Effective Date
Instructions
Updated: 5/2026
Purpose
The service provider uses the Preadmission Screening and Resident Review (PASRR) Implementation Plan (IP) to document how intellectual and developmental disability (IDD) habilitative specialized services will be delivered to support a person’s desired outcomes identified in the Habilitation Service Plan (HSP).
Procedure
The service provider must develop an IP for each IDD habilitative specialized service that has an Outcome Action Plan in the person’s HSP.
Note: The service provider must retain a copy of this form in the person’s record. The provider doesn’t need to submit this form to HHSC unless requested.
Detailed Instructions
Section 1 – Person and Service Provider's Information
Person’s Last Name — Enter the person’s last name.
Person’s First Name — Enter the person’s first name.
Medicaid No. — Enter the person’s nine-digit Medicaid number.
Service Provider — Enter the name of the provider of services.
Area Code and Phone No. — Enter the provider of services’ area code and phone number.
Email — Enter the provider of services’ email address.
Plan Begin Date — Enter plan begin date.
Plan End Date — Enter plan end date.
Plan Effective Date — Enter the IPC effective date this action plan was developed as a result of an HSP update or Individualized Plan of Care revision.
Name of Service — Select the name of the IDD habilitative specialized service from the drop-down list.
Total Authorized Units — Enter the total authorized units for the IDD habilitative specialized service.
Section 2 – Desired Outcome from Habilitation Service Plan (HSP) Action Plan for this Service Component
Enter the desired outcome(s) from the HSP exactly as it is written on the Outcome Action Plan for this service.
Note: If there is more than one outcome tied to this service, use the + or - buttons to add or remove outcomes.
Section 3 – Implementation of Specific Objectives
Implementation objectives were developed by — Check all the appropriate boxes to indicate the activity used to develop the implementation objectives to assist the person accomplish the outcomes.
- Conversation with – Check if one or more conversations were used to develop the IP and enter the names of all who participated in the conversation.
- Observation – Check if objectives were developed based on observations of the person.
- Formal or Informal Assessment – Check if objectives were developed on formal or informal assessments of the person. Formal assessments include evaluations by licensed or certified professionals or standardized assessments to identify the knowledge, skills and abilities possessed by the person and potential needs for support.
Specific Objectives — Enter the specific objectives that will be implemented to address or support the outcomes. Include any instructions related to personal preferences, special conditions or specific requirements that are necessary to assist the person achieve the outcomes.
Start Date — Enter the date the implementation objective will begin.
Targeted Completion — Enter the date the implementation objective is expected to be achieved.
Duration — Enter the duration from the assessment for that specific service. Duration is how long a person will receive a specialized service, such as six months.
Frequency — Enter the frequency from the assessment for that specific service. Frequency is how often a person will receive a specialized service, such as twice per week.
Time — Enter if the objective is completed daily, weekly, monthly or annually.
Units by Objectives — Enter the total units needed to complete an objective in the IPC year.
Note: More objectives can be added in the Implementation Objective section for the same outcome by using the + or - buttons to add or remove lines.
Section 4 – Signatures
Printed Name of Person — Enter the person’s full name.
Signature of Person — The person signs the form.
Date — Enter the date the person signs the form.
Printed name — Legally Authorized Representative (LAR)—Enter the LAR’s full name.
Signature of LAR — The LAR signs the form.
Date — Enter the date the LAR signs the form.
Printed Name of Provider— Enter the service provider’s full name.
Signature of Provider — The service provider signs the form.
Date — Enter the date the service provider signs the form.