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

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Effective Date: 10/2022


Updated: 10/2022


The Implementation Plan (IP) for the Home and Community-based Services (HCS) Program, Texas Home Living (TxHmL) Program and Community First Choice (CFC) is used by the program provider to document how HCS, TxHmL and CFC services will be delivered to support an individual’s desired outcomes or purposes identified in the Person-Directed Plan (PDP).


The program provider develops the IP in conjunction with the individual and legally authorized representative (LAR) to achieve the outcomes or purposes identified in the PDP. 

The program provider must understand the HCS Program Billing Guidelines, TxHmL Program Billing Guidelines, and CFC Billing Guidelines necessary for identifying billable supports to be provided through the HCS, TxHmL and CFC programs.

Click here for the HCS Program Billing Requirements.

Click here for the TxHmL Program Billing Requirements.


The program provider must develop an IP for each service for which there is an Action Plan on the individual’s PDP. Examples can be found in the Home Community-based Services (HCS) Handbook and Texas Home Living (TxHmL) Program Handbook.

Detailed Instructions

Implementation Plan for – Enter the first and last name of the individual.

Client Assignment and Registration (CARE) System ID – Enter the individual’s CARE System identification (ID). Do not enter the local case number.

Component Code – Enter the program provider’s component code.

Service Component – Enter an HCS service component identified on the individual’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 individual. Service backup plans are not limited to Consumer Directed Services delivered services only.)

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 Outcome(s)/Purpose(s) from Person Directed Plan (PDP) Action Plan for this Service Component – Enter the desired outcome(s) or purpose(s) from the PDP exactly as it is written on the Action Plan sheet for this service component. Enter all outcomes or purposes, placing 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 box(es) to indicate what activity was used to develop the implementation strategies to assist the individual in accomplishing the outcome(s) or purpose(s).

Conversation(s) with – Check this box if one or more conversations were used to develop the IP and enter the name(s) of all who participated in the conversation.

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

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

Implementation Strategy – Enter the specific strategies that will be implemented to address or support the outcome(s) or purpose(s). Include any instructions related to personal preferences, special conditions or specific requirements that are necessary when assisting the individual in achieving the outcome(s) or purpose(s).

Start Date – Enter the date that the implementation strategy will begin.

Targeted Completion – Enter the date by which the implementation strategy is expected to be completed or achieved.

Calculation of Units (if applicable) – Enter the calculations used to determine the total units that are required for this implementation strategy.

Total Units (per strategy) – Enter the total units calculated per strategy.

Total IPC Units Needed for this Service Component Add the amounts entered in the “Total Units” 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 using synchronous audio-visual technology for an allowable service.

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

Signature of Individual – The individual signs the form.

Signature of Legally Authorized Representative (LAR) – The LAR signs the form and designates the relationship with the individual by checking the applicable box.

Signature of Family Member or Advocate – The family member or advocate signs the form and designates the relationship with the individual by checking the applicable box.

Signature of HCS/TxHmL/CFC Provider Representative – The HCS, TxHmL or CFC provider representative signs the form.

Signatures for Discontinuation of Implementation Plan – The HCS, TxHmL or CFC provider representative and individual or LAR sign to indicate an agreement with the discontinuation of this Action Plan.

Date – Enter the date the IP was discontinued.