TITLE
8 SOCIAL SERVICES
CHAPTER
371 DEVELOPMENTAL DISABILITIES
PART
7 (APPENDIX
A) INDIVIDUAL TRANSITION PLANNING PROCESS
8.371.7.1 ISSUING AGENCY: New Mexico Health Care Authority,
Developmental Disabilities Division.
[8.371.7.1
NMAC - N, 7/1/2024]
8.371.7.2 SCOPE:
A. The regulations provide a systematic process for the
individualized planning and implementation of a developmentally disabled
resident’s transition from the two large, state-operated institutional
facilities into a community setting.
B. The ITP process described in this document is intended to
develop a proposed community placement for an individual based upon the
individual’s preferences and upon community service provider selections made
generally by the individual’s parent/guardian in consultation with the
individual. As specified in Activity 19,
below, the placement proposal developed by this process is subject to the health
care authority review of the cost of the individual’s plan or aggregate costs.
[8.371.7.2
NMAC - N, 7/1/2024]
8.371.7.3 STATUTORY AUTHORITY: Section 9-7-6 NMSA 1978. Section 9-8-1 et
seq. NMSA 1978 establishes the health care authority (authority) as a single,
unified department to administer laws and exercise functions relating to health
care facility licensure and health care purchasing and regulation.
[8.371.7.3
NMAC - N, 7/1/2024]
8.371.7.4 DURATION: Permanent.
[8.371.7.4
NMAC - N, 7/1/2024]
8.371.7.5 EFFECTIVE DATE: July 1, 2024, unless a later date is cited at
the end of a section.
[8.371.7.5
NMAC - N, 7/1/2024]
8.371.7.6 OBJECTIVE:
A. These regulations are promulgated, in part, to satisfy
requirements arising from the implementation of the decision in Jackson, et al, v. Fort Stanton, et al.,
N.M. Dist. Ct. No. Civ. No. 87-839. The
transition process appearing in these regulations has evolved over time,
initially appearing as Appendix A to the Jackson Management Manual. This transition planning process history
accounts for the continuing reference in the regulation title to Appendix
A. The regulations embody certain
agreements and arrangements reached by the parties to the Jackson lawsuit. And they
reflect the developmental disabilities division’s cumulative experience in
planning and administering the transition process.
[8.371.7.6
NMAC - N, 7/1/2024]
8.371.7.7 DEFINITIONS: The transition interdisciplinary team:
A. The individual:
The individual with a developmental disability must participate to the
greatest extent possible. There must be
a serious effort to ensure that the individual is present and that they, even
when lacking verbal skills, are given the opportunity to express their
interests, choices and strengths.
However, no individual shall be compelled to participate in the planning
process. The individual’s normal daily
routine and schedule should be followed as much as possible on days when
meetings occur; special accommodations for the individual should be identified
prior to each meeting and appropriate adjustments and modifications in the
meeting should be planned to enable them to participate as fully as
possible. An individual may choose
someone to represent them consistent with their wishes in the TIDT
meetings. If such a representative is
chosen, that person shall receive all notices and other documents sent to TIDT
participants.
B. The parent/guardian:
As used in these procedures, the phrase “parent/guardian” shall mean the
individual’s legal guardian or, if the individual is a minor, the individual’s
parent(s). The division shall attempt to
inform and involve the parent/guardian in the transition planning process,
including making reasonable scheduling accommodations and providing
interpreters as necessary.
C. The helper: The
helper is someone who knows the individual’s capabilities, interests, likes and
dislikes and who communicates with the individual. The helper may be a friend, roommate, family
member, teacher, co-worker, current or former employee of the institutional
facility, foster grandparent, or any other person from the individual’s circle
of relatives, friends, or acquaintances.
D. The social worker:
The social worker should be the social worker at the facility, i.e.,
either Los Lunas or Fort Stanton, who has worked with the individual or, if
unavailable, the social worker who has been assigned.
E. Facility interdisciplinary team (IDT) members: Facility interdisciplinary team members,
designated pursuant to division Jackson
office policy memoranda, who have been trained to participate in the transition
process and who have knowledge of the individual shall assist with ITP
planning, implementation and follow-up, as required.
F. Jackson transition representative (JTR): The Jackson
transition representative (JTR) is the division’s representative at transition
meetings and activities.
G. Key community service providers: Key community service providers are selected
prior to the TIDT meeting pursuant to Activity 7. The term key community service providers
means the community residential provider and other providers of significant
services for the individual, including but not limited to the competitive and
supportive employment provider, medical professional(s) if the individual’s
medical condition so requires, and other support service providers identified
by the expanded IDT as key community service providers. When the individual is of school age, a
representative of the local education agency is a key community service
provider. [8.371.7.7 NMAC - N, 7/1/2024]
8.371.7.8 INTRODUCTION:
A. There are two planning components that must be
accomplished concurrently:
(1) planning and effecting the move for
each individual who will be moving; and
(2) planning and preparing the system of community
supports.
B. This document provides the process by which each
individual transition plan (ITP) shall be developed. The Jackson
systemic plan and Jackson management
manual address the preparation of the system of community placements and
supports. These documents have been
developed so that the systemic components are consistent with and support the
proposed means of individualized planning and placement.
C. The developmental disabilities division, hereinafter
“division”, is committed to preparing and implementing ITPs expeditiously,
consistent with professional judgement.
The ITP process reflects the fact that New Mexico is currently seeking
to create a system of supports and services for individuals who are moving from
institutional facilities to community living.
The division anticipates that as its service system for individuals with
developmental disabilities expands, the time associated with several activities
may be shortened. Therefore, prior to
October 1, 1994, the division shall review its experience in implementing these
procedures to determine whether any of the provisions may be modified and
particularly whether any of the time periods should be shortened. These procedures shall remain in effect
unless modified by the division after consultation with the parties in Jackson et al. v. Fort Stanton
et al., Civ. No. 87-839 JP. The health
care authority, hereinafter, “the authority”, intends that the procedures
described herein shall be consistent with federal regulations and
requirements. If there is a conflict
between these procedures and the federal regulations and requirements, the
federal regulations and requirements shall govern.
[8.371.7.8
NMAC - N, 7/1/2024]
8.371.7.9 BASIC CONCEPTS AND ITP
DEVELOPMENT GUIDELINES:
A. Individual transition planning is founded on the
following basic concepts:
(1) Individual transition planning
strives for the goal that the individual can live in and be a part of a
community in the same manner and to the same extent as would any other person
of like age and interests.
(2) There are no starting assumptions
based on models of service. Planning is
not performed in order to fit an individual into existing models of service,
but rather to tailor necessary supports to the individual who is moving,
through uniquely individualized planning.
(3) Supports and services are provided to
the extent there is a demonstrated individual need, and no more.
(4) All persons have strengths and
interests and are capable of growth and development, at differing paces.
(5) Successful human planning starts from
and builds on individual strengths and interests, not deficits.
(6) Human planning must be flexible and
responsive to changing individual circumstances and environments.
B. The TIDT shall develop the ITP in accordance with the
following guidelines:
(1) The contents of the ITP are
reasonable and appropriate to meet the individual’s needs and promote
identified strengths and capacities.
(2) The ITP reflects the individual’s
preferences, to the extent appropriate, unless the individual communicates no
preference or is incapable of communicating any preference.
(3) The ITP is designed to utilize
services that allow the individual to be more, rather than less, integrated in
the community and rely on available generic services to the extent feasible and
consistent with the individual’s needs.
(4) The ITP provides services which are
least restrictive, not unduly intrusive and not excessive in light of the
individual’s needs.
(5) The ITP can be practicably
implemented.
[8.371.7.9
NMAC - N, 7/1/2024]
8.371.7.10 THE INTERDISCIPLINARY TEAM: Each individual residing at Los Lunas or Fort
Stanton hospital and training school has an interdisciplinary team (IDT), which
is responsible for developing the individual program plan (IPP) as long as the
individual resides in the facility. It
is the individual’s IDT that, among its other activities, has the
responsibility for recommending the individual for community placement. Once that recommendation is made, transition
planning is begun. To successfully
accomplish the development of an ITP, each individual’s IDT shall expand to
include community membership and become the transition interdisciplinary team
(TIDT).
[8.371.7.10
NMAC - N, 7/1/2024]
8.371.7.11 THE TRANSITION INTERDISCIPLINARY
TEAM (TIDT):
A. In order to develop a transition plan that is tailored to
the individual, and in order to help achieve successful placement of the
individual in the community, the IDT shall expand to include a number of
non-professionals, managers and prospective community service providers, as
well as the IDT’s professionals. There
is no universal combination of persons necessary for the TIDT meeting. The individual’s participation at the TIDT
meeting is necessary unless the individual objects. The participation of the parent/guardian at
the meeting is usually required unless the absence is by choice or by
necessity. The persons who comprise the
TIDT shall normally be present at the TIDT meeting, but in the absence of any
person, the team members may proceed with the individual planning process if
those present determine it to be appropriate under the circumstances.
B. The TIDT shall usually include the following persons:
(1) The Individual: The individual with a developmental
disability must participate to the greatest extent possible. There must be a serious effort to ensure that
the individual is present and that he or she, even when lacking verbal skills,
is given the opportunity to express their interests, choices and
strengths. However, no individual shall
be compelled to participate in the planning process. The individual’s normal daily routine and
schedule should be followed as much as possible on days when meetings occur;
special accommodations for the individual should be identified prior to each
meeting and appropriate adjustments and modifications in the meeting should be
planned to enable them to participate as fully as possible. An individual may choose someone to represent
them consistent with their wishes in the TIDT meetings. If such a representative is chosen, that
person shall receive all notices and other documents sent to TIDT participants.
(2) The parent/guardian:
(a) The division shall attempt to inform
and involve the parent/guardian in the transition planning process, including
making reasonable scheduling accommodations and providing interpreters as
necessary.
(b) If by 30 days prior to the transition
interdisciplinary team (TIDT) meeting described in Activity 11 a
parent/guardian has advised the division that the guardian is unwilling or
unable to be an active participant during the transition planning process, the
division shall seek prompt modification of the guardianship and, if needed,
appointment of a co-guardian or a successor guardian to ensure that the
individual’s guardian, if any, is an informed and active participant in the
planning process. A parent/guardian may
choose someone to represent him/her consistent with his/her wishes in TIDT
meetings. If such a representative is
chosen, that person shall receive all notices and other documents sent to TIDT
participants.
(3) The helper:
(a) The role of the helper is to assist
the individual in participating in the transition planning process by helping
the individual to communicate his or her interests, likes and dislikes to other
TIDT members. The same helper should be
available throughout the transition process.
Whenever the helper is a facility employee, accommodation should be made
to facilitate his/her availability for all meetings.
(b) The individual can select their helper. For those individuals who do not select a
helper, but do not object to the assistance of a helper, the facility’s
director of social work shall identify a qualified helper. If necessary, the division shall reimburse
the helper for reasonable travel expenses incurred solely to visit the
individual at least once before the TIDT meeting and to attend TIDT meeting(s)
described in Activity 11.
(4) The social worker:
(a) The social worker should be the
social worker at the facility i.e., either Los Lunas or Fort Stanton, who has
worked with the individual or, if unavailable, the social worker who has been
assigned.
(b) The social worker shall work with the
case manager on behalf of the facility to assist with the proposed transition
and any follow-up support as required.
(5) The case manager:
(a) The case manager should be the
individual selected or assigned pursuant to activity 2.
(b) The case manager shall have a good
working knowledge of the available generic and specialized services in the
geographic area to which the individual will be moving. The case manager, in addition to the duties
described herein and in the Jackson
management manual, shall review the bi-weekly reports of the Jackson office on the status of
pre-placement activities and monitor ITP implementation at the facility and in
the community and shall review the ITP and the community programs identified
for the individual immediately prior to the move to ensure the necessary
supports and services are in place.
(6) Facility interdisciplinary team (IDT)
members: Facility interdisciplinary team
members, designated pursuant to division Jackson
office policy memoranda, who have been trained to participate in the transition
process and who have knowledge of the individual shall assist with ITP
planning, implementation and follow-up, as required.
(7) Jackson
transition representative (JTR): The Jackson transition representative (JTR)
is the division’s representative at transition meetings and activities. This individual’s primary purpose shall be to
assist in identifying community service providers and facilitating and
documenting the transition planning process.
(8) Key community service providers: Key community service providers are selected
prior to the TIDT meeting pursuant to Activity 7. The term key community service providers
means the community residential provider and other providers of significant
services for the individual, including but not limited to, the competitive and
supportive employment provider, medical professional(s) if the individual’s
medical condition so requires, and other support service providers identified
by the expanded IDT as key community service providers. When the individual is of school age, a
representative of the local education agency is a key community service
provider, and should be present at transition planning meetings.
C. The individual and or the parent/guardian may invite
other individuals to attend TIDT meetings.
Parents or family members who are not guardians of an adult individual
may be invited, unless the adult individual objects. Voting privileges are limited to TIDT core
group members, pursuant to DDD Jackson
office policy memoranda. Scheduling of
the TIDT meeting(s) shall not be delayed for the convenience of these “other
individuals” who have been invited to attend, nor rescheduled if such “other
individuals” fail to attend.
[8.371.7.11
NMAC - N, 7/1/2024]
8.371.7.12 PREPARATION FOR PARTICIPATION IN
TRANSITION PLANNING: In order to prepare
team members for participation in the team process, the following activities,
as provided in the Jackson systemic
plan and management manual should occur:
A. Team members who are staff of the health care authority
or of the case management agencies providing services on behalf of the state
shall be trained in the TIDT process.
B. The case manager and the helper shall meet with and
provide assistance to the individual so that the individual understands and is
prepared to participate in the TIDT process to the extent possible.
C. The case manager shall meet with the parent/guardian and
provide information on the TIDT process.
D. The information developed for the individual and
parent/guardian pursuant to the Jackson
Management Manual shall be provided to the individual and parent/guardian.
E. The authority shall provide for an interpreter, if
necessary, and for transportation for the parent/guardian to attend team
meetings as needed.
[8.371.7.12
NMAC - N, 7/1/2024]
8.371.7.13 THE PROCESS FOR THE DEVELOPMENT OF
THE INDIVIDUAL TRANSITION PLAN (ITP) - TIME LINES:
A. The individual transition plan (ITP) process provides
timelines by which specific actions are scheduled to occur. Although the health care authority intends to
accomplish the specified activities within the time lines provided, the quality
of individual program planning and the involvement of the individual will not
be compromised in order to achieve a specific time line.
B. The health care authority shall provide to the plaintiffs
and plaintiff-intervenors a “planning initiation schedule” on a quarterly basis
that will identify the date by which Activity 11, the TIDT meeting, shall be
initiated for each individual on the schedule.
The initial transition interdisciplinary team (TIDT) meeting is
scheduled by the Jackson office of
the developmental disabilities division (DDD) upon the recommendation of the
facility IDT for community placement.
Except as provided herein, effective August 1, 1994, and thereafter, the
initial transition interdisciplinary team (TIDT) meeting will be scheduled
within sixty days of a community placement recommendation of the facility
interdisciplinary team (FIDT). If, as of
July 31, 1994, new Los Lunas center for persons with developmental disabilities
FIDT community placement recommendations exceed one, but do not exceed two per
month, the requirement to schedule the TIDT meeting within 60 days is effective
September 1, 1994. If, as of July 31,
1994, new Los Lunas hospital and training school FIDT community placement
recommendations exceed two per month, the requirement to schedule the TIDT
meeting within 60 days is effective October 1, 1994. TIDT dates are fixed and subject to change
only on condition of extraordinary circumstances, absence of key team members
or due process initiation.
C. The time lines shall be extended only so long as
necessary to accommodate:
(1) additional TIDT meetings, as
determined by the TIDT under Activity 11 or the case manager under activity 17;
(2) a pending dispute pursuant to the
dispute resolution process (DRP) for individual transition plans (see Activity
18 and 8.371.8 NMAC) dispute resolution process (Appendix B); or
(3) extraordinary circumstances as
determined by:
(a) the case manager under Activities 16
and 17, for example.or
(b) the Jackson coordinator as a result of significant changes in an
individual’s condition or circumstances.
(4) A delay for extraordinary
circumstances is subject to review by the TIDT upon the request of the
individual, the parent/guardian or their representative.
D. Absent such events, the division shall schedule and
accomplish the activities identified below within the following time lines:
(1) TIDT meeting (Activity 11): No more than 228 days prior to placement, and
as set by Jackson transition office
calendar (absent extraordinary circumstances or judicial stay order); updated
calendars submitted to the court;
(2) additional TIDTs (Activity 11): within 21 days of initial TIDT meeting;
(3) cost proposals (Activity 13 -
14): submitted 30 days after
distribution of the ITP; reviewed within 30 days;
(4) ITPQA review meeting (Activity
17): scheduled at the final TIDT
meeting; to occur 30 - 45 days prior to placement date.
E. Case manager activities (activities 2 - 9) may begin as
early as 120 days, but no later than 90 days prior to the established initial
TIDT meeting date.
F. Interim target time lines are more fully set forth below
in the specific paragraph describing the activity. Activities 1 - 10 may begin for each
individual at the division’s discretion sufficiently in advance of the planning
initiation schedule identified by the division.
In no event shall activity 10 be completed later that 14 days before
each individual’s planning initiation date.
Unless otherwise specified, days means calendar days.
[8.371.7.13
NMAC - N, 7/1/2024]
8.371.7.14 THE PROCESS FOR THE DEVELOPMENT OF
THE INDIVIDUAL TRANSITION PLAN (ITP) - TRANSITION PLANNING ACTIVITIES:
A. Prior to the start of the formal transition process, the
facility interdisciplinary team (FIDT) shall convene to conduct the annual IPP
meeting. At this facility IDT meeting,
the following transition activities shall be conducted:
(1) Review individual for community
placement; if appropriate, make formal recommendation for community transition
to begin and identify probable geographic area of community move. The individual and parent/guardian(s) shall,
in consultation with the FIDT, choose the probable area of relocation.
(a) If a recommendation for community
placement is made, the presumption is that the individual shall, if a child,
move home with necessary supports, or, if an adult, move to the family’s home
town or nearby. This presumption may be
altered by factors such as individual interest and choice, work interest and
opportunities, friendships, families with competing interests, and the
potential availability and costs of medical resources and other support
services or service providers. The
social worker shall notify the Jackson
office of the facility of the individual’s community placement recommendation
and probable area of relocation within five days.
(b) After notification regarding an
individual’s probable area of relocation, the Jackson office shall add the individual to the transition planning
calendar. The Jackson transition representative (JTR) shall inform the individual
and the individual’s parent/guardian of the identity of potential community
service providers and the types of services the community service provider
offers. The facility social worker and
case manager, if already chosen, shall assist the individual and
parent/guardian in making the community service provider selection (see Activity
7, below).
(2) Establish goals and objectives in the
IPP that will facilitate the individual’s transition, if community placement is
recommended.
(3) Identify strengths and supports
within the ten “life areas” (profile of supports form). Make support descriptions useful.
(4) Access regional office staff for
community resource information and liaison.
Identify generic resources in the area of relocation that could be
utilized by the individual.
B. Transition planning for individuals recommended for
community placement shall proceed after the facility IDT meeting with the
following activities. Unless the context
requires otherwise, activities may occur concurrently.
[8.371.7.14
NMAC - N, 7/1/2024]
8.371.7.15 ACTIVITY 1: SELECTION OF HELPER: At least 90 days before the TIDT meeting
identified in Activity 11, the social worker shall contact the individual and,
using appropriate communication assistance or aids, explain to the individual their
right to identify a helper or representative to assist in the upcoming TIDT
meetings and the right to invite any other person as provided in Section
11. The individual may refuse to have
the assistance of a helper.
[8.371.7.15
NMAC - N, 7/1/2024]
8.371.7.16 ACTIVITY 2: CASE MANAGER ASSIGNED:
A. For the individual moving to the community the social
worker shall, after identification of the probable area of relocation, provide
the individual and mail to the parent/guardian a listing of eligible case
management agencies that serve the individual’s probable area of
relocation. The Jackson transition representative (JTR) shall also provide the
individual and the parent/guardian with the information necessary for them to
make an informed selection. The
parent/guardian, in consultation with the individual, shall, within 21 days of
the date the list was mailed, select a case management agency.
B. The social worker shall confirm, in writing, the
selection of the agency with the individual, the agency, the parent/guardian
and the case management unit of the community programs bureau of the DDD. The social worker shall identify the date by
which a case manager must be assigned.
The agency shall assign a case manager by the date contained in the
written confirmation, which shall be no later than 90 days prior to the initial
TIDT meeting described in Activity 11.
The assigned case manager must be located in or close to the probable
area of relocation but in no instance more than 150 miles from the probable
area of relocation.
C. This activity is to be accomplished concurrently with Activity
7, selection of community service provider(s), whenever possible.
D. If, within 85 days of the established initial TIDT
meeting described in Activity 11, the parent/guardian has not consulted with
the individual and selected a case management agency, the authority shall
consult with the individual and make the selection.
[8.371.7.16
NMAC - N, 7/1/2024]
8.371.7.17 ACTIVITY 3: MEETING WITH INDIVIDUAL:
A. The case manager shall meet with and, using appropriate
communication assistance or aids and observation, get to know the
individual. The case manager and the
helper shall meet with and provide assistance to the individual so the
individual understands and is prepared to participate in the TIDT process to
the extent possible.
B. The case manager shall also explain to the individual and
helper the process by which the individual’s placement shall be designed and
implemented, including the TIDT process for developing a proposed placement,
the state’s implementation decision described in Activity 19, and the process
for resolving disputes. As appropriate,
the case manager shall provide a copy of the ITP process, the DRP, and the case
manager’s phone number and address to the individual prior to or at the first
meeting.
C. In addition, the case manager shall explain the selection
of community service providers, Activities 6 and 7, and make all effort to
encourage and expedite this selection, if it has not already occurred, prior to
convening any transition meetings. The
case manager shall encourage the individual’s preference for living
arrangements and housemates.
D. If the individual is not familiar with other persons who
are identified as probable housemates, the individual will be offered an
opportunity to meet with such persons.
The individual shall be given an opportunity to approve or object to any
identified housemates. The case manager
shall communicate with the individual as frequently as necessary before
placement to keep the individual informed and involved in the team process. The case manager shall inform the individual
and helper that the individual may invite others to attend the TIDT meetings,
and arrange co-scheduling of TIDTs where housemates are agreed to.
[8.371.7.17
NMAC - N, 7/1/2024]
8.371.7.18 ACTIVITY 4: RECORD REVIEW: Specified staff at the facility where the
individual resides shall prepare a summary of the individual’s record as set
forth in the Jackson management
manual, with particular attention to those historic events, medical or
otherwise, that may affect community living design. The record summary shall be prepared pursuant
to division Jackson office policy
memoranda. This summary of pertinent
historic factors shall be provided to the case manager, social worker and key
community service providers.
[8.371.7.18
NMAC - N, 7/1/2024]
8.371.7.19 ACTIVITY 5: MEETING WITH INDIVIDUAL’S PARENT/GUARDIAN:
A. The case manager shall meet with the individual’s
parent/guardian to explain the case manager’s role and the process by which the
individual’s placement will be designed and implemented, including the TIDT
activities for developing a placement plan, the state’s implementation decision
described in Activity 19, and the process for resolving disputes. In addition, the case manager shall explain
the selection of community service providers, Activities 6 and 7, and make all
effort to encourage and expedite this selection, if it has not already
occurred, prior to convening any transition meetings.
B. The case manager shall solicit any concerns the
parent/guardian might have with any aspect of the transition process of
eventual placement in the community. The
case manager shall carefully consider and attempt to address those concerns and
shall endeavor to reassure the parent/guardian of the authority’s commitment to
a successful and appropriate placement.
C. The case manager shall provide a copy of the ITP process,
8.371.7 NMAC, individual transition planning process (Appendix A), the dispute
resolution process, 8.371.8 NMAC, dispute resolution process (Appendix B) and
the case manager’s phone number and address to the parent/guardian prior to or
at the first meeting with the parent/guardian.
The case manager shall encourage the parent/guardian’s full participation
in the placement process and arrange for interpreter services by coordinating
with the Jackson transition
representative (JTR) and arrange transportation as needed; which shall be paid
for by the division, if needed.
D. The case manager shall communicate with the
parent/guardian before placement as frequently as necessary (through meetings
whenever practical) to keep the parent/guardian informed and involved in the
team process. The information developed
for the individual and parent/guardian pursuant to the Jackson management manual shall be provided to the individual and
parent/guardian.
[8.371.7.19
NMAC - N, 7/1/2024]
8.371.7.20 ACTIVITY 6: DISTRIBUTION OF LIST OF ELIGIBLE COMMUNITY
SERVICE PROVIDERS:
A. At the first meeting between the case manager and the
individual, and the case manager and the parent/guardian(s), the case manager
shall explain the basic community service models, including alternatives to
traditional service providers; explain the selection of community service
provider(s); and provide the individual and the parent/guardian(s) with a
listing of eligible community service provider agencies serving the
individual’s probable area of relocation.
The case manager will encourage a timely selection of community service
provider(s).
B. Community service providers could be selected as early as
the facility IDT meeting (see above), if the individual and parent/guardian(s)
are familiar with community service provider agencies in the area of
relocation. Community service providers
must be selected no later than 30 days after the parent/guardian(s) initial
meeting with the case manager (Activity 5, above). The Jackson
transition representative (JTR) may supplement the list of eligible community
service providers at any time. The Jackson transition representative (JTR)
shall assist the individual and the parent/guardian with the information
necessary for them to make an informed selection. The case manager shall review with the
parent/guardian and the individual all possible community service providers in
the chosen area of re-location during Activities 3 and 5.
[8.371.7.20
NMAC - N, 7/1/2024]
8.371.7.21 ACTIVITY 7: SELECTION OF COMMUNITY SERVICE PROVIDER(S):
A. The parent/guardian, in consultation with the individual,
shall select community service provider(s) to be included in the TIDT and shall
notify the case manager of the community service provider selection(s). Community service providers could be selected
as early as the facility IDT meeting (see above), if the individual and
parent/guardian(s) are familiar with community service provider agencies in the
area of relocation. Community service
providers must be selected no later than 30 days after the parent/guardian(s)
initial meeting with the case manager (Activity 5, above). If the individual’s choice of community
service provider differs from that of the parent/guardian, the case manager
shall arrange for both community service providers to be present at the TIDT
meeting if possible. If there is more
than one eligible community service provider for a particular service, the
parent/guardian may indicate alternate community service provider(s) in order
of preference in the event the parent’s or guardian’s first choice is
unavailable to provide the applicable service.
B. The Jackson
transition representative (JTR) shall confirm community service provider
selection within 10 days by contacting the community service provider(s) by
telephone and in writing. If the
parent/guardian has indicated alternate community service provider(s) in order
of preference, the Jackson transition
representative (JTR) shall document the reason for the unavailability of the
higher ranked community service provider before contacting the next ranked
provider. If key community service
provider(s) are not selected by the parent/guardian and individual, within 49
days of the initial TIDT meeting, the Jackson
transition representative (JTR) and case manager shall make the
selection(s). The Jackson transition representative (JTR) shall notify the
parent/guardian(s) of the selection, as well as the community service
provider(s). Notice of the TIDT meeting
as provided in Activity 10 shall be mailed.
The TIDT shall review these selection(s) and shall select the non-key
provider(s) at its first meeting, if the individual or parent/guardian(s) does
not do so.
C. The individual and the parent/guardian should give
priority to selecting the community residential provider and other key
community service providers within the timelines specified above. The key community service provider(s) shall,
either before or at the TIDT meeting, acknowledge that it is able to provide
the residential placement or other type of services for which the key service
provider(s) shall be brought into the planning process as expeditiously as
possible, preferably prior to the TIDT, and shall receive all previous planning
and client information.
[8.371.7.21
NMAC - N, 7/1/2024]
8.371.7.22 ACTIVITY 8: WRITTEN INDIVIDUAL PREFERENCE ASSESSMENT: After completing the activities specified
above, but at least 26 days before the TIDT meeting described in Activity 11,
the case manager shall complete, with the individual and helper, a written
assessment of the individual’s strengths, interests, likes and dislikes. This assessment shall detail what the
individual would like their life to be like in the community, including
maintaining existing friendships and building new ones, community involvement,
employment for the individual who is an adult, hobbies, leisure activities, and
housemates. This assessment and review
shall be individualized and rely as much as possible on available community
generic resources rather than specialized service models. The case manager will collaborate with the Jackson transition representative (JTR)
and the facility Q.M.R.P. or social worker to facilitate any co-scheduling of
the TIDTs where other class member housemates are identified as a preference.
[8.371.7.22
NMAC - N, 7/1/2024]
8.371.7.23 ACTIVITY 9: WRITTEN COMMUNITY ASSESSMENT: After completing the activities specified
above, but at least 26 days before the TIDT meeting described in Activity 11,
the case manager shall prepare a written assessment of the resources and
services available in the community or relocation. At the TIDT, this assessment shall be
reviewed, in light of the individual’s preferences, as assessed under Activity
8, and the identification of the individual’s strengths and needs during their
daily activities, as identified at the facility annual IPP meeting.
[8.371.7.23
NMAC - N, 7/1/2024]
8.371.7.24 ACTIVITY 10: TIDT MEETING SCHEDULE, NOTICE, AND AGENDA: The Jackson
transition representative (JTR), shall schedule the full TIDT meeting, which
shall be held as promptly as possible after completion of the activities
required by Activities 6 and 7. Notice
of the date, time and place of the TIDT meeting shall be sent to all
participants at least 10 days prior to the meeting. The notice shall also state that participants
are to be prepared to address all issues for the individual to ensure a successful
transition into a community setting. If
any activities required by Activities 6 and 7 occur in less than the maximum
time allotted for them by the activity, the Jackson
transition representative (JTR) shall, whenever possible, proceed to schedule
the next required activity (for example, the TIDT meeting required by Activity
11 will be scheduled as promptly as possible after community service providers
are selected under Activity 7).
[8.371.7.24
NMAC - N, 7/1/2024]
8.371.7.25 ACTIVITY 11: FULL TIDT MEETING TO DEVELOP THE ITP:
A. The purpose of the TIDT meeting is to develop the
individual transition plan (ITP). The
ITP is the document developed by TIDT participants identifying the proposed
steps to be taken before and after placement and until implementation of a new
annual community individual service plan (CISP).
B. The team should attempt to identify or develop services
that use the same resources that the general population uses. For instance, the team should make attempts
to use or adapt for use local adult education resources instead of looking for
a way to set up a special adult education program for individuals who are
transitioning.
C. Upon failing to find a generic solution or one that might
be adapted, the team should match the preferred specialized solution to the
individual’s needs and not provide additional services if the need cannot be
demonstrated. For instance, if an
individual needs staff support only to assist in preparing the evening meal,
the team should find ways to deliver that service and no more, rather than
developing a residential placement that provides 24 hour staff support because
that service is available at the facility.
D. In addition, the TIDT should specify the training and
other necessary supports for direct care staff persons who would work directly
with the individual in the community setting.
Therapeutic and behavioral supports should be delivered primarily
through direct care staff persons since they are the most consistently present,
interact the most with the individual, and thus know the individual best. Therapists and psychologists should design
the individual interventions, train staff to carry them out through the course
of the normal daily routine, monitor the program implementation and be
available to coach staff and solve problems.
E. The team shall identify each activity in objective form
with specific assignment of responsibility and timelines for the accomplishment
of each transition activity. For
example, a home living provider would be responsible for the accomplishment of
home living related tasks, a work/education provider for work/education tasks,
and the case manager for monitoring service provision and assuring the presence
and preparation of community life and professional services tasks.
F. All team members are encouraged to participate in all
areas of the team process, not just in their area or expertise, skill or
involvement. Decisions should be made by
consensus. Where there is disagreement,
the team should continue to work towards a solution that all participants can
accept. If consensus is not reached, the
team shall make decisions by majority rule.
A record shall be maintained of team decisions. The result of the team’s effort is the ITP
proposed to the division for implementation.
G. The TIDT should attempt to complete the preparation of
the ITP in one meeting. Additional TIDT
meetings should be scheduled only if the first meeting does not resolve
significant issues, such as the identity of the community residential provider
or the competitive or supported employment provider, major medical resources or
safety issues. For some individuals,
planning for the move will be complex and lengthy and may require more than one
meeting. For others, addressing the
basic requirements of home, work/education, community life and necessary
supports will be straightforward and less complex. The case manager, with the concurrence of the
TIDT, shall specify in writing the issue(s) necessitating the additional
meeting, the identity of the person or entity responsible for addressing and
resolving the issue prior to the next meeting, and any other relevant
information.
H. Each additional TIDT meeting shall be held within 21 days
of the preceding TIDT meeting. The case
manager shall mail a copy of the written reasons for the additional meeting to
the Jackson transition representative
(JTR) and shall notify TIDT members of specific tasks and the date of the next
TIDT meeting. Absent extraordinary
circumstances agreed upon by the TIDT, there shall be no more than two additional
TIDT meetings.
I. The TIDT meeting shall be chaired by the case
manager. The team shall begin by
reviewing the previous assessments made pursuant to Activities 8 and 9 and the
community service provider selections made pursuant to Activity 7. Issues identified and solutions suggested
throughout the meeting shall be compared with the assessments to ensure
consistency with the individual’s preferences where possible.
J. The TIDT shall review and revise the assessments
developed in Activities 8 and 9; describe what life should be like for that
individual in that community, starting with a discussion of what life is like
for other persons of the individual’s age and interests and taking into
consideration the assessment developed as a result of Activity 9 above;
describe those supports that will be needed by the individual; identify the
area’s generic resources that will be used to provide those supports, or, if
generic resources are not readily available, a consideration of those actions
that could be taken to enhance existing generic supports for the individual;
describe and justify the use of any specialized community service
providers. Specialized providers are to
be used only when either no generic supports exist or existing generic supports
cannot reasonably be enhanced to meet the needs of the individual.
K. TIDT meeting guidelines and agenda: The TIDT shall develop the ITP in accordance
with the following guidelines:
(1) The contents of the ITP are
reasonable and appropriate to meet the individual’s needs and promote
identified strengths and capacities.
(2) The ITP reflects the individual’s
preferences, to the extent appropriate, unless the individual communicates no
preference or is incapable or communicating any preference.
(3) The ITP is designed to utilize
services that allow the individual to be more, rather than less, integrated in
the community and rely on available generic services to the extent feasible
consistent with the individual’s needs.
(4) The ITP provides services which are
least restrictive, not unduly intrusive and not excessive in light of the
individual’s needs. The ITP can be
practically implemented.
L. Life area planning:
(1) The primary task of the TIDT shall be
to discuss all issues to be considered for the individual’s transition to
succeed. This discussion shall include a
review of specific items within each of the following “life areas”: home
environment, vocational, educational, self-care, communication, leisure/social,
community resource use, safety, psychological/behavioral/emotional, and
medical/health; as well as other pre-placement planning.
(2) The TIDT should review the existing
facility IPP objectives related to each of the above “life areas”, and identify
which objectives are to be continued during the transition period into the
community. The TIDT may develop
transition objectives to begin at the facility.
M. Supports needed:
For each of the life areas discussed, the following general supports
should be identified for each relevant transition objective:
(1) human resources needed (volunteers,
family, friends/neighbors, paid staff);
(2) assistive technology and adaptive
equipment needs listed;
(3) environmental modifications needed /
environmental supports described;
(4) transfer and mobility issues
identified;
(5) transportation and community access
needs identified;
(6) additional support needs identified.
N. Life area discussion items: Life area discussions items include the
following (other transition objectives may need to be developed in specific
life areas in order to assure a successful transition):
(1) Home environment:
(a) roommate(s) / housemates desired;
(b) location of home identified;
(c) type of home preferred;
(d) orientation to new home;
(e) housing agreements signed, telephone
and utilities deposits, and household maintenance;
(f) arrangement for furnishings and
households items;
(g) housekeeping skills training required;
(h) food management/ assistance with
meals;
(i) respite needs (not applicable for
individuals living independently);
(j) banking, financial and budget/ money
management;
(k) transfer of personal belongings and
description of actual move;
(l) self-management of home and daily
routine described.
(2) Vocational:
(a) referral to DVR/NMCB completed;
(b) type of employment or environment
preferred;
(c) orientation to new work environment;
(d) assessments needed, vocational
training required or training in related skills required.
(3) Educational:
(a) type of educational goal desired;
(b) alternative community based education;
(c) orientation to new school environment.
(4) Self-care:
(a) toileting;
(b) menses;
(c) dental hygiene;
(d) bathing, grooming and shaving;
(e) dressing and clothing care.
(5) Communication:
(a) method or style individual prefers to
use;
(b) communication strengths maintained in
new home or communication skills training needed;
(c) speech therapy;
(d) audiology.
(6) Leisure/social:
(a) opportunities to continue with or
increase personal support systems and friends;
(b) opportunities to continue with or
increase identified interests and hobbies;
(c) opportunities to continue with or
increase family interactions and involvement;
(d) current or desired pets;
(e) sexual education, choices and needs
(e.g., relationship or dating skills, AIDS/STD awareness).
(7) Community resource use:
(a) orientation to community and social
life, including cultural and ethnic heritages of the community and individual;
(b) religious affiliation;
(c) access to community resources
(shopping, laundry, library, post office, etc).
(8) Safety:
(a) safety and hazard awareness training
required in home (use of stoves, heaters; emergency use of telephone; poisons,
wiring, fire prevention);
(b) safety and hazard awareness training
required in community (street safety, dealing with strangers);
(c) alert devices required in
home/community;
(d) identification card or medical alert
bracelet/ necklace;
(e) updated medical summary.
(9) Psychological/behavioral/emotional:
(a) development of self-advocacy and
decision making skills;
(b) reinforcers and coping mechanisms
identified;
(c) psychoactive meds used for emotional
or psychiatric purposes;
(d) community psychologist/ psychiatrist
identified;
(e) transition or ongoing counseling
needs;
(f) behavioral responses to new home;
(g) crisis intervention needs anticipated;
(h) emergency response anticipated;
(i) behavior management plan reviewed.
(10) Medical/health:
(a) physical condition identified and
medical services or appointments needed;
(b) how the individual communicates
illness identified;
(c) physician identified and medical
records transferred;
(d) physical and occupational therapies;
(e) dental appointments made;
(f) pharmacy identified and
prescriptions transferred;
(g) ophthalmologist;
(h) nursing services required;
(i) medication/self-administration;
(j) emergency medical needs anticipated;
(k) hospitalization issues discussed;
(l) nutritionist needed, special diet;
(m) training needs for community medical
personnel.
(11) Other pre-placement
activities/community IDT planning:
(a) pre-placement visit(s);
(b) cross training activities and
community service provider skills development;
(c) specific strategies to provide
stability to children not moving to a family home;
(d) guardianship status reviewed;
(e) establish a placement date: The
placement date established by the TIDT shall be no later than 228 days after
the date of the established initial TIDT meeting.
[8.371.7.25
NMAC - N, 7/1/2024]
8.371.7.26 ACTIVITY 12: DISTRIBUTION OF THE ITP:
A. Within 14 days of the conclusion of the TIDT meeting, the
Jackson transition representative
(JTR) shall produce and distribute the ITP to the case manager, the
parent/guardian, the facility Jackson
office (for distribution to the facility TIDT members), the community service
provider(s), advocate (if appropriate), the division Jackson office, other agencies mentioned in the ITP, counsel for
plaintiffs, counsel for intervenors (when appropriate).
B. The case manager, after receipt of the ITP, shall meet
with the individual, the QMRP and the helper, and review the completed ITP and
what it means from the individual’s perspective. The case manager shall assist the
parent/guardian by providing information and answering questions concerning the
completed ITP and the DRP process.
[8.371.7.26
NMAC - N, 7/1/2024]
8.371.7.27 ACTIVITY 13: COMMUNITY SERVICE PROVIDER CONTRACTS: No later than 30 days after the distribution
of the ITP, each community service provider identified in the ITP shall submit,
in writing, to the health care authority its cost proposal, including the
following information:
A. start up funds required;
B. staff training that will be provided as specified in the
ITP, to whom and by when;
C. facility modifications that may be required;
D. provision for administration of medication;
E. any other information as specified by the ITP to be
provided in this submission;
F. any other information as specified by the authority.
[8.371.7.27
NMAC - N, 7/1/2024]
8.371.7.28 ACTIVITY 14: PROPOSAL REVIEW: The health care authority shall review the
community service provider’s proposal and may discuss or clarify any aspect of
the proposal with the community service provider. The cost proposals shall be negotiated and
approved, according to agreed upon costs, by the division’s community programs
bureau. The authority shall submit to
the community service provider a written notice of the state’s intent to fund
services for an individual within 30 days of receipt of the community service
provider’s written proposal. The written
notice of intent is not a contract.
Unusual costs or specialized services may require an additional two
weeks to negotiate and approve. It is
incumbent upon the community service providers to submit cost proposals no
later than 30 days after the distribution of the ITP.
[8.371.7.28
NMAC - N, 7/1/2024]
8.371.7.29 ACTIVITY 15: COMMUNITY SERVICE PROVIDER / STATE AGREEMENT: Unless delayed because of extraordinary
circumstances or an administrative (DRP) or judicial stay order, within 30 days
of the community service provider’s submittal described in Activity 13 above,
providers of service and the health care authority shall negotiate and execute
agreements for the delivery of services as specified in the ITP. The medicaid waiver plan of care (POC) shall
be approved and submitted to the case manager for signatures. The case manager shall obtain signatures on
the completed plan of care, based upon the approved authority cost proposals,
at the ITP quality assurance review meeting (Activity 17, below).
[8.371.7.29
NMAC - N, 7/1/2024]
8.371.7.30 ACTIVITY 16: ALTERNATE COMMUNITY SERVICE PROVIDER
SELECTION:
A. An ITP quality assurance review meeting shall be held
within 30 - 45 days prior to the placement date specified in the ITP. The purpose of this meeting is to assure that
the ITP is being successfully implemented, assigned responsibilities have been
or are being met and that activities are appropriately accomplished in
preparation for the community placement.
Participants at the ITPQA review meeting are the same TIDT members, including
designated representatives, who were responsible for the development of the
ITP. The Jackson transition representative (JTR) is responsible for
documenting activities at this meeting.
Activities occurring at this meeting include:
(1) review of ITP objectives that occur
prior to placement and their implementation status;
(2) confirm accomplishment or initiation
of tasks by TIDT members;
(3) amendments to the ITP, if required,
due to failure to implement objectives or a change in the individual’s
circumstances;
(4) confirm identity of housemates, staff
and others;
(5) confirm cross-over training agenda,
participants and schedule with the facility;
(6) describe and plan activities of the
actual transition day, including responsible parties and times;
(7) recommend a change in placement date,
if required, to assure a successful transition;
(8) finalization of the waiver plan of
care: The case manager shall obtain signatures on the completed approved plan
of care, based upon the approved cost proposals.
B. The TIDT may review the placement date and recommend a
change or extension beyond the 228 day placement requirement; however, changing
the originally established placement date requires authorization of the Jackson coordinator. Such authorization shall only be given upon
evidence of extraordinary circumstances, a judicial stay order or other due
process activity.
C. Within two working days following the ITPQA review
meeting, the case manager shall submit the completed plan of care with original
signatures to the community programs bureau (CPB).
D. In addition to the regularly scheduled ITPQA review
meeting, described above, the case manager may, in extraordinary circumstances,
reconvene the TIDT, in person or by teleconference if planning activity time
lines fall behind schedule, the implementation of the ITP is in jeopardy, or
the ITP requires significant modification, such as substitution of a key
community service provider. In the case
of such reconvened TIDT meetings, the assigned Jackson transition representative (JTR) will not attend the meeting,
and the case manager shall be responsible for documenting the amendments to the
ITP that are developed. Amendments
should be distributed, in a hand-written form, to all TIDT members and
designated representatives at the conclusion of the meeting, if xerox
capabilities are available.
[8.371.7.30
NMAC - N, 7/1/2024]
8.371.7.31 ACTIVITY 18: DISPUTES: See: Appendix B, Dispute Resolution Process
(DRP) for Individual Transition Plans.
[8.371.7.31
NMAC - N, 7/1/2024]
8.371.7.32 ACTIVITY 19: IMPLEMENTATION DECISION BY HEALTH CARE
AUTHORITY:
A. Within seven days of the completion of the DRP, if any,
the health care authority shall inform the parties to the DRP in writing
whether, on the basis of the cost of the individual’s ITP or the aggregate
costs of individual ITPs, or because the health care authority believes the ITP
fails to satisfy constitutional or statutory requirement, it is unable to
implement the ITP. If the decision was
based on cost, the authority shall not implement the ITP until and unless they
have sufficient funds to do so. The authority
has the sole discretion to determine whether there are sufficient funds
available to implement an ITP. The
decision of the authority as to the allocation of funds to ITPs is final and
not reviewable. The authority shall
engage in good faith efforts to seek the necessary funds through the
supplemental and regular budgetary process for the developmental disabilities
division of the health care authority and the medicaid DD waiver program and
through federal funding which might be available to these programs. Upon appropriation of funding determined by
the authority to be sufficient, the TIDT or the community IDT, as appropriate,
shall convene to review the final ITP in light of the individual’s current
circumstances and determine whether any changes should be made.
B. In the event the ITP is not implemented because of cost
or because the authority believes the ITP fails to satisfy constitutional or
statutory requirements, within 14 days of the completion of the DRP, the authority
(with the assistance of its qualified professionals) shall prepare and mail to
everyone specified in Activity 12, an interim plan which can be implemented
immediately within available resources and which meets constitutional and
statutory requirements; or the authority shall immediately request the
reconvening of the TIDT and direct the team to develop an interim plan which
can be implemented immediately. The
interim plan shall be distributed within 14 days of its completion by the
reconvened TIDT. Any party eligible to
initiate a DRP of the original ITP may initiate a DRP of the interim plan
pursuant to Section IV(E) of the DRP.
However, the authority’s decision regarding the allocation of resources
to any ITP or interim plan is within the authority’s sole discretion and is not
reviewable in the DRP process.
C. If within 20 days of mailing the interim plan no party
challenges the plan in a DRP, and the authority approves, the interim plan
shall be implemented forthwith.
[8.371.7.32
NMAC - N, 7/1/2024]
8.371.7.33 ACTIVITIES 20 - 23: Activities
20 - 23 shall take place in the time frame specified unless delayed because of
the DRP, or extraordinary circumstances.
[8.371.7.33 NMAC - N, 7/1/2024]
8.371.7.34 ACTIVITY 20: IMPLEMENTING THE ITP: TIDT members shall carry out their assigned
pre-placement responsibilities. The TIDT
is responsible for assuring the completion of placement activities and the
readiness of the placement unless delayed pursuant to the policies of Appendix
B, Section IV.F., dispute resolution process.
[8.371.7.34
NMAC - N, 7/1/2024]
8.371.7.35 ACTIVITY 21: MONITORING IMPLEMENTATION OF THE ITP: The
assigned Jackson office
representative shall check and document progress twice per month beginning 60
days prior to the placement date on fulfillment of responsibilities assigned in
the ITP. If the representative learns of
serious implementation problems the Jackson
office shall direct the case manager to reconvene the TIDT, either in person or
through teleconference, to correct the problem.
[8.371.7.35
NMAC - N, 7/1/2024]
8.371.7.36 ACTIVITY 22: REPORTING ON IMPLEMENTATION OF THE ITP: Every other week the division’s Jackson office representative shall send
to TIDT members a report on the status of pre-placement activity. The Jackson
coordinator shall report specifically on the status of all agreements and
community service provider plans of care.
Any delay in execution of agreements that may affect other time lines or
pre-placement activities shall be identified and strategies for specific action
developed and implemented.
[8.371.7.36
NMAC - N, 7/1/2024]
8.371.7.37 ACTIVITY 23: COMMUNITY PLACEMENT: Pre-placement visits with staff and to the
new home and work site shall take place as provided in the ITP. Placement shall be accomplished on the date
established by the TIDT consistent with the timelines established in Section 13
above.
[8.371.7.37
NMAC - N, 7/1/2024]
8.371.7.38 TRANSITION ACTIVITIES AFTER
PLACEMENT:
A. Absent extraordinary circumstances or an administrative
(DRP) or judicial stay order, placement shall occur when planned pre-placement
ITP activities have been completed.
Moving is a stressful experience for anyone. Change in an individual’s environment may
result in changes in behavior or the need to make adjustments in program
design. Thus, intensive interaction and
monitoring shall be necessary immediately following placement. During the two months following placement the
following activities shall take place:
(1) Habilitation, treatment and services
shall be implemented as provided in the ITP.
(2) During the first week following
placement, the case manager shall visit the individual on three of seven
calendar days at both the individual’s residence and day program with one of
the visits occurring in the evening and one occurring on the weekend. The case manager shall observe the
implementation of planned services. The
case manager, in consultation with the appropriate TIDT member(s) and with the
prior approval of the health care authority, may make adjustments in the plan
that do not alter the extent of the plan or the frequency, duration or scope of
services. Any significant adjustments to
the ITP shall be made by the community IDT convened by the case manager as
provided in Paragraph (7) below. The
case manager shall record the time of the visit, their observations regarding
program implementation, and adjustments made to the plan, if any.
(3) During the first month following
placement, the community service provider(s) specified in the ITP shall perform
assessments as identified and scheduled in the ITP. The direct care staff may collect base line
data for the assessments.
(4) During the second through the fourth
week following placement, the case manager shall visit the individual at least
two times per week.
(5) During the second month following
placement the case manager shall visit the individual at least weekly, or more
often if required, by the team or the circumstances in order to ensure program
implementation in the new environment.
(6) Case managers shall comply with all
developmental disabilities division reporting requirements relevant to
post-placement activities and reporting.
(7) The case manager should convene and
chair the first meeting of the individual’s new community IDT (CIDT) within 14
days of placement. The CIDT shall
normally consist of the individual (and their chosen representative, if any),
the parent/guardian (and their chosen representative, if any), the helper, the
case manager, and professional and direct care provider(s). In the absence of any member, the CIDT may
proceed with the meeting if appropriate under the circumstances. The team shall meet to:
(a) review program implementation;
(b) provide for any necessary program
adjustments;
(c) identify and resolve any problems or
potential problems in successful implementation;
(d) determine if assessments are
occurring as scheduled pursuant to the ITP; and
(e) schedule the next IDT meeting to
develop the community IPP, which shall be developed within 60 days of
placement.
(8) The case manager shall convene and
chair the second meeting and subsequent meetings of the CIDT to prepare and
complete the individual’s community individual service plan (ISP). If the current placement plan is an interim
plan developed pursuant to Activity 19, in the course of developing the
individual’s ISP the CIDT shall review the original ITP that was not
implemented by the health care authority (see Activity 19) to determine whether
any of the components of the original ITP should be incorporated into the
ISP. By agreement of the individual,
parent/guardian and health care authority or as a result of a decision through
a DRP, the ISP shall supersede all previous plans.
(9) Subject to the community DRP and to
the principles set forth in Activity 19, the ISP shall be implemented within 60
days following placement. Adjustments to
the plan of care or community service provider contracts shall be completed
pursuant to the ISP.
B. The goal of the community IDT is to ensure the
implementation of the community individual service plan (ISP). In order to do this, the case manager or the
case manager’s local representative should visit the individual as specified in
the ISP or as often as necessary, but no less than two times per month, to
assure that the plan is being fully implemented and to assist the individual in
becoming a part of their community.
[8.371.7.38
NMAC - N, 7/1/2024]
HISTORY
OF 8.371.7 NMAC: [RESERVED]