Most Integrated Setting Practices

Transcription

1 State Supported Living Centers Statewide Policy & Procedures Policy Number: Effective: xx/xx/2013 Replaces: POLICY: PURPOSE: Most Integrated Setting Practices The purpose of this policy is to encourage and assist individuals in moving to the most integrated setting in accordance with the Americans with Disabilities Act and the United States Supreme Court s decision in Olmstead v. L.C.; identifying needed supports and services to ensure successful transition in the new living environment; identifying obstacles to moving to a more integrated setting; and establishing post-move monitoring and reporting procedures. APPROVED BY: Joe Vesowate Assistant Commissioner State Supported Living Centers APPLIES TO: All employees, agents, and contractors of State Supported Living Centers and the ICF component of Rio Grande State Center ( state centers ) DISTRIBUTION: The state center must ensure the policy, all exhibits, and forms are distributed to applicable staff, contractors, agents and to any individual or legally authorized representative (LAR) requesting a copy. CONTACT: Eric Moorad Policy/Rules Coordinator (512) EXHIBITS AND FORMS: Exhibits: Exhibit A Obstacle Categorization Forms: SSLC 018A Living Options SSLC 018B Post-Move Monitoring Checklist SSLC 018C Community Living Discharge Plan REFERENCES: Settlement Agreement, Section T 42 Code of Federal Regulations (CFR) Texas Administrative Code (TAC), Chapter 2, Subchapter F The Americans with Disabilities Act Olmstead vs. L.C. United States Supreme Court decision of 1999 Policy #004 Individual Support Plan Process Page 1 of 11

2 Draft New or Updated Definitions (to be Placed in the Definitions Dictionary) Actively involved person (AIP): A person with significant and ongoing involvement with an individual who lacks the ability to provide legally adequate consent and who does not have an LAR. The individual s interdisciplinary team (IDT) determines if the person is actively involved based upon the person s: (A) observed interactions of the person with the individual; (B) knowledge of and sensitivity to the individual's preferences, values and beliefs; (C) availability to the individual for assistance or support; and (D) advocacy for the individual s preferences, values, and beliefs. (40 TAC 4.105(1)) Client Assignment and Registration System (CARE): A database with demographic and other data about an individual who is receiving services and supports or on whose behalf services and supports have been requested. (40 TAC 2.253(3)) Community living options information process (CLOIP): The activities performed by a contract local authority (contract LA) to provide information and education about community living options to an individual who is 22 years of age or older residing in a state center or to the individual's legally authorized representative (LAR). In conducting the CLOIP, the contract LA must: (A) provide standardized educational materials approved by DADS describing living options and supports in the community; (B) offer the individual or LAR the opportunity to visit examples of living options available in the community and to visit with peers utilizing these options; and (C) document the results of the CLOIP in a format approved by DADS. (40 TAC 2.253(4) and 40 TAC 2.274(a)(2)) Community placement: An individual s move from a state center to a community setting. Consensus: A negotiated agreement that all parties can and will support in implementation. The negotiation process involves the open discussion of ideas with all parties encouraged to express opinions. (40 TAC 2.253(6)) Contract local authority (contract LA): A LA that has a contract with DADS to conduct the community living options information process (CLOIP). (40 TAC 2.253(7)) Designated local authority (designated LA): The LA assigned to an individual in the Client Assignment and Registration System (CARE). (40 TAC 2.253(12)). Legally adequate consent: Consent received from a person who has legal status that meets the statutory requirements for comprehension of information and voluntariness as specified in Texas Health and Safety Code (THSC) , which provides: (A) consent given by a person is legally adequate if the person: (1) is not a minor and has not been adjudicated incompetent to manage the person's personal affairs by an appropriate court of law; (2) understands the information; and Page 2 of 11

3 (3) consents voluntarily, free from coercion or undue influence. (B) the person giving the consent must be informed of and understand: (1) the nature, purpose, consequences, risks, and benefits of and alternatives to the procedure; (2) that the withdrawal or refusal of consent will not prejudice the future provision of care and services; and (3) the method used in the proposed procedure if the person is to receive unusual or hazardous treatment procedures, experimental research, organ transplantation, or nontherapeutic surgery. (40 TAC 3.101(34) and THSC )) Local authority (LA): An entity with the authority and responsibility within a specified region for planning, policy development, coordination, and resource development and allocation, and for supervising and ensuring the provision of intellectual disability services to individuals in one or more local service areas. (Texas Health & Safety Code (11); 40 TAC 1.3(4)) Local service area: A geographic area composed of one or more Texas counties delimiting the population which may receive services from a local authority (LA). (40 TAC 2.253(27)) Minor: An individual under 18 years of age who is not and has not been married or who has not had the disabilities of minority removed for general purposes. (THSC (15)) Most integrated setting: A setting that allows the greatest opportunity for the individual to be integrated into the community and to interact with non-disabled individuals. Permanency planning: A philosophy and planning process that focuses on the outcome of family support for an individual under 22 years of age by facilitating a permanent living arrangement in which the primary feature is an enduring and nurturing parental relationship. (40 TAC 2.253(33)) Provider: A public or private entity that delivers community-based residential services and supports for individuals, including, but not limited to, an ICF/IID or a nursing facility, HCS community provider, etc. The term also includes a public or private entity that provides waiver services. (40 TAC 2.253(36)) Services and supports: Programs and assistance for individuals with intellectual disabilities that may include a determination of intellectual disability, interdisciplinary team (IDT) recommendations, education, special training, supervision, care, treatment, rehabilitation, residential care, and counseling, but does not include those services or programs that have been explicitly delegated by law to other state agencies. (40 TAC 2.253(41)) I. State Center Responsibilities A. All state centers must implement this policy consistently and effectively by: Page 3 of 11

4 1. Encouraging and assisting individuals to be served in the most integrated setting appropriate to their needs and preferences; 2. Ensuring that 100% of the individuals served by the state center have a living options discussion annually; when requested by the individual, legally authorized representative (LAR), or actively involved person (AIP); and as needed; 3. Encouraging and providing opportunities for education about community services to individuals and their LARs; and 4. Ensuring staff in the applicable disciplines and the interdisciplinary teams (IDTs) are trained in the proper completion and distribution of forms and actions relating to this policy. B. This policy is subject to the limitations of court-ordered confinements for individuals determined incompetent to stand trial in a criminal court proceeding or unfit to proceed in a juvenile court proceeding. C. Exceptions to this policy may be made with justification and approval by the Assistant Commissioner of State Supported Living Centers. II. Assisting Individuals with Movement to the Most Integrated Setting A. Education about Living Options and Supports Available in the Community 1. The state center encourages and provides each individual the opportunity to participate in individualized and/or group tours of a variety of community living arrangements, day programs and activities, and employment opportunities, when possible. The state center facilitates and schedules tours in conjunction with the local authority (LA), and ensures that: a. The Admissions/Placement Coordinator (APC) enters tour participation information into the tour database, and the information is provided to the IDT; and b. Tour information is documented upon completion of each tour, including responses and reactions of the individual. The documentation is provided to the qualified individual disability professional (QIDP) for discussion at any review of living options. 2. Each individual over the age of 22 and the individual s LAR or AIP is provided with information related to community living options through participation in the community living options information process (CLOIP). Page 4 of 11

5 a. The contract LA in the state center s service area is responsible for completing the CLOIP worksheet at least two weeks before the individual s annual individual support plan (ISP) meeting for use in the discussion of living options. b. The CLOIP worksheets are provided to the QIDPs and made available to all IDT members for use during living options discussions. c. A copy of the CLOIP worksheets is placed in the individual s active record. 3. Each individual under the age of 22 and the individual s LAR or AIP is provided with information related to community living options through the permanency planning process conducted semi-annually by the designated LA. a. Copies of the permanency plans are distributed to the QIDPs and made available to all IDT members for use during living options discussions and other appropriate routine meetings. b. A copy of the permanency plan is placed in the individual s active record. c. The state center must maintain documentation of both the date the permanency plan was completed and the date it was received by the state center. 4. State centers will explore additional opportunities for providing exposure or sharing information to individuals and their LARs about community living options. These additional opportunities include, but are not limited to: a. Self-advocacy meetings; b. House meetings for the individuals; c. Family association meetings; d. Visiting with individuals and families/lars who have experienced successful transitions; e. Visiting friends who live in the community; and f. Newsletter articles or presentations by individuals or families who have experienced a successful transition to the community setting. 5. At least annually, the state center hosts a community provider fair. a. The state center collects information/data on the community provider fair, including: Page 5 of 11

6 i. Outreach to provide notice of the provider fair to individuals, LARs, AIPs, staff, and providers; ii. iii. iv. Accommodations for individuals, LARs, AIPs, staff, and providers to attend the provider fair at various times of the day and evening, based on input from individuals, LARs, AIPs, staff, and providers; Attendance information (individuals, LARs, AIPs, staff, and providers); and Satisfaction and recommendations information from all participants. b. Upon a review of the data/information collected, the state center makes changes and/or provisions for upcoming community provider fairs, as appropriate. c. The APC maintains copies of all data/information collected and makes this data/information available to the DADS State Office Continuity of Services (COS) Coordinator upon request. 6. At least annually, the state center hosts a community living options in-service to discuss community programs and the referral process with participation from LAs. a. The state center collects data/information on the community living options inservice, including records demonstrating: i. Attendance (individuals, LARs, AIPs, and staff; and ii. Satisfaction and recommendations from all participants. b. Upon a review of the data/information collected, the state center makes changes and/or provisions for upcoming community living options in-services, as appropriate. c. The APC maintains copies of all data/information collected and makes this data/information available to the DADS State Office COS Coordinator upon request. 7. Regular state center meetings are held with LAs. 8. State center s management team promotes and encourages participation in opportunities for exposure to community living options to management staff, clinical staff, and direct support professionals. B. Review of Living Options Page 6 of 11

7 1. Living options discussions take place during each individual s initial and annual ISP meetings and upon request by the individual, the individual s LAR, another IDT member, or an AIP. a. For living options discussions that occur during the initial or annual ISP meeting, the IDT follows the format outlined in statewide operational policy #004, Individual Support Plan Process. b. For living options discussions that occur outside of the initial or annual ISP meeting, the IDT follows the format outlined in form SSLC018A, Living Options. c. If an individual or individual s LAR requests community placement at a time that is not in conjunction with the initial or annual ISP, the individual s IDT convenes to discuss living options within two weeks of the request. The individual s LAR (if available) must be a participant in the discussion. Living options discussions will not be held more frequently than quarterly, unless approved by the state center director. 2. If the individual is not referred for transition, the IDT identifies obstacles to transition and develops strategies and action plans to overcome such obstacles, including persons responsible and timeframes for completion. (See Exhibit A, Obstacle Categorization) 3. If there is a lack of consensus by the IDT regarding a referral for community placement, the following steps are taken: a. The QIDP notifies the state center director within one working day of the date that the IDT determines it cannot reach consensus. b. The state center director names a review team, consistent with the state center s written policies and procedures, to evaluate the situation and make a recommendation to the director within 14 calendar days. c. The individual, the individual s LAR, AIPs, or any IDT member who participated in the IDT meeting is provided the opportunity to attend the review team meeting and to present any information, in writing or in person, that will assist the review team in its evaluation. d. Within three working days of receiving the review team s recommendation, the state center director issues a written decision to: i. The individual; ii. iii. The LAR, if applicable; AIP(s), if applicable; Page 7 of 11

8 iv. The staff members on the IDT; and v. The review team members. e. The state center includes with the written decision sent to the individual, individual s LAR, if applicable, or AIP(s), if applicable, a notice that the individual, individual s LAR, if applicable, or AIP(s), if applicable, may request a review of the state center director s decision by the DADS Ombudsman. i. The individual, individual s LAR, if applicable, or AIP(s), if applicable, may request the review within 10 working days following receipt of the state center director s decision. ii. The request for a review by the DADS Ombudsman may be made in writing to Consumer Services and Rights Protection, Ombudsman, Texas Department of Aging and Disability Services, P.O. Box 12668, Austin, Texas, , or by calling f. The DADS Ombudsman decides whether the processes have been followed by reviewing relevant documentation from the IDT, the review team, the director, and the person who requested the review. g. The DADS Ombudsman issues a written decision within 14 calendar days of the request to the person who requested the review and to the director of the state center. h. If the DADS Ombudsman decides that the processes have been followed, then the director will take action to implement the decision. i. If the DADS Ombudsman decides that the processes have not been followed, then the director must take action as necessary to follow the processes. C. Community Transition Process 1. When a referral for community placement is made, the IDT, in coordination with the LA, begins development and implementation of a community living discharge plan (CLDP) using form SSLC 018C, Community Living Discharge Plan. 2. Within 14 days after a referral for community placement, the APC will convene the IDT to discuss: a. Geographic location; b. Type of placement; c. Pre-and post-move supports; Page 8 of 11

9 d. Pre-selection visits; e. Current restrictions; f. Current level of need (LON); g. Adaptive/assistive/protective equipment needed, along with any medical/nursing needs; h. Positive behavioral support needs; i. Court commitment/guardianship orders; j. Input from individual, LAR, and AIP(s); k. Burial contract/pre-need arrangements; and l. Reimbursement status/issues. 3. Supports and services will continue to be reviewed and modified as needed throughout the community transition process. a. The inclusion of supports and services must be derived from the following: i. The individual s personal preferences and interests relating to transition; ii. iii. iv. The preferences of family members and LARs; Written assessments and updates from IDT members (i.e., needed services for health, safety and skill development); and Other documents, such as individual support plan addendums. b. Supports and services must be written using observable, measurable, and verifiable terminology. The wording must provide the state center, the receiving provider, and the post-move monitor with adequate guidance regarding the provision and monitoring of each support or service. 4. The state center must verify, through the pre-move site review that the pre-move supports and services identified in the CLDP are in place at the individual s new home before the individual moves from the state center. D. Identifying Obstacles to Transition to a More Integrated Setting Page 9 of 11

10 1. Obstacles consist of issues or impediments that delay an individual from moving to a community setting of the individual s choice. These include any supports and services not currently available to meet the needs and preferences of the individual in the community setting. Obstacles to transition are identified after an individual has been referred for community placement. 2. If the individual cannot be transitioned within the 180-day timeframe, in accordance with the State s Promoting Independence Plan, created and revised annually in response to the US Supreme Court ruling in Olmstead v. Zimring (1999), and the Governor s Executive Order GWB99-2 (1999), then: a. The IDT identifies the obstacles that are preventing the individual from a successful transition within the 180 days; and b. The IDT must convene every 30 days following the 180-day timeframe to discuss any obstacles to transition and implement plans/strategies to overcome these obstacles. 3. All state centers use the categories and subcategories of obstacles described in Exhibit A, Obstacle Categorization, for identification and data collection. Administrative staff at the state center reviews information collected quarterly for analysis and development of specific action plans to address identified trends and patterns of issues. 4. Based on the comprehensive assessment of obstacles, DADS will implement steps to overcome or reduce identified obstacles to serving individuals in the most integrated setting appropriate to their informed choice and needs. 5. The state center s Quality Assurance Department submits an assessment of identified obstacles to the state center director on a quarterly basis, and to DADS State Office on a yearly basis. Reports are submitted to other appropriate agencies as necessary. III. Post-Move Monitoring & Reporting A. The post-move monitor conducts post-move monitoring visits at 7, 45, and 90 day intervals, at minimum, following an individual s movement to the community setting from a state center. The post-move monitor documents the monitoring visit on the Post-Move Monitoring Checklist (see SSLC 018B, Post-Move Monitoring (PMM) Checklist). B. The purpose of the monitoring visits is to assess whether the supports and services identified in the individual s CLDP are in place through on-site reviews of both the residential and program sites. During the monitoring visits, if the post-move monitor identifies areas of concern that are not specifically identified in the CLDP (e.g., cleanliness of the home, plumbing problems, kitchen pantry not properly stocked, etc.) or concerns that the CLDP is not being properly followed, or other concerns raised by another party, the post-move monitor makes necessary recommendations to the community provider to address the monitor s concerns, notifies the service coordinator at the LA and documents such actions on Page 10 of 11

11 the PMM Checklist. The QIDP, ADOP, APC, provider, and LA service coordinator are provided a copy of the PMM checklist. The QIDP coordinates with the LA to convene an IDT meeting to include the provider, as appropriate, to address any identified issues. IV. Quality Assurance A. The state center ensures the CLDP is reviewed by designated staff prior to submission to the director for final approval before the individual s transition date. B. The APC submits final CLDPs to DADS COS Coordinator within seven calendar days after transition. C. State Office staff reviews a sample of CLDPs from each state center and identifies trends and areas of needed improvements related to transition planning, informed choice, assessments, identification, and implementation needed supports. Information is shared with state center staff. Page 11 of 11

12 May 2013 Exhibit A Obstacle Categorization All State Centers use the following categories of obstacles. The interdisciplinary team (IDT) must determine how they will overcome each obstacle chosen. Reasons/Obstacles to not make a community referral Category Individual s reluctance for community placement Legally authorized representative s (LAR s) reluctance for community placement Medical needs requiring 24-hour nursing services/frequent physician monitoring Behavioral health/psychiatric needs requiring frequent monitoring by psychiatric/psychology staff and/or enhanced levels of supervision maintained by direct service staff Evaluation period (Ch. 55/46B only) Court will not allow placement (Ch. 55/46B only) Lack of funding Subcategories o Lack of understanding of community living options o Individual has been provided information and exposure to community living options, but is not interested in community placement o Individual is not interested in being provided information and exposure to community living options o Mistrust of providers o Unsuccessful prior community placement(s) o Lack of understanding of community living options o LAR has been provided information and exposure to community living options, but is not interested in community placement o LAR is not interested in being provided information and exposure to community living options o Mistrust of providers o Unsuccessful prior community placement(s) Obstacles to transition Category Lack of supports for people with significant challenging behaviors Lack of specialized mental health supports Need for services Comments o Reimbursement rates sufficient to hire and retain direct care and professional staff able to meet the challenging needs of individuals o Availability of trained and qualified professional staff (e.g., behavior analysts to develop and assure appropriate implementation of successful behavior support plans) o Availability of specialized evaluation and treatment for individuals with cooccurring IID and mental illness in the community o Availability of easily accessible psychiatric crisis support o Availability of specialized counseling services related to prior offense (e.g.

13 May 2013 Exhibit A and supports for individuals with forensic needs/ backgrounds Need for environmental modifications to support the individual Need for transportation modifications to support the individual Lack of availability of specialized medical supports Lack of availability of specialized therapy supports Lack of specialized educational supports Need for meaningful employment and supported employment Individual/LAR indecision Limited residential opportunities Medicaid/SSI funding Other drug abuse counseling, sex offender counseling) o Alternate opportunities for employment for individuals who cannot secure meaningful employment if they cannot pass a criminal history background check o Architectural changes to the living environment are needed o Geographic location of the identified placement area does not allow easy access to medical/behavioral/habilitation/etc. supports and services o Public transportation vehicle/assistance is not currently available to meet the individual s mobility/translocation needs o Viable transportation to accommodate the individual s mobility/transportation needs is not currently available (e.g. customization of the vehicle is needed to safely and appropriately transport the individual) o Staffing adequacy and training competency to meet the medical needs of the individual may not be readily available o Frequent interventions from direct support staff to assist with medical needs, catheterizations, etc., which may require higher levels of staff support in the home o Immediate and/or frequent attention by nursing staff, etc., is needed in the home/day program environments o Staffing adequacy and training competency to meet the therapy needs of the individual may not be readily available o Frequent interventions from direct support staff to assist with positioning, dining assistance, etc., which may require higher levels of staff support in the home o Immediate and/or frequent attention by physical and occupational therapists, speech therapists, etc., is needed in the home/day program environments o Local school district does not have the supports in place to serve individuals with mental health, challenging behaviors and/or specialized medical needs o Assistance to obtain meaningful employment in identified geographic area is not readily available o Continuation of supported employment services to maintain employment o Transportation assistance to and from employment site o Individual/LAR have not reached a decision regarding provider selection o There are limited residential opportunities in the preferred area and individual/lar is unwilling to consider other areas. o Individual is not eligible for SSI funding o Provide a description of the obstacle

14 SSLC 018A 2013 Living Options (Note: This shell is to be used for all Living Options Discussions outside of the annual Individual Support Plan (ISP). For Living Options discussions held during the annual ISP, follow the format outlined in DADS Policy #004, ISP Process.) The Optimistic Living Vision for the Individual: I. Awareness by individual and/or legally authorized representative (LAR) of living options (including experience, known information, and exposure to living options): II. Preferences of individual for a specific living option: III. Preferences of LAR for a specific living option: IV. Supports needed to educate individual and/or LAR regarding living options: V. The interdisciplinary team (IDT) (independent of the individual and LAR/family) recommendation regarding transition to a less restrictive setting: VI. The supports and services needed by the individual in the areas of: Rights/Need for a Guardian or Advocate: Safety: Mobility: Medical: Behavioral/Psychiatric: 1

15 SSLC 018A 2013 Employment/Day Programs/School: Quality of Life (i.e., leisure and recreation, spirituality, relationships): (Add others as needed) VII. Essential and Non-Essential Supports & Services: Pre-Move (Essential) Responsible Person Supports/Services Comments/Date Due (List supports individually) Post-Move (Non-Essential) Supports/Services (List supports individually) Responsible Person Comments/Date Due VIII. Local Authority (LA) Input and Recommendations: IX. Permanency Plan discussion (if applicable): X. Identify obstacles to a referral and the plans to overcome the obstacles Obstacle to a Referral Description Action Plan to Overcome Obstacle: The IDT determined that should/should not be referred for transition to a less restrictive setting. If the IDT determines that the individual will not be referred for transition, then the obstacles to a referral were identified as: Individual Choice - o Lack of understanding of community living options o Individual has been provided information and exposure to community living options, but is not interested in alternate placement. (Note: Opportunities for information regarding and exposure to alternate living environments will continue 2

16 SSLC 018A 2013 to be provided by the State Center at least annually.) o Individual is not interested in being provided information and exposure to alternate community living options o Mistrust of providers o Prior community placement(s) have been unsuccessful LAR Choice- Select one of the following: o Lack of understanding of community living options o LAR has been provided information and opportunity for exposure to alternate community living options, but is not interested in alternate placement. (Note. Opportunities for information regarding and exposure to alternate living environments will continue to be provided by the State Center at least annually.) o LAR is not interested in being provided information and exposure to alternate community living options o Mistrust of providers o Prior community placement(s) for the individual have been unsuccessful Lack of funding Medical needs requiring 24-hour nursing services and frequent physician monitoring Behavioral health/psychiatric needs requiring frequent monitoring by psychiatric/psychology staff and/or enhanced levels of supervision to be maintained by direct service staff Evaluation Period (Ch. 55/46B commitments only) Court will not allow placement (Ch. 55/46B commitments only) 3

17 SSLC 018C May 2013 COMMUNITY LIVING DISCHARGE PLAN (CLDP) Purpose: To provide individuals residing in state centers with a transition plan that is representative of the individual s preferences and choices, identifies the wants and needs of the individual, and ensures that needed supports and services are in place to facilitate a successful transition to an alternate community setting. Instructions for Completion: 1. Development of the community living discharge plan (CLDP) will begin at the time of the referral for alternate community placement with the completion of the Profile, and should continue past the transition date. 2. The CLDP should be completed using the person directed planning philosophy. 3. Interdisciplinary Teams (IDTs) will meet at various stages of the community transition process. Deliberations from these meetings will be maintained with the CLDP. 4. Direction from the individual and/or LAR (if applicable) should be solicited and documented at each stage of the process. CLDP Sections: I. Profile Historical and demographic information, current medication orders, adaptive equipment, etc. II. Community Living Data Contact information III. Findings and Observations Current discipline summaries and recommendations IV. Community Living Personal likes/dislikes, preferences, activities related to transition process, outcomes and goals, pre-move and post-move supports V. Community Living Monitoring Activities Facility, local authority (LA), and Provider monitoring activities VI. Agreements Agreements between the facility, LA, and Provider VII. Discharge Plan/Activities

18 Community Living Discharge Plan Name CLDP CP Referral Date: I. Profile Name: SSLC Name: SSLC Address: Admission Date: Case Number: Level of Care: CARE ID Number: CLDP Date: SSLC Contact (APC): Level of Need: Transition Date: Phone Number: Reason for Recommendation: Date of Birth: Legal Status: Guardian Name: Type: Expiration Date: Admission Type: Commitment Co: Cause Number: Date: Type: Social Security #: Medicaid or MAO #: Monthly Income: Earned: Source: Unearned: Source: Medicare #: Private Insurance: Burial Plans: Correspondent: Relation: Address: City, St Zip: Home Phone: Work Phone: Cell Phone: 2

19 Name CLDP County of Residence: Preferences of individual, family and or legally authorized representative (LAR) and IDT (e.g., geographic preference, type of home, etc.): Method of communication: Primary language spoken or understood: Sensory impairments: Psychological: IQ: Test Instrument: Date: ABL: Test Instrument: Date: ICAP Service Score: Date: Behavior Issues: Behavior Plan: Determination of Mental Retardation Date (DMR) or C D & E Date: DMR Update Date: Psychiatric Diagnosis: Axis I: Axis II: Physical Description: Gender: Race: Age: 3

20 Height: Weight: Hair Color: Eye Color: Identifying Marks: Name CLDP Ambulation status: Mobility/Transfer: Adaptive Equipment Needed: Medical Diagnosis: Hep B Status: Diet: Ideal Weight: Medications & Purpose: Allergies: Special Medical Needs: (e.g., maintenance needs monthly lab work, daily blood sugar levels, etc.) 4

21 Name CLDP II. Community Living Data Community Physician: Hospital: Current LA: Contact: Receiving LA: Contact: New Residence: Contact: Title: Provider Agency: Contact: Title: Independent School District: Day Program: Contact: Title: Name Address City, St Zip Name Address City, St Zip Business Name Address City, St Zip Name Business Name Address City, St Zip Name Address City, St Zip Name Title Number of Beds: Business Name Address City, St Zip Name Title Name Business Name Address City, St Zip Name Title Phone Phone Phone Phone Phone Type: Phone Phone LA HCS Service Coordinator: Name Phone IPC/QDDP (ICF/ID only): Name Phone Provider Service Manager: Name Phone LA Continuity of Services Worker: Name Phone Community Psychiatrist: Name Phone Community Psychologist: Name Phone Community RN/LVN: Name Phone Community Dietician: Name Phone Community Behavioral Therapist: Name Phone Post Move Monitor: Name Phone 5

22 Name CLDP III. Findings and Observations A. Current Summaries/Assessments and Recommendations 1. Social/QDDP: Date of Summary/Assessment: Discussion/Review of Recommendations: Final recommendations: 2. Medical Date of Summary/Assessment: Active Problem List Inactive Problem List Allergies Current Medications with dosages, schedule, and purpose Immunizations are/are not current Lab results Pap smear date results X-ray date results Weight: present weight, frame EDWWR Vision exam results Type(s) of sedation needed Discussion/review of recommendations: Final recommendations: 3. Nursing: Date of Summary/Assessment: Discussion/review of recommendations: Final recommendations: 4. Dental: Date of Summary/Assessment: (include type of sedation needed) Discussion/review of recommendations: Final recommendations: 6

23 Name CLDP 5. Nutrition: Date of Summary/Assessment: Discussion/review of recommendations: Final recommendations: 6. Hearing Date of Summary/Assessment: Discussion/review of recommendations: Final recommendations: 7. Speech and Language Date of Summary/Assessment: Discussion/review of recommendations: Final recommendations: 8. OT/PT Date of Summary/Assessment: Discussion/review of recommendations: Final recommendations: 9. Psychological Date of Summary/Assessment: (to include behavioral issues which need to be addressed) Discussion/review of recommendations: Final recommendations: 7

24 Name CLDP 10. Residential/Daily Living Skills Date of Summary/Assessment: Discussion/review of recommendations: Final recommendations: 11. Vocational/Day Program Date of Summary/Assessment: Discussion/review of recommendations: Final recommendations: 12. Other: Note: Every recommendation that is approved by the IDT must be identified as either a pre-move or postmove support. B. Date of IDT Review of Current Summaries/Assessments: Note: Date must be within 45 days of transition. 8

25 Name CLDP IV. COMMUNITY LIVING A. Personal likes, dislikes, and preferences, including friends and important relationships: (Preferences & Strengths Inventory) B. Summary of transition activities, to include (These may not result in separate items in the completed document because they are so closely interwoven. Instead, these elements are intended to prompt your thought processes concerning this section): Individual involvement (includes visits) Family involvement (includes visits) LA involvement State Center involvement Other considerations (advocates, etc.) Home(s) considered (including location and description of home to which movement is planned) Elements of choice (various considerations and perceived advantages and disadvantages) C. Outcomes important to the individual and related personal goals: D. Supports and services necessary to support the individual in achieving the outcomes important in the individual s life Pre-Move (Essential) supports and services must be in place prior to move or day of transition. Post-Move (Non-essential) supports and services with plan setting forth implementation dates are not a barrier to move Be sure to include in-service requirements, including a train the trainer in-service Staffing needed Home modifications Evidence required may include observation, documentation, demonstration, etc. Pre-Move (Essential) Supports Evidence Responsible Person Comments/Date Due 9

26 Name CLDP Post-Move (Non-essential) Supports Evidence Responsible Person Comments/Date Due E. The following will be provided and/or arrangements will be made for on the day of transition: Designate responsible person: 30-day supply of medications Individual s personal property to include a complete inventory list - $0.00 will be sent from the individual s Trust Fund account - Date the facility will notify the Social Security Administration of the individual s transition from the facility: Signed Physician Orders - 90-day Orders - List items and designate responsible person: 30-day supply of medical/nursing needs (i.e. glucometer, colostomy/urostomy equipment, etc.) - Adaptive/assistive/protective equipment that will accompany the individual 10

27 V. Community Living Monitoring Activities Name CLDP A. Responsibilities of each party for verifying that the outcomes and supports established in the CLDP for successful transition have been met. These responsibilities may include on-site visitation, phone contacts, record reviews, and written reports with specific timelines for the completion of activities: LA Responsibilities How Often or Date Due Evidence Comments APC/Designee Responsibilities How Often or Date Due Evidence Comments PMM Responsibilities How Often or Date Due Evidence Comments LA Local Authority APC Admissions/Placement Coordinator PMM Post Move Monitor B. Criteria by which the LA will make a recommendation to the head of the State Center that the individual be discharged from the State Center: 1. Individual and his/her family are satisfied with both his/her home and day habilitation/work environments as evidenced by reports of satisfaction, and development of bonds with new peers and staff. 2. Home and work environments are safe 3. Individual is receiving services and supports to maximize his/her independent living, domestic and personal living skills. 4. Provider is not known to be on vendor hold. 5. Individual is receiving all required and recommended medical/health/dental services. 6. Individual is not exhibiting any behavior that may put the placement in jeopardy. C. If the individual was committed to the SSLC through Article or Chapter 46B of the Texas Code of Criminal Procedure, and charges are pending, the LA must coordinate with the SSLC to obtain an evaluation to determine if the individual continues to be incompetent to stand trial prior to discharge from the State Supportive Living Center. D. Expected date of discharge: 11

28 VI. Agreements Name CLDP A. Provider agrees that all the information contained in the community living/discharge plan will be shared with the community physician, assigned direct care staff, provider consultants, and other service providers; B. Provider agrees that the LA, as an agent of the department, shall have access to the individual, the living setting, and the necessary records; C. Provider agrees to immediately notify the LA and the individual s LAR of any conditions which may indicate the living arrangement is in jeopardy and the give the LA and LAR written notice of intent to discharge (ICF/IID placement only) the individual at least 30 working days before the planned day of discharge; D. LA agrees that the provider and a designated facility staff person will receive accurate and timely written reports, including a list of specific findings for any significant monitoring activity; E. Facility and LA agree that the individual and LAR have had an opportunity to participate in the development of the community living/discharge plan (to be accompanied by notations concerning the individual s and LAR s participation in the development of the CLDP); F. Individual, LAR, State Center, LA and provider agree to make a good faith effort to resolve issues that may be identified by any of these parties until the community living/discharge plan culminates in the individual s discharge from the State Center. 12

29 Name CLDP My signature below serves as my agreement with the proposed supports identified, persons responsible for ensuring those supports are implemented/obtained, and the target dates for completion. (Can be an electronic signature.) Name State Center Admissions/Placement Coordinator Date Name State Center Placement Coordinator Date Name LA Date Name Program Provider Date APPROVED: Name State Center Director Date 13

30 Name CLDP Community Living Discharge Plan Date of Meeting: State Supported Living Center Name: DOB: Printed Name Signature Relationship to Individual 14

31 Name CLDP VII. Discharge Plans/Activities Note: completed by the facility upon completion of the terms and conditions specified in section V to include information regarding letter to judge. A. Summary of the outcomes and status of the community living arrangements. B. Resolution of any issues that occurred during the transition (include summary of PMM checklists). C. Date of discharge from the facility: 15

32 Name CLDP Discharge Plan State Supported Living Center Name: Date of Meeting: DOB: Printed Name Signature Relationship to Individual 16

33 SSLC Form 018B May 2013 POST-MOVE MONITORING CHECKLIST Name of individual: Name of staff performing this checklist (print): Residential Provider: Home Address: Home Phone Number: Date individual moved into home: Signature of staff completing this form: Date of visit: Circle one: 1-7 days 8-45 days days Name & phone # of Case Manager/ QMRP: Name & phone # of Residential Provider contact person: Instructions: Complete the checklist to assess whether supports called for in the Community Living Discharge Plan (CLDP) are in place. Yes = supports identified in the CLDP are in place; No = identified supports are not in place; N/A = not a support identified in the CLDP. NOTE: All No responses must include a narrative on the attached page explaining why the support is not in place. Yes No N/A 1 Identified pre-move (essential) supports, per CLDP, in place? (List all items mentioned in CLDP Section IV. Item D.) 2 Identified post-move (non-essential) supports, per CLDP, in place? (List all items mentioned in CLDP Section IV. Item D.) 3 Has the support plan been updated? (If so, enter date meeting held or date meeting scheduled) 4 Have there been any changes in medication? (If so, list medications changed, date of change and reason for change) 5 Does the provider have documentation to confirm staff have been trained on:

34 a. individual s medical needs? b. individual s dietary/nutritional needs? c. individual s personal hygiene needs? d. mobility needs? POST-MOVE MONITORING CHECKLIST e. individual s behavioral considerations and/or psychiatric needs/symptoms? f. individual s communication needs? g. individual s adaptive aids? 6 Personal belongings in the home and available to the individual? 7 Home generally clean and in good repair? 8 Do the individual s records indicate the individual has remained free of injury/illness? 9 Do the individual s records indicate any behavioral incidents, and, if so, were the incidents effectively managed? 10 Has there been a change in home, provider or Case Manager/QMRP? 11 Does the individual express satisfaction with his/her new life, or, if individual is unable to indicate, does the individual s LAR or primary correspondent indicate individual is satisfied with his/her new life? 12 Were the medical and other specialty provider appointments kept, consistent with the individual s CLDP and/or the individual s support plan, as applicable? Item number ACTION/FOLLOW-UP FOR ANY ITEMS MARKED NO ACTION TAKEN DATE AND RESPONSE TO ACTION TAKEN