Documents
Instructions
Updated: 6/2024
Note: An individual as defined in 26 Texas Administrative Code (TAC) Sections 262.3 and 263.3 is referred to as a person in this form.
Purpose
To develop the Individual Data portion of the Person-Directed Plan (PDP) for the Home and Community-based Services (HCS) Program and update, as needed. Person-directed planning is a process that empowers the person and the legally authorized representative (LAR), on the person’s behalf, to direct the development of a plan of supports and services that meets the person’s personal outcomes.
Introduction
The service coordinator (SC) at the local intellectual and developmental disabilities authority (LIDDA), using the discovery process as the basis for collecting information, develops the Individual Data portion of the PDP with the person or LAR and others, as requested by the person or LAR. This portion of the PDP is completed upon enrollment and maintained with the person's record. Update the Individual Data sheet only when the person's information changes. It is not necessary to submit a copy of the Individual Data sheet to the provider every time the PDP is updated unless the information on the Individual Data sheet has changed. The provider receives a copy of the Individual Data sheet when the person is enrolled, when the information on the Individual Data sheet is updated and when the person is transferred to a new provider.
Procedure
The SC gathers the information from appropriate sources to complete the form.
Detailed Instructions
Name of Person – Enter the person’s full name.
CARE ID – Enter the Client Assignment and Registration (CARE) System number for the person.
Date of Birth – Enter the person’s date of birth.
Permanency Plan Required – Check the Yes box if the person is younger than 22 and will be or is residing in an HCS group home receiving Residential Support Services or Supervised Living. Check the No. box for all others.
Local Case No. – Enter the case number assigned by the person’s LIDDA.
Social Security No. – Enter the person’s Social Security number. This is not a required field if the person’s Medicaid number is included on this form.
ICAP Date – Enter the date the Inventory for Client and Agency Planning (ICAP) was completed.
LON – Enter the level of need (LON), as documented on the intellectual disability/related conditions (ID/RC) Assessment.
Medicaid No. – Enter the individual’s Medicaid number. If no Medicaid number is available, the person’s Social Security number must be included in the space provided.
Medicaid Type – Enter the person’s Medicaid type. For HCS, the Medicaid codes must be (R) or (P), the Medicaid type can be 01, 02, 03, 07, 08, 09, 10, 11, 12, 13, 14, 15, 18, 20, 21, 22, 37, 40, 43, 44, 45, 47, 48, 55, 78, 79, 80, 81 or 82.
Medicare No. – Enter the person’s Medicare number, if applicable.
Medicare Type – Enter the person’s Medicare type, if applicable.
If not currently receiving Medicaid, has a Medicaid application been filed? – If the person does not have an active Medicaid status at the time of enrollment, a Medicaid application must be filed to determine financial eligibility for the HCS program. Mark the Yes or No box to indicate whether an application has been filed.
Medicaid Application Date – If the Yes box is marked, enter the date the application was filed.
Private Insurance – If the person has coverage through a private insurance company, enter the name of the insurance company. If the person does not have coverage through a private insurance company, enter N/A.
Emergency Contact Name and Phone No. – Enter the name and phone number of the family member or friend identified by the person or LAR as someone to contact in case of an emergency. This may be the primary correspondent identified on the PDP.
Primary Correspondent (if different from Emergency Contact) – Enter the name of the primary correspondent, if different from the name of the emergency contact above.
Phone No. – Enter the phone number of the person identified as the primary correspondent, if different from the emergency contact.
Guardian – Check the Yes or No box to indicate if the person has a court-appointed guardian.
Guardianship Current – If Yes is selected in the Guardian section, check the Yes or No box as it applies to the status of the guardianship.
Sex – Check the Male or Female box for the person’s gender.
Marital Status – Check the appropriate box to indicate the person’s current marital status.
Language – Check the appropriate box to indicate the primary language the person uses to communicate. If Other is checked, enter the person’s primary language.
Reads English – Check the Yes or No box to indicate if the person can read and comprehend the English language.
Understands English – Check the Yes or No box to indicate if the person understands the English language when addressed.
Race or Ethnicity – Check the appropriate box to indicate the person’s ethnicity. If Other is checked, enter the person’s race or ethnicity.
Housing Assistance – Check the appropriate box to indicate if the person currently has access to, or an application for, one of the government programs for housing assistance. If the person does not have access to, or an application on file for one of these, check the N/A box.
Living Arrangement before enrollment – Check the appropriate box to indicate the person’s living arrangement before enrolling into the HCS program. If Other is checked, enter the person’s living arrangement.
Legal Status* – Check the appropriate box to indicate the person’s current legal status.
Communication* – Check the appropriate box to indicate the type of communication the person uses most often to interact with others. Multiple boxes may be checked, if applicable. If the Other box is selected, include a brief description of the type of communication the person uses to communicate with others.
Ambulation* – Check the appropriate box to indicate the person's ability to move from one area to another. If assistance is required, include a brief description of what kind of assistance is needed.
Community or Home Safety* – Check the appropriate box to indicate the person's ability to safely navigate his or her community, home or both independently.
Check any needs that apply* – Check all appropriate boxes as they pertain to the person's specific needs.
Check adaptive aids that apply* – Check all appropriate boxes as they pertain to the person's use of adaptive aids.
*Additional information may be needed in the PDP if this box is checked. This subject may require more information in the PDP so the service provider has enough detail about the person's needs as they relate to the services and supports.
Host Home or Companion Care (HH or CC) Relationship – Check the Yes or No box to show if, for a person who lives in a host home or companion care setting, the HH or CC service provider is an immediate family member of the person. An immediate family member means a person's spouse, natural or adoptive parent, child or sibling, stepparent, stepchild, stepsibling, grandparent, spouse of a grandparent, grandchild or spouse of a grandchild or father-, mother-, daughter-, son-, brother- or sister-in-law. If Yes is selected in the Host Home or Companion Care Relationship section, check the appropriate box to show how the HH or CC service provider is related to the person.
Completed or updated on – Enter the date the form is completed or updated.