Effective Date
Instructions
Updated: 4/2025
Purpose
The LIDDA uses Form 1043 to document a post-move monitoring visit for a person who has transitioned or diverted from a nursing facility (NF), transitioned from a medium or large community intermediate care facility for individuals with an intellectual disability or related conditions (ICF/IID) or a person in crisis who has diverted to the Home and Community-based Services (HCS) program. The LIDDA Enhanced Community Coordination (ECC) coordinator prepares Form 1043 and conducts a post-move monitoring visit at least three times within the first 90 days after the person transitioned or diverted. Post-move monitoring visits must be conducted at all sites where essential supports are provided.
The time frames for conducting post-move monitoring visits are:
- within the first 7 days after the person transitioned or diverted;
- between 8 and 45 days after the person transitioned or diverted; and
- between 46 and 90 days after the person transitioned or diverted.
Detailed Instructions
Person’s Name — Enter the name of the person who transitioned or diverted.
CARE ID — Enter the person’s Client Assignment and Registration (CARE) System identification number.
Transition or Diversion Date — Enter the date the person transitioned or diverted.
Review Date — Enter the date the ECC coordinator conducted the post-move monitoring visit.
Required Post-Move Time Frame — Check the time frame that reflects the monitoring visit. Check Additional Monitoring if the visit is conducted within the same time frame as a previous monitoring visit.
Community Provider Information
Provider Name — Enter the business name of the community provider the person has selected.
Contact Name — Enter the first and last name of the contact person at the community provider.
Contact’s Area Code and Phone No. — Enter the area code and phone number for the contact person.
Type of Provider — Enter the type of community program provider, such as an HCS or other community Medicaid provider.
Day Program or Work Address — Enter the street address, city, state and ZIP Code for the day program or place of employment.
Day Program or Work Area Code and Phone No. — Enter area code and phone number for the day program or place of employment.
Type of Residence — Check to indicate which type of residence the person has selected: Residential Support Services, Supervised Living, Host Home or Companion Care, or Own Home or Family Home.
Residence Address — Enter street address, city, state and ZIP Code for the residence.
Residence Area Code and Phone No. — Enter area code and phone number of the residence.
Location Visited — Check to indicate which location was visited: Residence, Day Program or Work or Other site. Note: The ECC coordinator must conduct post-move monitoring at all sites where essential supports are provided.
Provider Staff or Family Members Interviewed — Enter the first and last names of any provider staff or family members interviewed while conducting the post-move monitoring.
Essential Supports
Enter the essential supports in the first column that are listed in the Transition or Diversion Plan.
Enter the evidence in the second column that was reviewed to determine if the support is in place. For example, if the person needs a pureed diet, a blender in the kitchen is evidence of the support being in place. Some essential supports such as oxygen or tube feeding supplies may be required at multiple sites. Post-move monitoring must be conducted at all sites where essential supports are provided.
Check Yes or No in the third column to indicate if the essential support is in place.
If No is checked for any essential support listed, explain the provider’s justification for discontinuing the support and whether the lack of support has had an adverse impact on the person. — Provide an explanation of the provider's justification for discontinuing the support, whether it has had an adverse impact on the person and, if so, describe the adverse impact.
Non-Essential Supports
Enter the non-essential supports identified in the Transition or Diversion Plan in the first column. Each item identified is monitored during post-move monitoring visits to ensure each is in place by the specified due date.
Enter the evidence that was reviewed to determine if the support is in place or was in place by the specified due date in the second column. Note: If the due date has not passed and the non-essential support is not in place, enter NA.
Enter the due date for the non-essential support identified in the Transition or Diversion Plan in the third column.
Indicate Yes or No in the fourth and fifth columns to indicate if the non-essential support is in place or was in place by the due date. Note: If the due date has not passed and the non-essential support is not in place, do not check Yes or No.
If the due date has passed and No is checked, explain the justification for not having the support in place by the specified due date and whether the lack of support has had an adverse impact on the person. — Provide an explanation of the provider's justification for discontinuing the support, if it has had an adverse impact on the person and, if so, describe the adverse impact.
Since the ECC Coordinator’s Last Visit
Check Yes or No in questions 1 through 16 to indicate if the event occurred since the ECC coordinator’s last visit. If indicated, provide details as requested.
Post-Move Monitoring Follow-up Activities
Area of Concern — Identify any areas of concern noted during the post-move monitoring visit.
Action Taken by ECC Coordinator — Describe the action taken or to be taken by the ECC coordinator to address the area of concern. This includes immediate attempts to remedy the situation during the on-site monitoring visit.
Additional Comments —Include comments as necessary.
Printed Name of ECC Coordinator — Print the ECC Coordinator’s name.
ECC Coordinator's Signature and Date —The ECC Coordinator signs and dates the form.
Printed Name of Provider Staff or Family Member – Print the provider staff or family member’s name.
Provider Staff or Family Member’s Signature – The provider staff or family member signs and dates the form.