Form 3597
Instructions

Habilitation Training Plan

09-2003

PURPOSE

To establish specific training goals and plans for individual participants that will assist in reaching personal goals for independence.

PROCEDURE

When to Prepare

This form is prepared by the direct services agency (DSA) only when habilitation training areas are identified on Form 3596, Habilitation Plan.

Number of Copies

The DSA completes an original and one copy.

Transmittal

The DSA retains the original in the participant's service record and provides a copy via Form 2067, Case Information, to the case manager.

Form Retention

The DSA retains this form according to the terms in the CLASS Provider Manual.

Supply Source

This form may be downloaded through the DADS web site at www.dads.state.tx.us/handbooks/classpm/forms/index.asp.

DETAILED INSTRUCTIONS

Participant —  Enter the name of the CLASS participant as it appears on the participant's Form 3621, Page 1, CLASS Individual Service Plan (ISP).

Medicaid Number —  Enter the participant's nine-digit Medicaid number as it appears on the participant's Form 3621, Page 1, CLASS Individual Service Plan (ISP).

Date —  Enter the date Form 3597 is completed.

ISP Effective Period (mm/dd/yyy) —  Enter the ISP Effective Period documented in Item 13 of Form 3621, Page 1, CLASS ISP. If this form is being completed at the participant's reassessment, this period will be the next budget year.

Habilitation Training Goal —  Enter the description of each habilitation training goal. The individual program plan (IPP) establishes broad goals based on the services authorized for the participant. The habilitation training plan is a specific plan developed to reach those goals. The training goal should have a direct relationship to Form 3596, Habilitation Plan, and the IPP goals. The plan should state how the goal is integrated with other CLASS services and community resources.


Example: The IPP goal might be that "John would like to learn to manage his own money." The skills goals would begin where John's knowledge ends: "John will learn to write a check;" "John will learn to balance a checkbook." The training task might be: "The trainer will provide copies of a typical checkbook and assist John in writing checks and entering them in the register." Integration of services might include asking a local bank to allow a visit to the bank and a beginning lesson about writing a check. The trainer should work with the participant and habilitation attendant on "homework tasks" to practice writing and listing checks.

Why is this goal important to you? —  Enter the information provided by the participant/guardian.

How is this goal integrated with other CLASS services? —  Enter a description of how the habilitation training goal(s) will be integrated and/or relate to other CLASS services authorized on the participant's ISP and outlined on the IPP.

Habilitation Trainer(s) —  Enter the name and title of the habilitation trainer(s).

Frequency of Training (number of hours per week/month/quarter) —  Enter the number of hours per week, month, or quarter that will be required for meeting the habilitation training objective.

Duration (estimated time for development of skill) —  Enter the estimated time it will take for the participant to meet the goal.

Task(s) to be trained: —  List the series of tasks to be completed by the participant.

Signatures —  The participant/guardian and DSA representative must sign and date Form 3597, Page 1.

Page 2 — Quarterly Summary of Habilitation Training

Individual habilitation training goals must be reviewed and updated on a quarterly basis. The DSA should inform the case manager of all changes and quarterly reviews. The habilitation trainer must document progress toward habilitative training goal, if the participant is independent in meeting identified task(s), and/or additional needs of the participant on a quarterly basis. If goals are met, the appropriate box must be checked. If the plan is not working, Form 3597 should be revised.

Participant —  Enter the name of the participant as it appears on the participant's Form 3621, page 1, CLASS Individual Service Plan (ISP).

Habilitation Trainer —  Enter the name of the participant's habilitation trainer.

Quarter: 1st, 2nd, 3rd, 4th —  Check the appropriate quarter of the participant's annual ISP effective period.

Evaluation of Progress Toward Habilitation Training Goal: —  The habilitation trainer documents progress notes for each habilitation goal identified on page 1 of this form.

Is Participant Independent in Identified Task(s)? —  Check either "Yes" or "No" box if the participant has/has not become independent in completing the identified task(s) during the quarter. If marked "No," explain if more training is required and identify specific training tasks.

Is Habilitation Training Goal Met? —  Check either "Yes" or "No" if the habilitation training goal is met/not met during the quarter. If marked yes, enter the date the habilitation training goal was met.

Evolving Needs (if applicable) —  Document additional habilitation needs identified by the habilitation trainer during the quarter, if applicable.

Revised Plans (if applicable) —  Enter any changes to be made to the participant's current habilitation training plan, if applicable. Document specific steps the participant will need to meet to become more independent in the identified task.

Signatures/Date of Signatures —  The form is to be signed and dated by the participant/guardian and the DSA representative.