Form 1042, Pre-Move Site Review

Instructions

Updated: 7/2019

Purpose

Form 1042 is used to document the local intellectual and developmental disability authority’s (LIDDA’s) pre-move site review for an individual transitioning or diverting from a nursing facility (NF) or an individual in crisis who is diverting to the Home and Community-based Services (HCS) Program. The LIDDA prepares Form 1042 prior to the individual’s transition or diversion by documenting community provider information and essential supports. The LIDDA service coordinator is responsible for ensuring the essential supports identified on Form 1042, and also in the individual’s transition plan or diversion plan, are in place before the individual’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 individual’s service planning team (SPT) must reconvene to discuss and resolve all outstanding issues. Before the individual is transitioned or diverted to a community program, the service coordinator must conduct another pre-move site review using Form 1042.

Before Entering Information on the Form

Before entering information on the form, you must:

• rename the file using "save as;"
• close the file; and
• open the renamed file.

Detailed Instructions

Name of Individual — Enter the name of the individual who is being transitioned or diverted.

CARE ID — Enter the individual’s Client Assignment and Registration (CARE) System identification number.

Projected Transition/Diversion Date — Enter the date that the SPT has agreed upon as a projected transition or diversion date for the individual. This date may change due to unforeseen circumstances and may be updated, if necessary. All essential supports must be in place before the projected transition/diversion date.

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 individual has selected.

Contact Name — Enter the first and last name of the contact person at the community provider.

Contact’s Area Code and Telephone No. — Enter the area code and telephone number for the contact person.

Type of Provider — Enter the type of community program provider (for example, HCS or Intermediate Care Facility for Individuals with an Intellectual Disability or Related Conditions (ICF/IID)).

Day Program Address — Enter the address, including the street, city, state and ZIP code for the day program.

Day Program Area Code and Telephone No. — Enter area code and telephone number for the day program.

Type of Residence — Check the appropriate box to indicate which type of residence the individual has selected: Group Home, Host Home, Own Home/Family Home or Other. If Other, describe.

Address of Residence — Enter the address, including the street, city, state and ZIP code for the residence.

Area Code and Telephone No. — Enter area code and telephone number of the residence.

Location Visited — Check the appropriate box to indicate which location was visited: Residence or Day Program/Work site.

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

In the first column, enter the essential supports that are listed in the individual’s Transition Plan or Diversion Plan. These supports must be in place before the individual’s transition or diversion.

In the second column, enter the evidence that was reviewed to determine whether the support is in place (e.g., if the individual needs a pureed diet, a blender in the kitchen is evidence of the support being in place).

In the third column, check Yes or No to indicate whether the essential support is in place.

Additional Items/Issues To Be Reviewed

Is the potential site generally clean and in good repair? — Check Yes or No.

If no, provide details — Provide examples about why the reviewer believes the potential site is not generally clean and in good repair.

When asked, did the staff or family member respond that the potential site presents an environmental concern that would impact the individual’s identified needs? — Check Yes or No.

If yes, provide details — Explain any environmental concern identified that could potentially impact the individual.

Additional Comments — Provide additional comments, as necessary.

Printed Name of Service Coordinator Conducting Review — Print the name of the service coordinator.

Printed Name of Provider Staff or Family Member — Print the name of the provider staff or family member.

Service Coordinator’s Signature — The service coordinator signs and dates the form.

Provider Staff or Family Member’s Signature — The provider staff or family member signs and dates the form.