Form 8665, Person-Directed Plan

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Documents

Effective Date: 8/2024

Instructions

Updated:  8/2024

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.

The form contains some answer fields with text limits. If more space is needed than allowable in an answer field, record the information in a separate document as an addendum to the Person-Directed Plan (PDP).

Purpose

To develop the Person-Directed Plan (PDP) for a person to participate in the Home and Community-based Services (HCS) Program, Texas Home Living (TxHmL) Program and Community First Choice (CFC) and update the plan, as needed, per the person-centered planning process and the rules governing the Programs (26 Texas Administrative Code, Chapters 262 and 263).

Introduction

The service coordinator (SC) at the local intellectual and developmental disabilities authority (LIDDA) uses the discovery process as the basis for collecting information to develop the PDP with the person, legally authorized representative (LAR) and others the person or LAR may request.

The person-centered planning process:

  • identifies existing supports and services necessary to achieve the person's desired outcomes;
  • identifies natural supports available to the person and negotiates needed service system supports;
  • occurs with the support of a group of people chosen by the person (and the LAR on the person's behalf); and
  • accommodates the person’s style of interaction and preferences regarding time and setting.

Find more guidance and information about person-centered planning at Person Centered Planning – The Learning Community for Person Centered Practices (tlcpcp.com).

Examples of the discovery process include:

  • conversations with the person, LAR and those who know the person best, such as a provider staff member, caregiver, family member and friends;
  • a method called Planning Alternative Tomorrows with Hope (PATH);
  • methods taught by The Learning Community for Person Centered Practices (TLCPCP);
  • use of activities and tools from Person Centered Planning; and
  • prompts from the Discovery Guide.

In addition to understanding person-centered planning, the SC must understand the HCS Program Billing Requirements, TxHmL Billing Requirements and CFC Program Billing Requirements for HCS and TxHmL Program Providers. This is to facilitate the gathering of outcome information necessary for justifying support and services to be provided through the HCS program.

Procedures

Following the discovery process and before developing the PDP, the SC helps the person and LAR choose members of the person's service planning team (SPT). The SC should discuss with the person and LAR the importance of including the HCS, TxHmL or CFC provider when the person discusses his or her preferences and goals. Since the provider is responsible for designing and providing services to the person, understanding the person’s strengths, capabilities and desires is critical to providing services that are meaningful to the person. The SC should request permission from the person or LAR to invite the HCS, TxHmL or CFC provider to the planning meeting to develop the PDP. The SC should also ask the person or LAR to invite anyone, such as a family member or friend, to participate in the service planning process.

Detailed Instructions

Plan Date – The date a meeting is held to discuss the PDP.

Enter the later of the date of the meeting to discuss the PDP:

  • first is developed; or
  • is updated during the individual plan of care (IPC) year; or
  • is updated before the latest IPC renewal.

Person’s Information – Enter all data elements in the section for the person and LAR. Enter N/A for those data elements that do not apply to the person or LAR.

Provider Agency Information – Enter all data elements in the section for the provider agency. Enter N/A for those data elements that do not apply to the provider.

Financial Management Services Agency (FMSA) — Enter the FMSA's information if the person chooses to self-direct his or her supported home living (transportation), CFC personal assistance services and habilitation (PAS and HAB) or respite services. If Consumer Directed Services (CDS) is chosen, enter the date the SC provided a list of FMSA providers to the person or LAR. This date will remain the same until a new list of FMSA providers is given to the individual or LAR.

Local Intellectual and Development Disabilities Authority (LIDDA) Information – Enter the data elements in the LIDDA section.

List the discovery process(es) and participants used to obtain information about the person.

Describe how information was gathered – Describe all the ways information was gathered to discover the person's desires and preferences. Examples include: 

  • conversations with the person or LAR and those who know the person best, such as a provider staff, caregiver, family member and friends;
  • a method called PATH;
  • methods taught by TLCPCP;
  • use of activities and tools from Person Centered Planning; and
  • prompts from the Discovery Guide.

This information may change for PDP updates.

Participants – Enter the names of all who participated in the discovery process including the person or LAR. The names may change when the PDP is updated and new information is gathered.

Plan Summary – Enter the Plan date for the summary being added. Add the SC’s name and a brief description of relevant information discussed about the person's preferences and needs that support the PDP.

One Page Description – The format of this “One-Page Description” is based on work by TLCPCP.

____________'s One Page Description – Enter the person's name.

Insert Photo Here – Insert one or two recent photos of the person or photos of people, places or things that are important to the person, if available.

What people like and admire about me – Enter a descriptive narrative including what you have learned through the discovery process that others like and admire about the person.

What's important to me – Enter what you have learned through the discovery process that is important to the person. “Important to” reflects what is important from the person's perspective and is based on the person's words and behavior. When words or behavior are in conflict, listen to the behavior. The information might include important relationships, how the person prefers to interact, things the person likes to do or not do, preferred routines, relevant background information that may affect how the service should be delivered and what the person wants to do in the future. Remember the person’s response is limited to the knowledge and experiences he or she has to date. Additional efforts should be explored to increase his or her awareness of other possibilities and experiences to increase his or her options.

What others need to know and do to support me – Enter important information you have learned through the discovery process about the person. Include what you have learned through the discovery process that is important for the person, as identified by those who know him or her best. “Important for” reflects information that is important for the service provider to know and understand about the person. This information should be related to health, safety and any supports regarded as necessary to enhance the person to be a valued member of the community.

Enter information such as health needs, supervision requirements, specific behavioral needs and special instructions for those who support the person. This section includes contraindications and special justifications for deviating from typical routines or activities. For example, school-age children should be in educational services five days a week, six hours a day, unless contraindicated. This section can identify a non-HCS, TxHmL or CFC service that is supported by a desired HCS, TxHmL or CFC service. For example, supported home living (transportation) may be necessary for the person's supported employment activities. List any barriers that could prevent the outcomes from being achieved. Things identified as “important for” are not usually included as “important to” the person. A good person-centered plan should be a good balance between “Important to” and “Important for” to help the person achieve a good life.

Date Completed – Enter the date information was added or changed on this page.

I Communicate Using: List information learned about the person’s communication needs such as how the person communicates and how to best communicate with him or her.

Historical Information – Enter historical or background information that continues to significantly affect the person or his or her services. Do not repeat information contained on the One Page Description or elsewhere in the PDP.

People in____________’s Life – Enter the person's name.

LAR Status: Check the person’s LAR status. If the person has an LAR, list the type of LAR. If a current copy of LAR paperwork is on file, list the expiration date of the LAR paperwork. If not, explain. If the person does not have an LAR, the SPT must determine if the person would benefit from a guardian or less restrictive alternative to a guardian such as a Power of Attorney or Supported Decision Making Agreement. If the service planning team determines the person would benefit from having a guardian, make a referral to the appropriate court.

List the people who are close to the person and who know and care about the person. – List the people who are close to the person and who know and care about him or her. This will help the provider determine who to speak with in certain situations. It will also help ensure the person does not lose contact with important people in his or her life. Additional rows may be added if necessary. Enter the names, relationships, phone numbers, addresses, email addresses and the reason the person or LAR has identified this contact as being important. Examples of “Important because” are:

  • He takes the person to work.
  • She is a friend the person calls every weekend.
  • He stays with the person until mom comes home from work.
  • She is the person's favorite teacher and helps tutor on weekends.
  • He takes the person to Special Olympics practices and out to eat.
  • The person stays with him during the holidays.

Services – The first portion of the section is the SC’s attestation about the HCS, TxHmL or CFC services included on the person's PDP. The next portion of the section serves to meet the requirement of the service coordination rule by identifying the frequency and duration based on the person's preference and needs. Frequency is determined by completing Form 8647, Service Coordination Assessment – Intellectual Disability Services, for the person. Once Form 8647 has been completed, enter how often the SC will meet in-person with the person. Based on the person or LAR’s consent and preference, enter how often the SC may meet with the person via audio-only or synchronous audio-visual technology for comprehensive service encounters, commonly referred to as Type A visits. Audio-only or synchronous audio-visual meetings do not replace in-person meetings required by 26 TAC Chapter 331, Section 331.11(d).

Non-HCS, TxHmL or CFC services – List all non-HCS, TxHmL or CFC services provided by family, other funding sources or both to be coordinated or monitored by the SC.

Identify type of non-HCS, TxHmL or CFC service and enter what the individual wants from this service – Enter the type of non-HCS, TxHmL or CFC service and describe the outcome or purpose of the service. Examples of non-HCS, TxHmL or CFC services are education services provided by an independent school district (ISD), attendant care, transportation, mental health services, counseling, medical specialist such as a neurologist or podiatrist, or Texas Workforce Commission supports.

Person, specialty, or agency providing services – Enter the name of the person, specialty or agency that will provide this service. Examples of a person, specialty or agency providing a non-HCS, TxHmL or CFC service are: ISD, Personal Assistance Services (PAS) through the Texas Health and Human Services Commission (HHSC), family member to include name and relationship, neurologist (name optional), private psychiatrist (name optional) and community resources, such as a church — include name of church — or a non-profit organization — include name of non-profit organization.

HCS, TxHmL or CFC services that will be used to support the individual to access this non-HCS, TxHmL or CFC service, if any – Enter  the HCS, TxHmL or CFC service to be used in conjunction with the non- HCS, TxHmL or CFC service. An example could be the person receives supported employment as a type of non-HCS, TxHmL or CFC service through the Texas Workforce Commission and supported home living (transportation), a type of HCS service used to provide transportation to and from the  person’s work site. If an HCS, TxHmL or CFC service is identified in this section, documentation must be made in the “pertinent information” area of the Action Plan for that service to describe how the service will be provided in conjunction with the non-HCS, TxHmL or CFC service.

Service Coordinator's Follow-up Responsibilities – The SC documents actions the SC will take to facilitate non-waiver services, such as making a referral, scheduling an intake or assisting with an application.

Action Plan – These sections identify the HCS, TxHmL or CFC service components necessary to assist the person to achieve his or her desired outcome(s). Complete an Action Plan for each HCS, TxHmL or CFC service the person will receive during the IPC year. Organize the person's “important to” and “important for” items into an Action Plan the program provider can use to begin service provision, and as a starting point for the development of the Implementation Plan (IP). If a person receives residential support, supervised living or host home/companion care, the SPT must discuss and document the resources available for room and board as it relates to the person's choice of residential setting. 

Person’s Name – Enter the person's name.

Client Assignment and Registration (CARE) System ID – Enter the person's CARE System identification (ID).

Plan Date – Enter the PDP date this Action Plan was developed. This date will change to a new PDP date when a PDP meeting is held that affects any section of this Action Plan.

Desired Service – Enter the HCS, TxHmL or CFC service this Action Plan will address.

Does this service require a backup plan? – Mark only one box based on the SPT’s decision for a service backup plan. The SPT must recommend a service backup plan for any HCS, TxHmL or CFC service identified as critical for the person. Service backup plans are not limited to CDS delivered services only.

Service Delivery Option – Mark only one box based on the person's preference of service deliver option for allowable CDS option services.

CFC Support Management — Voluntary training with selecting, managing and dismissing attendants. A person can select this benefit by indicating yes on the PDP.

Outcome – Enter what the person wants from this service. The person or LAR may have identified one or more outcomes. Outcome can be specific or general depending on the request of the person or LAR and his or her specific needs.

Pertinent Information – Enter information identified by the person or the SPT as needs, requests or considerations specific to the identified services for this Action Plan. This information is necessary for the service provider to know how to support the person in achieving his or her outcomes. Specific preferences related to how the person wants the service delivered are important to include, if known. This could be a preference for a specific gender of service provider or special preferences for a morning or evening routine. State a person's fears or concerns about the delivery of services that would be helpful to the service provider. This section may change and grow as the SC has more conversations and interactions with the person or LAR and as more information about the person's needs and preferences are discovered.

For Update Purposes During the IPC Year Only – Complete this section any time information for this Action Plan changes or when a new Action Plan is added or discontinued during the IPC year. Once the Action Plan is revised, the SC enters the date the revision was made and the date the change is effective and prints his or her name. The SC submits to the provider a copy of only the page(s) of the PDP that were revised.

This service was changed, added or removed from this plan and will be implemented on – Check the appropriate box to indicate if a change, such as revising an outcome or new information on how the person wants his or her services delivered, was made to an existing service, if adding a new service or discontinuing a service. Insert the Plan date from the front page of the PDP. This should be the same date of the Plan meeting that supported the changes identified in the Action Plan. A summary should be included on the first page with the same date. Insert the date the provider agreed the changes, new service or discontinued service will be implemented. The implemented date cannot be a date before the Plan date.

Service Coordinator's printed name – Insert the printed name of the SC who facilitated the plan meeting.

Service Settings: For each program service identified on the person’s PDP, mark the setting(s) selected by the person or LAR from setting options available for the delivery of HCS or TxHmL services. Mark N/A for a service that is not on the person's IPC. The setting selected must be based on the person's needs and preferences. For HCS Program services delivered in provider-owned or controlled residential settings, the setting must also be based on resources available for room and board.

Mark how the service would be delivered to the person. The mode of service delivery selected must be accessible to the person.

Record of Forms: The service coordinator must review all required forms annually or if any change in service occurs with the service planning team members, to include the person and LAR where appropriate. The service coordinator must check each box as appropriate to indicate the document was explained to the person or LAR in a method or language they understand. The service coordinator must provide a copy of all documents discussed during the meeting to the person or LAR. The service coordinator must keep a copy of all required documents in the person’s record.

Process for PDP Updates for an IPC Revision

The PDP may be updated at any time during the IPC year based on the person's needs and desires. After the SPT meets and discusses the need to update the PDP, the SC revises the PDP as appropriate and completes the Plan Summary. Note: The summary of a subsequent PDP update meeting during the IPC year is identified as a subsequent PDP update meeting by entering “PDP Update,” the date of the subsequent meeting and the SC’s name and title. This makes it easier to find the new information during the IPC year. This process also provides information on when and by whom the other information was added.

Process for Annual PDP Update for an IPC Renewal

After the SPT has met and discussed the updates needed to the annual PDP, the SC revises the PDP as appropriate and completes the Plan Summary. Note: Because it is a new PDP year, this is the only summary in this section.

  • A new plan date on the first page of the PDP and all Action Plan pages. Note: The Action Plan will not contain anything in the box at the bottom of the page titled “For update purposes during the IPC year only.” All Action Plans, even if continued from the previous PDP are represented as a new Action Plan for the annually updated PDP. The annual updated PDP will not contain any Action Plan for services that have been discontinued from a previous year.

Signatures – All people involved in the PDP process, including the person, must sign the signature page if able, state the relationship to the person and include the date.