Introduction
A Ligas Transition Service Plan shall be developed specific to, and centered on, each Ligas Class Member (Ligas Consent Decree, Paragraph 10). For individuals presenting a crisis situation, refer to the Crisis Transition Plan.
Within no more than 12 months prior to the development of a Ligas Transition Service Plan, the individual and/or guardian, in an objective manner, will be presented all of his or her service alternatives.
The Ligas Transition Service Plan will be developed by a Qualified Intellectual Disability Professional (QIDP) employed by the Pre-Admission Screening/Independent Service Coordination (PAS/ISC) agency in conjunction with:
- Individual;
- Individual's legal guardian, if applicable;
- Individual's family members;
- Friends;
- Support Staff (This person is familiar with the Individual and could be staff from current service [Home Based Services, ICF/DD] and would have valuable input).
The role of the QIDP will be the PAS/ISC having geographical jurisdiction.
The Ligas Transition Service Plan meetings shall be held face-to-face between the individual and the QIDP. It is imperative that the individual be given a choice on selecting the participants involved in the Ligas Transition Service Plan development. The location of guardian, family members, and other members contributing to the plan may require exceptions being made for telephone participation. In order to obtain sufficient documentation, the transition planning process may require more than one meeting in order to obtain input from different contributing participants.
The Ligas Transition Service Plan shall be initiated as individuals are selected to receive Medicaid Waiver services through the Prioritization of Urgency of Need for Services (PUNS) or a request is received reflecting a choice of Waiver services (e.g., Individuals residing in private ICFs/DD with nine or more residents).
The Ligas Transition Service Plan shall:
- Describe the services the individual requires in a community-based setting or through community-based services;
- Include where and how such services can be developed and obtained;
- Include supports and services the individual will need during his or her transition to a community-based setting;
- Identify the timetable for completing the transition.
Ligas Transition Service Plan development should focus on the individual's personal vision, preferences, strengths and needs in home, community, and work environments. The plan shall reflect the value of supporting the individual with relationships, productive work, participation in community life, and personal decision-making. (Ligas Consent Decree, Paragraph 13)
All services and supports in the Ligas Transition Service Plan must be integrated into the community to the maximum extent possible, consistent with the choices of the individual and where applicable, the individual's legal guardian. (Ligas Consent Decree, Paragraph 14)
The Ligas Transition Service Plan shall not be limited by current availability of services. It should be understood that no obligation is made to providing the types of services beyond those included in the Waiver and/or the State Plan. (Ligas Consent Decree, Paragraph 15)
The Ligas Transition Service Plan shall be completed within sufficient time to provide appropriate and sufficient transitions of individuals in accordance with the deadlines set forth in the Decree. (Ligas Consent Decree, Paragraph 16)
The Ligas Transition Service Plan should be completed with dialogue involving the Individual, Individual's legal guardian, if applicable, Individual's family members, friends, and support staff who are familiar with the individual.
The Ligas Transition Service Plan is a formal document. It must be typed, not hand-written.
The Ligas Transition Service Plan may be supplemented with a Person-Centered Plan (PCP), such as a Relationship Map.
A Ligas Transition Service Plan is not required for those individuals who will be receiving Home-Based Support Services (HBS) in their own home or the family's home.
The Ligas Transition Service Plan is not intended to duplicate information. Assessments and reports can be attached to provide further details of specific needs (e.g., psychological, ICAP, MAR). The Ligas Transition Service Plan must have a primary focus on individual choice and preferences.
Ligas Transition Service Plan Completion
-
Name
Record individual's legal name as it would appear on a service funding packet. This area of the Ligas Transition Service Plan should also reflect any common names or nicknames.
-
Address
Current Residence
-
Type of Current Residence
Describe current residence by setting and/or service type.
-
Current Daytime Activity
What type of structured activity does the individual engage in during the day? (e.g., school, work, social settings, recreational program, or day program)
-
Date of Birth (DOB)
Record DOB (MM/DD/YYYY). Ensure individual is age 18 or older for established eligibility.
-
Guardian
If an individual retains his/her own rights, this section would be left blank. The Ligas Transition Service Plan should state in summary that the individual retains his/her own rights. The Ligas Transition Service Plan document has made accommodations to reflect those having co-guardians. If no guardian has been assigned, the individual may choose to involve someone to assist with Ligas Transition Service Plan development. These individuals should be listed and a consent form/release of information completed to allow contact.
-
PAS/ISSA/ISC
Record the Pre-Admission Screening, Individual Service and Support Advocacy (PAS/ISSA/ISC) agency having geographical jurisdiction. The Ligas Transition Service Plan shall reflect the PAS/ISSA/ISC that is responsible for Ligas Transition Service Plan completion and contact information for that person. The date must reflect the completion date of the plan.
-
Where does the Individual want to live?
Record the desire to live with or live near a friend, group of friends, or others. Description should be provided to narrow choice to a geographical area of the state (e.g., Within 20 minutes or 5 miles of a desired person).
-
Preferred Living Arrangement
Describe setting/choice of residence.
-
Is there anyone you would like to live with, or near?
Summarize dialogue addressing desires to maintain/establish friendships or social relationships with action steps to achieve.
-
Preference of Day Activity
Activities the individual would like to engage in during the day (e.g., vocational opportunities, competitive employment, supported employment, developmental training, specific desired work experience, other).
-
Personal Preferences
This section is intended to identify personal likes and dislikes. The current and future vision/hopes should be addressed in detail to summarize desire and choice. Discussion shall focus on a variety of settings and aspects (e.g., home, community, social, recreational, spiritual, and educational opportunities).
-
Family Involvement/Relationships
This area should summarize relationships which support personal success. It should further identify those relationships which may pose an obstacle in recording achievement and gaining independence.
-
Communication Skills
How does the individual choose to communicate? (e.g., preferences and choices on how the person communicates and with whom). For further detail, assessments and reports may be attached.
-
Mobility
Choices and desires associated with mobility issues (e.g., accessibility, space, level of assistance).
For further detail, assessments and reports may be attached.
-
Personal Care
Summarize tasks which may be attempted and/or completed. Level of support needed to complete certain tasks.
For further detail, assessments and reports may be attached.
-
Meal Time Assistance
Summarize the level of supports needed at meal times. Is staff needed to assist with monitoring? Document personal preferences at meal time.
-
Special Dietary Needs
Summarize restrictions and/or programming which will ensure dietary needs.
For further detail, assessments and reports may be attached.
-
Personal Decision-Making
Summarize situations when personal decision making can be maximized. (E.g., money skills, ability to make purchases, community access, giving directions, following direction, time management, attention to task, participation, other).
-
Adaptive Equipment/Protective Equipment
Summarize equipment or resources which increase independence or maintain safety (e.g., hearing aids, glasses, helmet, lift, plate guard, AFO, language device, specialized chair).
For further detail, assessments and reports may be attached.
-
Behavior Supports
Summarize behavior and needed supports.
For further detail, assessments and reports may be attached.
-
Medical/Physical Well-Being
Summarize services of support.
For further detail, assessments and reports may be attached.
-
Medications
Describe ability to self-medicate. What level of assistance is currently being provided to take medication(s)?
For further detail, assessments and reports may be attached.
-
Legal Issues
Summarize court involvement, trust fund Issues, guardianship, consents.
-
Other Risk Issues Not Identified
Summarize events or actions which may lead to certain consequences.
For further detail, assessments and reports may be attached.
Summary
-
Supports for Transition
Summarize supports/activities needed to transition (e.g., overnight visit, day visit, dinner visit, staff familiarization, adjustment period)
-
Time Table
Summarize a chronological schedule and process of transitioning once a provider is selected.
-
People who contributed to the Ligas Transition Service Plan
Ensure all participants in the Ligas Transition Plan have been identified by name and title/relationship (e.g., multiple meetings may be held to complete the Ligas Transition Service Plan process.)
