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Documents
Instructions
Updated: 4/2025
Purpose
The LIDDA uses Form 1042 to document the pre-move site review for a person transitioning or diverting from a nursing facility (NF), transitioning from a medium or large community intermediate care facility for individuals with an intellectual disability or related conditions (ICF/IID) with nine or more beds, or a person in crisis who is diverting to the Home and Community-based Services (HCS) Program. The LIDDA prepares Form 1042 before the person’s transition or diversion by documenting community provider information and essential supports. The LIDDA Enhanced Community Coordination (ECC) coordinator is responsible for making sure the essential supports identified in the person’s transition or diversion plan are in place before the person’s projected transition or diversion date.
At the time of the review, if any of the essential supports are not in place or if issues are raised about the suitability of the site, the person’s service planning team (SPT) must reconvene to discuss and resolve all outstanding issues. The ECC coordinator must use a new Form 1042 to conduct another pre-move site review before the person transitions or diverts.
If essential supports are scheduled to accompany the person on transition or diversion day, the ECC coordinator should be present at the site or otherwise take action to make sure the essential supports arrive with the person. The move must not be completed until all essential supports are in place.
Detailed Instructions
Person’s Name — Enter the name of the person who is being transitioned or diverted.
CARE ID — Enter the person’s Client Assignment and Registration (CARE) System identification number.
Projected Transition or Diversion Date — Enter the date the SPT has agreed on as a projected transition or diversion date for the person. This date may be updated if necessary. All essential supports must be in place before the person transitions or diverts to the community.
Review Date — Enter the date of the pre-move site review.
Community Provider Information
Provider Name — Enter the business name of the community provider the person has selected.
Contact Name — Enter the first and last name of the contact person at the community provider.
Contact’s Area Code and Phone No. — Enter the area code and phone number for the contact person.
Type of Provider — Enter the type of community program provider, such as HCS or other community Medicaid program.
Day Program or Work Address — Enter the address, include the street, city, state and ZIP Code for the day program or place of employment.
Day Program or Work Area Code and Phone No. — Enter area code and phone number for the day program or place of employment.
Type of Residence — Check to indicate which type of residence the person has selected: Residential Support Services, Supervised Living, Host Home/Companion Care, or Own Home or Family Home.
Residence Address — Enter the address, include the street, city, state and ZIP code for the residence.
Area Code and Phone No. — Enter area code and phone number of the residence.
Provider Staff or Family Members Interviewed — Enter the first and last names of any provider staff or family members interviewed while conducting the pre-move site review.
Essential Supports
Enter the essential supports listed in the person’s Transition or Diversion Plan in the first column. These supports must be in place before the person’s transition or diversion.
Enter the evidence that was reviewed to determine if the support is in place in the second column. For example, if the person needs a pureed diet, a blender in the kitchen is evidence of the support being in place.
Check Yes or No in the third column to indicate if the essential support is in place.
Additional Items, Issues To Be Reviewed
Is the potential site clean and in good repair? — Check Yes or No.
If no, provide details — Provide examples of why the reviewer believes the potential site is not clean and in good repair.
When asked, did the staff or family member voice any concerns about the site or if the site will meet the person’s identified needs? — Check Yes or No.
If yes, explain in comments — Explain any concerns identified that could potentially impact the person.
Additional Comments — Provide additional comments as necessary. Include any concerns noted by the ECC coordinator during the visit.
Printed Name of ECC Coordinator Conducting Review — Print the name of the ECC coordinator.
Printed Name of Provider Staff or Family Member — Print the name of the provider staff or family member.
ECC Coordinator’s Signature — The ECC coordinator signs and dates the form.
Provider Staff or Family Member’s Signature — The provider staff or family member signs and dates the form.