Form 8630, Local Intellectual and Developmental Disability Authority (LIDDA) Continuity of Care

Instructions for Opening a Form

Some forms cannot be viewed in a web browser's PDF viewer and must be opened in the Adobe Reader application on your desktop system. Click here for instructions on opening this form.

Documents

Effective Date: 1/2025

Instructions

Updated: 1/2025

Purpose

Form 8630 is used to document the local intellectual and developmental disability authority’s (LIDDA’s) pre-move site review for a person transitioning to the community from a state supported living center (SSLC). The LIDDA uses Form 8630 to document if the proposed community placement site meets the criteria described in 26 TAC Chapter 904, Subchapter D, and is recommended for interdisciplinary team (IDT) approval. The review must be done in person at the site.

Detailed Instructions

Name of Person — Enter the name of the person who is transitioning from the SSLC.

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

Projected Transition Date — Enter the date agreed upon by the IDT as the projected transition date for the person. This date may change due to unforeseen circumstances and may be updated, if necessary.

Projected Community Placement Site Address — Enter the address of the provider site that is being reviewed.

Site Administrator or Manager Name— Enter the name of the provider staff in charge of the community placement site.

Provider Agency Name — Enter the business name of the community provider the person has selected.

State Supported Living Center (SSLC) — Enter the name of the SSLC from which the person is transitioning.

Date of On-site Review — Enter the date of the pre-move site review.

Community Placement Setting Type — Check the appropriate box that indicates the setting type: 

  • Residential Support Services;
  • Supervised Living;
  • Host Home/Companion Care;
  • Own Home/Family Home; or
  • ICF/IID.

Items or Issues to be Reviewed

For the following questions, check yes or no.

  1. When asked, did the site administrator or manager respond that HHSC identified environmental or safety concerns at the time of its last visit to the residence? If yes provide details in the box provided. Attach a copy of the last residential review if available.
  2. When asked, did the site administrator or manager respond that the potential site presents any environmental or safety concerns that would impact the person’s identified needs? If yes provide details in the box provided.
  3. During the visit, did the LIDDA staff observe any environmental or safety concerns that would impact the person’s identified needs? If yes provide details in the box provided.
  4. When asked, did the site administrator or manager have a copy of the person’s Community Living Discharge Plan (CLDP) and know of the outcomes important to the person or their legally authorized representative (LAR)? If the answer is no explain in the box provided.
  5. When asked, did the site administrator or manager verify services and supports could be provided that are necessary to assist the person in achieving their desired outcomes? If the answer is no explain in the box provided.

The following section is an attestation that the LIDDA staff completing this form visited and evaluated the residential setting and has determined if the site meets the criteria set forth in 26 TAC Chapter 904, Continuity of Services—State Facilities, and is recommended for IDT approval:

  • Check the box that indicates if the person will receive HCS or ICF/IID services.
  • Enter the person’s name on the provided line.
  • Check the box that indicates if the site meets the criteria and is recommended for IDT approval.
  • If the site does not meet the criteria and is not recommended for IDT approval, describe the criteria that was not met and how this was determined.

Additional people involved in this on-site review — Enter the first and last names of anyone interviewed during the review.

Printed name of LIDDA staff who conducted on-site review — Print the first and last name of the person who conducted the review.

Date — Enter the date the form is signed by the LIDDA staff who conducted the review.

Signature-LIDDA Staff — The LIDDA staff who conducted the review signs the form.

Title — Print the title of the LIDDA staff who conducted the review.

Name of LIDDA — Print the name of the LIDDA.

Signature-Site Administrator or Manager — The provider staff in charge of the residence signs the form.

Date — Enter the date the site administrator or manager signs the form.

Date submitted to SSLC — Enter the date the form is provided to the SSLC.