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Documents
Instructions
Updated: 11/2023
Purpose
Form 1055 is used by the local intellectual and developmental disability authority (LIDDA) for submission of the State Supported Living Center (SSLC) Transition Reports for people transitioning out of the SSLC. The LIDDA Handbook 9500, Post Enrollment in HCS as an SSLC Transition, discusses these requirements for reporting. The LIDDA prepares Form 1055 on a quarterly basis for each person transitioning out of an SSLC. They submit to the IDD Money Follows the Person Unit following the name convention listed below:
When submitting a person’s SSLC transition report, the LIDDA must provide each person’s required information in separate PDF attachments. The LIDDA must name each submission with the following file naming convention:
- the person’s last name
- the person’s first name
- fiscal year (FYXX)
- quarter (QtrX)
- the date of the submission (May 1, 2022=05012022)
Example: SmithBobFY22Qtr2-05012022
Once the form is complete, submit it to the transitioning SSLC and the Home and Community-based Services (HCS) provider, before submitting to the mailbox below.
Submit all completed reports to IDDMFPSubmissions@hhs.texas.gov.
Submit all questions about reports to IDDMFPSupport@hhs.texas.gov.
If the correct items are not attached or in the correct format, the MFP Oversight Specialist will email back reminding the LIDDA of the protocol and asking them to resend based on the correct process.
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 Person — Enter the name of the person who transitioned.
Client Assignment and Registration (CARE) System ID — Enter the person’s CARE ID.
Transition from SSLC Date — Enter the date the person transitioned using the drop-down menu.
SSLC Transitioned from — Select the name of the SSLC the person transitioned from using the drop-down menu.
Monitoring Year — Select the year from the drop-down menu that corresponds to the year of monitoring being submitted. This is based on the year the person transitioned. Example: Person transitioned to the community on Jan. 5, 2023. Their first year would go until Jan. 4, 2024, and their second year would begin Jan. 5, 2024.
90 Day Period — Select the 90-day period from the drop-down menu that corresponds to the period being submitted for the current year. Each person’s 90-day period will be different depending on their transition date. Example: Person transitioned to the community on Jan. 5, 2023. Their first 90 days will end on April 5, 2023, and the report submitted will indicate first 90 days.
Community Transition Information
Current LIDDA Name — Enter the name of the LIDDA completing the form.
Component Code — Enter the component code for the LIDDA completing the form.
Did a Transfer Between LIDDAs Occur During the Quarter? — Check Yes or No
Transferring LIDDA — Enter the name of the LIDDA who completed the transfer to the current LIDDA, if answered yes to a transfer. Otherwise, put N/A.
Receiving LIDDA — Enter the name of the current LIDDA who received the transfer, if answered yes to a transfer. Otherwise, put N/A.
Effective Transfer Date — Enter the date the transfer was effective using the drop-down menu, if answered yes to a transfer. Otherwise, leave blank.
Program Person Transitioned to — Check the appropriate box to indicate which program the person is currently in. If ”Other” is checked, provide the program name or where the person went.
HCS Residential Type, if applicable — If the person is in HCS, select the residential type they are currently in from the drop-down menu. If the person is not in HCS, select N/A.
Post-move Monitoring – This is where the LIDDA documents the three post-move visits that occur during the first 90 days after transition.
Post-move Monitoring Visits — Check the appropriate box to indicate which of the three post-move monitoring visits is being documented. Enter the date of the visit next to the box that was checked. Check N/A if a post-move monitoring visit did not occur during the reporting period.
Essential/Pre-move Supports — Enter each pre-move support listed on the Community Living Discharge Plan (CLDP). These are the essential supports which must be in place prior to the move-in date. For each support listed, check “yes” or “no” to indicate if the support continues to be in place. If “no” is checked for any pre-move support, explain the provider’s justification for discontinuing the support, whether there was an adverse impact on the person, and if so, what steps the service coordinator has taken to resolve the issue.
Questions — For Questions 1-16 check appropriate boxes and provide detail if answered yes.
Additional Comments — If there is any other pertinent information or events that took place during the quarter, describe here.
SSLC Staff Name and SSLC Name — Enter the name of the SSLC staff who received the report and the SSLC name.
Provider Staff Name and Designated Provider Agency — Enter the name of the provider staff who received the report and the designated provider agency name.
Printed Name of Service Coordinator — Enter the name of the enhanced community coordinator or service coordinator assigned who completed the monitoring visits for the quarter and completed this transition reporting form.
Service Coordinator’s Signature — The assigned enhanced community coordinator or service coordinator who completed the form should sign, attesting that the information above is correct.
Date — List the date the enhanced community coordinator or service coordinator signed the form.
Printed Name of Supervisor — Enter the name of the enhanced community coordinator’s or service coordinator’s supervisor who reviewed the form.
Supervisor’s Signature — The assigned supervisor should sign attesting that they have reviewed the form and all information is correct.
Date — List the date the supervisor signed the form.