Some forms cannot be viewed in a web browser and must be opened in Adobe Reader on your desktop system. Click here for instructions on accessing your form.
To document the service backup plan developed by the employer or designated representative (DR) for each program service that is required by program rules or that the service planning team has identified as "critical" to the health, safety or welfare of the individual when normal service delivery is interrupted, in the absence of the regular service provider, or in an emergency.
When to Prepare
The employer or DR completes this form:
- after the individual's service planning team has identified which services to be delivered through the Consumer Directed Services (CDS) option are critical to the health and welfare of the individual, and
- any time a revision to the service backup plan is needed based on problems with implementation of the plan or changes in the resources required to carry out the plan.
Note: The case manager or service coordinator must review the service backup plan upon initiation of services and annually thereafter. If the backup plan requires no revisions, the case manager or service coordinator may initial and date the current backup plan.
Number of Copies
Original and at least two copies.
The employer or DR keeps a copy in the file for the individual receiving services through the CDS option and sends a copy to the Financial Management Services Agency (FMSA) and to the case manager or service coordinator. The employer or DR sends copies to other service planning team members, as applicable.
The employer or DR must provide a copy of the initial and revised service backup plans and, if a revision is required, the budgets to the FMSA within five working days after a plan's approval by the case manager or service coordinator.
The employer or DR, the FMSA, and the case manager or service coordinator keep this form while in effect and for five years thereafter.
Name of Individual — Enter the name of the individual receiving services.
Program — Enter the program name.
Service — Enter the service identified by the service planning team as "critical" to the individual's health, safety or welfare.
Employer — Enter the employer's name. If the individual receiving services is the employer, enter the individual's name again.
Designated Representative — Enter the designated representative's name, if applicable.
Support Advisor — Enter the support advisor's name, if a support advisor provided assistance in the development of the plan.
Type of Service Backup Plan — Check the type of service backup plan, as applicable.
Date of Service Planning Team Meeting — Enter the date the individual's service planning team met, identified the program service as critical, and required a service backup plan to be developed.
Effective Date of Service Backup Plan — Enter the date the service backup plan will be effective.
Reason(s) a service backup plan is required for this service — State each reason the team or case manager or service coordinator determined this service to be critical. An individual's service planning team must describe each service the team determines to be critical and the length of time that constitutes a service interruption, absence of the regular provider, or type of situations that would cause an emergency for the individual.
Backup Plan Strategies and Sequence* — The employer or DR must develop a service backup plan that ensures the delivery of the service when the employer's regular service provider is not available to deliver the service or in an emergency, and may include the use of:
- paid service providers;
- unpaid service providers, such as family members, friends or non-program services; or
- respite, if included in the authorized service plan.
Specific Action(s) to Be Taken in Absence of Service Delivery* — The employer or DR must list the steps the employer or DR will follow to implement the backup plan.
Resource Person, Area Code and Telephone Number* — The employer or DR will enter the name of the resource person to be contacted according to the backup plan and the resource person's phone number.
* This form field is expandable. You are not limited to the space provided. The box will expand to accommodate up to 2,000 characters. All of the text you enter will show when the form is printed.
Plan Approval — An individual's case manager or service coordinator must approve each service backup plan, as well as any revision, before implementation by the employer or DR. The case manager or service coordinator may schedule a service planning team meeting to review the proposed service backup plan.
Annual Review — An individual's case manager or service coordinator must review each service backup plan on an annual basis. The case manager or service coordinator will ask questions about backup plan implementation and request revision if needed. The case manager or service coordinator will initial and date the form if the backup plan is still deemed effective.
Note: An employer must:
- budget sufficient funds in the service budget to implement a service backup plan, and complete any budget revisions in accordance with Texas Administrative Code (TAC), Title 40, Part 1, Chapter 41, §41.511, Budget Revisions and Approvals;
- review each service backup plan at least annually; and
- revise a service backup plan if the employer experiences a problem in the implementation of a service backup plan, or if there are changes in availability of service backup plan resources or the employer redistributes funds that are not used in carrying out a service backup plan.
The employer or designated representative must receive approval from the case manager or service coordinator for initial, revised and annual reviews for each service plan.