Form 1054 "Community Living Options" - Texas

What Is Form 1054?

This is a legal form that was released by the Texas Health and Human Services - a government authority operating within Texas. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on October 1, 2020;
  • The latest edition provided by the Texas Health and Human Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form 1054 by clicking the link below or browse more documents and templates provided by the Texas Health and Human Services.

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Download Form 1054 "Community Living Options" - Texas

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Form 1054
October 2020-E
Local Intellectual and Developmental Disabilities Authorities (LIDDA)
Community Living Options
PASRR Evaluation Community Living Options (CLO) Date:
Date of CLO presentation:
The following information regarding CLO is provided to the individual and legally authorized representative (LAR):
• by the staff conducting the Preadmission Screening and Resident Review (PASRR) Evaluation (PE) during the PE;
• by the habilitation coordinator (HC) at least once every six months after the date of the PE CLO, and no more than 30 days before the
scheduled second quarterly service planning team (SPT) meeting or annual interdisciplinary team (IDT)/SPT meeting;
• when the HC is notified or becomes aware that the individual, or the LAR on the individual’s behalf, is interested in speaking with
someone about transitioning to the community;
• upon request by the individual/LAR; and
• when notified by HHSC that the individual’s response in Section Q of the Minimum Data Set (MDS) assessment indicates the individual is
interested in speaking with someone about transitioning to the community.
Section 1, Individual's Information
Name of Individual:
CARE System ID:
Medicaid No.:
Name of LIDDA:
Name of Staff Presenting CLO:
Name of Nursing Facility:
Address (Street, City, State and ZIP Code):
Area Code and Telephone No.:
Name of Legally Authorized Representative:
Relationship to Individual:
Area Code and Telephone No.:
Name of Other Actively Involved Person:
Relationship to Individual:
Area Code and Telephone No.:
Section 2, Current Knowledge of Community Living
Describe the individual’s history of community living experiences.
Describe what the individual knows about community services, supports and programs.
Describe what the LAR knows about community services, supports and programs.
Form 1054
October 2020-E
Local Intellectual and Developmental Disabilities Authorities (LIDDA)
Community Living Options
PASRR Evaluation Community Living Options (CLO) Date:
Date of CLO presentation:
The following information regarding CLO is provided to the individual and legally authorized representative (LAR):
• by the staff conducting the Preadmission Screening and Resident Review (PASRR) Evaluation (PE) during the PE;
• by the habilitation coordinator (HC) at least once every six months after the date of the PE CLO, and no more than 30 days before the
scheduled second quarterly service planning team (SPT) meeting or annual interdisciplinary team (IDT)/SPT meeting;
• when the HC is notified or becomes aware that the individual, or the LAR on the individual’s behalf, is interested in speaking with
someone about transitioning to the community;
• upon request by the individual/LAR; and
• when notified by HHSC that the individual’s response in Section Q of the Minimum Data Set (MDS) assessment indicates the individual is
interested in speaking with someone about transitioning to the community.
Section 1, Individual's Information
Name of Individual:
CARE System ID:
Medicaid No.:
Name of LIDDA:
Name of Staff Presenting CLO:
Name of Nursing Facility:
Address (Street, City, State and ZIP Code):
Area Code and Telephone No.:
Name of Legally Authorized Representative:
Relationship to Individual:
Area Code and Telephone No.:
Name of Other Actively Involved Person:
Relationship to Individual:
Area Code and Telephone No.:
Section 2, Current Knowledge of Community Living
Describe the individual’s history of community living experiences.
Describe what the individual knows about community services, supports and programs.
Describe what the LAR knows about community services, supports and programs.
Form 1054
Page 2 / 10-2020-E
Section 3, CLO Presentation
A checked box indicates the document was explained to the individual/LAR in a method or language they understand and a copy of the
document was provided to the individual/LAR. (Check all that apply.)
Explanation of Intellectual and Developmental Disability (IDD) Services and Supports
HHSC Long Term Services and Supports (Appendix to LIDDA Handbook)
Making Informed Choices: Community Living Options for Individuals Residing in Nursing Facilities booklet
The Friends and Family Guide to Adult Mental Health Services
Making Informed Choices: Community Living Options for Legally Authorized Representatives of Residents in Nursing Facilities booklet, if applicable
Section 4, Identifying Supports and Service for Community Living
What supports and services would be needed for the individual to live in the community? Consider each support/service and provide details.
Supports/Services
Provide Details
Residential Setting
Level of Supervision
Architectural Modifications
Behavioral Support Services
Behavioral/Mental Health Services
Durable Medical Equipment
In-Home Health Services
Day/Vocational Activities
Medical Services
Personal Assistance with Activities of Daily Living
Respite
Special Equipment (include Adaptive Aids)
Specialized or Professional Therapies
Transportation
Training for the Caregiver
Legal Guardianship/Alternatives to Guardianship
Social Security Office Notified
Leisure/Recreational
Mobility Issues
Safety Considerations
Spirituality/Religion
Relationships
Communication
Other
Form 1054
Page 3 / 10-2020-E
Section 5, Preference Regarding Transitioning
Describe the individual’s preference on transitioning to the community.
Wants to transition into the community, and has selected a program (Proceed to Section 8, Barriers to Transitioning to a Program)
Wants to transition into the community but wants more information before selecting a program (Proceed to Section 7, Undecided about
Community Program)
Does not want to transition (Proceed to Section 6, Barriers Preventing a Transition to the Community)
Undecided (Proceed to Section 6, Barriers Preventing a Transition to the Community)
Unable to determine (Proceed to Section 6, Barriers Preventing a Transition to the Community)
Does the LAR agree with the individual’s preference on transitioning to the community above?
Yes
No
No LAR
If “Yes” or “No LAR,” proceed to the section indicated by the individual’s selection.
If “No,” summarize why the LAR disagrees:
Identify the LAR’s preference in the drop-down box to the right and then proceed to the section indicated by the LAR’s preference.
Section 6, Barriers Preventing a Transition to the Community
Identify the barriers that are preventing the individual from transitioning to the community. (Indicate all reasons that apply.)
Copy all identified barriers in this section into Section 7 of Form 1057, Habilitation Service Plan (HSP), to address each barrier.
Individual’s reasons that prevent community living:
Lack of understanding of CLO
Individual has been provided information and exposure to CLO, but is not interested in community living
Mistrust of providers
Individual is not interested in being provided information and exposure to CLO
Prior community living for the individual was unsuccessful or resulted in an adverse experience
LAR’s reasons that prevent community living:
Lack of understanding of CLO
LAR has been provided information and exposure to CLO, but is not interested in community living for individual
LAR is not interested in being provided information and exposing individual to CLO
Mistrust of providers
Prior community living for the individual was unsuccessful or resulted in an adverse experience
Behavioral/mental health needs require frequent monitoring by psychiatric/psychology staff and/or enhanced levels of
supervision by direct service staff
Other (Describe)
Proceed to Section 9 to continue.
Form 1054
Page 4 / 10-2020-E
Section 7, Wants More Information Before Selecting a Community Program
For an individual who wants to transition to the community, but wants more information before selecting a program, identify barriers preventing
program selection. (Indicate all reasons that apply.)
Copy all barriers identified in this section into Section 7 of Form 1057, Habilitation Service Plan (HSP), to address each barrier.
Needs assistance to explore CLO (e.g., peer to peer, group home tours, invite providers to visit)
Individual/LAR wants more information regarding programs
Behavioral/mental health needs require frequent monitoring by psychiatric/psychology staff and/or enhanced levels of
supervision maintained by direct service staff
Other (Describe)
Proceed to Section 9 to continue.
Section 8, Barriers to Transitioning to a Program
If the individual wants to transition to the community and has selected a program, identify the barriers to transitioning to the selected program.
(Indicate all reasons that apply.)
Copy all barriers identified in this section into Section 6 of Form 1053, Transition Plan, to address each barrier.
Lack of supports for people with significant challenging behavior. Explain:
Lack of specialized behavioral/mental health supports. Explain:
Need for environmental modifications to support the individual. Explain:
Lack of availability of specialized medical supports. Explain:
Lack of availability of specialized therapy supports. Explain:
Other (Describe)
Proceed to Section 9 to continue.
Section 9, Comments
Enter any additional comments related to the CLO process. Additionally, if the individual/LAR refused to participate in this CLO process,
identify the reasons for the refusal and encourage participation in future CLO.
Form 1054
Page 5 / 10-2020-E
Section 10, CLO Participants
Printed Name of CLO Presenter:
Signature:
Date:
Printed Name of Individual:
Printed Name of LAR:
Relationship to Individual:
Printed Name of Actively Involved Person:
Relationship to Individual:
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