Form 2125, Home and Community-based Service (HCS), Texas Home Living (TxHmL) and Community First Choice (CFC) Implementation Plan

Instructions

Updated: 10/2024

Note: A person in this form refers to an individual as defined in 26 Texas Administrative Code (TAC) Chapters 262 and 263.

Purpose

The program provider or the consumer directed services (CDS) employer, if applicable, use the Implementation Plan (IP) for the Home and Community-based Services (HCS) Program, Texas Home Living (TxHmL) Program and Community First Choice (CFC) to document how HCS, TxHmL and CFC services will be delivered to support a person’s desired outcomes identified in the Person-Directed Plan (PDP).

Introduction

The program provider or the CDS employer, if applicable, develops the IP with the person and legally authorized representative (LAR) to achieve the outcomes identified in the PDP.

The program provider must understand the HCS Program Billing Requirements, TxHmL Program Billing Requirements, and CFC Billing Requirements necessary to identify billable supports to be provided through those programs.

Procedure

The program provider or CDS employer must develop an IP for each service that has an Action Plan on the person’s PDP.

Detailed Instructions

Name of Person – Enter the first and last name of the person.

Medicaid No. – Enter the person’s Medicaid number.

Vendor No. – Enter the program provider’s vendor number.

Service Component – Enter an HCS, TxHmL or CFC service component identified on the person’s PDP Action Plan sheet.

Backup Plan Required – Mark only one box based on the service planning team's (SPT's) decision on a need for a service backup plan. A service backup plan must be recommended by the SPT for any HCS, TxHmL or CFC service identified as critical for the person. Service backup plans are not limited to CDS delivered services.

Date Plan Developed – Enter the date the IP was developed or revised.

Individual Plan of Care (IPC) Begin Date – Enter the IPC begin date for the IPC year the Action Plan was developed.

IPC Effective Date – Enter the IPC effective date this Action Plan was developed because of a PDP update and IPC revision.

IPC End Date – Enter the IPC end date for the IPC year the Action Plan was developed.

Desired Outcomes from Person Directed Plan (PDP) Action Plan for this Service Component – Enter the desired outcome or outcomes from the PDP exactly as it is written on the Action Plan sheet for this service component. If there is more than one outcome for a service, enter all outcomes and place one on each line. Additional lines can be added if necessary.

In Addition to the PDP, Development of Implementation Strategies based on, check all that apply – Mark the appropriate boxes to indicate what activity was used to develop the implementation strategies to help the person accomplish the outcomes.

Conversations with – Check this box if one or more conversations were used to develop the IP and enter the names of all who participated in the conversation.

Observation – Check this box if strategies were developed based on observation of the person.

Formal Assessments – Check this box if strategies were developed based on a formal assessments of the person. Formal assessments include evaluations completed by licensed or certified professionals or standardized assessments completed to identify the knowledge, skills and abilities possessed by the person and potential needs for support.

Specific Objectives to Implement Desired Outcomes – Enter the specific objectives that will be implemented to address or support the person’s outcomes. The objectives must be specific to the person and written in observable, measurable and outcome-oriented terms. Measurable means anyone can consistently and reliably determine if an action or event has occurred. Observable means the action or event can be detected with one or more of the five senses: sight, hearing, touch, taste, or smell. Outcome-oriented means it can be determined when a desired result has been achieved. Include any instructions related to personal preferences, special conditions or specific requirements that are necessary when helping the person achieve the outcomes.

Start Date – Enter the date the objectives will begin.

Targeted Completion – Enter the date when the objective is expected to be completed or achieved. Objective or objectives should span the entire IPC year unless the service is added or removed from the IPC through an IPC revision.

Duration – Enter the number of hours needed to complete an objective.

Frequency – Enter how often the objective is completed.

Time – Enter if the objective is completed daily, weekly, or monthly.

Units by Objectives – Enter the total units needed to complete an objective in the IPC year. The Units by Objectives is obtained by multiplying the duration by frequency by time (daily-365, weekly-52, monthly-12). 

Total IPC Units Needed for this Service Component – Add the amounts entered in the Units by Objectives column and enter the sum in this box.

Requisition Fee, if applicable – Document the requisition fee up to the maximum amount allowed for the dollar amount designated for adaptive aids, minor home modifications and dental services.

Consent:  Mark only one box if synchronous audio-visual technology is used for an allowable service.

Signatures for Implementation Plan – The provider checks the Signature sheet for implementation plan(s) on file box if the provider has elected to have a separate signature sheet. The provider or CDS employer checks the Signatures below box if no separate signature sheet is on file.

Signature of Person – The person signs the form.

Signature of Legally Authorized Representative (LAR) – The LAR signs the form.

Signature of Family Member or Advocate – The family member or advocate signs the form.

Signature of HCS, TxHmL Provider Representative, or CDS Employer – The HCS, TxHmL provider representative, or CDS employer if applicable, signs the form.

Signatures for Discontinuation of Implementation Plan

Signature of Individual – The person signs to indicate an agreement to discontinue this Action Plan.

Signature of LAR – The LAR signs to indicate an agreement to discontinue this Action Plan.

Signature of HCS, TxHmL Provider Representative or CDS Employer – The HCS or TxHmL provider representative or CDS employer if applicable, signs to indicate an agreement to discontinue this Action Plan.

Date – Enter the date the IP was discontinued.