SECTION 904.107. Community Living/Discharge Plan for Alternative Living Arrangements

(a) Designated state MR facility staff will prepare the community living/discharge plan as described in §412.277 of this title (relating to Arrangements for the Move to an Alternative Living Arrangement of an Individual Residing in a State MR Facility) and this section. The plan incorporates information provided by the individual, LAR, MRA, other state MR facility staff, and the provider. The plan:

(1) is customized based on the abilities and needs of the individual to specify the:

(A) timelines and intervals for monitoring activities;

(B) form those monitoring activities will take (e.g. on-site visitations, phone contacts, record reviews, and written reports);

(C) responsibilities of the designated MRA and other MRAs if the proposed move is outside the designated MRA's local services area;

(D) responsibilities of the provider; and

(E) criteria for a recommendation for discharge from the state MR facility;

(2) identifies the individual's or LAR's desired outcomes for an alternative living arrangement that serve as the basis for the person directed plan and service coordination plan to be developed by the designated MRA or the MRA for the local service area where the individual will live; and

(3) is approved by the individual, LAR, MRA, state MR facility, and provider before the individual moves from the state MR facility.

(b) The plan can be in any format acceptable to all parties (individual, LAR, MRA, state MR facility, and provider), but must contain the elements described in this section. A sample format provided by the department may be used as is or modified as deemed appropriate. Copies are available by contacting the Office of State Mental Retardation Facilities, Texas Department of Mental Health and Mental Retardation, P.O. Box 12268, Austin, Texas 78711-2668, 512/206-4516.

(c) The community living/discharge plan will be completed as follows:

(1) The community living profile (section I of the sample format), completed by the IDT when a recommendation for an alternative living arrangement has been made and accepted, describes:

(A) essential information identifying the individual;

(B) the preferences and desired outcomes of the individual or LAR;

(C) health and safety issues;

(D) the date of the determination of mental retardation conducted as described in §415.155 of this title (relating to Determination of Mental Retardation (DMR)); and

(E) name and telephone number of state MR facility contact person.

(2) The community living data (section II of the sample format), completed by the state MR facility upon selection of a provider, with information from the provider and MRA, describes:

(A) the name, address, and telephone number(s) of the physician or health care entity that will become the individual's primary health care provider;

(B) the name(s), address(es), and telephone numbers of contacts at the designated MRA, and others, as appropriate;

(C) the name, address, telephone number, and type (e.g. HCS or ICF/MR) of provider, and contact person (address and telephone number, if different);

(D) the name, address, telephone number for school, job, or day program and contact person (address and telephone number, if different);

(E) the name, address, and telephone number of individual program coordinator; and

(F) the identification of the MRA service coordinator assigned to provide continuity of services.

(3) The findings and observations (section III of the sample format) are described by the state MR facility and include:

(A) thorough medical and behavioral information, which will be communicated to the physician who will be providing care in the community;

(B) all current physician orders and treatments, including rationale for all medications prescribed and dispensed by the state MR facility, and amount dispensed which will be continued after the move; and

(C) a brief summary of findings, events, and progress during the period the individual resided in the state MR facility;

(4) The community living information (section IV of the sample format) is compiled based on information supplied by the individual, LAR, state MR facility and MRA staff, and the provider and includes:

(A) the individual's personal likes, dislikes, and preferences (including friends and important relationships);

(B) the specific steps and activities necessary to accomplish a successful transition;

(C) the outcomes important to the individual and related personal goals; and

(D) the services and supports necessary to support the individual in achieving the personal outcomes important in the individual's life (e.g. residential, vocational, social, leisure, religion, health, safety, financial, and transportation);

(5) The community living monitoring activities (section V of the sample format) include:

(A) the responsibilities of the MRA(s), as the agent of the department, for determining whether the outcomes and criteria established for successful transition have been met with a description of how the determination is to be accomplished (e.g. on-site visitation, phone contacts, record reviews, and written reports) and specific timelines for the completion of monitoring activities;

(B) the specific actions to be taken by the MRA(s) and state MR facility in the event that the outcomes and criteria are not being met;

(C) the criteria by which the MRA(s) will make a recommendation to the head of the state MR facility that the individual be discharged from the state MR facility;

(D) a list of the persons, which must include the individual or LAR, to be notified of the recommendation that the individual be discharged from the state MR facility and how such notice will be accomplished;

(E) the timeframe for changing the county of residence in CARE if the move is outside the local service area of the designated MRA; and

(F) the expected date of discharge from the state MR facility.

(6) The agreements portion (section VI of the sample format) is reviewed and signed by the individual, if appropriate, LAR, and an authorized representative of the state MR facility, MRA(s), and provider, and contains the typed names and titles of the signatories, and the date the plan is approved and signed. This portion includes, at a minimum, the following terms:

(A) the provider agrees that the community physician, assigned direct care staff, provider consultants, and other service providers have been informed of all the information contained in the community living/discharge plan;

(B) the provider agrees that the MRA(s), as the agent of the department, shall have access to the individual, the living setting, and necessary records;

(C) the provider agrees to notify the MRA(s) and the individual's LAR of any conditions which may indicate the living arrangement is in jeopardy and to give the MRA(s) and LAR written notice of intent to discharge the individual at least 30 calendar days before the planned day of discharge;

(D) the MRA(s) agrees that the provider and a designated state MR facility staff person will receive accurate and timely written reports, including a list of specific findings for any significant monitoring activity described in paragraph (5) of this subsection;

(E) the state MR facility and MRA(s) agree that the individual and LAR have had an opportunity to participate in the development of the community living/discharge plan; and

(F) the individual, LAR, state MR facility, MRA(s), and provider agree to make a good faith effort to resolve issues that may be identified by any of these parties until the community living/discharge plan culminates in the individual's discharge from the state MR facility.

(7) The discharge plans/activities (section VI of the sample format) are summarized by the state MR facility upon completion of the terms and conditions specified in the community living monitoring activities portion of the plan and will include:

(A) a summary of the outcomes and status of the alternative living arrangement;

(B) a resolution of any issues that occurred during the transition process; and

(C) date of discharge from the state MR facility.

(d) If the provider does not actively participate in the development of the community living/discharge plan before the individual is moved from the state MR facility to the alternative living arrangement, the IDT will inform the individual or LAR of the circumstances.

(1) The individual with the ability to provide legally adequate consent or the LAR has the option of:

(A) continuing with the move after resolution of the problems;

(B) continuing with the move without resolution of the problems with the understanding that the individual will be discharged from the state MR facility 30 calendar days after the move; or

(C) selecting another provider.

(2) If the individual does not have the ability to provide legally adequate consent and does not have an LAR, then the individual will remain in the state MR facility until:

(A) the problems are resolved (in a reasonable period of time as determined by the IDT) and community living/discharge plan is completed satisfactorily; or

(B) another provider is selected by the IDT because the problems cannot be resolved.

(e) In the event that issues cannot be resolved during the development or implementation of the community living/discharge plan, the issue may be forwarded to the commissioner or designee for review and recommended action.

(f) If, following the individual's move to the community, the provider doesn't comply with the provisions of the community living/discharge plan and the MRA(s) has exhausted all options to resolve the conflict, the IDT at the state MR facility will be reconvened.

(1) If the IDT determines that the individual with the ability to provide legally adequate consent or the LAR wants to continue with the alternative living arrangement the IDT will recommend to the head of the state MR facility that the individual be discharged from the state MR facility within 30 calendar days of the IDT meeting and that monitoring activities required by the community living/discharge plan be discontinued.

(2) If the IDT determines that the individual with the ability to provide legally adequate consent or the LAR is not satisfied with the alternative living arrangement and the issues are not resolved, the individual or LAR may request that the IDT reconvene to address the issues causing the dissatisfaction and to assist the individual or LAR to find another alternative living arrangement.

(3) If the individual does not have the ability to provide legally adequate consent and does not have an LAR, the IDT will research the situation and will refer the issue to the commissioner or designee for review and recommended action. If it is determined that the individual should be removed from the provider's services, the IDT and MRA(s) will work cooperatively to find alternative services.

(g) If during the term of this plan representatives of the department and staff of the MRA have evidence to believe that an individual is in an unsafe environment or that the individual's needs are not being met, they will immediately notify:

(1) the appropriate licensing or regulatory agency;

(2) the LAR; and

(3) the state MR facility from which the individual moved.

(h) If the necessity for an out-of-state transfer is indicated, the state MR facility will contact the department's Interstate Compact coordinator in Central Office.

Source Note: The provisions of this §904.107 adopted to be effective January 1, 2001, 25 TexReg 12746; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8841; transferred effective September 1, 2023, as published in the August 11, 2023, issue of the Texas Register, 48 TexReg 4397