Current through Reg. 50, No. 13; March 28, 2025
(a) A LIDDA must assign a habilitation
coordinator to each designated resident within two business days after a PE is
completed if the PE is positive for ID or DD.
(1) The habilitation coordinator must attend
the initial IDT and provide habilitation coordination while the designated
resident is residing in the NF.
(2)
A designated resident may refuse habilitation coordination.
(b) Unless a designated resident
has refused habilitation coordination, the assigned habilitation coordinator
must:
(1) assess and reassess quarterly, and
as needed, the designated resident's habilitative service needs by gathering
information from the designated resident and other appropriate sources, such as
the LAR, family members, social workers, and service providers, to determine
the designated resident's habilitative needs and preferences and the
specialized services that will address those needs and preferences;
(2) develop and revise, as needed, an
individualized HSP in accordance with HHSC's rules and IDD PASRR Handbook, and
using HHSC forms;
(3) assist the
designated resident to access needed specialized services agreed upon in an IDT
or SPT meeting, including:
(A) monitoring to
determine if a specialized service agreed upon in an IDT or SPT meeting is
requested within required timeframes in accordance with the IDD PASRR Handbook
or documenting delays and the habilitation coordinator's follow-up activities;
and
(B) ensuring the delivery of
all specialized services agreed upon in an IDT or SPT meeting or documenting
delays and the habilitation coordinator's follow-up activities;
(4) coordinate other habilitative
programs and services that can address needs and achieve outcomes identified in
the HSP;
(5) facilitate the
coordination of the designated resident's HSP and NF comprehensive care plan,
including ensuring the HSP is shared with members of the SPT within 10 calendar
days after the HSP is updated or renewed;
(6) monitor and provide follow-up activities
that consist of:
(A) monitoring the initiation
and delivery of all specialized services agreed upon in an IDT or SPT meeting
and following up when delays occur;
(B) monitoring the designated resident's and
LAR's satisfaction with all specialized services; and
(C) determining the designated resident's
progress or lack of progress toward achieving goals and outcomes identified in
the HSP from the designated resident's and LAR's perspectives;
(7) meet with the designated
resident to provide habilitation coordination:
(A) at least monthly if the designated
resident is receiving a specialized service in addition to habilitation
coordination; and
(i) meet in person at least
quarterly or more frequently as determined by the SPT using the findings of the
HHSC Habilitative Assessment form; and
(ii) subject to subsection (d) of this
section, meet via audio-visual communication in a month when a meeting is not
conducted in person; or
(B) at least quarterly in person, if the
designated resident is receiving only habilitation coordination, unless the
designated resident or the designated resident's LAR requests more frequent
meetings;
(8) convene and
facilitate an SPT meeting:
(A) at least
quarterly; and
(B) between
quarterly SPT meetings if:
(i) there is a
change in the designated resident's service needs or medical condition;
or
(ii) requested by the designated
resident or LAR;
(9) coordinate with the NF in accessing
medical, social, educational, and other appropriate services and supports that
will help the designated resident achieve a quality of life acceptable to the
designated resident and LAR on the resident's behalf;
(10) initially and annually thereafter:
(A) provide the designated resident and LAR
an oral and written explanation of the designated resident's rights in
accordance with the IDD PASRR Handbook; and
(B) inform the designated resident and LAR
both orally and in writing of all the services available and requirements
pertaining to the designated resident's participation;
(11) for a designated resident who has a
guardian, determine at least annually if the letters of guardianship are
current; and
(12) if appropriate,
for a designated resident who does not have a guardian, ensure the SPT
discusses whether the designated resident would benefit from a less restrictive
alternative to guardianship or from guardianship and make appropriate
referrals.
(c) Regardless
of whether the designated resident is receiving or has refused habilitation
coordination, the habilitation coordinator must:
(1) address community living options with the
designated resident and LAR by:
(A) offering
the educational opportunities and informational activities about community
living options that are periodically scheduled by the LIDDA;
(B) providing information about the range of
community living services, supports, and alternatives, identifying the services
and supports the designated resident will need to live in the community, and
identifying and addressing barriers to community living in accordance with
HHSC's IDD PASRR Handbook and using HHSC materials at the following times:
(i) six months after the initial presentation
of community living options during the PE described in §
303.302(a)(2)(B)(i)
of this Chapter (relating to LIDDA, LMHA,
and LBHA Responsibilities Related to the PASRR Process) and at least every six
months thereafter;
(ii) when
requested by the designated resident or LAR;
(iii) when the habilitation coordinator is
notified or becomes aware that the designated resident, or the LAR on the
designated resident's behalf, is interested in speaking with someone about
transitioning to the community; and
(iv) when notified by HHSC that the
designated resident's response in Section Q of the MDS Assessment indicates the
resident is interested in speaking with someone about transitioning to the
community; and
(C)
arranging visits to community providers and addressing concerns about community
living; and
(2) annually
assess the designated resident's habilitative service needs by gathering
information from the designated resident and other appropriate sources, such as
the LAR, family members, social workers, and service providers, to determine
the designated resident's habilitative needs and preferences.
(d) Before the habilitation
coordinator conducts the meeting described in subsection (b)(7)(A)(ii) of this
section via audio-visual communication, the habilitation coordinator must:
(1) obtain the written informed consent of
the designated resident or LAR; or
(2) obtain the designated resident's or LAR's
oral consent and document the oral consent in the designated resident's
record.
(e) If the
habilitation coordinator does not obtain the written or oral consent required
by subsection (d) of this section, the habilitation coordinator must document
the designated resident's or LAR's refusal in the designated resident's
record.