships, how the person prefers to interact, things the person likes to do or not do, preferred routines, relevant background information that may affect how services should be delivered and what the person wants to do in the future. Remember, the person’s response is limited to the knowledge and experiences they have to date. Additional efforts should be explored to increase awareness of o possibilities and experiences to increase  options of choice. This section could also include personal preferences (e.g., sleep with the light on, blackout curtains needed on windows, baths in the evenings only).

This is what others need to know and do to support me in the following areas: A descriptive narrative about what is important for the person, as identified by those who know him or her best. “Support me” reflects information that is important for the service provider to know and understand about the person. All specific areas listed below must be addressed and include specificity about health needs, risk factors and special instructions for those who support the person. See Appendix IV, Risk Factors, for more information about identifying risks.

  • Communication — A descriptive narrative about how the person communicates and how to best communicate with the person. Describe the person’s communication-related needs. For instance, what is the person’s primary or preferred method of communication? How does the person communicate or express a need (gestures, sounds, facial expressions, adaptive equipment, etc.)? What is the best way to determine if the person is expressing satisfaction, happiness, comfort or agreement, as opposed to dissatisfaction, unhappiness, discomfort or disagreement? Among those who know the person best, who seems better able to interpret what the person is trying to communicate? What is the best way for others to learn how to communicate effectively with the person?
  • Nursing Care — A description of the person’s nursing-related needs, such as assistance taking medication, suctioning, wound care and oxygen. Describe how staff should attend to the person’s nursing needs.
  • Clinical (Behavioral/Mental Health) — A description of the person’s behavioral health and mental health-related needs. What kind of behavior supports does the person need? Does the person need counseling services or psychiatric services for medication management?
  • Medical and Dental — A description of all medical and dental concerns, diagnoses and routine procedures (e.g., medication management, blood work, history of constipation, dental cleaning, x-ray or sedation needs).
  • Adaptive Aids and Medical Supplies — A description of the adaptive aids (e.g., wheelchair, walker, shower chair) and medical supplies (e.g., briefs, test strips) needed by the person and how they are funded (e.g., Medicaid, personal funds) or obtained (e.g., leased, purchased).
  • Nutrition Management — A description of the person’s nutritional-related needs (e.g., thickened, pureed, textured, use of supplements, food allergies or restrictions, choking risk).
  • Supervision Needs — A description of the person’s supervision needs. Consider if there are any personal issues that might present risk for harm in the person’s living arrangement (e.g., daily rituals, threats of suicide or physical harm to self or others, inability to handle a personal crisis). Describe the supports needed to address any risks, such as line of sight, one-to-one, limited proximity or door alarm. Is the person currently receiving these supports?
  • Other things people need to know about me, if any.
  • Risk factors not otherwise addressed above, such as those related to safety or exploitation.

Historical information: Include background information that continues to significantly affect the person or their services.

5460.2 Habilitation Service Plan

Revision 22-1; Effective Nov. 28, 2022

Information documented on Form 1057, Habilitation Service Plan (HSP).

Section 1, Individual Information — This section gathers identifying information about a person and identifies the HSP year and plan date.

Section 2, Discovery — This section describes all the ways information was gathered to discover a person’s desires and preferences, such as observation of the person and conversations with the person or LAR and those who know the person best, such as a NF staff, caregiver, family member or friend.

Section 3, Changes Made to the HSP — This section is where changes to the HSP made within the previous 12 months are described.

Section 4, Habilitation Coordination Plan — This section describes the habilitation coordination plan, including duration and frequency of face-to-face meetings between the person and the habilitation coordinator. The duration of habilitation coordination is while the person is living in the NF and is pre-printed on the form. The frequency of face-to-face visits is determined by the SPT within the constraints of Section 5100, Required Face-to-Face Visits, and  may be either at least monthly or at least quarterly.

This section also lists all the activities to be coordinated and monitored by the habilitation coordinator. The first two activities are pre-printed because they are mandatory. If the NF agreed to provide NF PASRR support activities, then each support activity to be provided by the NF must be listed as an activity that will be monitored by the habilitation coordinator. The PASRR rules provide a definition of “NF PASRR support activities” and includes the following examples of support activities:

  • arranging transportation for [a person ] to participate in an IHSS or a MI specialized service outside the [NF];
  • sending a person to a IHSS service or MI specialized service with food and medications required by the person; and
  • stating in the NF comprehensive care plan an agreement to avoid, when possible, scheduling NF services at times that conflict with IHSS or MI specialized services.

Note: The examples above are not all inclusive. A support activity can be any type of activity that supports the person to receive specialized services.

Section 5, Outcome Action Plan — A separate outcome action plan is needed for each identified outcome. An outcome identifies what the person wants to do, achieve, change, maintain or experience. For an identified outcome, the outcome action plan must identify all specialized services and other resources and natural supports the person receives that will help the person achieve the outcome. Each outcome action plan provides space to identify IDD habilitative specialized services, NF specialized services, MI specialized services and other resources/natural supports, as necessary and unique to the outcome. For each specialized service and resources or natural support listed, a description is necessary of how the specialized service or resource or natural support helps the person achieve the outcome.

Note: While a NF specialized service or MI specialized service may be listed in a particular outcome action plan, all NF specialized services and MI specialized services for the person must be included in Section 6 of the HSP.

Section 6, NF Specialized Services to be Monitored by the SPT — This section is for recording all NF specialized services and MI specialized services provided to the person during the HSP year, including:

  • the goals for the service as identified by the licensed therapist on the therapy assessment or as identified by the LMHA or LBHA staff;
  • the amount, frequency and duration of the service; and
  • if the service was discontinued during the HSP year, and if so the date of discontinuance.

The form allows the user to add lines for more than one NF specialized service and MI specialized service.

Section 7, Preference Regarding Transitioning — Each time the habilitation coordinator presents CLO to the person or LAR during the HSP year, the CLO date is included in this section of the HSP. Also included in this section are barriers to preventing a transition to the community from Section 6 of Form 1054, Community Living Options, or barriers to selecting a community program from Section 7 of Form 1504, if any. If there are barriers, the SPT’s proposed solutions and follow-up activities are also included in this section of the HSP. The SPT may identify additional barriers.

Section 8, Educational Activities — This section is used to describe all CLO educational, informational, and support activities offered to the person, LAR, and actively involved people. If an offered activity was attended, the information about attendance is also included in this section.

Section 9, Documentation of Exploration of Community Programs — This section is used to describe the community living settings where a visit is planned or has occurred. When the visit has occurred, a summary of the outcome of the visit is included in this section.

Section 10, HC Signature — This section is for the habilitation coordinator to affirm that the HSP was developed based on IDT or SPT decisions and includes the habilitation coordinator’s printed name, signature and date.

5470 Sharing the Habilitation Service Plan, Individual Profile and Habilitation Packet

Revision 22-1; Effective Nov. 28, 2022

The habilitation coordinator is responsible for providing a copy of the current Form 1057, Habilitation Service Plan (HSP), and Form 1063, Individual Profile – Nursing Facility, to all SPT members within 10 calendar days after the SPT meeting during which they were developed  or revised.

The habilitation coordinator must share a person’s habilitation packet with an SPT member upon request.

5480 SPT Member Believes HSP or Individual Profile Does Not Accurately Reflect SPT Decisions or Information about the Individual

Revision 22-1; Effective Nov. 28, 2022

If an SPT member believes Form 1057, Habilitation Service Plan (HSP), or Form 1063, Individual Profile – Nursing Facility, does not accurately reflect an SPT decision or information about the person, then:

  • if the habilitation coordinator agrees with the SPT member, the habilitation coordinator corrects Form 1057 or Form 1063 to accurately reflect the SPT decision or person’s information; or
  • if the habilitation coordinator does not agree with the SPT member, the habilitation coordinator presents the issue to the SPT to resolve the discrepancy.