Revision 25-1; Effective Nov. 12, 2025

These words and terms, when used in this handbook, have the following meanings unless the context clearly indicates otherwise.

• Actively involved person — A person who has significant, ongoing and supportive involvement with a person receiving services, as determined by the SPT based on the person’s:
  • observed interactions with the person receiving services;
  • availability to the person receiving services for assistance or support when needed; and
  • knowledge of, sensitivity to and advocacy for the person's needs, preferences, values and beliefs.
• Acute care hospital — A facility where a person receives short-term treatment for a severe physical injury or episode of physical illness, an urgent medical condition or recovery from surgery and:
  • may include a long-term acute care hospital, an emergency room within an acute care hospital or an inpatient rehabilitation hospital; and
  • does not include a stand-alone psychiatric hospital or a psychiatric hospital within an acute care hospital.
• Amount —The amount of a specialized service a person will receive, such as two hours.
• Audio-only — An interactive, two-way audio communication that uses only sound and meets the privacy requirements of the Health Insurance Portability and Accountability Act (HIPAA). Audio-only includes the use of telephonic communication. Audio-only does not include audio-visual or in-person communication.
• Audio-visual — An interactive, two-way audio and video communication that conforms to privacy requirements under HIPAA. Audio-visual does not include audio-only or in-person communication.
• Behavioral support — Specialized interventions by a qualified service provider to help a person increase adaptive behaviors and to replace or modify maladaptive behaviors that prevent or interfere with the person's inclusion in home and family life or community life.
  • Behavioral support includes:
    • assessing and analyzing assessment findings so that an appropriate behavior support plan is designed;
    • developing a personalized behavior support plan consistent with the outcomes identified in the Habilitation Service Plan (HSP);
    • training and consulting with family members or other providers and, as appropriate, the person; and
    • monitoring and evaluating the success of the behavior support plan and modifying the plan as needed.
  • A qualified service provider of behavioral support:
    • is a licensed psychologist;
    • is licensed as a psychological associate per Texas Occupations Code, Chapter 501;
    • has been issued a provisional license to practice psychology per Texas Occupations Code, Chapter 501;
    • is a certified authorized provider as described in 26 TAC Section 304.302, Certified Authorized Provider;
    • is a licensed clinical social worker (LCSW);
    • is a licensed professional counselor (LPC); or
    • is licensed as a behavior analyst per Texas Occupations Code, Chapter 506.
• Business day — Any day except Saturday, Sunday, or a national or state holiday listed in Texas Government Code Section 662.003(a) or (b).
• Calendar day — Any day, including weekends and holidays.
• Community living options (CLO) — A process where the LIDDA gives information to a person and their legally authorized representative (LAR) about the range of community living services, supports and programs the person may be eligible for. The LIDDA discusses services and supports the person will need to live in the community, individual preferences and barriers to community living.
• Customized manual wheelchair (CMWC) — Per 26 TAC Section 554.2703, a wheelchair that consists of a manual mobility base and customized seating system. It is adapted and fabricated to meet the individualized needs of a person.
• Collateral contact — A person who is knowledgeable about the person who seeks admission to a nursing facility (NF) or the resident, such as family members, previous providers or caregivers, and who may support or corroborate information provided by the person or resident.
• Comprehensive care plan — Refer to the definition of NF comprehensive care plan.
• Day habilitation — Aid to a person to get, retain or improve self-help, socialization and adaptive skills necessary to live successfully in the community and participate in home and community life. Day habilitation provides:
  • individualized activities consistent with achieving the outcomes identified in the person's service plan;
  • activities necessary to reinforce therapeutic outcomes targeted by other support providers and other specialized services;
  • services in a group setting, other than the person's residence, for typically up to five days a week, six hours per day on a regularly scheduled basis;
  • personal assistance for someone unable to manage personal care needs during the day habilitation activities; and
  • transportation during the day habilitation activity necessary for a person to participate in the day habilitation activities.
• Developmental disability (DD) — A disability that meets the criteria in the definition of persons with related conditions in 42 Code of Federal Regulations (CFR) Section 435.1010.
• Determination of intellectual disability (DID) — An assessment conducted per 26 TAC Section 304.301 by an authorized provider to determine if a person meets the criteria for a diagnosis of intellectual disability.
• Diversion Plan — A plan developed by the SPT that describes the activities, timetable, responsibilities, services and essential supports needed to help a person remain in the community when they may be at risk for NF or other institutional admission.
• Durable medical equipment (DME) — Per 26 TAC Section 554.2703, the following items, including any accessories and adaptations needed to operate or access the item:
  • a gait trainer;
  • a standing board;
  • a special needs car seat or travel restraint;
  • a specialized or treated pressure-reducing support surface mattress;
  • a positioning wedge;
  • a prosthetic device; and
  • an orthotic device.
• Duration — How long a person will receive a specialized service, such as six months.
• Employment assistance — Assistance given to a person to help them locate competitive employment in the community. This consists of a service provider performing the following:
  • identifying a person's employment preferences, job skills and requirements for a work setting and work conditions;
  • locating prospective employers who offer employment compatible with a person's identified preferences, skills and requirements;
  • contacting a prospective employer on behalf of a person and negotiating the person's employment;
  • transporting the person to help them locate competitive employment in the community; and
  • participating in SPT meetings.
• Enhanced community coordination (ECC) — Funding available to LIDDAs pursuant to the performance contract for assisting persons in transitioning from an NF to the community or in diverting from NF admission.
• ECC coordinator — A LIDDA staff who meets the qualifications of a service coordinator per 26 TAC Section 331.17, Minimum Qualifications, and has two years of experience in providing service coordination to someone with an intellectual or developmental disability.
• Essential supports — Those supports identified in a transition plan that are critical to a person’s health and safety and are directly related to the person’s successful transition to living in the community from residing in an NF.
• Exempted hospital discharge — A category of NF admission that occurs when a physician has certified that a person who is being discharged from an acute care hospital is likely to require less than 30 days of NF services for the condition they were hospitalized.
• Expedited admission — A category of NF admission that occurs when a person meets the criteria for one of the following categories:
  • convalescent care,
  • terminal illness,
  • severe physical illness,
  • delirium,
  • emergency protective services,
  • respite, or
  • coma.
• Extenuating circumstances — Circumstances beyond the LIDDA's, LMHA's or LBHA's control that prevent meeting in person. A disaster declared by the governor is excluded from this definition.
• Frequency — How often a person receives a specialized service, such as twice a week.
• Habilitation coordination — Assistance for a person living in an NF to access appropriate specialized services necessary to achieve a quality of life and level of community participation acceptable to the person and LAR on the person's behalf.
• Habilitation coordinator — A LIDDA employee who provides habilitation coordination.
• Habilitation Service Plan (HSP) — A plan developed by the service planning team (SPT) while a person is living in an NF that:
  • is individualized and developed through a person-centered approach;
  • identifies the person’s:
    • strengths;
    • preferences;
    • desired outcomes; and
    • psychiatric, behavioral, nutritional management and support needs as described in the NF comprehensive care plan or Minimum Data Set (MDS) assessment; and
  • identifies the specialized services that will accomplish the desired outcomes of the person or LAR, including the amount, frequency, and duration of each service.
• Habilitative therapy services — Per 26 TAC Section 554.2703, assessment and treatment to help a person learn, keep or improve skills and functioning of daily living affected by a disabling condition. Habilitative therapy services are limited to:
  • physical therapy;
  • occupational therapy; and
  • speech therapy.
• HHSC — Texas Health and Human Services Commission.
• HSP year — An approximate 12-month period starting on the date of the initial or annual interdisciplinary team (IDT)/SPT meeting.
• IDD — Intellectual and developmental disability.
• IDD habilitative specialized services (IHSS) — The following specialized services available to a person with ID or DD:
  • day habilitation;
  • independent living skills training;
  • behavioral support;
  • employment assistance; and
  • supported employment.
• Independent living skills training (ILST) — Individualized activities consistent with the HSP and provided in a person's residence and at community locations, such as libraries and stores. These activities include:
  • habilitation and support activities that foster or facilitate improvement or maintenance of the person's ability to perform functional living skills and other daily living activities;
  • activities for the person's family that help preserve the family unit and prevent or limit out-of-home placement of the person; and
  • transportation to facilitate the person's employment opportunities and participation in community activities, and between the person's residence and day habilitation site.
• In-person or in person — Within the physical presence of another person. The term does not include audio-visual or audio-only communication.
• Intellectual disability (ID) — As defined in 42 CFR Section 483.102(b)(3)(i).
• Interdisciplinary team (IDT) — Consists of:
  • a person with MI, ID or DD;
  • the person's LAR, if any;
  • a registered nurse (RN) from the NF with responsibility for the person;
  • a representative of the:
    • LIDDA if the person has ID or DD;
    • LMHA or LBHA if the person has MI; or
    • LIDDA and the LMHA or LBHA if the person has MI and DD, or MI and ID; and
  • a:
    • concerned person whom the person or LAR requests be included;
    • person specified by the person, LAR, NF, LIDDA, LMHA or LBHA, as applicable, who is professionally qualified, certified or licensed with special training and experience in the diagnosis, management, needs and treatment of people with MI, ID or DD; and
    • representative of the appropriate school district if the person is school age and the district representative the person or LAR requests.
• Legally authorized representative (LAR) — A person authorized by law to act on behalf of a person seeking admission to an NF or resident about a matter described by this chapter, and who may be the parent of a minor child, the legal guardian or the surrogate decision maker. Refer to limitations on authority of surrogate decision maker in the definition of surrogate decision maker. Also refer to Appendix III, Legal Authority to Make Decisions.
• Local authority (LA) — In this handbook, LA means a local intellectual and developmental disability authority (LIDDA), a local behavioral health authority (LBHA) or local mental health authority (LMHA).
• Local behavioral health authority (LBHA) — An entity designated by the HHSC executive commissioner per Texas Health and Safety Code, Section 533.0356.
• Local intellectual and developmental disability authority (LIDDA) — An entity designated by the HHSC executive commissioner per Texas Health and Safety Code, Section 533A.035.
• Local mental health authority (LMHA) — An entity designated by the HHSC executive commissioner per Texas Health and Safety Code, Section 533.035.
• Long-term care online portal (LTC online portal) — A web-based application used by Medicaid providers to submit forms, screenings, evaluations and other information.
• Managed care organization (MCO) service coordinator — The staff person assigned by a resident’s Medicaid MCO to ensure access to, and coordination of, additional Medicaid services that are needed.
• Minimum Data Set assessment or MDS assessment — A standardized collection of demographic and clinical information that describes a resident's overall condition, which a licensed NF in Texas is required to submit for a resident admitted into the facility.
• Mental illness (MI) — Serious mental illness, as defined in 42 CFR Section 483.102(b)(1).
• MI specialized services — Specialized services for a resident with MI, if eligible, as described in the Texas Resilience and Recovery Utilization Management Guidelines, including:
  • crisis intervention services;
  • day programs for acute needs;
  • medication training and support services;
  • psychiatric diagnostic interview examination;
  • psychosocial rehabilitation services;
  • routine case management; and
  • skills training and development.
• NF baseline care plan — A plan developed per 26 TAC Section 554.802(a), by an NF within 48 hours of a resident’s admission and that includes the minimum health care information needed to properly care for a resident, including PASRR recommendations. The NF baseline care plan is only in place until there is an NF comprehensive care plan.
• NF comprehensive care plan — A plan developed per 26 TAC Section 554.2703(3) by an NF for a resident within seven days after completing the comprehensive assessment. It includes measurable short-term and long-term objectives and time frames to meet a resident's medical, nursing, rehabilitative, psychosocial, dietary, activity and resident's rights needs.
• NF PASRR support activities — Consistent with 26 TAC Section 554.2703, actions an NF takes in coordination with a LIDDA, LMHA or LBHA to facilitate the successful provision of IDD habilitative specialized services or MI specialized services, including:
  • arranging transportation for a resident to participate in an IDD habilitative specialized service or an MI specialized service outside the facility;
  • sending a resident to a scheduled IDD habilitative specialized service or MI specialized service with food and medications required by the resident; and
  • stating in the NF comprehensive care plan an agreement to avoid, when possible, scheduling NF services at times that conflict with IDD habilitative specialized services or MI specialized services.
• NF specialized services — The following specialized services available to a resident with ID or DD:
  • habilitative therapy services;
  • CMWC; and
  • DME.
• Nursing facility (NF) — A Medicaid-certified facility licensed per the Texas Health and Safety Code, Chapter 242.
• PASRR — Preadmission screening and resident review. Required by 42 CFR 483.100-138.
• PASRR level I (PL1) screening  — The process of screening a person who seeks admission to an NF to identify if the person is suspected of having MI, ID or DD.
• PASRR level II evaluation (PE) — An evaluation:
  • of a person who seeks admission to an NF and is suspected of having MI, ID or DD; and
  • performed by a LIDDA, LMHA or LBHA to determine if the person has MI, ID or DD and, if so, to:
    • assess the person’s need for care in an NF;
    • assess the person’s need for specialized services; and
    • identify alternate placement options.
• Person or Individual — A person:
  • whose active PASRR evaluation (PE) or resident review is positive for ID or DD;
  • who is 21 or older; and
  • who is a Medicaid recipient.
• Preadmission process — A category of NF admission:
  • from a community setting, such as a private home, an assisted living facility, a group home, a psychiatric hospital or jail, but not an acute care hospital or another NF; and
  • that is not an expedited admission or an exempted hospital discharge.
• Referring entity (RE) — The entity that refers a person to an NF, such as a hospital, attending physician, LAR or other personal representative selected by the person, a family member of the person or a representative from an emergency placement source, such as law enforcement.
• Registered nurse (RN) — A person licensed to practice professional nursing as an RN per Texas Occupations Code, Chapter 301.
• Relocation specialist — An employee or contractor of an MCO who provides outreach and relocation activities to people in NFs who express a desire to transition to the community.
• Resident — A person who resides in an NF and receives services provided by professional nursing personnel of the facility.
• Resident review — An evaluation of a resident performed by a LIDDA, LMHA or LBHA:
  • for a resident whose PE is positive for  MI, ID or DD who experienced a significant change in condition, to:
    • assess the resident's need for continued care in an NF;
    • assess the resident's need for specialized services; and
    • identify alternate placement options; and
  • for a resident suspected of having MI, ID or DD, to determine if the resident has MI, ID or DD and, if so:
    • assess the resident's need for continued care in an NF;
    • assess the resident's need for specialized services; and
    • identify alternate placement options.
• Service coordination — Assistance in accessing medical, social, educational and other appropriate services and supports, including alternate placement assistance, that will help a person achieve a quality of life and community participation acceptable to the person and LAR on the person’s behalf.
• Service coordinator — A LIDDA employee who provides service coordination.
• Service planning team (SPT) —A team convened by a LIDDA staff person that develops, reviews and revises the HSP and the transition plan for a person. The team must include:
  • the person;
  • the person's LAR, if any;
  • the habilitation coordinator for discussions and service planning related to specialized services or the service coordinator for discussions related to transition planning if the person is transitioning to the community;
  • the MCO service coordinator, if the person does not object;
  • the person who develops a permanency plan using the HHSC Permanency Planning Instrument for Children Under 22 Years of Age form and performs other permanency planning activities for a person younger than 22 years, if the person is at least 21 years old but younger than 22;
  • while the person is in an NF:
    • an NF staff person familiar with the person's needs; and
    • a person who provides a specialized service for the person or a representative of a provider agency that is providing specialized services for the person;
  • if the person is transitioning to the community:
    • a representative from the community program provider, if one has been selected; and
    • a relocation specialist;
  • a representative from the LMHA or LBHA, if the person's PE is positive for MI;
  • a concerned person the person or the LAR requests be included; and
  • at the discretion of the LIDDA, a person who is directly involved in the delivery of services for people with ID or DD.
• Significant change in condition — When a person experiences a major decline or improvement in status that:
  • will not normally resolve itself without further intervention by NF staff or by implementing standard disease-related clinical interventions;
  • has an impact on more than one area of the person’s health status; and
  • requires review or revision of the NF comprehensive care plan.
• Specialized services — The following specialized services, other than NF services, that are identified through the PE or resident review and may be provided to a resident who has a PE or resident review that is positive for MI, ID or DD:
  • NF specialized services;
  • IDD habilitative specialized services; and
  • MI specialized services.
• Supported employment — Assistance to sustain competitive employment for a person who, because of a disability, requires intensive, ongoing support to be self-employed, work from the person's residence or perform in a work setting where people without disabilities are employed. Assistance includes the following:
  • making employment adaptations, supervising and providing training related to the person's assessed needs;
  • transporting the person to support them to be self-employed, work from the person's residence or perform in a work setting; and
  • participating in SPT meetings.
• Surrogate decision maker — An actively involved family member of a resident who has been identified by an IDT in accordance with Texas Health and Safety Code Section 313.004 and who is available and willing to consent to medical treatment on behalf of the resident. Note: A surrogate decision maker is authorized to make decisions related to NF specialized services. A surrogate decision maker is not authorized to make decisions related to IDD habilitative specialized services or decisions related to community programs or where the person lives or will live.
• Transition plan — A plan developed by the SPT or MI quarterly meeting attendees that describes the activities, timetable, responsibilities, services and essential supports involved in assisting a person to transition from residing in an NF to living in the community.

Revision 25-1; Effective Nov. 12, 2025

In the PASRR program, LIDDAs, LMHAs or LBHAs are allowed to use audio-visual communication options for extenuating circumstances if consent is obtained.

1210 Extenuating Circumstances                          

Revision 25-1; Effective Nov. 12, 2025

Extenuating circumstances are situations beyond the LIDDA's, LMHA's or LBHA's control that prevent an in-person meeting. A disaster declared by the governor is excluded from this definition.

The following scenarios may be extenuating circumstances, however, this is not an exhaustive list:

• the nursing facility (NF) denies entry because of an outbreak of the flu or other highly contagious virus;
• the person is in isolation at the NF because of temporary illness;
• the roadways to the NF are impassable because of inclement weather.

Extenuating circumstances should be reviewed on a case-by-case basis. Habilitation coordinators should discuss questionable circumstances with a supervisor. Contact PASRR.Support@hhs.texas.govif more assistance from HHSC is required.

1220 Consent

Revision 25-1; Effective Nov. 12, 2025

LIDDA, LMHA or LBHA staff may use Form 1035, PASRR Consent for Use of Audio-Only and Audio-Visual Communication to indicate the person’s or their LAR’s agreement to receive certain PASRR activities via audio-visual communication.

Note: This is an optional HHSC form. The LIDDA, LMHA or LBHA may choose to use their own consent form.

1220.1 Consent for PE or Resident Review

Revision 25-1; Effective Nov. 12, 2025

Before the LIDDA, LMHA or LBHA staff conducts the PASRR level II evaluation (PE) via audio-visual communication because of extenuating circumstances, one of the following must be completed:

• obtain the written consent of the person or their LAR; or
• obtain the person's or their LAR's oral consent and document the oral consent in the person's record; and
• document a description of the extenuating circumstances that prevented meeting in person in the person's record.

If the person or their LAR refuses to give written or oral consent, the LIDDA, LMHA or LBHA must:

• conduct the PE by meeting with the LAR and NF staff most familiar with the person to review and gather all necessary information to complete the PE; and
• enter the PE in the LTC online portal.

1220.2 Consent for Quarterly SPT Meetings

Revision 25-1; Effective Nov. 12, 2025

A habilitation coordinator must facilitate a quarterly SPT meeting in person, or in extenuating circumstances via audio-visual communication.

Before the habilitation coordinator conducts quarterly meetings via audio-visual communication, the habilitation coordinator must:

• record a description of the extenuating circumstances that required the use of audio-visual communication in the person’s record, and
• obtain the written consent of the person or their LAR; or
• obtain the person’s or their LAR’s oral consent and document the oral consent in the person’s record.

If the person or their LAR refuses to give written or oral consent, the habilitation coordinator must:

• document the person’s or their LAR's refusal in the person's record; and
• convene an SPT meeting in person as soon as possible after the extenuating circumstances no longer exist.

1220.3 Consent for Transition Planning

Revision 25-1; Effective Nov. 12, 2025

The ECC coordinator facilitates an in-person SPT meeting during transition planning. The meeting is conducted via audio-visual communication in extenuating circumstances.

Before the ECC coordinator conducts the transition planning meetings via audio-visual communication, the ECC coordinator must:

• obtain the written consent of the person or their LAR; or
• obtain and document the person's or their LAR's oral consent in the person's record; and
• document a description of the extenuating circumstances that prevented meeting with the person in person in the person's record.

If the person or their LAR refuses to give written or oral consent for audio-visual meetings, the ECC coordinator must:

• document the person’s or LAR’s refusal in the person’s record; and
• convene an SPT meeting in person as soon as possible after the extenuating circumstances no longer exist.

1220.4 Consent for Habilitation Coordination

Revision 25-1; Effective Nov. 12, 2025

Habilitation coordinators may meet via audio-visual communication in a month when an in-person meeting is not required. Specific information about the frequency of in-person habilitation coordination visits is in 5100, Required In-Person Visits.

Habilitation coordinators must obtain consent before conducting visits via audio-visual communication.

If the person or their LAR refuses the written or oral consent required, the habilitation coordinator must:

• document the person's or their LAR's refusal in the person's record; and
• conduct habilitation coordination contacts in person.

Note: Habilitation coordinators may not use audio-only communication for visits.

Revision 22-1; Effective Nov. 28, 2022

PASRR screening and evaluation must be administered to identify:

• people seeking admission to a nursing facility (NF) who have MI, ID or DD;
• the appropriateness of placement in the NF; and
• eligibility for specialized services.

The process begins with the referring entity, the first entity (RE)  that considers admission into an NF for a person.

Revision 22-1; Effective Nov. 28, 2022

An RE is a person or entity who refers someone to a NF for admission. The most common referring entities are hospital discharge planners. Other referring entities can be:

• Acute care hospitals
• Psychiatric hospitals
• NFs (limited to when a NF resident is discharging from one NF and admitting directly to another NF)
• LARs or family members
• Physicians (including office staff)
• Assisted living facilities
• Group homes
• Hospice providers
• Home health agencies
• LBHAs
• LMHAs
• LIDDAs
• Adult protective services staff
• State supported living centers
• Emergency placement sources (e.g., law enforcement agency)
• Community healthcare providers

PASRR requires that all people seeking admission to an NF have a PASRR Level 1 Screening (PL1) form completed prior to admission, and the RE is responsible for completing the paper version of the form.

The PL1 documents the suspicion of an MI, ID or DD based on information available to the RE. The RE responds to the questions regarding a diagnosis provided within Section C of the PL1 form.

Revision 22-1; Effective Nov. 28, 2022

This section provides an overview of the PL1 Screening and its role in the PASRR process. The PL1 Screening form may be downloaded from the Texas Medicaid & Healthcare Partnership (TMHP).

2310 Purpose

Revision 22-1; Effective Nov. 28, 2022

The PL1 Screening form is designed to identify people suspected of having an MI, ID, or DD who are seeking admission to a NF. The PL1 screens for possible eligibility for PASRR specialized services and is the first step toward enabling people to be served  per their unique needs.

2320 PL1 Screening Form

Revision 22-1; Effective Nov. 28, 2022

The PL1 Screening form contains the following sections:

• Section A:
  • Submitter Information (NF and LA only) — Identifies contact information for the person submitting the PL1 into the LTC online portal.
  • Referring Entity Information — Contains information about the person who performed the PL1 Screening.
• Section B:
  • Personal Information — Contains information about the person who is being screened. This section also contains fields used to update the PL1 due to a death or discharge.
• Section C:
  • PASRR Screen — Completed for all people seeking admission to a NF. The PL1 documents the suspicion of an MI, ID or DD based on information available to the RE.
  • Local Authority Information — Documents information about the LIDDA, LMHA, or LBHA associated with the PL1 submission.
• Section D:
  • Nursing Facility Choices — Documents the person’s or LAR's choice(s) of NFs for admission.
• Section E:
  • Alternate Placement Preferences — Documents the person’s or LAR’s alternate placement preferences.
  • Alternate Placement Disposition — Documents to which alternate placement program the person was admitted. 

Note: See Section 2320.2, Positive PL1 for more instructions about how to complete Section E of the PL1 if positive.  

• Section F:
  • Admission Category — Documents the NF admission type for the person.

2320.1 PL1 Submission

Revision 22-1; Effective Nov. 28, 2022

Only LIDDA, LMHA, LBHA, or NF can submit the PL1 Screening form in the LTC online portal. Following successful submission, the LTC online portal will issue alerts based on the information in Section C of the completed form.

Note: When the PL1 is positive and the admission type is preadmission, the LIDDA, LMHA, or LBHA must enter the PL1 in the LTC online portal within three business days of receipt from the RE.

2320.2 Positive PL1

Revision 22-1; Effective Nov. 28, 2022

If the RE selects “Yes” to any of the fields in Section C, PASRR Screen, then the PL1’s status is considered positive for suspicion of an MI, ID or DD. A positive PL1 triggers an alert to the LIDDA, LMHA, or LBHA, or both, via the LTC online portal to proceed to the next step of the PASRR process — the PASRR evaluation (PE).

When the LIDDA, LMHA or LBHA receives a PL1 Screening form from the RE, the LIDDA, LHMA or LBHA must:

• Review the PL1 Screening form to confirm the RE has completed the required fields before submitting the PL1 screening form on the LTC Online Portal.  
• If Section E fields E0100-E0400, or any other required field of the PL1 screening form, is not completed, the LIDDA, LMHA, or LBHA should contact the RE for the information needed to complete the required fields. 
• Enter the information received for Section E fields E0100-E0400, which are enabled and required for the PL1 screening form to be submitted. 

 
The nursing facility is responsible for entering the RE’s initial report in Section E of the PL1 if the admission type is exempted hospital discharge or expedited admission. If the person’s alternate placement preferences change after the PL1 submission, these changes should be documented in the PE, in the initial CLO done at the time of PE, and on the PCSP form. 

Note: If the applicable “Section E” tab fields are not completed for a PL1 screening form submission, the PL1 screening form submission will not submit. The Texas Health and Human Services Commission made these system changes to ensure that the person’s alternate placement disposition is documented and available on the LTC Online Portal at the time of discharge.
 

2320.3 Negative PL1

Revision 22-1; Effective Nov. 28, 2022

If the RE selects “No” to all three fields in Section C, PASRR Screen, then the PL1 status is considered negative for suspicion of an MI, ID or DD. The NF admits a person with a negative PL1 screening and the PASRR process formally ends.

2320.4 Additional PL1 Responsibilities 

Revision 22-1; Effective Nov. 28, 2022

LIDDAs, LMHAs and LBHAs are also responsible for inactivating a PL1 screening form when a person is either not admitted to the NF or passes away before being admitted to the NF. This is the only time LIDDAs, LMHAs, and LBHAs are responsible for inactivating a PL1 screening form. 

To inactivate a PL1 screening form, the LIDDA, LMHA and LBHA must:

• Complete Section B fields B0650-0655 – Discharge or deceased.
• If field B0650 indicates that the person is deceased, then the Section E tab will not be enabled for data entry and the P1 screening form will submit.  
• If field B0650 indicates the person was discharged, fields E0500-E0900 (Alternate Placement Disposition) are enabled and required for the PL1 Screening form to be submitted.  

If the applicable “Section E” tab fields are not completed for a PL1 screening form submission or updated for a discharge, the PL1 screening form submission or update will not submit.  The Texas Health and Human Services Commission made these system changes to ensure that the person’s alternate placement disposition is documented and available on the LTC Online Portal at the time of discharge.
 

2330 Admission Types

Revision 22-1; Effective Nov. 28, 2022

There are three types of NF admissions:

• exempted hospital discharge;
• expedited admission; and
• preadmission.

2330.1 Exempted Hospital Discharge

Revision 22-1; Effective Nov. 28, 2022

Exempted hospital discharge occurs when a physician has certified that a person being discharged from an acute care hospital is likely to need less than 30 days of NF services for the condition that the person was hospitalized. An example of this type of admission would be for a person who falls, breaks a hip and goes into the NF for rehabilitation services.

The RE (acute care hospital) provides the NF with a copy of the PL1. The NF enters the PL1 into the LTC online portal upon the person’s admission.

A person in this category with a positive PL1 only requires a PASRR evaluation if their stay in the NF exceeds 30 days. If the person's stay exceeds 30 days, the LTC online portal sends an alert to the LIDDA, LMHA, or LBHA to complete a PE.

2330.2 Expedited Admission

Revision 22-1; Effective Nov. 28, 2022

Expedited admission occurs when a person meets the criteria for any of the following seven categories:

• Convalescent Care
• Terminal Illness
• Severe Physical Illness
• Delirium
• Emergency Protective Services
• Respite
• Coma

The RE provides the NF with a copy of the PL1. The NF enters the PL1 into the LTC online portal upon the person’s admission.

The length of stay or the type of expedited admission  determines when the LTC online portal sends an alert to the LIDDA, LMHA, or LBHA to complete a PE for a person. For example, a person admitted who is in a coma will not receive a PE until they regain consciousness.

2330.3 Preadmission

Revision 22-1; Effective Nov. 28, 2022

Preadmission occurs when admitting a person from a place other than an acute care hospital, such as a community setting like home, hospice, group home, psychiatric hospital or jail. If the RE is a family member, LAR, other personal representative selected by the person or an emergency placement source, the RE may request assistance from the LIDDA, LMHA, LBHA, or NF to complete the PL1.

If the PL1 is positive (see Section 2320.2, Positive PL1), the RE provides the LIDDA, LMHA, or LBHA with a copy of the PL1. The person may not be admitted to a NF until the LIDDA, LMHA, or LBHA completes a PE.

If the PL1 is negative (see Section 2320.3, Negative PL1), the RE provides the NF with a copy of the PL1 when the person presents at the NF for admission.

Medical necessity (MN) is the determination that a person requires the level of care provided at a NF. It is important to note that the information entered in the PE for a preadmission is used by TMHP to determine MN for a person whose PE is positive. An MN determination is critical for people who want to admit to a NF or divert from a NF admission and instead go directly into a community setting.

2340 Admission Type on PL1

Revision 22-1; Effective Nov. 28, 2022

A part of completing the PL1 requires the RE to determine the admission type or category based on the answers to Section F of the PL1 Screening form.

The LTC online portal determines admission type or category by responses in Section F of the PL1. If the response in F0100 is “0” (meaning No) and the response in F0200 is “0” (meaning not expedited admission), then the admission category is considered “preadmission” by default.

2350 PL1 Submission

Revision 22-1; Effective Nov. 28, 2022

After completing the PL1, the RE has the final responsibility to send the completed paper PL1 Screening form to the appropriate party for submission to the LTC online portal. The chart below summarizes which party the PL1 is sent depending on the admission type in Section F and positive or negative status in Section C of the PL1 Screening form.

Revision 22-1; Effective Nov. 28, 2022

This section provides an overview of the PE form and its purpose in the PASRR process. Refer to Appendix I, Resources for detailed information on completing a PE, and steps for submitting a PE into the LTC online portal.

2410 Purpose, PASRR Status and Staff Qualifications

Revision 25-1; Effective Nov. 12, 2025

If the PASRR level I (PL1) shows a suspicion of MI, ID or DD, the local authority completes the PASRR level II evaluation (PE) to confirm if the person is positive for MI, ID or DD. When completing the PE, use medical records, interviews with the person and LAR, school records and any available statewide historical records.

If a PL1 indicates negative suspicion for a PASRR condition, a PE may also be performed on request from HHSC or an NF. The PE is administered to identify:

• if a person has an MI, ID or DD;
• if a person’s total needs can be met in appropriate community settings;
• a person’s need for specialized services; and
• for preadmissions, if a person meets medical necessity and can be admitted to the NF.

When the PE confirms a person has an MI, ID or DD, the PASRR determination for the person is PASRR positive.

2410.1 PASRR Negative

Revision 25-1; Effective Nov. 12, 2025

When the PE does not confirm a person has an MI, ID or DD, the PASRR determination for the person is PASRR negative.

Note: If the person is PASRR negative based on the PE, the Long-Term Care (LTC) online portal generates a letter to the person and their LAR, if an LAR is documented on the PE. The local authority sends a PASRR negative letter, which includes information about the fair hearing process.

2410.2 Staff Qualifications

Revision 25-1; Effective Nov. 12, 2025

The qualifications for staff completing a PE are in 26 Texas Administrative Code (TAC) Chapter 303, Section 303.303, Qualifications and Requirements for Staff Person Conducting a PE or Resident Review.

2420 LTC Online Portal Notification

Revision 22-1; Effective Nov. 28, 2022

The LIDDA, LMHA or LBHA receives an automatic alert notification in the LTC online portal generated by a NF’s submission of a positive PL1 into the LTC online portal for an expedited admission or an exempted hospital discharge.

The LIDDA, LMHA or LBHA will not receive an automatic alert notification if the LIDDA, LMHA or LBHA submitted the positive PL1 for preadmission into the LTC online portal. The RE provides a copy of the PL1 to the LIDDA, LMHA or LBHA. This serves as the alert to the LIDDA, LMHA or LBHA to conduct the PE.

2420.1 Timing of Alert is Based on Admission Type

Revision 22-1; Effective Nov. 28, 2022

The type of admission from the PL1 determines when an alert will be sent to the LIDDA, LMHA or LBHA to conduct a PE. The timings for alerts are explained in the Long-Term Care (LTC) Preadmission Screening and Resident Review (PASRR) User Guide (PDF).

The LIDDA, LMHA or LBHA must:

• check the LTC online portal daily for PE alerts;
• have a single, identified fax line to receive PL1 forms from REs; and
• check the fax line daily to ensure all requests to conduct a PE are acted on promptly.

2420.2 Change of Ownership Extensions

Revision 25-1; Effective Nov. 12, 2025

A change of ownership (CHOW) occurs when another facility, entity or corporation purchases an NF. A new contract number is assigned when a CHOW takes place. Once the new contract number is assigned, the NF being purchased must enter a new PL1 for every resident in the NF within 90 calendar days after the new contract number’s effective date.

Depending on the NF’s census and the number of PASRR positive residents, the LIDDA, LMHA or LBHA may receive multiple alerts to complete PEs. The LIDDA, LMHA or LBHA may request an extension to the seven-day time frame to complete all the PEs for that NF. The LIDDA, LMHA or LBHA must contact the HHSC PASRR Unit at PASRR.Support@hhs.texas.gov to request an extension.

2420.3 Information Gathered by a LIDDA Following an Alert to Conduct a PE

Revision 25-1; Effective Nov. 12, 2025

A LIDDA that receives an alert in the LTC online portal to conduct a PE or resident review must determine if the person has:

• a prior PE*;
• transferred from another NF, this information is on the PL1**; and
• full Medicaid benefits through being eligible for***:
  • Supplemental Security Income; or
  • Medicaid benefits if institutionalized.

*Information on if the person has a prior PE is available by checking in the LTC online portal. A LIDDA can view a prior PE within the LIDDA’s local service area and PEs completed by other LIDDAs.

Note: The LIDDA staff who completes PEs must use an LTC online portal login unique to them. The staff given PE Evaluator permission can see any form types for a specific person across local service areas. This must be the only permission assigned to this login.

**If the PL1 shows that the person transferred from another NF in Texas, the receiving LIDDA will contact the transferring LIDDA and request relevant records of the person, including previous PEs, assessments and service plans be sent to the receiving LIDDA.

***Information about if a person has full Medicaid benefits is available through discussions with the NF’s business office.

2420.4 Using Information Gathered by a LIDDA Following an Alert to Conduct a PE

Revision 22-1; Effective Nov. 28, 2022

If the person has Medicaid benefits* and is 21 or older, the LIDDA must be prepared to assign a habilitation coordinator if the person has a positive PE. *Refer to Section 4910, Medicaid Eligibility Guidelines for information about eligible Medicaid types.

If one LIDDA receives a request for records from another LIDDA that received an alert to conduct a PE, then the LIDDA receiving the request must send all available requested records within two business days after the request was made.

A LIDDA that received an alert to conduct a PE must ensure the staff conducting the PE is provided all relevant records sent by other LIDDAs.

2430 Completing and Submitting the PE

Revision 25-1; Effective Nov. 12, 2025

The LIDDA is responsible for completing a PE for a person whose PL1 indicates the person is suspected of having ID or DD.

The LMHA or LBHA is responsible for completing a PE for a person whose PL1 indicates the person is suspected of having an MI.

Both the LIDDA and LMHA or LBHA are responsible for completing their respective part of a PE for people suspected of having a dual diagnosis of ID or DD and MI.

Note: While an LMHA and LBHA generally have the same responsibilities as a LIDDA for completing and submitting a PE, this handbook provides instructions and procedures for LIDDAs to implement PASRR requirements. From here forward, the handbook will not reference LMHA, LBHA or MI from here unless it is within the context of a person with dual diagnoses, which means ID or DD and MI.

The LIDDA uses the following to complete the PE:

• documentation reviews,
• interviews with:
  • the person,
  • family,
  • others who know or have known the person, and
  • NF staff.

The LIDDA has the following responsibilities when completing a PE:

• Conduct a state-wide historical record review per 2430.3, Documentation Review for PE Completion.
• Contact the RE or NF to make sure the person is still in the location submitted on the PL1 and is available and alert before traveling to the location to complete the PE.
• Travel to the NF to conduct the PE for exempted hospital discharge admissions and expedited admissions or, for preadmissions, to the location of the person in the community to conduct the PE, and carry proper identification provided by the LIDDA.
• Bring a release of confidential information to obtain the person’s or LAR’s consent to obtain more information as needed from collateral contacts.
• Meet in person* with the person within 72 hours after notification from the LTC online portal or receiving a copy of the PL1 from the RE.
• Notify HHS Complaint and Incident Intake at 800-458-9858 immediately if they are prevented from seeing a person or reviewing the person’s medical record.
• Use the medical information or documents in the person’s NF record to confirm if the person has a diagnosis for ID or DD. The LIDDA should seek assistance and clarification of documentation from available medical staff as needed and record only what is documented in the medical record. The LIDDA must document on the PE the information and documentation used to complete the evaluation.
• Submit the PE into the LTC online portal within seven calendar days after notification.

The PE can be completed on paper or electronically. The LIDDA ultimately must submit the information collected on the LTC online portal within the seven-day time frame.

*In extenuating circumstances, the LIDDA may obtain consent to conduct the PE via audio-visual communication. For more information, refer to 1210 Extenuating Circumstances.

2430.1 Interpreter Services

Revision 22-1; Effective Nov. 28, 2022

The person or LAR should be given the opportunity for interpreter services. The LIDDA must arrange or work in cooperation with the RE, NF and person or LAR for interpreter services as needed.

2430.2 Person or LAR Refuses to Participate in PE

Revision 22-1; Effective Nov. 28, 2022

If a person or LAR refuses participation in the PE, the LIDDA should request assistance from NF staff that have the greatest knowledge and rapport with the person or LAR in explaining the process . If the person or LAR continues to refuse to participate, the LIDDA completes the PE solely from chart review and  documents the person’s or LAR’s refusal in a comment field located within Section F1000 of the PE.

2430.3 Documentation Review for PE Completion

Revision 25-1; Effective Nov. 12, 2025

When investigating a person’s history for a PE, the LIDDA should search all applicable service records, including those available in online databases such as the Client Assignment and Registration (CARE) system, Clinical Management for Behavioral Health Services, and, if available, LTC online portal and Service Authorization System Online for evidence of previous diagnostic testing or services received in previous settings.

Investigating these systems can provide the LIDDA with insight on where to look for records and may yield valuable information about previous placement in settings, including:

• Home and Community-based Services (HCS);
• Community Living Assistance and Support Services (CLASS);
• Deaf Blind with Multiple Disabilities (DBMD);
• Texas Home Living (TxHmL);
• STAR+PLUS Home and Community Based Services, sometimes referred to as STAR+PLUS Waiver;
• Intermediate care facility for individuals with an intellectual disability or related condition (ICF/IID);
• state supported living center (SSLC);
• state hospital;  
• Department of Family and Protective Services (DFPS) programs and residential operations;
• criminal justice facilities; and
• private psychiatric hospitals.

Documentation gathering and record review should include:

• school records;
• diagnostic records;
• medical records;
• previous PEs, service plans, and assessments; and
• all relevant records from other LIDDAs, LMHAs or LBHAs.

2430.4 Presenting Information About Community Services as Part of the PE

Revision 25-1; Effective Nov. 12, 2025

Person’s PE is Negative for ID or DD

For a person whose PE is negative for ID or DD, the staff conducting the PE must provide and explain to the person and LAR Appendix II, Long Term Services and Supports, in the LIDDA Handbook. Note: This process is instead of presenting the full community living options (CLO) required for someone who is PASRR positive.

If the person wants to pursue community living after receiving information about long-term services and supports, the PE staff must arrange for the person to be referred to the regional Aging and Disability Resource Center (ADRC). The PE staff also must arrange for the person to be referred to the family-based alternatives contractor if appropriate.

Person’s PE is Positive for ID or DD

For a person whose diagnosis of ID or DD is confirmed, the LIDDA staff conducting the PE must present CLO per 5810.3, CLO Materials Provided to Individual or LAR, and 5820, Documenting CLO. The staff must document the CLO discussion on Form 1054, Community Living Options.

CLO must be presented in a manner that allows the person and their LAR to fully understand the options available. Therefore, CLO duration may vary but should last as long as needed to completely and meaningfully present all available community options.

2430.5 PE for Resident Review

Revision 25-1; Effective Nov. 12, 2025

When a resident with ID or DD who has been living in an NF experiences a significant change in condition, the NF submits an updated Minimum Data Set (MDS) assessment referred to as a Significant Change in Status Assessment (SCSA) into the LTC online portal. When an SCSA is submitted, the LTC online portal issues an alert to the LIDDA to conduct a resident review within seven calendar days after receiving the alert.

Before conducting the resident review, the LIDDA must contact the NF to determine if the change affects the resident’s PASRR eligibility or specialized services. A significant change in condition may require new, different or fewer specialized services than the resident had been receiving. If the change does not meet the definition of a significant change in condition, the LIDDA is not required to conduct a resident review. The LIDDA must determine if a resident review is required based on the information provided by the NF.

If the LIDDA determines the change is not significant and does not conduct a resident review, the LIDDA must document the justification for its decision by adding a note to the history section of the current PE and in a progress note in the person’s record.

The LIDDA uses the same form used to conduct a PE and submit the resident review the same way as the PE on the LTC online portal. The resident review is conducted to:
 

• assess the resident's need for continued care in an NF;
• assess the resident's need for specialized services as the need may have changed because of the significant change in condition; and
• identify alternate placement options.

The NF must convene the IDT meeting within 14 calendar days after the LTC online portal generates an automated notification to the LIDDA to conduct a resident review. The LIDDA should coordinate with the NF to schedule the initial IDT and SPT meeting and must document attempts to facilitate timely meetings if the NF convenes the initial IDT meeting after more than 14 calendar days.

2430.6 When a DID is Required to Adequately Complete the PE

Revision 25-1; Effective Nov. 12, 2025

If, during a PE, a LIDDA suspects a person of having ID or DD but is unable to confirm the diagnosis because of lack of records or access to family history, the LIDDA must ensure compliance with the following procedure.

The LIDDA must make sure staff conducting the PE:

• completes a referral in section F1000 of the PE:
  • in F1000A, by marking 18 for Other;
  • in F1000B, by entering a statement that the person or resident is being referred for a determination of intellectual disability (DID);
  • in F1000C, by entering the phone number of the LIDDA staff completing the PE or resident review;
  • in F1000D, by entering the date of referral for the DID; and
  • by marking the PE or resident review negative to indicate the person’s or resident’s diagnosis cannot be confirmed, for example, in Section B, fields B0100 and B0200, enter No; and
• does not send the person or LAR a notice of denial of eligibility for specialized services and an opportunity for a fair hearing.

The LIDDA must, within 45 calendar days after the date of referral entered in Section F, field F1000D, make sure a DID is conducted for the person per rules governing diagnostic assessment, refer to 26 TAC Chapter 304.

The LIDDA must submit a copy of the written DID report to the PASRR unit by the Secure File Transfer Protocol file folder named PASRR Reporting within 30 calendar days after the DID is conducted.

If the DID report indicates the person does not have ID or DD, the LIDDA must:

• enter a note on the previously completed negative PE by clicking on the add note button on the yellow Form Action bar of the PE and state that the person does not have ID or DD per the result of the DID; and
• send the person or LAR a:
  • denial of specialized services because the person does not have a diagnosis of ID or DD per CFR Section 483.102(b)(1); and
  • an opportunity for a fair hearing.

If the DID report indicates the person has ID or DD, then within seven calendar days after the DID report is completed, the LIDDA must complete a new PE for the person and mark it positive to indicate the person has ID or DD.

2430.7 PE Submission

Revision 25-1; Effective Nov. 12, 2025

The LIDDA must:

• enter the data recorded from the PE into the LTC online portal within seven days of notification.
• retain a copy of the PE in the person’s record.

2430.8 Specialized Services Recommendation Mapping

Revision 25-1; Effective Nov. 12, 2025

When the LIDDA staff enters the PE in the LTC online portal and checks boxes to indicate areas of support the person may need in Section B, Specialized Services Determination/Recommendations, of the PE, the LTC online portal automatically populates the associated specialized services in B0500 Recommended Services Provided/Coordinated by the Local Authority and B0600 Recommended Services Provided/Coordinated by the Nursing Facility.

These auto-populated specialized services help make sure the LIDDA includes all specialized services recommended for the person and are displayed in the Recommended Specialized Services section. For a complete list of the specialized services mapping, refer to the Long-Term Care (LTC) Preadmission Screening and Resident Review (PASRR) User Guide (PDF).

The entity that completes the PE must complete Form 1014, Pre-Admission Screening and Resident Review (PASRR) Evaluation Summary Report. Only one form should be completed per person. For a person whose PE is positive for ID or DD, a LIDDA must complete Form 1014 following the completion of a PE. Form 1014 is used to summarize the recommended specialized services for a person who is eligible for specialized services. For a person who has a dual diagnosis, ID or DD and MI, the LIDDA should take the lead on completing Form 1014. Detailed step-by-step instructions on how to complete the form are available with the form link above.

2430.9 Fair Hearing Related to Negative PE

Revision 25-1; Effective Nov. 12, 2025

A person whose PE is negative is not eligible for PASRR specialized services, which are funded through Medicaid. A negative PE does not affect the person's eligibility for nursing facility services.

Within three business days after entering the data from the PE or resident review in the LTC online portal, a LIDDA must notify the person or their LAR about the negative PASRR determination using Form 2360, Negative PASRR Evaluation Letter. This form informs the person or their LAR of their PASRR determination and their right to request a fair hearing.

When HHSC receives a fair hearing request for a negative PE, HHSC contacts the LIDDA and requests supporting documentation. The LIDDA must submit all requested material or information related to the negative PE by the date established by HHSC. The LIDDA must also attend the fair hearing in person or by phone to defend the PE determination.

2430.10 PE Retention Period

Revision 25-1; Effective Nov. 12, 2025

HHSC currently requires a LIDDA to keep all handwritten PE documentation in the person’s record indefinitely. The electronic version of the PE is retained in the LTC online portal system.

2430.11 Preadmissions Involving Two LIDDAs

Revision 25-1; Effective Nov. 12, 2025

When a person in one LIDDA’s service area plans to move to an NF in a different LIDDA’s service area, follow this process.

The transferring LIDDA:

• receives a positive PL1 completed by the RE;
• submits the PL1 into the LTC online portal within one business day of receipt;
• completes and submits the PE per rule and policy;
• confirms that medical necessity (MN) is approved in the LTC online portal;
• notifies the admitting NF that it can proceed with the admission; and
• sends copies of the submitted PL1 and PE to the receiving LIDDA and notifies the receiving LIDDA within two business days that the person has been admitted to an NF in the receiving LIDDA’s service area.

After receiving the PL1 and PE from the transferring LIDDA, the receiving LIDDA:

• submits a new PL1 within one business day of receipt, changing only the date of assessment (A0600) and signature date (A1200B) to the current date; and
• completes and submits a new PE per rule and policy, including conducting CLO.

After the NF certifies in the LTC online portal that it can meet the needs of the person and MN has been met again, the receiving LIDDA and admitting NF will have access to view the PL1 and PE in the LTC online portal.

During this process, the LIDDAs and NFs must maintain communication about the status of the person’s move. A person or LAR may change their mind and select an alternate placement or a different NF. All parties involved should be aware of where the person is living.

Revision 25-1; Effective Nov. 12, 2025

For any person with a positive PE for ID or DD, the NF convenes an IDT meeting within 14 calendar days after the person's NF admission. For a resident review, the NF convenes an IDT meeting within 14 calendar days after the LTC online portal has generated an alert to the LIDDA to complete a PE. 

A LIDDA representative is a required member of the IDT. HHSC strongly encourages the LIDDA representative to be the LIDDA staff who conducted the PE. The NF is responsible for scheduling, conducting and documenting the IDT meeting in the LTC online portal. For a person with a positive PE for ID or DD and MI, both LIDDA and LMHA or LBHA representation is required. However, the LIDDA assumes primary responsibility for completion of required PASRR processes during the initial IDT and SPT meeting. An IDT without all the mandatory participants is invalid and must be reconvened.

The mandatory participants of the IDT meeting are:

• the person with MI, ID or DD;
• the person's LAR, if any;
• an RN from the NF with responsibility for the person;
• a representative of the:
  • LIDDA, if the person has ID or DD;
  • LMHA or LBHA, if the person has MI; or
  • LIDDA and the LMHA or LBHA, if the person has MI and DD, or MI and ID.

For a person who is eligible for habilitation coordination, the habilitation coordinator must be present at the IDT meeting. Unless the person receiving services or their LAR objects, the IDT and SPT must include and invite the MCO service coordinator.

The IDT reviews the results of the person’s CLO to determine if the person’s total needs can be met in appropriate community settings. The IDT also reviews and discusses which of the PE’s recommended specialized services the person or LAR wants to receive.

2510 NF Enters Initial IDT and SPT Meeting Information

Revision 22-1; Effective Nov. 28, 2022

The NF enters the following information from the IDT meeting in the LTC online portal on the PASRR Comprehensive Service Plan (PCSP) form after the IDT meeting:

• the date of the IDT meeting;
• the names and titles of the IDT members in attendance;
• all specialized services agreed upon during the IDT meeting, if any; and
• the determination of whether the person is best served in a facility or community setting.

Note: The specialized services agreed upon during the IDT meeting for a person with a positive PE for ID or DD who:

• has Medicaid and is 21 or older are documented on the PCSP form in the Specialized Services Information section, fields A2800 NF Specialized Services, A2900 Durable Medical Equipment (DME), and A3000 IDD Specialized Services, as appropriate, and in field A3100 MI Specialized Services if the person also has MI.
• does not have Medicaid or is 20 or younger are documented on the PCSP form in the Comments section, field A3200 Nursing Facility Comments. If the person will be receiving the service through other funding sources, the NF is responsible for identifying the funding source or entity that will provide the specialized service in the comments field.

2520 Confirmation of IDT and SPT Meeting Information

Revision 25-1; Effective Nov. 12, 2025

A LIDDA must check the LTC online portal and take one of the three actions in the chart below, as appropriate. They must do this within five business days after receiving notification from the LTC online portal that the NF entered information from an initial or annual IDT meeting into the PCSP form.

Step 1

If a LIDDA representative did not participate in the IDT meeting:

• Upon receiving the LTC online portal alert to confirm the IDT meeting, the LIDDA must select No-Did not attend in Field A3500. LA-IDD Specialized Services and Participation Confirmation. This will invalidate the PCSP form and IDT meeting that was entered into the LTC online portal.
• An alert will be sent to the NF to conduct another IDT meeting that includes a LIDDA representative.

Step 2

If a LIDDA representative participated in the IDT meeting but determines the information the NF entered in the LTC online portal about the specialized services or the LIDDA’s attendance at the IDT meeting is incorrect, the LIDDA must contact the NF to address the discrepancy. They must allow seven calendar days for the NF to correct the information in the LTC online portal.

• If the NF corrects the information in the LTC online portal within seven calendar days, the LIDDA must document in the LTC online portal in Section A3500 agreement with the:
  • specialized services listed in the LTC online portal; and
  • LIDDA representative’s attendance at the IDT meeting.
• If the NF does not correct the information in the LTC online portal within seven calendar days, the LIDDA must document in the LTC online portal in Section A3500 disagreement with whichever of the following is still incorrect:
  • the specialized services listed in the LTC online portal; or
  • the LIDDA representative’s attendance at the IDT meeting.

Step 3

If a LIDDA representative participated in the IDT meeting and agrees with the information the NF entered in the LTC online portal about the specialized services and the LIDDA’s attendance at the IDT meeting, the LIDDA must document in the LTC online portal in Section A3500 agreement with the:

• specialized services listed in the LTC online portal; and
• LIDDA representative’s attendance at the IDT meeting.

For instructions on confirming the IDT form, refer to the Long-Term Care (LTC) User Guide for Preadmission Screening and Resident Review (PASRR).

Revision 22-1; Effective Nov. 28, 2022

If funding for NF specialized services is available (i.e., Medicaid), the NF is responsible for the successful submission of a complete and accurate prior authorization request for NF specialized services in the LTC online portal within 20 business days after the date of the IDT meeting. The NF must start providing a habilitative therapy service within three business days after receiving approval from HHSC in the LTC online portal. Additionally, the NF must:

• order all DME devices and CMWCs per NF rules in 26 TAC Section 554.2754(e);
• provide ongoing habilitative therapy services as approved by HHSC; and
• document annually on the PCSP form in the LTC online portal all NF specialized services, IDD habilitative specialized services, and MI specialized services being provided to a person.

Revision 25-1; Effective Nov. 12, 2025

A local intellectual and developmental disability authority (LIDDA) must designate a qualified staff member as the diversion coordinator as described in the performance contract. A LIDDA must make sure the diversion coordinator performs the following duties:

• identifies available community living options, services and supports to help people live in the community successfully;
• provides information and assistance to service coordinators, habilitation coordinators and other LIDDA staff who are facilitating diversion for people at risk of admission to a nursing facility (NF) and for people transitioning to the community from an NF;
• coordinates educational activities for service coordinators, habilitation coordinators and other LIDDA staff about available community services and strategies to avoid NF admission;
• coordinates educational activities for referring entities about available community resources, services and strategies to avoid NF admission;
• within 45 to 75 calendar days after a person is admitted into an NF, reviews the person’s admission to make sure community living options, services and supports that could provide an alternative to NF services have been explored and if not, refer the person to their habilitation coordinator for that purpose;
• identifies, arranges and coordinates access to community services as a diversion to NF admission for a person who has chosen community living during the PE process; and
• requests a targeted NF Home and Community-based Services (HCS) diversion slot for a person as described in 3220, Requesting a Targeted NF HCS Diversion Slot, or transition slot as described in 6500, Transitioning to the HCS Program.

Revision 22-1; Effective Nov. 28, 2022

HHSC may make available a targeted NF HCS diversion slot to a person with intellectual disability (ID) or developmental disability (DD) who is determined to be at imminent risk of a long term stay in a NF. After a positive PASRR Level 1 (PL1) screening for preadmission is completed and entered in the Long-Term Care (LTC) online portal, a LIDDA must conduct a PASRR Evaluation (PE) on the person to determine if the person:

• has ID or DD; and
• meets medical necessity.

3210 Criteria for Diverting from NF Admission

Revision 25-1; Effective Nov. 12, 2025

To be eligible for a targeted NF HCS diversion slot, a diversion coordinator must document the following:

• the person is at imminent risk of a long-term stay in an NF;
• the person has a PE, conducted within the past 21 calendar days, that indicates they have ID or DD, meet NF medical necessity and are appropriate for community placement;
• the person has a diagnosis that will meet HCS diagnostic eligibility criteria, meaning they have an intermediate care facility (ICF) Level of Care (LOC) I or VIII*; and
• other adequate and appropriate community resources, excluding SSLCs, are unavailable to meet the person’s needs after attempts to obtain community-based services and supports, such as:
  • for a person 21 years or older:
    • Medicaid State Plan services;
    • community-based intermediate care facilities for individuals with an intellectual disability or related conditions (ICF/IIDs) with six beds or fewer; and
    • general revenue-funded services; or
  • for a person 20 years or younger:
    • Medicaid State Plan services;
    • supports through the local school district;
    • general revenue-funded services; and
    • community-based ICF/IIDs with six beds or fewer unless out-of-home placement is not desired.

*If a LIDDA determines the person meets the criteria for both ICF LOC I and VIII, then the LIDDA documents ICF LOC I. If the person only meets the criteria for ICF LOC VIII, then the LIDDA documents ICF LOC VIII.

3220 Requesting a Targeted NF HCS Diversion Slot

Revision 25-1; Effective Nov. 12, 2025

If a LIDDA determines a person meets the criteria for a targeted NF HCS diversion slot, the diversion coordinator completes and submits Form 1047, Request for HCS Targeted NF Diversion Slot, per the form’s instructions to request a slot for the person.

Upon receipt, HHSC staff reviews the completed Form 1047. HHSC staff may request more information or documentation. Within three business days after receipt of Form 1047 and any other needed documents, HHSC determines if the person meets the criteria for a targeted NF HCS diversion slot.

• If HHSC determines the person does not meet the criteria, staff will notify the LIDDA and the person or legally authorized representative (LAR) in writing of the denial of an offer of a targeted NF HCS diversion slot within one business day. HHSC will provide the person or LAR with an opportunity for a fair hearing.

If HHSC determines the person meets the criteria and a targeted NF HCS diversion slot is immediately available, staff will send a letter authorizing the LIDDA to offer the person the opportunity to enroll in HCS.

3230 Enhanced Community Coordination Responsibilities for Enrolling in HCS as a Diversion from NF Admission

Revision 25-1; Effective Nov. 12, 2025

Enhanced Community Coordination (ECC) helps people with intellectual or developmental disabilities divert or transition from NFs to homes in the community.

All people diverting or transitioning from an NF and enrolling in a 1915(c) waiver are eligible to receive ECC. ECC is not to be used for diversions or transitions to an ICF/IID.

Note: Refer to 9000 of the Local Intellectual and Developmental Disability Authority Handbook for ECC responsibilities for diverting or transitioning from an SSLC or ICF/IID.

A person may enroll in the HCS program as an alternative to NF admission, per 26 Texas Administrative Code (TAC) Chapter 331, LIDDA Service Coordination, and 26 TAC Section 263.901, LIDDA Requirements for Providing Service Coordination in the HCS Program, and the LIDDA Handbook. A LIDDA must make sure an ECC coordinator:

• is assigned within three business days after an HCS waiver slot is received;
• completes the initial visit with the person and their LAR, if applicable, within seven business days after being assigned;
• develops and revises as necessary a diversion plan, using Form 1050, Nursing Facility or Crisis Diversion Plan, with the person and LAR;
• develops Form 8665, Person-Directed Plan, per the HCS program rules, using all available assessments, and includes the person’s strengths and preferences;
• initiates development of the initial individual plan of care (IPC) as outlined in 13240, Individual Plan of Care of the LIDDA handbook;
• conducts, in person, a pre-move site review using Form 1042, Pre-Move Site Review;
• determines whether all essential supports identified on Form 1050, Nursing Facility or Crisis Diversion Plan, are in place and any areas of concern have been addressed before the person enrolls in the HCS Program; and
• completes the following activities before the person enrolls in HCS if, during the pre-move site review, any one of the essential supports is not in place or if issues are raised about the suitability of the site:
  • convenes the Service Planning Team (SPT) to resolve the issues; and
  • conducts another pre-move site review following resolution.

When a person expresses the desire to divert from an NF admission to a home in another LIDDA’s service area, the sending LIDDA’s ECC coordinator should invite the receiving LIDDA’s ECC coordinator to all diversion planning meetings. The receiving LIDDA’s ECC coordinator may attend diversion planning meetings in person, by audio-visual technology or by phone.

The sending and receiving LIDDAs must work together to make sure essential supports are in place before the person’s move. This includes determining who will be responsible for conducting the pre-move site review, considering time and distance to the site, and sharing a copy of the pre-move visit with the other LIDDA. The sending LIDDA should document any discussions with the receiving LIDDA.

The transfer of LIDDAs must not occur until all essential supports have been verified through a pre-move visit.

At its discretion, HHSC may determine the designated LIDDA for any person or assign a LIDDA the duties of the designated LIDDA for any person, as outlined in LIDDA Handbook 5000, Guidelines for Determining and Changing the Designated LIDDA.

A non-designated LIDDA is not prohibited from serving a person who is currently being served by their designated LIDDA. 

3240 ECC-Designated Funds

Revision 25-1; Effective Nov. 12, 2025

ECC-designated funds are available to LIDDAs through the performance contract for a person enrolling in HCS as a diversion or transition from an NF. The purpose of the funds is to enhance a person’s natural supports and promote successful community living. Funds are intended to pay for:

• one-time emergency assistance, such as:
  • security deposit or utility assistance;
  • nutritional supplements;
  • clothing; and
  • medication;
• items to address a person’s special needs, including minor home modifications not funded by other sources;
• transportation to and from trial visits with community providers; and
• educational tuition assistance, such as for vocational programs through community colleges so a person can develop job skills.

All other funds, including transition assistance services (TAS) and supplemental transition services (STS), must be exhausted, and all purchases must be approved before ECC designated funds may be used.

LIDDA staff may access ECC funds by completing Form 8658 and submitting it to IDDMFPsupport@hhs.texas.gov.

3250 Post Enrollment in HCS as a Diversion from NF Admission

Revision 25-1; Effective Nov. 12, 2025

For one year after a person has enrolled in the HCS program as a diversion from NF admission, an ECC coordinator must:

• conduct and document on Form 1043, Post-Move Monitoring, at least three onsite post-move monitoring visits of community service delivery sites during the first 90 calendar days after the person’s move at the following times*:
  • within the first seven calendar days after enrollment in the HCS program;
  • between eight and 45 calendar days; and
  • between 46 and 90 calendar days; and
• during the post-move monitoring visits:
  • assess whether essential supports identified in Form 1050, Nursing Facility or Crisis Diversion Plan, are in place;
  • ensure concerns of the person, program provider, staff or family member are being addressed;
  • identify gaps in care; and
  • address any gaps to reduce the risk of crisis, re-admission to an NF or other negative outcome.
• conduct monthly in-person visits with the person, or more frequently if determined by the HCS SPT based on risk factors, and monitor the delivery of all services and supports;
• conduct HCS SPT meetings at least every 90 days**, or more frequently if there is a change in the person’s needs or if requested by the person or LAR;
• revise the HCS person-directed plan (PDP) as necessary, and coordinate the person’s services and supports;
• ask about any recent hospitalizations, emergency department contacts, increased physician visits or other crises, including medical crises, and if the person experiences such, convene the HCS SPT to identify all necessary revisions to the HCS PDP to address other need for services;
• make sure the person receives timely assessments of behavioral, medical, nursing, specialized therapies and nutritional management needs, as necessary, and as indicated on the HCS PDP;
• record health care status sufficient to readily identify when changes in the person's status occurs;
• conduct service planning, ensure the program provider’s implementation of services, and monitor all services identified on the HCS PDP, including:
  • reviewing the HCS program provider’s implementation plans and provider records;
  • visiting service delivery sites as needed to determine the person’s needs are being met; and
  • monitoring critical incidents involving the person and convening the HCS SPT to develop a plan for needed prevention or intervention services for the person; and
• monitor the person while on suspension from the HCS program at least monthly, maintain communication with the program provider, and provide reports to HHSC upon request.

*More frequent onsite visits may be required to determine if supports continue to be in place and any areas of concern are being addressed during the first 90 calendar days after enrolling in HCS.

**SPT meetings may be held up to 10 days before the next scheduled SPT meeting. The SPT meeting schedule does not reset.

The ECC coordinator must conduct post-move monitoring at all sites where essential supports are provided.

If, by the 335th day of ECC, the SPT believes the person will require more than 365 days of enhanced monitoring, the ECC coordinator must contact IDDMFPSupport@hhs.texas.gov for guidance.

 

Revision 22-1; Effective Nov. 28, 2022

A person is eligible for habilitation coordination funded by Medicaid if he or she:

• has an active PASRR Evaluation (PE) or resident review that is positive for intellectual disability (ID) or developmental disability (DD);
• is a Medicaid recipient;
• is 21 or older; and
• is living in a nursing facility (NF)

Note: Receiving hospice services does not affect a person’s eligibility for habilitation coordination or other PASRR specialized services, if the interdisciplinary team (IDT) agrees the person would benefit from specialized services.

Revision 22-1; Effective Nov. 28, 2022

A local intellectual and developmental disability authority (LIDDA) must assign a habilitation coordinator  to an eligible person within two business days after the PE is entered in the Long-Term Care (LTC) online portal. The habilitation coordinator must attend the person’s initial IDT meeting along with the LIDDA representative who is a required member of the IDT. See Section 2500, PASRR Initial IDT and SPT Meeting, and Section 4300, Initial IDT and SPT Meeting. If the assigned habilitation coordinator functions in another LIDDA capacity, the habilitation coordinator will indicate all represented functions on the sign-in sheet.

The habilitation coordinator must review the individual’s PE, Form 1054, Community Living Options, completed by the PE evaluator, and any other available supporting documentation (e.g., diagnostic information in the Client Assignment and Registration system (CARE), previous LIDDA services, previous service plans) before the initial IDT meeting.

Revision 25-1; Effective Nov. 12, 2025

The habilitation coordinator must attend the person’s initial IDT meeting. The PE evaluator, or LIDDA representative if the person who completed the PE is not in attendance, shares the results of the Community Living Options (CLO) presented during the PE, that is completed Form 1054, Community Living Options. If barriers are identified in Sections 6, 7 or 8 of Form 1054, then the habilitation coordinator and IDT members should determine if receiving any specialized service could help eliminate barriers. If so, the specialized service is considered recommended and must be identified as such on the PASRR Comprehensive Service Plan (PCSP) form.

4310 Attendance at Initial IDT and SPT Meeting

Revision 25-1; Effective Nov. 12, 2025

At the person’s initial IDT and SPT meeting, the following LIDDA staff must attend:

• the LIDDA staff representative who is a required member of the IDT. HHSC strongly encourages this LIDDA staff representative to be the LIDDA staff who conducted the PE*; and
• the assigned habilitation coordinator**.

The assigned habilitation coordinator can be designated as the LIDDA required member of the initial IDT if the habilitation coordinator completed the PE.

*Attendance at the initial IDT and SPT meeting as a required IDT member is an activity that is included in the PE reimbursement rate.

**A habilitation coordinator's attendance at the initial IDT and SPT meeting is reimbursed through the habilitation coordination reimbursement rate if the habilitation coordinator and person attend in person, or via audio-visual communication in extenuating circumstances. The person must have Medicaid at the time of the meeting to be eligible for habilitation coordination.

Note: Following an initial IDT and SPT meeting, a LIDDA must comply with 2520, Confirmation of IDT and SPT Meeting Information.

Note: Before the LIDDA, LMHA or LBHA conducts the IDT or SPT meeting via audio-visual communication in extenuating circumstances, the LIDDA, LMHA or LBHA must gain consent. Refer to 1220 Consent, which includes more details. 

Revision 22-1; Effective Nov. 28, 2022 

4410 IDT Agrees to Habilitation Coordination

Revision 25-1; Effective Nov. 12, 2025

If the IDT agrees the eligible person should receive habilitation coordination, the habilitation coordinator requests authorization per the Habilitation Coordination Billing Guidelines.

4420 Refusal of Habilitation Coordination

Revision 25-1; Effective Nov. 12, 2025

If an eligible person or LAR does not want habilitation coordination, the habilitation coordinator:

• requests authorization for habilitation coordination per the Habilitation Coordination Billing Guidelines to fund the habilitation coordinator’s attendance at the IDT meeting;
• uses Form 1044, Refusal of Habilitation Coordination, to document the refusal of habilitation coordination, gets necessary signatures, provides the nursing facility, the person and LAR a copy of the completed form and maintains the original completed form in the person’s record;
• completes Form 1064, Habilitative Assessment, regardless if the person refused habilitation coordination;
• maintains documentation of the specialized services discussed in the initial IDT and any SPT or IDT specialized services review meeting; and
• maintains the completed HHSC forms that document discussions with the person and LAR about the range of community living options and alternative services and supports available.

Revision 25-1; Effective Nov. 12, 2025

If the IDT agrees to habilitation coordination for a person, the habilitation coordinator convenes the first SPT meeting immediately after the initial IDT meeting.

At the first SPT meeting, the habilitation coordinator continues the discovery process and develops and uses Form 1063, Individual Profile – Nursing Facility, and Form 1057, Habilitation Service Plan (HSP). This section describes developing an individual profile and an HSP at the first SPT meeting. Although 5400, Develop and Revise Habilitation Service Plan and Individual Profile, describes the process to develop and revise an HSP and individual profile, a fully robust HSP and individual profile are not expected by the end of the first SPT meeting.

Information from the following sources is discussed with the SPT and included in the HSP and individual profile where appropriate:

• the PE or resident review;
• the CLO that was conducted during the PE;
• CARE, for example, diagnostic data, previous LIDDA services;
• previous service plans; and
• other available supporting documentation, including previous assessments such as those listed in 5210, Reviewing Assessments.

Also included in the HSP are all specialized services, including habilitation coordination, agreed upon during the IDT meeting. At a minimum, for each specialized service agreed upon during the IDT meeting, the HSP must indicate either:

• an assessment will be conducted; or
• the amount, frequency and duration of the specialized service to be provided.

The habilitation coordinator must complete the HSP and individual profile and send them to the SPT members within 10 calendar days following the first SPT meeting.

The habilitation coordinator should ask the NF to include all PASRR specialized services identified on the HSP in the NF baseline care plan or NF comprehensive care plan, whichever is most current. The habilitation coordinator must request a copy of the NF baseline care plan or comprehensive care plan from the NF. 

4510 Specialized Services Requiring an Assessment

Revision 22-1; Effective Nov. 28, 2022

An assessment is required for:

• all NF specialized services; and
• the following intellectual and developmental disability (IDD) habilitative specialized services:
  • behavioral support;
  • employment assistance; and
  • supported employment.

The HSP must state an outcome that supports starting an assessment.

When there is lack of consensus among all IDT members about whether a person should receive a NF specialized service or an IDD habilitative specialized service (IHSS), then obtaining an assessment for the specialized service is required. The assessment will indicate whether the person can benefit from the specific NF specialized service or IHSS.

An assessment is not completed for a person who refuses specialized services or in cases in which there is no funding for specialized services.
 

4520 Specialized Services that Do Not Require an Assessment

Revision 22-1; Effective Nov. 28, 2022

For independent living skills training and day habilitation, the SPT identifies for inclusion in Section 5 of Form 1057, Habilitation Service Plan (HSP):

• the outcome(s); and
• the amount, frequency and duration based on the person's identified needs, interests and desired outcomes.

4530 Frequency and Duration of Habilitation Coordination

Revision 25-1; Effective Nov. 12, 2025

The duration of habilitation coordination is while the person is living in the nursing facility, which is pre-printed on Form 1057, Habilitation Service Plan (HSP). The SPT determines the frequency of habilitation coordination per the requirements in rule and 5100, Required In-Person Visits.

Revision 22-1; Effective Nov. 28, 2022

The LIDDA is responsible for initiating IDD habilitative specialized services within 20 business days after the date of the IDT meeting. “Initiating” means to take necessary action resulting in a person  receiving an assessment or the specialized service in a timely manner.

Revision 22-1; Effective Nov. 28, 2022

The habilitation coordinator provides ongoing habilitation coordination per Section 5000, Habilitation Coordination. They continue  the discovery process and revising Form 1057, Habilitation Service Plan (HSP), with the SPT as assessments become available and as the individual’s needs change or are more fully realized.

Revision 22-1; Effective Nov. 28, 2022

4810 Determining Guardianship

Revision 22-1; Effective Nov. 28, 2022

The habilitation coordinator determines if a person  has a legal guardian and verifies that letters of guardianship are current by requesting a copy of the letters of guardianship or by contacting the court. If the person has a current legal guardian, then all forms must be signed by the guardian. If the person does not have a legal guardian, then all forms must be signed by the him or her.

If the guardianship information is not current, the habilitation coordinator should obtain signatures of both the individual and the person listed as guardian, until appropriate steps can be taken to verify current guardianship.

For more information, see Section 5920, Activities Related to Guardianship.

4820 Communication of Complaint Process

Revision 22-1; Effective Nov. 28, 2022

The habilitation coordinator ensures that the person or LAR is informed orally and in writing of the processes for:

1. filing complaints about services delivered by the LIDDA, such as habilitation coordination, service coordination, and IHSS, with:
   • the LIDDA; and 
   • the IDD Ombudsman at 800-252-8154; 
2. filing complaints about the provision of NF specialized services with:
   • the LIDDA; and
   • HHSC Complaint and Incident Intake at 800-458-9858; and
3. reporting an allegation of abuse, neglect, or exploitation to DFPS at 800-647-7418.

Each LIDDA must develop a process for receiving and resolving complaints about a provider of NF specialized services, MI specialized services, or the LIDDA’s provision of IHSS, habilitation coordination or service coordination. This process must include the LIDDA's phone number and the toll-free number to the IDD Ombudsman.

The processes for people and LARs to request a review of their concerns or dissatisfaction must be easily understood. The policy must explain how the person or LAR may receive assistance to request the review, the time frames for the review, and the method that the person or LAR is informed of the outcome of the review. The LIDDA must present this policy in the languages that the person and LAR are most comfortable.
 

Revision 22-1; Effective Nov. 28, 2022

4910 Medicaid Eligibility Guidelines

Revision 22-1; Effective Nov. 28, 2022

HHSC requires all people to meet Medicaid eligibility for PASRR. Eligibility must be attained and maintained for the person to continue receiving PASRR specialized services. People eligible for certain types of Medicaid coverage are eligible for PASRR. However, not all types of Medicaid coverage ensure eligibility.

Every person certified for Medicaid benefits has a "TOA code" and a "program code" assigned to their Medicaid record. See the table below for the appropriate coverage codes for participation in PASRR. CARE Screen C63 (Medicaid Eligibility Search), Screen 192 and Screen 193 (Medicaid Eligibility Information) can be used to verify a person’s current and past Medicaid records.

Required Medicaid Codes

Contact your local HHSC office by calling 211, or visiting the HHSC website for specific questions about Medicaid coverage. 

4920 Responsibility to Reestablish Medicaid Eligibility

Revision 22-1; Effective Nov. 28, 2022

If a person loses Medicaid eligibility or is delayed in having Medicaid eligibility determined or re-determined, a NF and LIDDA may be unable to receive authorizations or bill for PASRR specialized services, including habilitation coordination. It is the responsibility of the representative payee to contact the appropriate entity to determine the necessary action to reinstate benefits.

If the individual or family is the representative payee, the habilitation coordinator must assist, if requested.

If the NF is the representative payee, the NF is responsible for ensuring action is taken to reestablish Medicaid eligibility. In most circumstances, assisting people with Medicaid eligibility determinations, re-determinations, and MCO selection is allowable as a medically related social service, which is a service provided by the NF that help the individual in attaining the highest practicable physical, mental, or psychosocial well-being.

If needed, the LIDDA is expected to work with the NF to help a person reestablish Medicaid eligibility. Failure of a representative payee to help reestablish Medicaid eligibility may be reported to HHSC Complaint and Incident Intake.

To minimize billing issues about habilitation coordination, LIDDAs should review the service authorization in Medicaid Eligibility Service Authorization Verification (MESAV) to verify that the person is admitted into the correct Medicaid program.

4930 MCO Selection

Revision 22-1; Effective Nov. 28, 2022

STAR+PLUS is the Texas Medicaid managed care program for people who live in NFs. A NF resident must select a STAR+PLUS managed care organization (MCO). If a NF resident fails to select an MCO, the resident will be assigned an MCO.  

A person enrolled with an MCO is assigned a service coordinator. The MCO service coordinator has responsibility for coordinating and ensuring the delivery of NF add-on services and acute care services. An MCO service coordinator must conduct quarterly visits with the individual. MCO service coordinators also work with the individual, families, habilitation coordinators, and other service coordinators or case managers to ensure a smooth transition to the community, when appropriate. The individual’s MCO service coordinator should be a part of the care planning process and is a member of the IDT and SPT, if the individual does not object. The habilitation coordinator should ask the individual or LAR, if applicable, directly whether they are okay with or object to the MCO service coordinator’s attendance at IDT and SPT meetings and must document evidence of this discussion in the individual’s record. 

4930.1 Individual Does Not Have an MCO

Revision 22-1; Effective Nov. 28, 2022

If a LIDDA becomes aware that a person is not assigned an MCO, the LIDDA must contact the NF and request the NF give information and guidance to the person or LAR on how to select and enroll in an MCO. The LIDDA must not delay transition planning activities if the person does not have an MCO and is ready to transition to the community.

Note: As part of medically related social services, a NF may provide information to a person or the person’s LAR about available MCOs and guidance on how to enroll in the preferred MCO. A NF may not choose an MCO on behalf of the individual.

4940 Individual is Dual Eligible

Revision 22-1; Effective Nov. 28, 2022

Many people who live in NFs are eligible for both Medicaid and Medicare. A NF stay for a person admitting from an acute care hospital may initially be funded by Medicare. However, the person’s Medicaid eligibility, and therefore their eligibility for PASRR, does not change. If the person is Medicaid-eligible and meets the other criteria for habilitation coordination, he or she must not be refused access to those services whether or not the current stay is paid for by Medicare or Medicaid. 

Revision 25-1; Effective Nov. 12, 2025

The habilitation coordinator meets with a person at least monthly if the person is receiving a specialized service and habilitation coordination.

If the person is receiving only habilitation coordination, the habilitation coordinator meets in person at least quarterly, unless the person or their LAR requests more frequent meetings.

A habilitation coordinator’s meeting with a person may be conducted by audio-visual communication or as an in-person visit, as determined by the service planning team (SPT), which includes the person and their LAR, if applicable. Using the results of Form 1064, Habilitative Assessment, and a determination on available technology for audio-visual communication, the SPT should find out the person’s and LAR’s preference for audio-visual habilitation coordination visits.

1. The SPT should also consider risk, health or safety concerns when deciding the frequency of in-person habilitation coordination. If the person's needs, services or supports change during the year, the in-person frequency must be reassessed.

In a month when a meeting is not conducted in person, the habilitation coordinator can meet via audio-visual communication whenever the following requirements are met:

• The habilitation coordinator obtains written informed consent of the person or LAR; or
• The habilitation coordinator receives the person’s or LAR’s oral consent and documents the oral consent in the person’s record.

Note: If the habilitation coordinator does not obtain the written or oral consent required, the habilitation coordinator must document the person's or their LAR's refusal in the person's record. Habilitation coordinators may not use audio-only communication for habilitation coordination visits.

Revision 22-1; Effective Nov. 28, 2022

The habilitation coordinator must assess and periodically reassess a person’s habilitative service needs by gathering information from the person and other appropriate sources, such as the legally authorized representative (LAR), family members, social workers and service providers. This will determine the person’s habilitative needs and the specialized services that will address those needs.

The habilitation coordinator must complete Form 1064, Habilitative Assessment, for the person, whether or not the he or she  will receive or has refused habilitation coordination:

• within 75 calendar days following the initial interdisciplinary team (IDT) meeting; and
• between 10 and 60 calendar days before the scheduled annual IDT meeting.

The habilitation coordinator ensures the completed assessment is sent to each SPT member at least 10 business days before the first quarterly SPT meeting after the initial IDT and SPT meeting and before the annual IDT and SPT meeting. 

Based on formal and informal assessments, the SPT determines if a person’s current specialized services need to be discontinued or if a new specialized service needs to be added.

5210 Reviewing Assessments

Revision 22-1; Effective Nov. 28, 2022

The habilitation coordinator reviews all applicable and available assessments and makes available copies of the assessments to each member of the SPT for review. If an assessment indicates:

• the person can benefit from the specialized service,* the habilitation coordinator  monitors to determine that the service begins in the amount, frequency and duration identified on the assessment;
• the person cannot benefit from the specialized service, the habilitation coordinator convenes the SPT to discuss how the identified outcome can be met; and
• an outcome or goal that was not previously identified, the habilitation coordinator convenes the SPT to discuss the newly identified outcome or goal.

*A person can benefit from a specialized service if the service will help the person acquire new skills, maintain skills, or delay or slow the loss of skills or functioning.
Reviewing assessments provides a more comprehensive understanding of a person’s strengths, preferences and service needs, and helps SPT members outline services to meet the person’s identified goals and objectives. As the facilitator of the SPT meeting, the habilitation coordinator must ensure the needs identified in all assessments are addressed.
HHSC encourages the habilitation coordinator to bring copies of all current assessments to the SPT meeting, so that the SPT can review and discuss recommendations. The habilitation coordinator must provide copies of assessments to the nursing facility (NF). It is recommended for assessments to be grouped together to make maximum use of the quarterly SPT for review and discussion.
Functional assessments to consider as part of Form 1057, Habilitation Service Plan (HSP), and the NF comprehensive care planning process include, but are not limited to:

• PASRR Evaluation (PE) or resident review;
• MDS assessment;
• Form 1064, Habilitative Assessment;
• therapy  assessments;
• psychiatric assessments;
• behavior support assessments;
• community participation and independent living skills training assessments;
• medical and other clinical assessments; and
• assessments conducted before admission to an NF, if still applicable (e.g., CFC Personal Assistance Services/Habilitation (PAS/HAB) assessment).

Revision 25-1; Effective Nov. 12, 2025

The habilitation coordinator must convene and facilitate SPT meetings as described in this section for a person receiving habilitation coordination.

The habilitation coordinator must make sure all members of the SPT receive notice to participate in the SPT meeting at least 10 business days before the scheduled meeting.

By facilitating the SPT meeting, the habilitation coordinator helps SPT members accomplish their responsibilities, which are to:

• make sure the person, whether or not they have an LAR, participates in the SPT to the fullest extent possible and receives the support necessary to do so, including communication supports;
• review all available assessments to determine the person’s need for specialized services;
• develop Form 1057, Habilitation Service Plan (HSP), for the person;
• review and monitor identified risk factors, such as choking, falling and skin breakdown, and report to the proper authority, such as HHS Complaint and Incident Intake, if they are not addressed;
• make timely referrals, service changes and revisions to Form 1057 as needed; and
• consider the person’s preferences, monitor to determine if they are given opportunities to engage in integrated activities:
  • with residents of the NF who do not have ID or DD; and
  • in community settings with people who do not have a disability.

The habilitation coordinator must make sure a sign-in sheet is provided at an SPT meeting they convene to document the attendance of each participant and the meeting date. If an SPT member participates by phone or video call, the habilitation coordinator must make sure the member’s name is included on the sign-in sheet. The habilitation coordinator must maintain all sign-in sheets. 

5310 First SPT Meeting

Revision 22-1; Effective Nov. 28, 2022

See Section 4500, Developing Individual Profile and Habilitation Service Plan at First SPT Meeting.

5320 Quarterly SPT Meetings

Revision 25-1; Effective Nov. 12, 2025

The initial or annual SPT meeting date sets the base schedule for the quarterly SPT meetings held between it and the next annual SPT meeting. A quarterly SPT meeting should take place three months after the first SPT meeting or the previous quarterly SPT meeting. A quarterly meeting should be held no more than two weeks before or two weeks after the three-month mark, as set by the base schedule.

Note: The base schedule only resets annually and does not reset with each quarterly SPT meeting.

The habilitation coordinator must maintain the every-three-month base schedule regardless of when a particular quarterly SPT meeting takes place. HHSC permits a habilitation coordinator to revise a person’s schedule for quarterly SPT meetings to accommodate alignment with the NF’s care plan meeting schedule if the new date is within two weeks of the base schedule. Revising a person’s schedule for quarterly SPT meetings requires detailed documentation in the habilitation coordinator’s progress notes. The habilitation coordinator is responsible for coordinating with the NF so the quarterly SPT meetings coincide with the NF’s quarterly service planning schedule.

5320.1 Required Activities During a Quarterly SPT Meeting

Revision 25-1; Effective Nov. 12, 2025

During each quarterly SPT meeting, the SPT must review:

• all assessments conducted since the last SPT meeting to determine if:
  • the person is receiving all necessary specialized services and in the appropriate amount, frequency and duration; and
  • all identified outcomes are being addressed;
• each specialized service being provided to the person to evaluate the effectiveness and adequacy of specialized services, including reviewing the written reports submitted by SPT members who are providers of specialized services as required by 5350, SPT Member Who is a Provider of a Specialized Service;
• discuss the progress or lack of progress in achieving all outcomes identified on Form 1057, Habilitation Service Plan (HSP), including if the person is maintaining progress toward outcomes; and
• if CLO was conducted since the last quarterly SPT meeting, review and discuss the person’s completed Form 1054, Community Living Options, including addressing barriers to transitioning to the community or selecting a community program, if identified in Sections 6 or 7 of Form 1054 or by the SPT.

If Form 1057 or Form 1063, Individual Profile – Nursing Facility requires revisions based on the quarterly SPT meeting, the habilitation coordinator must revise Form 1057 or Form 1063 as needed and send it to the SPT members. They must do this within 10 calendar days after the meeting.

5320.2 Documenting Summary of Quarterly SPT Meeting

Revision 22-1; Effective Nov. 28, 2022

The habilitation coordinator must summarize the SPT discussions and decisions at a quarterly SPT meeting in a progress note.

5320.3 Documenting Specialized Services in the LTC Online Portal

Revision 22-1; Effective Nov. 28, 2022

Within five calendar days after a quarterly SPT meeting, the habilitation coordinator enters in the Long-Term Care (LTC) online portal all required information on the PASRR Comprehensive Service Plan (PCSP) form.

5330 Update SPT Meetings

Revision 22-1; Effective Nov. 28, 2022

The habilitation coordinator must convene an update SPT meeting: 

• if the person experiences a change in medical condition that will affect the person’s specialized services;
• if a change in the person’s specialized services is necessary;
• if a recent assessment shows:
  • the person cannot benefit from a specialized service; or
  • an outcome or goal that was not previously identified.

The habilitation coordinator must summarize the SPT discussions and decisions at an update SPT meeting in a progress note.

If Form 1057, Habilitation Service Plan (HSP), or Form 1063, Individual Profile – Nursing Facility, requires revisions based on the update SPT meeting, the habilitation coordinator must revise Form 1057 or Form 1063, as needed, and send it to the SPT members, within 10 calendar days after the meeting.
Within five calendar days after an update SPT meeting is held per the information in this section, the habilitation coordinator enters in the LTC online portal all required information on the PCSP form.

5340 Annual IDT and SPT Meeting

Revision 22-1; Effective Nov. 28, 2022

5340.1 Annual IDT/SPT Meeting

Revision 25-1; Effective Nov. 12, 2025

An annual IDT and SPT meeting is held for a person even if the person is receiving habilitation coordination or any other specialized service. The habilitation coordinator invites all SPT members to the annual IDT and SPT meeting.

Note: There is no SPT for the person who has refused habilitation coordination. The habilitation coordinator still must attend the annual IDT meeting. The NF invites IDT members to the annual IDT meeting. The IDT and SPT members must discuss Form 1064, Habilitative Assessment, conducted by the habilitation coordinator and all recommended specialized services and decide:

• the specialized services the person, or LAR on the persons behalf, wants to receive;
• if the person is best served in the NF or the community; and
• if the person wants to transition to the community.

The habilitation coordinator must confirm the annual IDT and SPT meeting information in the LTC online portal on the PCSP form per 2520, Confirmation of IDT and SPT Meeting Information.

5340.2 Preparation for Annual IDT and SPT Meeting

Revision 22-1; Effective Nov. 28, 2022

The habilitation coordinator must complete Form 1064, Habilitative Assessment, for the person between 10 and 60 calendar days before the scheduled annual IDT and SPT meeting regardless of if the person is receiving habilitation coordination or any other specialized service. The habilitation coordinator provides a copy of the completed Form 1064 to all IDT and SPT members at least 10 business days before the annual IDT and SPT meeting.

5340.3 IDT Agrees to Habilitation Coordination

Revision 22-1; Effective Nov. 28, 2022

If the IDT agrees to the provision of habilitation coordination for the person, the habilitation coordinator requests a renewal authorization for habilitation coordination per the Habilitation Coordination Billing Guidelines.

5340.4 Refusal of Habilitation Coordination

Revision 25-1; Effective Nov. 12, 2025

If an eligible person or LAR does not want habilitation coordination, the habilitation coordinator:

• requests authorization for habilitation coordination per the Habilitation Coordination Billing Guidelines to fund the habilitation coordinator’s attendance at the IDT meeting; and
• must complete Form 1044, Refusal of Habilitation Coordination, to document the refusal of habilitation coordination, obtains necessary signatures, provides the person or LAR a copy of the completed form and maintains the original completed form in the person’s record.

5340.5 Annual SPT Meeting

Revision 22-1; Effective Nov. 28, 2022

If the IDT agrees to the provision of habilitation coordination for a person, the habilitation coordinator convenes the annual SPT meeting immediately after the annual IDT meeting. An annual SPT meeting is conducted as described in Section 5320, Quarterly SPT Meetings.

5350 SPT Member Who is a Provider of a Specialized Service

Revision 25-1; Effective Nov. 12, 2025

Each SPT member who is a provider of specialized services must:

• submit to the habilitation coordinator a copy of all assessments the provider completed for the person;
• submit to the habilitation coordinator a written report that describes the person’s progress or lack of progress at least five calendar days before a quarterly or annual SPT meeting;
• provide the habilitation coordinator with a copy of the provider’s implementation plan for the person’s specialized service if requested; and
• actively participate in an SPT meeting, in person or by phone, unless the habilitation coordinator determines active participation by the provider is not necessary. Refer to 5360, Determination that Participation in SPT Meeting is Not Necessary.

5360 Determination that Participation in SPT Meeting is Not Necessary

Revision 22-1; Effective Nov. 28, 2022

If the habilitation coordinator determines active participation by a provider of a specialized service is not necessary, as described above in Section 5350, SPT Member that is a Provider of a Specialized Service, the habilitation coordinator must:

• base the determination on:
  • the information in the written report submitted per Section 5350 above; and
  • the needs of the SPT; and
• document the reasons for exempting participation.

5370 Guidance for Convening SPT Meeting When an Individual or LAR Does Not Want to Attend

Revision 22-1; Effective Nov. 28, 2022

This section gives guidance when the habilitation coordinator receives information from a person or LAR that they will not attend a scheduled SPT meeting.

• Offer to reschedule the SPT meeting. Ask the person or LAR for a date and time they prefer and work with them to reschedule.
• Provide adequate notice of the meeting. “Adequate notice” may mean something different to each person or LAR. An LAR may need several weeks’ notice. For a person who is disturbed by SPT meeting preparations, one hour may be adequate notice.
• Offer to change the location of the SPT meeting. A person may prefer the meeting in their room instead of a conference room.
• Offer the person or LAR the opportunity to participate by phone.
• Offer to have other SPT members participate by phone if the meeting is too crowded for the person or LAR. Note that a provider agency representative may attend for two or more service providers if the representative is knowledgeable about the person’s services, implementation plans, progress or lack of progress, and satisfaction with services.
• If a person or LAR states that the SPT meeting should proceed without them, the habilitation coordinator must find out what topics they want discussed at the meeting and afterward share with the person or LAR a summary of the discussion and the results of the SPT meeting.
• If a person absolutely refuses to attend or participate in SPT meetings, the habilitation coordinator must initiate an SPT discussion about why the person refuses to attend or participate. The SPT members must attempt to identify and resolve barriers.

Revision 25-1; Effective Nov. 12, 2025

The habilitation coordinator must develop and revise a person’s Form 1057, Habilitation Service Plan (HSP), and Form 1063, Individual Profile – Nursing Facility, with the SPT as needed. Form 1057 and Form 1063 are individualized and developed through a person-centered process using ongoing discovery per each form’s instructions.

5410 Person-Centered Planning

Revision 25-1; Effective Nov. 12, 2025

Person-centered planning helps a person discover and describe what they need from services and from the service provider. The goal is to improve the person’s quality of life by making sure their preferences are gathered, written and honored throughout the planning process. This includes scheduling an SPT meeting at a time that is best for the person and the LAR.

See the HHS website for more information about person-centered planning, including training.

5420 Discovery Process

Revision 25-1; Effective Nov. 12, 2025

Discovery is the process of listening to people and learning what they want from their lives. It is getting to know people so that their personal outcomes, preferences, choices and abilities are identified, developed and documented  to form the foundation for planning their services and supports. Discovery is the basis for person-centered planning and service delivery. It is an ongoing discussion that occurs each time the habilitation coordinator talks to the person or those who know the person best. The habilitation coordinator leads the discovery process, advocates on behalf of the person whose services and supports are being planned, and records the information learned so it can be used when developing or updating Form 1057, Habilitation Service Plan (HSP).

5430 Developing Habilitation Service Plan and Individual Profile

Revision 25-1; Effective Nov. 12, 2025

Form 1057, Habilitation Service Plan (HSP), and Form 1063, Individual Profile – Nursing Facility, identify a person’s strengths, preferences, desired outcomes and mental health, behavioral, nutrition management and support needs. This information is gathered through discovery and through other sources, such as:

• the PE;
• records from the NF and previous providers;
• LTC Online Portal
• Client Assignment and Registration system (CARE), such as diagnostic data, previous LIDDA services; and
• previous ISPs and HSPs.

The HSP also addresses barriers to transitioning to the community or selecting a community program. These barriers are identified in Sections 6 or 7 of the most recent Form 1054, Community Living Options. The SPT may also identify and address barriers.

The HSP identifies the services and supports necessary to meet the person’s needs, achieve the desired outcomes and maximize the person’s ability to live successfully in the most integrated setting appropriate to their needs. The HSP must include all specialized services, including habilitation coordination, agreed on during an IDT or SPT meeting within the HSP year, including the person’s desired outcomes.

The HSP year:

• begin date is the date of the initial IDT and SPT meeting; and
• end date is the 365th day following the begin date or 366th day in a leap year.
• an assessment will be conducted; or
• the amount, frequency and duration of the specialized service to be provided.

At a minimum, for each specialized service agreed on during the IDT meeting, the HSP must indicate either:

• an assessment will be conducted; or
• the amount, frequency and duration of the specialized service to be provided. 

5430.1 Specialized Services Requiring an Assessment

Revision 22-1; Effective Nov. 28, 2022

An assessment is required for:

• all NF specialized services; and
• the following IDD habilitative specialized services:
  • behavioral support;
  • employment assistance; and
  • supported employment.

The HSP must state an outcome that supports initiating an assessment.

5430.2 Specialized Services that Do Not Require an Assessment

Revision 22-1; Effective Nov. 28, 2022

For independent living skills training and day habilitation, the SPT identifies for inclusion in Section 5 of the HSP:

• the outcome(s); and
• the amount, frequency and duration based on the person's identified needs, interest and desired outcomes.

5430.3 Frequency and Duration of Habilitation Coordination

Revision 25-1; Effective Nov. 12, 2025

The duration for habilitation coordination is while the person is residing in the nursing facility, which is pre-printed on Form 1057, Habilitation Service Plan (HSP). The frequency of habilitation coordination is determined by the SPT per the requirements in rule and 5100, Required In-Person Visits.

5430.4 Barriers to Transitioning to the Community or Selecting a Community Program Identified During CLO

Revision 22-1; Effective Nov. 28, 2022

If barriers are identified during CLO and described in Sections 6 or 7 of Form 1054, Community Living Options, the habilitation coordinator initiates at an SPT meeting a discussion of possible solutions to the barriers, how the SPT can implement the solutions and any follow-up activities. If the SPT identifies an additional barrier to the person’s transitioning to the community, the SPT must identify possible solutions to the barrier, how the SPT can implement the solutions (including who and when) and any follow-up activities.

Solutions to a barrier can include the provision of a specialized service or an additional outcome for an existing specialized service. For example, if a barrier to a person’s transition to the community is an inability to navigate public transportation, then the person may benefit from receiving independent living skills training with an outcome of learning how to use the public bus system.

The habilitation coordinator documents all identified barriers (i.e., from Sections 6 or 7 of Form 1054 and barriers identified by the SPT) and the solutions and follow-up actions for implementation in Section 7 of Form 1057, Habilitation Service Plan (HSP).

5440 Revising the Habilitation Service Plan and Individual Profile

Revision 22-1; Effective Nov. 28, 2022

Form 1057, Habilitation Service Plan (HSP), and Form 1063, Individual Profile – Nursing Facility, are reviewed at least quarterly and revised as necessary. Revisions to Form 1057 or Form 1063 must be completed and sent to the SPT members within 10 calendar days following the SPT meeting in which the revisions were agreed upon.

5440.1 Revising the HSP Because an Assessment for a NF Specialized Service is Completed

Revision 22-1; Effective Nov. 28, 2022

An assessment must be conducted for all NF specialized services. The results of an assessment are reflected in Section 6 of Form 1057, Habilitation Service Plan (HSP) as follows.

• If the person can benefit from the service, the HSP includes:
  • the amount, frequency and duration from the assessment, except for CMWC or DME; and
  • the goals from the assessment.
• If the person cannot benefit from the service, the HSP will indicate “discontinued.”

Note: The assessment results may impact the provision of an IDD habilitative specialized service. For example, if the person is receiving day habilitation five days per week and a therapy assessment shows they need therapy two days per week, then the amount or frequency of day habilitation may need to be reduced to allow for the provision of therapy.

A copy of all assessments for NF specialized services must be maintained in the person's record.

5440.2 Revising the HSP Because an Assessment for an IDD Habilitative Specialized Service is Completed

Revision 22-1; Effective Nov. 28, 2022

An assessment must be conducted for behavioral support, employment assistance and supported employment. The information included in a completed assessment indicates whether the person can benefit from the specialized service, and if so, should identify the necessary amount, frequency and duration for the service.

The results of an assessment are reflected in Section 5 of Form 1057, Habilitation Service Plan (HSP) in the appropriate outcome action plan as follows.

• If the person can benefit from the service, the HSP includes the amount, frequency and duration. If the assessment identifies an additional outcome, include the additional outcome in Section 5 of the HSP as an additional outcome action plan if agreed to by the SPT.
• If the person cannot benefit from the specialized service, the assessment should state why. This information is included in Section 5 of the HSP in the appropriate outcome action plan, and the HSP will indicate “discontinue.”
• Assessment results may impact the provision of another IDD habilitative specialized service. Additionally, following delivery of an IDD habilitative specialized service, the SPT may revise the amount, frequency and duration to better reflect the person’s identified needs, interest and desired outcomes.

A copy of all assessments for behavioral support, employment assistance and supported employment must be maintained in the person's record.

5440.3 Revising the HSP to Address Barriers Identified During CLO

Revision 25-1; Effective Nov. 12, 2025

If barriers are during CLO and described in Sections 6 or 7 of Form 1054, Community Living Options, the habilitation coordinator initiates a discussion at an SPT meeting of:

• possible solutions to the barriers,
• how the SPT can implement the solutions, and
• any follow-up activities.

If the SPT identifies an additional barrier to the person transitioning to the community, the SPT must:

• identify potential solutions to the barrier,
• how the SPT can implement these solutions – including who and when, and
• any follow-up activities.

Solutions to a barrier can include the provision of a specialized service or an added outcome for an existing specialized service. For example, if a barrier to a person’s transition to the community is an inability to navigate public transportation, the person may benefit from receiving independent living skills training with an outcome of learning how to use the public bus system.

The habilitation coordinator documents all identified barriers, that is, from Sections 6 or 7 of Form 1054, and barriers identified by the SPT, and the solutions and follow-up actions for implementation in Section 7 of Form 1057, Habilitation Service Plan (HSP).

5450 New Habilitation Service Plan for Next HSP Year

Revision 22-1; Effective Nov. 28, 2022

Following an annual SPT meeting, the habilitation coordinator must complete a new Form 1057, Habilitation Service Plan (HSP), for the next HSP year that includes all new and ongoing information, such as:

• outcomes and the specialized services and natural supports that help the person achieve the outcomes, including amount, frequency and duration;
• NF and MI specialized services, including amount, frequency and duration;
• barriers preventing transition to the community or selection of a community program identified during a CLO or by the SPT; and
• informational and educational opportunities that have been offered to the person and LAR but have not yet occurred.

Discontinued specialized services and barriers that have been resolved are not included in the new HSP for the next HSP year.

The new HSP year:

• begin date is the date of the annual IDT and SPT meeting; and
• end date is the 365th day following the begin date or 366th day in a leap year.

Note: It is unlikely the annual IDT and SPT meeting date will occur exactly 12 months after the initial or previous annual IDT/SPT meeting date. The LTC online portal allows for an annual IDT and SPT meeting to take place as early as 334 calendar days after the initial or previous annual IDT and SPT meeting. This means the HSP year will not always be a full 12-month period.

5460 Documents in an Individual’s Habilitation Packet

Revision 25-1; Effective Nov. 12, 2025

A complete habilitation packet for a person has:

• Form 1063, Individual Profile – Nursing Facility, refer to 5460.1, Individual Profile;
• Form 1057, Habilitation Service Plan (HSP), 5460.2, Habilitation Service Plan); and
• the following attachments:
  • the most current Form 1054, Community Living Options; and
  • the NF baseline care plan or comprehensive care plan, whichever is most current.

5460.1 Individual Profile

Revision 25-1; Effective Nov. 12, 2025

Information documented on Form 1063, Individual Profile – Nursing Facility.

Section 1, Individual’s Information — This section gathers identifying information about a person as well as contact information for the person, LAR and primary contact, if any, and information about a person’s language preferences, ambulation abilities and accommodation needs.

Section 2, Nursing Facility and LIDDA Information — This section gathers name and contact information for NF and LIDDA staff.

Section 3, People Important to the Individual — The section identifies the important people in the person’s life and who can provide information about the person, such as family, friends, mentor and clergy.

Section 4, Profile Information — This section provides an overall profile of a person’s strengths, preferences and needs learned during the discovery process.

These are my strengths and what people like and admire about me: A descriptive narrative about the person’s strengths and what others like and admire about the person.

These are my preferences and what is important to me: A descriptive narrative about what 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 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 services 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 they have to date. More efforts should be explored to increase awareness of possibilities and experiences to increase options of choice. This section could also include personal preferences, such as:

• sleep with the light on,
• blackout curtains needed on windows,
• baths in the evenings only.

This is what others need to know and do to support me in the following areas: A descriptive narrative about what is important for the person, as identified by those who know them best. Support me reflects information that is important for the service provider to know and understand about the person. All specific areas listed below must be addressed and include specificity about health needs, risk factors and special instructions for those who support the person. Refer to Appendix IV, Risk Factors, for more information about identifying risks.

• Communication — A descriptive narrative about how the person communicates and how to best communicate with the person. Describe the person’s communication-related needs. For instance, what is the person’s primary or preferred method of communication? How does the person communicate or express a need, by gestures, sounds, facial expressions, adaptive equipment, etc.? What is the best way to determine if the person is expressing satisfaction, happiness, comfort or agreement, as opposed to dissatisfaction, unhappiness, discomfort or disagreement? Among those who know the person best, who seems better able to interpret what the person is trying to communicate? What is the best way for others to learn how to communicate effectively with the person?
• Nursing Care — A description of the person’s nursing-related needs, such as assistance taking medication, suctioning, wound care and oxygen. Describe how staff should attend to the person’s nursing needs.
• Clinical (Behavioral/Mental Health) — A description of the person’s behavioral health and mental health-related needs. What kind of behavior supports does the person need? Does the person need counseling services or psychiatric services for medication management?
• Medical and Dental — A description of all medical and dental concerns, diagnoses and routine procedures, such as medication management, blood work, history of constipation, dental cleaning, X-ray or sedation needs.
• Adaptive Aids and Medical Supplies — A description of the adaptive aids, such as wheelchair, walker or shower chair, and medical supplies, such as briefs or test strips, needed by the person and how they are funded, such as Medicaid or personal funds, or obtained, such as leased or purchased.
• Nutrition Management — A description of the person’s nutritional-related needs, such as thickened, pureed, textured, use of supplements, food allergies or restrictions, or choking risk.
• Supervision Needs — A description of the person’s supervision needs. Consider if any personal issues might present risk for harm in the person’s living arrangement, such as daily rituals, threats of suicide or physical harm to self or others, or inability to handle a personal crisis. Describe the supports needed to address any risks, such as line of sight, one-to-one, limited proximity or door alarm. Is the person currently receiving these supports?
• Other things people need to know about me, if any.
• Risk factors not otherwise addressed above, such as those related to safety or exploitation.

Historical information: Include background information that continues to significantly affect the person or their services.

5460.2 Habilitation Service Plan

Revision 25-1; Effective Nov. 12, 2025

Information documented on Form 1057, Habilitation Service Plan (HSP).

Section 1, Individual Information — This section gathers identifying information about a person and identifies the HSP year and plan date.

Section 2, Discovery — This section describes all the ways information was gathered to discover a person’s desires and preferences, such as observation of the person and conversations with the person or LAR and those who know the person best, such as an NF staff, caregiver, family member or friend.

Section 3, Changes Made to the HSP — This section is where changes to the HSP made within the previous 12 months are described.

Section 4, Habilitation Coordination Plan — This section describes the habilitation coordination plan, including duration and frequency of  meetings between the person and the habilitation coordinator. The duration of habilitation coordination is while the person is living in the NF and is pre-printed on the form. The frequency of in-person visits is determined by the SPT within the constraints of 5100, Required In-Person Visits, and may be either at least monthly or at least quarterly.

This section also lists all the activities to be coordinated and monitored by the habilitation coordinator. The first two activities are pre-printed because they are mandatory. If the NF agreed to provide NF PASRR support activities, each support activity to be provided by the NF must be listed as an activity that will be monitored by the habilitation coordinator. The PASRR rules provide a definition of NF PASRR support activities and include the following examples of support activities:

• arranging transportation for a person to participate in an IHSS or an MI specialized service outside the NF;
• sending a person to an IHSS service or MI specialized service with food and medications required by the person; and
• stating in the NF comprehensive care plan an agreement to avoid, when possible, scheduling NF services at times that conflict with IHSS or MI specialized services.

Note: The examples above are not all inclusive. A support activity can be any type of activity that supports the person to receive specialized services.

Section 5, Outcome Action Plan — A separate outcome action plan is needed for each identified outcome. An outcome identifies what the person wants to do, achieve, change, maintain or experience. For an identified outcome, the outcome action plan must identify all specialized services and other resources and natural supports the person receives that will help the person achieve the outcome. Each outcome action plan provides space to identify IDD habilitative specialized services, NF specialized services, MI specialized services and other resources or natural supports, as necessary and unique to the outcome. For each specialized service and resources or natural support listed, a description is necessary of how the specialized service or resource or natural support helps the person achieve the outcome.

Note: While an NF specialized service or MI specialized service may be listed in a particular outcome action plan, all NF specialized services and MI specialized services for the person must be included in Section 6 of the HSP.

Section 6, NF Specialized Services to be Monitored by the SPT — This section is for recording all NF specialized services and MI specialized services provided to the person during the HSP year, including:

• the goals for the service as identified by the licensed therapist on the therapy assessment or as identified by the LMHA or LBHA staff;
• the amount, frequency and duration of the service; and
• if the service was discontinued during the HSP year, and if so the date of discontinuance.

The form allows the user to add lines for more than one NF specialized service and MI specialized service.

Section 7, Preference Regarding Transitioning — Each time the habilitation coordinator presents CLO to the person or LAR during the HSP year, the CLO date is included in this section of the HSP. Also included in this section are barriers to preventing a transition to the community from Section 6 of Form 1054, Community Living Options, or barriers to selecting a community program from Section 7 of Form 1504, if any. If there are barriers, the SPT’s proposed solutions and follow-up activities are also included in this section of the HSP. The SPT may identify more barriers.

Section 8, Educational Activities — This section is used to describe all CLO educational, informational and support activities offered to the person, LAR and actively involved people. If an offered activity was attended, the information about attendance is also included in this section.

Section 9, Documentation of Exploration of Community Programs — This section is used to describe the community living settings where a visit is planned or has occurred. When the visit has occurred, a summary of the outcome of the visit is included in this section.

Section 10, HC Signature — This section is for the habilitation coordinator to affirm that the HSP was developed based on IDT or SPT decisions and includes the habilitation coordinator’s printed name, signature and date.

5470 Sharing the Habilitation Service Plan, Individual Profile and Habilitation Packet

Revision 22-1; Effective Nov. 28, 2022

The habilitation coordinator is responsible for providing a copy of the current Form 1057, Habilitation Service Plan (HSP), and Form 1063, Individual Profile – Nursing Facility, to all SPT members within 10 calendar days after the SPT meeting during which they were developed  or revised.

The habilitation coordinator must share a person’s habilitation packet with an SPT member upon request.

5480 SPT Member Believes HSP or Individual Profile Does Not Accurately Reflect SPT Decisions or Information about the Individual

Revision 22-1; Effective Nov. 28, 2022

If an SPT member believes Form 1057, Habilitation Service Plan (HSP), or Form 1063, Individual Profile – Nursing Facility, does not accurately reflect an SPT decision or information about the person, then:

• if the habilitation coordinator agrees with the SPT member, the habilitation coordinator corrects Form 1057 or Form 1063 to accurately reflect the SPT decision or person’s information; or
• if the habilitation coordinator does not agree with the SPT member, the habilitation coordinator presents the issue to the SPT to resolve the discrepancy. 

Revision 22-1; Effective Nov. 28, 2022

5510 Initiating IDD Habilitative Specialized Services

Revision 22-1; Effective Nov. 28, 2022

The habilitation coordinator is responsible for initiating IDD habilitative specialized services identified on a person’s Form 1057, Habilitation Service Plan (HSP), within 20 business days after the date of an IDT meeting or SPT meeting of any kind. “Initiating” means to take necessary action that will result in the person receiving specialized services in a timely manner.

Note: The NF is responsible for requesting NF specialized services in the LTC online portal within 20 business days after the date of an IDT meeting or SPT meeting.

5520 Monitoring the Initiation and Delivery of all Specialized Services

Revision 22-1; Effective Nov. 28, 2022

The habilitation coordinator must document the initiation and delivery of all specialized services agreed upon in an IDT meeting or an SPT meeting.

The habilitation coordinator must report to Complaint and Incident Intake (800-458-9858) a noncompliant entity (i.e., LIDDA, NF or LMHA/LBHA) if the entity fails to:

• initiate or request a specialized service by the 20th business day after the service was agreed to in an IDT meeting or SPT meeting; or
• deliver a specialized service:
  • for NF therapy services — within three business days after receiving approval from HHSC in the LTC online portal;
  • for behavioral support, employment assistance and supported employment — within three business days after the habilitation coordinator receives the completed assessment; and
  • for independent living skills training and day habilitation — within 20 business days after the service was agreed to in an IDT meeting or SPT meeting.

Note: In addition to a report to Complaint and Incident Intake for a noncompliant entity, as noted above, a LIDDA is responsible for submitting monthly noncompliance reports to HHSC per the performance contract.

5530 Accessing Other Habilitative Programs

Revision 22-1; Effective Nov. 28, 2022

The habilitation coordinator must help a person access needed specialized services and other habilitative programs and services that can provide services to address the person’s needs and achieve outcomes identified in the HSP.

5540 Assisting Individual or LAR with Requesting a Fair Hearing for Denial of NF Specialized Services

Revision 22-1; Effective Nov. 28, 2022

If a person is denied a specialized service and the person or LAR wants to appeal the denial, the habilitation coordinator is responsible for helping the person or LAR with requesting a fair hearing. Form 2361, PASRR Specialized Services Fair Hearing Request may be used for this purpose.

Revision 22-1; Effective Nov. 28, 2022

The habilitation coordinator is responsible for:

• coordinating with other habilitative programs and services that can address needs and achieve outcomes identified in Form 1057, Habilitation Service Plan (HSP);
• facilitating the coordination of a person’s HSP and the NF comprehensive care plan; and
• coordinating with the NF in accessing medical, social, educational and other appropriate services and supports that will help a person achieve a quality of life acceptable to the person and LAR .

Revision 22-1; Effective Nov. 28, 2022

The habilitation coordinator must provide monitoring and follow-up activities to determine:

• whether a person receives the specialized services agreed upon in an IDT or SPT meeting and follow up when delays occur;
• whether a person’s Form 1057, Habilitation Service Plan (HSP), is fully implemented;
• a person’s and LAR’s satisfaction with all specialized services; and
• a person’s progress or lack of progress toward achieving goals and outcomes identified in Form 1057.

Monitoring  is accomplished through a combination of:

• observation of the person receiving services;
• conversations with the person, LAR, NF staff or provider; and
• review of documentation, service delivery logs or written reports from a provider.

When monitoring progress or lack of progress and satisfaction, the habilitation coordinator must be sure to include the perspective of the person and LAR.

The habilitation coordinator must share the results of the habilitation coordinator’s monitoring and follow-up activities with the STP .

Revision 22-1; Effective Nov. 28, 2022

5810 Presenting CLO

Revision 22-1; Effective Nov. 28, 2022

The habilitation coordinator provides information and discusses with a person and LAR the range of community living services, supports and alternatives. They identify the services and supports the person will need to live in the community, if the person or LAR has chosen to transition to community living, and identify and address barriers to community living. This activity is referred to as “CLO.”

Present CLO in a manner that allows the person and LAR to fully understand the options available. Therefore, CLO duration may vary but should last as long as needed to completely and meaningfully present all available community living options. If there are barriers to the person’s or LAR’s full understanding of CLO, the habilitation coordinator must document these barriers in Form 1054, Community Living Options, and how they will be addressed in Form 1057, Habilitation Service Plan (HSP).
 

5810.1 When CLO is Presented

Revision 22-1; Effective Nov. 28, 2022

CLO is presented at the following times regardless of whether the person is receiving or has refused habilitation coordination*:

• Six months after the initial CLO (which was presented during the PE) and at least every six months thereafter. HHSC recommends that CLO be completed no more than 30 days before the scheduled second quarterly SPT meeting or annual IDT and SPT meeting, so that it can be discussed during the meeting.
• When requested by the person or LAR.
• When the habilitation coordinator is notified or becomes aware that the person or LAR is interested in speaking with someone about transitioning to the community.
• When notified by HHSC that the person’s response in Section Q of the MDS assessment indicates the person is interested in speaking with someone about transitioning to the community.    

Note: CLO is presented anytime a PE is completed, including for a resident review or change of ownership.

*Some people and LARs who have refused habilitation coordination or are not interested in transitioning to the community may be reluctant to receive CLO every six months. As part of a person-centered approach, the habilitation coordinator should remain sensitive to the person’s or LAR’s preferences, ensure the person and LAR understand the importance of presenting CLO, and conduct CLO activities in a way that is responsive to the person’s or LAR’s concerns.

5810.2 Six-month Base Schedule

Revision 22-1; Effective Nov. 28, 2022

The habilitation coordinator presents CLO to the person or LAR six months after the initial CLO and at least every six months thereafter while the person continues to reside in the NF. The habilitation coordinator must maintain the every-six-month base schedule beginning with the initial CLO, even if an additional CLO was presented before the next six-month CLO is due.

5810.3 CLO Materials Provided to Individual or LAR

Revision 22-1; Effective Nov. 28, 2022

The habilitation coordinator uses the following materials to present CLO and explains each of the materials using the person’s preferred method of communication, taking the time necessary to ensure that the person and  LAR fully understand the materials and each of the person’s community options:

• Making Informed Choices: Community Living Options Information Process for Nursing Facility Residents booklet*;
• Making Informed Choices: Community Living Options Information for Legally Authorized Representatives of Residents of Nursing Facilities booklet, if the person has an LAR*;
• Appendix II, Long Term Services and Supports, in the LIDDA Handbook;
• Explanation of Services and Supports; and
• Friends and Family Guide to Adult Mental Health Services.

*CLO booklets are available by ordering from Pinnacle Cart.

5820 Documenting CLO

Revision 22-1; Effective Nov. 28, 2022

The HC documents the CLO presentation and discussion on Form 1054, Community Living Options. The habilitation coordinator must fill out Section 4 on Form 1054 whether the person is interested in transitioning to the community or not.

Note: The habilitation coordinator also documents barriers from Sections 6 or 7 of Form 1054 in Section 7 of Form 1057, Habilitation Service Plan (HSP). See Section 5460.2, Habilitation Service Plan.

5830 Habilitation Coordinator Actions Following CLO

Revision 22-1; Effective Nov. 28, 2022

The habilitation coordinator complies with the requirements in this section following:

• the habilitation coordinator’s receipt of CLO information from the PE evaluator per Section 2430.5, Presenting Information about Community Services as Part of the PE; and
• the habilitation coordinator’s presentation of CLO to the person or LAR.

5830.1 Individual or LAR Wants to Transition and has Selected a Community Program

Revision 22-1; Effective Nov. 28, 2022

If a person wants to transition to the community and has selected a community program, the habilitation coordinator must, within three business days after receipt of CLO information from the PE evaluator, or within three business days after the habilitation coordinator’s presentation of CLO,

• send a referral using Form 1579, Referral for Relocation Services, to the person’s  managed care organization (MCO) (see Appendix II, MCO Contact Information) so that a relocation specialist (RS) can be assigned and an assessment and evaluation completed within 14 calendar days; and
• notify the appropriate LIDDA staff to assign a service coordinator (SC) or an enhanced community coordinator (ECC) to begin transition planning with the person and LAR.

The habilitation coordinator must:

• ensure receipt of the RS’s assessment and evaluation;
• review the RS’s assessment and evaluation to determine if specialized services can help the person transition to the community and, if so, follow up with an SPT meeting to discuss the issue;
• ensure the assigned SC/ECC receives a copy of the RS’s assessment and evaluation;
• share a copy of the person’s habilitation packet with the RS and SC/ECC; and
• inform the RS of the name and contact information of the SC/ECC who will be facilitating transition planning for the person.

5830.2 Individual or LAR Wants to Transition, but has NOT Selected Community Program

Revision 22-1; Effective Nov. 28, 2022

If a person wants to transition to the community, but has not selected the community program to pursue, the habilitation coordinator must, within three business days after receipt of CLO information from the PE evaluator or after the habilitation coordinator’s presentation of CLO, send a referral, using Form 1579, Referral for Relocation Services, to the person’s MCO (see Appendix II, MCO Contact Information) so that an RS can be assigned and an assessment and evaluation completed within 14 calendar days.
The habilitation coordinator must:

• ensure receipt of the RS’s assessment and evaluation;
• review the RS’s assessment and evaluation to determine if specialized services can help the person transition to the community and, if so, follow up with an SPT meeting to discuss the issue;
• share a copy of the person’s habilitation packet with the RS;
• work with the RS to help the person and LAR in selecting a community program that best suits the person’s needs. Note: Waiver comparison chart is available here; and
• if the person has not refused habilitation coordination, ensure that if barriers to selecting a community program are identified in Section 7 of the completed Form 1054, Community Living Options, they are included in Section 7 of Form 1057, Habilitation Service Plan (HSP) for SPT discussion.

When the person or LAR has selected a community program, the habilitation coordinator must:

• notify the appropriate LIDDA staff to assign an SC or an ECC to begin transition planning with the person and LAR;
• share with the SC/ECC:
  • a copy of the RS’s assessment and evaluation; and
  • a copy of the person’s habilitation packet; and
• inform the RS of the name and contact information of the SC/ECC who will be facilitating transition planning for the person.

5830.3 Individual or LAR Does Not Want to Transition, is Undecided or Desire of Individual or LAR Cannot be Determined

Revision 22-1; Effective Nov. 28, 2022

For a person who has not refused habilitation coordination, if the person or LAR does not want to transition, is undecided or the desire of the person or LAR cannot be determined, the habilitation coordinator must:

• ensure that if barriers preventing a transition to the community are identified in Section 6 of Form 1054, Community Living Options, they are included in Section 7 of Form 1057, Habilitation Service Plan (HSP);
• ensure the barriers are discussed at the next quarterly SPT meeting with the SPT identifying possible solutions to the barriers, how the SPT can implement the solutions and any needed follow-up activities; and
• document the resolutions and actions for implementation in Section 7 of Form 1057.

5840 Exploring Community Programs

Revision 22-1; Effective Nov. 28, 2022

The habilitation coordinator arranges exploratory visits to community programs for a person, if requested, and addresses concerns about community living from the person and LAR. Additionally, the habilitation coordinator may assist a person and LAR with exploring different types of community programs using print and digital media, such as brochures, magazines, DVDs, virtual visit apps and virtual tours.

5850 Educational Opportunities

Revision 22-1; Effective Nov. 28, 2022

The habilitation coordinator offers a person and LAR the educational and informational opportunities that are required to be arranged by the LIDDA semiannually pursuant to the performance contract. The habilitation coordinator must document that the offer was made, including the specific educational or informational opportunity (i.e., description, location, date and time).

Revision 22-1; Effective Nov. 28, 2022

5910 Explanation of Rights

Revision 22-1; Effective Nov. 28, 2022

The habilitation coordinator must initially, and annually thereafter, provide a person and LAR an oral and written explanation of the person’s rights contained in the “Your Rights in Local Authority Services” booklet.

Rights booklets are available on the HHS website. Rights booklets may also be ordered by sending an email to OmbudsmanIDD@hhs.texas.gov.

The habilitation coordinator must document every time the habilitation coordinator gives the written and oral explanations to the person, LAR, or actively involved person. The documentation must be signed by the person or LAR and the habilitation coordinator.

5920 Activities Related to Guardianship

Revision 22-1; Effective Nov. 28, 2022

5920.1 Individual Has a Guardian

Revision 22-1; Effective Nov. 28, 2022

The habilitation coordinator must determine annually if the letters of guardianship for a person are current. The letter of guardianship is required to be renewed in the county court annually. The habilitation coordinator annually must request the current letter of guardianship and keep a copy in the person’s record.

The habilitation coordinator must document in the HSP whether the letter of guardianship is current.

If the letter of guardianship is not current, the habilitation coordinator must provide a reminder to the guardian that a renewal needs to be completed and document that the guardian was provided this reminder.

5920.2 Individual Does Not Have a Guardian

Revision 22-1; Effective Nov. 28, 2022

If a person does not have a guardian and may benefit from having one, the habilitation coordinator, along with the SPT, must assess if the person needs a guardian or would benefit from a less restrictive alternative to guardianship, and must document this discussion. If the SPT believes guardianship is the least restrictive option, the habilitation coordinator makes appropriate referrals, such as to the local probate court.

See Appendix III, Legal Authority to Make Decisions, for information about types of guardianship and alternatives.  

Revision 25-1; Effective Nov. 12, 2025

6110 Duties Related to Transitioning from an NF

Revision 25-1; Effective Nov. 12, 2025

When the habilitation coordinator notifies the appropriate LIDDA staff that a person or legally authorized representative (LAR) wants to transition to the community and has selected a community program, the LIDDA must make sure an ECC coordinator:

• is assigned within three business days after HHSC releases a 1915(c) waiver slot;
• complies with the rules governing service coordination for a person with an intellectual disability as required in 26 Texas Administrative Code (TAC) Chapter 331, LIDDA Service Coordination, and 26 TAC 263.901, LIDDA Requirements for Providing Service Coordination in the HCS Program;
• provides intensive and flexible support to achieve success in a community setting, including arranging for support needed to prevent and manage a crisis, such as Transition Support Team (TST), crisis respite or crisis intervention services;
• provides pre- and post-transition services;
• monitors the person for the first 365 days* after transition or diversion, as required by the LIDDA Performance Contract;
• maintains a case load of no more than 30 people, even if the ECC coordinator provides service coordination to other people who are not covered under this section; and
• enhances the person’s natural supports and promotes successful community living.

If, during transition planning, a person indicates they are no longer interested in transitioning to the community, the LIDDA unassigns the ECC coordinator and notifies the relocation specialist (RS) and the habilitation coordinator that the person is no longer interested in transitioning to the community.

*Important: If, by 30 days before ECC is scheduled to end, the service planning team (SPT) believes the person will require more than 365 days of enhanced monitoring, the ECC coordinator must contact IDDMFPSupport@hhs.texas.gov for guidance.

6120 Working with the Relocation Specialist

Revision 25-1; Effective Nov. 12, 2025

The ECC coordinator must review the relocation assessment and evaluation conducted by the RS and invite the RS and managed care organization (MCO) service coordinator (SC) to all service planning team (SPT) meetings for transition planning. The RS becomes a member of the SPT.

Note: The MCO SC is already an SPT member and is invited to all SPT meetings unless the person objects. The habilitation coordinator should ask the person or LAR directly if they agree with the MCO service coordinator’s attendance at interdisciplinary team (IDT) and SPT meetings and must document evidence of this discussion in the person’s record. 

6130 Relocation Specialist and MCO SC Responsibilities

Revision 25-1; Effective Nov. 12, 2025

The MCO SC and RS, as members of the SPT, assist a person with accessing:

• housing, transportation, medical, dental, and prescriptions, depending on the program the person chooses; and
• Supplemental Transition Services (STS) funding if the person qualifies.

STS is available to pay for essential items not covered by Transition Assistance Services (TAS), which is a waiver program service. STS may be used when TAS funds have been exhausted. The RS will provide the ECC coordinator with a copy of the completed STS form signed by the MCO, the RS and the ECC coordinator.

Note: For people transitioning to the Home and Community-based Services (HCS) program, the ECC coordinator is responsible for completing and submitting the assessment for TAS funding. For people transitioning to the Community Living Assistance and Support Services (CLASS), Deaf Blind with Multiple Disabilities (DBMD) or Home and Community Based Services (HCBS) (STAR+PLUS Waiver) program, the RS is responsible for completing and submitting the assessment for TAS funding.

6140 ECC Designated Funds  

Revision 25-1; Effective Nov. 12, 2025

ECC-designated funds are available to LIDDAs through the performance contract for a person who is transitioning to the community. The purpose of the funds is to enhance a person’s natural supports and promote successful community living. Funds are intended to pay for:

• one-time emergency assistance, such as:
  • security deposits or utility assistance;
  • nutritional supplements;
  • clothing; and
  • medication;
• items to address a person's special needs, including minor home modifications not funded by other sources;
• transportation to and from trial visits with community providers; and
• educational tuition assistance, such as vocational programs through community colleges so a person can develop job skills.

All other funds, including TAS, STS, waiver, non-waiver and third-party or community resources must be exhausted. All purchases must be approved before ECC-designated funds may be used.

LIDDA staff may access ECC funds by completing Form 8658, Enhanced Community Coordination (ECC) Designated Funds Request and Authorization, and submitting it to IDDMFPSubmissions@hhs.texas.gov.

Revision 25-1; Effective Nov. 12, 2025

For a person planning to transition from an NF to a community program, the LIDDA must make sure an assigned ECC coordinator:

• completes the initial in-person visit within seven business days of being assigned;
• completes  Form 1580, Texas Money Follows the Person Demonstration Project Informed Consent for Participation, as detailed in 13238, Money Follows the Person Demonstration Participation Process, of the LIDDA handbook;
• develops Form 1053, Transition Plan, with the SPT;
• makes sure the members of the SPT receive sufficient notice to participate in the SPT meeting, which is at least 10 business days before the scheduled meeting;
• makes sure the SPT uses the relocation assessment and evaluation, other assessments, such as medical and behavioral, and the latest Form 1054, Community Living Options, to guide the development of Form 1053;
• coordinates with the MCO SC and RS, as needed, to access community resources the person may need or be eligible for, including transportation, housing, medical, dental and other services; and
• shares a copy of the person’s completed Form 1053 with all members of the SPT within 10 business days after the meeting.

For an SPT meeting convened by the ECC coordinator, the ECC coordinator must make sure a sign-in sheet is provided to document the attendance of each participant, and the meeting date. If an SPT member participated by phone, the ECC coordinator must make sure the member’s name is included on the sign-in sheet. The ECC coordinator must maintain all sign-in sheets.

Note: Before the ECC coordinator conducts the SPT meeting for transitions via audio-visual communication in extenuating circumstances, the ECC Coordinator must gain consent. Refer to 1220 Consent, which includes more details.  

6210 SPT Meeting Participation

Revision 25-1; Effective Nov. 12, 2025

All members of the SPT must work together to develop the Transition Plan. The SPT must include:

• The person and their LAR, if applicable
• MCO SC
• MCO RS
• NF staff, including providers of specialized services
• Habilitation coordinator
• ECC coordinator
• Program provider, once selected
• Permanency planner, if applicable*
• LMHA and LBHA if the person is receiving PASRR MI specialized services
• Anyone else the person or LAR requests

The ECC coordinator must participate in person or by phone at all SPT meetings the habilitation coordinator convenes. The habilitation coordinator must participate in person or by phone at all SPT meetings the ECC coordinator convenes.

The ECC coordinator and habilitation coordinator must make sure the community program provider and RS are invited to all SPT meetings, including those the habilitation coordinator convenes. However, the program provider and RS are only required to attend SPT meetings the ECC coordinator convenes related to transition planning.

*The habilitation coordinator must invite the person who develops a permanency plan to participate as a member of all SPT meetings. The habilitation coordinator uses the HHSC Permanency Planning Instrument for Children Under 22 Years of Age form and performs other permanency planning activities for a person younger than 22 years, if the person is at least 21 but younger than 22.

6220 Barriers Preventing a Transition to the Community

Revision 25-1; Effective Nov. 12, 2025

The ECC coordinator must:

• make sure that if barriers preventing a transition to the community are identified in Section 8 of Form 1054, Community Living Options, they are included in Section 6 of Form 1053, Transition Plan, in addition to any barriers the SPT may identify;
• make sure the SPT discusses the barriers, possible solutions to the barriers, and how the SPT can implement the solutions and any needed follow-up activities; and
• document the resolutions and actions for implementation in Section 6 of Form 1053.

Revision 25-1; Effective Nov. 12, 2025

A complete transition packet for a person has:

• Form 1063, Individual Profile – Nursing Facility, refer to 5460.1, Individual Profile;
• Form 1053, Transition Plan; and
• Form 1042, Pre-Move Site Review, when completed, as described in 6530, Enrollment in HCS as an NF Transition, or 6700, Transitioning to a Community Medicaid Program other than the HCS Program.

Note: The habilitation coordinator develops and revises Form 1063, Individual Profile – Nursing Facility. If revisions to the person’s Form 1063 are necessary based on discussions during an SPT meeting, the habilitation coordinator must make the needed revisions. The habilitation coordinator shares the revised Form 1063 with the ECC coordinator and the other SPT members within 10 business days after the SPT meeting where it was revised.

The ECC coordinator must provide a copy of the person’s Form 1053, Transition Plan, to all SPT members within 10 business days after the SPT meeting where it was developed or revised, and upon request.

If an SPT member believes Form 1053, Transition Plan, does not accurately reflect SPT decisions, then:

• if the ECC coordinator agrees with the SPT member, the ECC coordinator corrects Form 1053 to accurately reflect the SPT decision; or
• if the ECC coordinator does not agree with the SPT member, the ECC coordinator presents the issue to the SPT to resolve the discrepancy.

Revision 25-1; Effective Nov. 12, 2025

Based on the Medicaid program the person or LAR chooses, the ECC coordinator is responsible for:

• HCS – Notifying the diversion coordinator to request a transition slot from HHSC as described in 6500, Enrollment in HCS as an NF Transition.
• CLASS or DBMD – Working with the RS to request a slot through the CLASS or DBMD interest list unit at HHSC.
• STAR+PLUS HCBS – Working with the RS and MCO SC to arrange for the person to enroll in the STAR+PLUS HCBS program.

Revision 25-1; Effective Nov. 12, 2025

HHSC may make available a targeted NF HCS transition slot for a person who meets the criteria described in 6510, Criteria for Transitioning to the HCS Program.

6510 Criteria for Transitioning to the HCS Program

Revision 22-1; Effective Nov. 28, 2022

A person is eligible for a targeted NF HCS transition slot if:

• the person has a PASRR Evaluation (PE) that was conducted when the person was admitted to the NF and the PE is positive for intellectual disability (ID) or developmental disability (DD);
• it is after the 30th day of the person’s admission if the person was admitted to the NF for rehabilitative purposes;
• the person is at least 21 years old;
• the person currently lives in a NF; and
• the person has expressed a desire to live in a community setting.

6520 Requesting a Targeted NF HCS Transition Slot

Revision 25-1; Effective Nov. 12, 2025

If a LIDDA determines a person meets the criteria for a targeted NF HCS transition slot and the person or LAR wants to enroll in HCS, the diversion coordinator requests the slot for the person by completing and submitting Form 1046, Request for HCS Adult NF Transition Slot, per the form’s instructions.

Upon receipt, HHSC staff reviews the completed Form 1046. HHSC staff may request additional information or documentation. If HHSC determines the person meets the criteria for the targeted NF HCS transition slot, HHSC will send a letter to the LIDDA authorizing the LIDDA to offer the person the opportunity to enroll in HCS. 

6530 Enrollment in HCS as an NF Transition

Revision 25-1; Effective Nov. 12, 2025

For a person transitioning to the community by enrolling in the HCS program, a LIDDA must enroll the person in the HCS Program per HCS rules and 13000, Medicaid Program Enrollment Requirements, of the LIDDA Handbook. The ECC coordinator must:

• comply with the rules governing service coordination for a person with an intellectual disability per 26 TAC Chapter 331, LIDDA Service Coordination, and 26 TAC Section 263.901, LIDDA Requirements for Providing Service Coordination in the HCS Program;
• facilitate trial visits to HCS program providers in the community for the person, including overnight or weekend visits where feasible, as requested by the person or LAR;
• develop and revise, as needed, Form 8665, Person-Directed Plan, using all available assessments and including the person’s strengths, preferences and support needs:
  • strengths and preferences; and
  • medical, nursing, clinical, dietary and other support needs.
• initiate development of the individual plan of care as outlined in 13240, Individual Plan of Care, of the LIDDA Handbook;
• conduct, in-person, a pre-move site review using Form 1042, Pre-Move Site Review, to determine if essential supports are in place and any areas of concern have been addressed before the person enrolls in the HCS Program; and
• complete the following activities before the person transitions if, during the pre-move site review, any one of the essential supports is not in place or if issues are raised about the suitability of the site:
  • convene the SPT to resolve the issues; and
  • conduct another pre-move site review following resolution.

When a person expresses the desire to transition from an NF to a home in another LIDDA’s service area, the transferring LIDDA’s ECC coordinator should invite the receiving LIDDA’s ECC coordinator to all transition planning meetings. The receiving LIDDA’s ECC coordinator may attend transition planning meetings either in person, by audio-visual technology or by phone.

The transferring and receiving LIDDAs must work together to make sure essential supports are in place before the person’s discharge from the NF. This includes determining who will be responsible for conducting the pre-move site review, considering time and distance to the site and sharing a copy of the pre-move visit with the other LIDDA. The sending LIDDA should document any discussions with the receiving LIDDA.

The transfer of LIDDAs must not occur until all essential supports have been verified through a pre-move visit.

At its discretion, HHSC may determine the designated LIDDA for any person or assign a LIDDA the duties of the designated LIDDA for any person.

A non-designated LIDDA is not prohibited from serving a person who is currently being served by their designated LIDDA. 

6540, Transition Day

Revision 25-1; Effective Nov. 12, 2025

The MCO SC and RS are expected to be present at the new address on transition day to make sure all services are in place. They also assist in setting up the household as needed. The ECC coordinator is also encouraged to be present.

Note: If the transition plan includes essential supports that are due to be delivered or transferred with the person on transition day, the ECC coordinator must verify the supports are in place.

 

Revision 25-1; Effective Nov. 12, 2025

For a person who transitioned from an NF to the HCS program, an ECC coordinator must:

• conduct at least three on-site visits of community services delivery sites* at the following intervals using Form 1043, Post-Move Monitoring:
  • within seven calendar days after enrollment in the HCS Program;
  • between eight and 45 calendar days; and
  • between 46 and 90 calendar days;
• during the post-move monitoring visits:
  • assess if supports identified on Form 1053, Transition Plan, continue to be in place;
  • address any concerns of the person, program provider, staff or family member;
  • identify any gaps in care; and
  • address such gaps, if any, to reduce the risk of crisis, re-admission to an NF or another negative outcome.

Note: The ECC coordinator must conduct post-move monitoring at all sites where essential supports are provided. More frequent on-site visits may be required to determine if supports continue to be in place and any areas of concern are being addressed during the first 90 calendar days after enrolling in HCS.

6610 Monitoring Activities for One Year Post-Move

Revision 25-1; Effective Nov. 12, 2025

For one year* following a person’s transition from an NF to the HCS program, an ECC coordinator must:

• conduct at least monthly in-person visits with the person;
• conduct HCS SPT meetings at least every 90 days**, or more frequently if there is a change in the person’s needs or if requested by the person or LAR;
• revise Form 8665, Person-Directed Plan, as necessary, and coordinate the person’s services and supports with the HCS service coordinator, if applicable;
• ask about any recent hospitalizations, emergency department contacts, increased physician visits or other crises, including medical crises. If the person experiences such, convenes the HCS SPT to identify all necessary revisions to the person’s Form 8665 to address the added need for services;
• make sure the person receives timely assessments of behavioral, medical, nursing, professional therapies and nutritional management needs, as necessary, and as indicated on Form 8665;
• record the person’s physical, behavioral, and mental health care status sufficiently to readily identify when changes in the person’s status occurs;
• conduct service planning;
• monitor all services identified on Form 8665, including:
  • making sure the program provider implements services;
  • reviewing the HCS Program provider’s implementation plans and provider records;
  • visiting service delivery sites, as needed, to determine if the person’s needs are being met; and
  • monitoring critical incidents involving the person and convening the HCS SPT to develop a plan for needed prevention or intervention services for the person; and
• monitor the person while on suspension from the HCS Program at least monthly, maintain communication with the program provider and provide reports to HHSC upon request.

*If, by 30 days before ECC is scheduled to end, the SPT believes the person will require more than 365 days of enhanced monitoring, the ECC coordinator must contact IDDMFPSupport@hhs.texas.gov for guidance.

**SPT meetings may be held up to 10 business days before the next SPT meeting is due. The SPT meeting schedule does not reset.

Per the IDD Submission Calendar, the LIDDA shall submit quarterly reporting using a format prescribed by HHSC. 
 

Revision 25-1; Effective Nov. 12, 2025

For a person transitioning from an NF to a community Medicaid program that is not HCS, an assigned ECC coordinator must:

• facilitate trial visits to providers in the community for the person and LAR, as requested by the person or LAR;
• convene and facilitate SPT meetings as necessary to conduct transition planning and to develop, revise and implement the person’s Form 1053, Transition Plan, regardless of the program chosen by the person;
• assist with service planning by:
  • making all available assessments available to the entity responsible for service planning; and
  • addressing the person’s:
    • strengths and preferences; and
    • medical, nursing, clinical, nutritional management and support needs;
• conduct a pre-move site review in person using Form 1042, Pre-Move Site Review, to determine if essential supports identified in the transition plan are in place and any areas of concern are addressed before the person enrolls in the identified program; and
• complete the following activities before the person transitions if, during the pre-move site review, any one of the essential supports is not in place or if issues are raised about the suitability of the site:
  • convenes the SPT to resolve the issues; and
  • conducts another pre-move site review following resolution.

6710, Transition Day

Revision 25-1; Effective Nov. 12, 2025

The MCO SC and RS are expected to be present at the new address on transition day to make sure all services are in place and to assist in setting up the household, as needed. The ECC coordinator is also encouraged to be present.

Note: If the transition plan includes essential supports that are due to be delivered or transferred with the person on transition day, the ECC coordinator must verify the supports are in place.
 

Revision 25-1; Effective Nov. 12, 2025

For a person who has transitioned to a community Medicaid program that is not HCS, an ECC coordinator must:

• conduct and document on Form 1043, Post-Move Monitoring, at least three on-site post-move monitoring visits of community service delivery sites during the first 90 calendar days after the person’s move at the following times:
  • within the first seven calendar days after transition;
  • between eight and 45 calendar days;
  • between 46 and 90 calendar days; and
• during the post-move monitoring visits:
  • assess if essential and non-essential supports identified in Form 1053, Transition Plan, are in place;
  • make sure any concerns of the person, program provider, staff or family member are being addressed;
  • identify gaps in care; and
  • address any gaps to reduce the risk of crisis, readmission to an NF or another negative outcome.

The ECC coordinator should conduct more post-move monitoring visits if indicated.

The LIDDA may not use targeted case management funding for an SC’s activities described in this section if the person is enrolled in the CLASS or DBMD program. The LIDDA may use ECC funds if an ECC coordinator conducts the activities described in this section.

Revision 25-1; Effective Nov. 12, 2025

If a person who has already received 365 days of ECC is admitted or readmitted to an NF and wants to return to the community, a LIDDA must determine if the person:

• was in the NF for more than 30 calendar days; or
• experienced a significant change of condition* during admission.

If the LIDDA determines the readmission exceeded 30 calendar days or the person experienced a significant change of condition, an ECC coordinator must:

• facilitate trial visits, when appropriate, to program providers in the community for the person, including overnight or weekend visits where feasible, as requested by the person or LAR;
• develop or revise in conjunction with the SPT, as needed, the person’s Form 1053, Transition Plan;
• develop and revise, as necessary, Form 8665, Person-Directed Plan, using all available assessments, and include the person’s strengths and preferences;
• conduct a pre-move site review using Form 1042, Pre-Move Site Review, to:
  • make sure any concerns of the person, program provider, staff or family member are being addressed; and
  • determine if all essential supports identified on Form 1053, Transition Plan, are in place before the person transitions;
• complete the following activities before the person transitions if, during the pre-move site review, any one of the essential supports is not in place or if issues are raised about the suitability of the site:
  • convene the SPT to resolve the issues; and
  • conduct another pre-move site review following resolution.
• conduct and document on Form 1043, Post-Move Monitoring, at least three onsite post-move monitoring visits of community service delivery sites during the first 90 calendar days after the person’s move at the following times:
  • within the first seven calendar days after enrollment in the HCS program;
  • between eight and 45 calendar days after enrollment in the HCS program;
  • between 46 and 90** calendar days after enrollment in the HCS program; and
• during the post-move monitoring visits:
  • assess if essential and non-essential supports identified in Form 1053, Transition Plan, are in place;
  • make sure any concerns of the person, program provider, staff or family member are being addressed;
  • identify gaps in care; and
  • address any gaps to reduce the risk of crisis, re-admission to an NF or another negative outcome.

* Significant change of condition: any change that requires added services, equipment or minor home modifications, such as new enteral feeding tube, respiratory equipment or wheelchair.

**If, by the 60th day after the person returns to the community, the SPT believes the person may require more than 90 days of enhanced monitoring, the ECC coordinator must contact IDDMFPSupport@hhs.texas.gov for more guidance.

For a qualified person who has never received ECC who is admitted or readmitted to an NF, if the stay is for at least 60 days, an ECC coordinator must initiate transition planning and one year of ECC as described in 6000 of this handbook, relating to monitoring activities for NF transitions. This includes the completion of Form 1580, Money Follows the Person Demonstration (MFPD) Project Informed Consent for Participation.

If a person is readmitted to an NF while receiving their initial 365 days of ECC, ECC will resume upon discharge to the community. The 365-day time frame does not restart. For example, if a person is admitted to an NF on day 181 of ECC and is put on suspension, when the person discharges from the NF, ECC resumes on day 182.

A person who is readmitted to an NF for the purpose of respite does not qualify for ECC on discharge unless the person is already receiving ECC at the time of readmission.

If a person is readmitted to an NF for fewer than 30 days and has not experienced a significant change in condition, but is discharging to a new residence, an ECC coordinator should use Form 1042, Pre-Move Site Review, to:

• address any concerns of the person, LAR or program provider; and
• determine if all previously identified essential supports are in place.
   

7100, Required Training for a Habilitation Coordinator  

Revision 22-1; Effective Nov. 28, 2022

7110 Training Completed Prior to Habilitation Coordination

Revision 22-1; Effective Nov. 28, 2022

LIDDAs must develop trainings at a local level to ensure, before providing habilitation coordination, a habilitation coordinator receives trainings that address:

• appropriate LIDDA policies, procedures, and standards;
• HHSC rules relating to PASRR, the provision of specialized services, and other HHSC rules affecting the LIDDA, including:
  • 26 TAC Chapter 303, related to PASRR; and
  • 26 TAC Chapter 554, Subchapter BB, Nursing Facility (NF) Responsibilities Related to PASRR.
• HHSC's IDD PASRR Handbook;
• developing and implementing a Habilitation Service Plan (HSP);
• conducting assessments, service planning, coordination, and monitoring;
• providing crisis prevention and management;
• community support services;
• presenting community living options using HHSC-developed materials and forms, and offering educational opportunities and informational activities about community living options;
• arranging visits to community providers;
• accessing specialized services for a person;
• the rights of a person with an intellectual disability (ID), including the right to live in the least restrictive setting appropriate to the person's individual needs and abilities and in a variety of living situations, as described in the Persons with an Intellectual Disability Act, Texas Health and Safety Code Chapter 592 and in an HHSC-developed rights handbook; and
• advocacy for individuals with ID or developmental disability (DD).

In addition to the trainings above, LIDDAs must also ensure the following trainings are completed before habilitation coordinators provide services: 

• HHSC computer-based training, An Overview of the PASRR Process ; and
• additional trainings designated by HHSC. Please refer to Section 7200, HHSC-developed Training. 

7120 Training Completed Within the First 60 Days of Habilitation Coordination

Revision 25-1; Effective Nov. 12, 2025

LIDDAs must make sure a habilitation coordinator completes the following training within the first 60 days of performing habilitation coordination duties:

• All HHSC instructor-led training about habilitation coordination, and
• HHSC computer-based training, Introduction to Person-Centered Planning.

Note: Habilitation coordinators must complete all trainings in 7110, Training Completed Prior to Habilitation Coordination, before providing habilitation coordination. Until the habilitation coordinator completes the trainings required in this section, a supervisor, team lead or quality monitoring staff person who has successfully completed the trainings in this section must review and sign off on work completed by a habilitation coordinator.

7130 Training Completed Within the First Year of Habilitation Coordination

Revision 25-1; Effective Nov. 12, 2025

A habilitation coordinator must complete person-centered thinking training approved by HHSC within the first year of performing habilitation coordination duties.

7140 LIDDA Responsibilities of Habilitation Coordinator

Revision 25-1; Effective Nov. 12, 2025

A LIDDA must:

• make sure a habilitation coordinator shows competency in providing habilitation coordination; and
• maintain documentation of the training received by habilitation coordinators.

Revision 22-1; Effective Nov. 28, 2022

All new PASRR staff regardless of role or function are required to complete the online course entitled An Overview of the PASRR Process. 

Additionally, the following instructor-led courses are required based upon the functions the staff person performs for the LIDDA:

• If new staff performs or supervises habilitation coordination duties, they must successfully complete Service Planning and Monitoring.
• If new staff performs or supervises PASRR service coordination/enhanced community coordination (SC/ECC) duties, they must successfully complete Transition and Diversion.
• If new staff performs or supervises staff who conduct PASRR evaluations (PEs), they must successfully complete PL1 and PE.
   

Revision 19-0; Effective July 7, 2019

Referring Entity References and Online Training Resources

Training designed to give PASRR referring entities the information, tools and resources needed to successfully complete the PASRR Level 1 Screening (PL1) may be accessed via the Texas Health and Human Services Learning Portal and enrolling in the course titled “PASRR Referring Entity (Online).”

Training designed to give a comprehensive knowledge for the PL1 may be accessed via the Texas Health and Human Services Learning Portal and enrolling in the course titled “PASRR PL1 (Online).”

Written step-by-step instructional guides regarding how to complete the PL1 form may be found by navigating to the PASRR Forms and Instructions page and clicking on one of the following hyperlinks:

• Detailed Item by Item Guide for completing the PL1 Screening Form (Referring Entities) [PDF] — This document provides complete step-by-step instructions for referring entities on when and how to complete the PL1.
• Detailed Item by Item Guide for completing the PL1 Screening Form and IDT Form (Local IDD Authorities and Nursing Facilities) [PDF] — This document contains complete step-by-step instructions for local authorities and nursing facilities on when and how to complete the PL1 and confirm IDT meetings.

LIDDA/LMHA/LBHA Training Materials

The LTC online portal can be accessed here. A log-on identification number is required to access the LTC online portal for alerts, PASRR Level II Evaluation (PE) submissions and corrections. Access details can be found in the Long-Term Care (LTC) User Guide for Preadmission Screening and Resident Review (PASRR)[PDF], which also provides information for LIDDAs and LMHAs/LBHAs for using the LTC online portal to submit all PASRR screenings and evaluations.

Written step-by-step instructional guides regarding how to complete the PE form may be found by navigating to the PASRR Forms and Instructions page or by clicking on of the following hyperlink:

• Detailed Item by Item Guide for Completing the PASRR Evaluation (PDF) — This document provides step-by-step instructions on when and how to submit the PE.

Revision 19-0; Effective July 7, 2019

Relocation Referrals

The following chart contains the email address for each STAR+PLUS managed care organization (MCO). A local intellectual and developmental disability authority (LIDDA) uses the appropriate email address to send a completed Form 1579, Referral for Relocation Services, as an attachment.

MCO Service Coordination Contact Information

If the LIDDA has already made a referral for relocation services and needs assistance from the MCO, the LIDDA should contact the MCO service coordinator (SC).

If the LIDDA is unable to locate or contact the MCO SC directly, then the LIDDA should contact the MCO service coordination hotline using the chart below.

Revision 19-0; Effective July 7, 2019

Below is a general description of the types of legal authority available to make decisions on behalf of another person or to support a person to make his or her own decisions. More information about some of these options and guardianship is available at: https://hhs.texas.gov/laws-regulations/legal-information/guardianship.

Revision 19-0; Effective July 7, 2019

Identifying and managing risks are part of providing services and supports to people with intellectual and developmental disabilities. Depending on their individual circumstances, people who receive institutional and community services can be at risk of adverse outcomes. Identifying risks is an important part of mitigating future risks and adverse outcomes to the individual.

Identifying and Planning to Mitigate Risk at the Individual Level

Effective risk management begins with assessment and service planning centered around the individual’s needs and preferences. Potential risks are identified and documented, and individualized mitigation strategies are mapped out. Ongoing documentation of services targeted to address risk and negotiations around risk provide evidence of risk management.

Risk Management Begins with the Individual Assessment Process

Just as service planning begins with a needs assessment, risk management should begin with an effort to identify potential and perceived risks to the individual. In many cases, these risks are directly linked to the disability-specific needs identified during the assessment process. However, the presence and projected consequences of such risks may not always be documented in an individual’s record. Risk identification is more than a conversation between an individual, their family members, service providers, case managers and others. It also involves a comprehensive documentation of that conversation. Such documentation provides the context and rationale for elements in the service plan and provides evidence that a risk management process is in place.

Behavioral Risks

Some people with disabilities may place themselves and others at greater risk through their behavior. Behavioral risks include:

• poor decision-making about safety and health issues, as a result of a brain injury or cognitive limitation;
• violent or criminal behavior;
• substance abuse; and
• suicide.

Risks to Personal Safety

Many people who are elderly or who have severe disabilities are vulnerable to abuse and exploitation. They are often dependent on others for assistance with everyday activities, such as eating or bathing, as well as with participation in the community. Thus, they face the additional risks of neglect, abuse and financial exploitation. In addition, personal safety, including safe evacuation, can be compromised by mobility and cognitive impairments. Other personal safety risks can include unsanitary or unsafe housing and social isolation.

For information about medical and health related risks, see the Common Risk Factors and Basic Clinical Guidelines to Gauge Level of Risk (PDF) chart.

Revision 25-1; Effective Nov. 12, 2025

The following changes were made in the Intellectual and Developmental Disability Preadmission Screening and Resident Review (IDD-PASRR) Handbook.

Revision 23-1; Effective Dec. 20, 2023

The following changes were made in the Intellectual and Developmental Disability Preadmission Screening and Resident Review (IDD-PASRR) Handbook.

Revision 22-1; Effective Nov. 28, 2022

The following changes were made in the Intellectual and Developmental Disability Preadmission Screening and Resident Review (IDD-PASRR) Handbook.

Effective July 7, 2019

The Intellectual and Developmental Disability Preadmission Screening and Resident Review (IDD-PASRR) Handbook contains policies and procedures regarding the responsibilities of local intellectual and developmental disability authorities related to the PASRR program.