| (a) Designated state MR facility staff will prepare
the community living/discharge plan as described in §412.277
of this title (relating to Arrangements for the Move to an Alternative
Living Arrangement of an Individual Residing in a State MR Facility)
and this section. The plan incorporates information provided by the
individual, LAR, MRA, other state MR facility staff, and the provider.
The plan:
(1) is customized based on the abilities and needs
of the individual to specify the:
(A) timelines and intervals for monitoring activities;
(B) form those monitoring activities will take (e.g.
on-site visitations, phone contacts, record reviews, and written reports);
(C) responsibilities of the designated MRA and other
MRAs if the proposed move is outside the designated MRA's local services
area;
(D) responsibilities of the provider; and
(E) criteria for a recommendation for discharge from
the state MR facility;
(2) identifies the individual's or LAR's desired outcomes
for an alternative living arrangement that serve as the basis for
the person directed plan and service coordination plan to be developed
by the designated MRA or the MRA for the local service area where
the individual will live; and
(3) is approved by the individual, LAR, MRA, state
MR facility, and provider before the individual moves from the state
MR facility.
(b) The plan can be in any format acceptable to all
parties (individual, LAR, MRA, state MR facility, and provider), but
must contain the elements described in this section. A sample format
provided by the department may be used as is or modified as deemed
appropriate. Copies are available by contacting the Office of State
Mental Retardation Facilities, Texas Department of Mental Health and
Mental Retardation, P.O. Box 12268, Austin, Texas 78711-2668, 512/206-4516.
(c) The community living/discharge plan will be completed
as follows:
(1) The community living profile (section I of the
sample format), completed by the IDT when a recommendation for an
alternative living arrangement has been made and accepted, describes:
(A) essential information identifying the individual;
(B) the preferences and desired outcomes of the individual
or LAR;
(C) health and safety issues;
(D) the date of the determination of mental retardation
conducted as described in §415.155 of this title (relating to
Determination of Mental Retardation (DMR)); and
(E) name and telephone number of state MR facility
contact person.
(2) The community living data (section II of the sample
format), completed by the state MR facility upon selection of a provider,
with information from the provider and MRA, describes:
(A) the name, address, and telephone number(s) of the
physician or health care entity that will become the individual's
primary health care provider;
(B) the name(s), address(es), and telephone numbers
of contacts at the designated MRA, and others, as appropriate;
(C) the name, address, telephone number, and type (e.g.
HCS or ICF/MR) of provider, and contact person (address and telephone
number, if different);
(D) the name, address, telephone number for school,
job, or day program and contact person (address and telephone number,
if different);
(E) the name, address, and telephone number of individual
program coordinator; and
(F) the identification of the MRA service coordinator
assigned to provide continuity of services.
(3) The findings and observations (section III of the
sample format) are described by the state MR facility and include:
(A) thorough medical and behavioral information, which
will be communicated to the physician who will be providing care in
the community;
(B) all current physician orders and treatments, including
rationale for all medications prescribed and dispensed by the state
MR facility, and amount dispensed which will be continued after the
move; and
(C) a brief summary of findings, events, and progress
during the period the individual resided in the state MR facility;
(4) The community living information (section IV of
the sample format) is compiled based on information supplied by the
individual, LAR, state MR facility and MRA staff, and the provider
and includes:
(A) the individual's personal likes, dislikes, and
preferences (including friends and important relationships);
(B) the specific steps and activities necessary to
accomplish a successful transition;
(C) the outcomes important to the individual and related
personal goals; and
(D) the services and supports necessary to support
the individual in achieving the personal outcomes important in the
individual's life (e.g. residential, vocational, social, leisure,
religion, health, safety, financial, and transportation);
(5) The community living monitoring activities (section
V of the sample format) include:
(A) the responsibilities of the MRA(s), as the agent
of the department, for determining whether the outcomes and criteria
established for successful transition have been met with a description
of how the determination is to be accomplished (e.g. on-site visitation,
phone contacts, record reviews, and written reports) and specific
timelines for the completion of monitoring activities;
(B) the specific actions to be taken by the MRA(s)
and state MR facility in the event that the outcomes and criteria
are not being met;
(C) the criteria by which the MRA(s) will make a recommendation
to the head of the state MR facility that the individual be discharged
from the state MR facility;
(D) a list of the persons, which must include the individual
or LAR, to be notified of the recommendation that the individual be
discharged from the state MR facility and how such notice will be
accomplished;
(E) the timeframe for changing the county of residence
in CARE if the move is outside the local service area of the designated
MRA; and
(F) the expected date of discharge from the state MR
facility.
(6) The agreements portion (section VI of the sample
format) is reviewed and signed by the individual, if appropriate,
LAR, and an authorized representative of the state MR facility, MRA(s),
and provider, and contains the typed names and titles of the signatories,
and the date the plan is approved and signed. This portion includes,
at a minimum, the following terms:
(A) the provider agrees that the community physician,
assigned direct care staff, provider consultants, and other service
providers have been informed of all the information contained in the
community living/discharge plan;
(B) the provider agrees that the MRA(s), as the agent
of the department, shall have access to the individual, the living
setting, and necessary records;
(C) the provider agrees to notify the MRA(s) and the
individual's LAR of any conditions which may indicate the living arrangement
is in jeopardy and to give the MRA(s) and LAR written notice of intent
to discharge the individual at least 30 calendar days before the planned
day of discharge;
(D) the MRA(s) agrees that the provider and a designated
state MR facility staff person will receive accurate and timely written
reports, including a list of specific findings for any significant
monitoring activity described in paragraph (5) of this subsection;
(E) the state MR facility and MRA(s) agree that the
individual and LAR have had an opportunity to participate in the development
of the community living/discharge plan; and
(F) the individual, LAR, state MR facility, MRA(s),
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 MR facility.
(7) The discharge plans/activities (section VI of the
sample format) are summarized by the state MR facility upon completion
of the terms and conditions specified in the community living monitoring
activities portion of the plan and will include:
(A) a summary of the outcomes and status of the alternative
living arrangement;
(B) a resolution of any issues that occurred during
the transition process; and
Cont'd... |
