Texas Department of Aging and Disability Services
Community Based Alternatives Provider Manual
Revision: 13-2
Effective: June 5, 2013

Section 4000

CBA Program Provider Responsibilities

4100  Emergency Response Services

Revision 06-1; Effective April 10, 2006

4110  Introduction

Revision 02-4; Effective Upon Receipt

Emergency response services (ERS) are provided through an electronic monitoring system used by functionally impaired adults who live alone or who are functionally isolated in the community. In an emergency, the participant can press a call button to signal for help. The electronic monitoring system, which has a 24-hour, seven-day-a-week monitoring capability, helps to ensure that the appropriate person or service agency responds to an alarm call from a participant.

4111  Program Purpose

Revision 02-4; Effective Upon Receipt

The purposes of ERS services under the Community Based Alternatives (CBA) program are to:

  • enable aged and disabled persons to achieve or maintain dignity, independence, individuality, privacy, choice and decision making ability; and
  • prevent or reduce inappropriate institutional care by providing home-based care and other forms of less intensive care.

4112  Emergency Response Services General Contracting Requirements

Revision 06-1; Effective April 10, 2006

For information regarding the contracting requirements for Emergency Response Services located in 40 Texas Administrative Code, Chapter 52, Contracting to Provide Emergency Response Services, go to: www.dads.state.tx.us/rules/TAC.html.

For information on ERS provider policy located in the ERS Provider Manual, go to: www.dads.state.tx.us/handbooks/ers/.

4200  Adult Foster Care

Revision 02-4; Effective Upon Receipt

4210  Introduction

Revision 02-4; Effective Upon Receipt

Adult Foster Care (AFC) provides a 24-hour living arrangement in a DADS-enrolled foster home for persons who, because of physical or mental limitations, are unable to continue independent functioning in their own homes. The CBA AFC participant must reside in the CBA AFC home. Services may include meal preparation, housekeeping, personal care and nursing tasks, help with activities of daily living, supervision and the provision of or arrangement of transportation. The delegation of nursing tasks by a registered nurse to the foster care provider will be required based on the provider's abilities and the needs of the participant. The three levels of payment for foster care are explained in Section 4242.1. CBA participants are required to pay for their own room and board costs, and contribute to the cost of their care, if able, through a copayment to the foster care provider.

AFC providers must be enrolled by DADS, pass inspections for fire safety and health conditions, receive all required training, and meet all applicable requirements in the CBA Provider Manual. Up to four residents may be served in a foster home, though there are limitations as to the number of participants at each level that may reside in one home.

4211  Purpose

Revision 02-4; Effective Upon Receipt

The purpose of CBA AFC is to promote the availability of appropriate services for elderly and persons with disabilities in a home-like environment to enhance the dignity, independence, individuality, privacy, choice and decision making ability of the participant.

CBA AFC requires the CBA Adult Foster Care provider to provide each participant enough living space to guarantee their privacy, dignity, and independence.

4212  General Contracting Requirements

Revision 02-4; Effective Upon Receipt

To enroll as a provider of CBA Adult Foster Care, in a four bed setting, the provider must obtain a Type C assisted living facility license. Settings of one to three beds do not require licensure.

All prospective AFC providers will be required to submit a copy of a current criminal history check before their AFC contract will be approved.

Any prospective substitutes for AFC providers will be required to submit a current criminal history check with their completed application. The prospective substitute may obtain this criminal history check themselves, or they may ask their authorized representative for assistance. The authorized representative for the criminal history check may be the AFC provider. The criminal history check must be given to the contract manager before the substitute will be approved.

Criminal history requests may be submitted to the Texas Department of Public Safety (DPS) by:

  • visiting the DPS Records web site at http://records.txdps.state.tx.us. The cost is approximately $3.50 per name request. Credits for records requests may be purchased by credit card or check.
  • mailing a written request for a criminal history record to DPS. Complete instructions for written requests can be found in Appendix XX. The cost is $15.00 per name (with fingerprints) or $10.00 per name (without fingerprints).

DPS will send a written response to each criminal history request processed, regardless of method of request or result of the search. The results of the search must be submitted to the contract manager regardless of the result.

4220  Staff Responsibility and Client Eligibility

Revision 02-4; Effective Upon Receipt

4221  CBA Case Manager Responsibilities

Revision 02-4; Effective Upon Receipt

The case manager is responsible for the following activities in the CBA AFC program:

  • Acting as coordinator of the Interdisciplinary Team (IDT) for the CBA participant;
  • Providing information to interested CBA participants about existing CBA Adult Foster Home providers and arranging visits to these homes;
  • Assessing the CBA AFC provider and the CBA AFC family to determine whether they can provide an appropriate environment for a specific CBA participant;
  • Negotiating with the CBA participant and provider an agreement that describes the rights and responsibilities of both the CBA AFC participant and the provider, including a room and board agreement, copayment amounts, and other miscellaneous arrangements; and
  • Monitoring the needs of the CBA participant and the care he is receiving to ensure his needs, including medical, are being met.

4222  CBA AFC Specialist Responsibilities

Revision 02-4; Effective Upon Receipt

The CBA AFC specialist is responsible for the following activities in the CBA AFC program:

  • Recruiting all CBA Adult Foster Homes;
  • Enrolling all CBA Adult Foster Homes, which includes assisting the new provider in completing all contract documents and forms, providing training and technical assistance on the CBA AFC program, and monitoring to see all health and safety inspections necessary for enrollment are completed;
  • Providing ongoing training and technical assistance on program and contracting matters to CBA AFC providers; and
  • Monitoring all CBA adult foster homes for compliance with the CBA Provider Manual, terms of the contract, and quality of service delivery, as well as identifying problems and requesting corrective action plans. The CBA AFC specialist will assume the duties of provider recruitment, enrollment, and some of the monitoring performed by the case worker in standard AFC. The AFC forms will be used for these procedures, with the exception of the Form 2331, Client Monitoring—Adult Foster Care. See Section 4224, Steps in Adult Foster Care Placement. The case manager will complete Form 2331. The CBA AFC specialist will also function like a contract manager, monitoring the provider for compliance with CBA AFC rules and the contract documents.

4222.1  Recruitment of CBA AFC Homes

Revision 02-4; Effective Upon Receipt

Recruiting adult foster home providers for the CBA program is the responsibility of the CBA AFC specialist. Through use of available materials such as department publications, public service announcements, and speaking to community services organizations, information is given to the public regarding the need for CBA adult foster homes.

4223  Reserved

Revision 02-4; Effective Upon Receipt

4224  Steps in Adult Foster Care Placement

Revision 02-4; Effective Upon Receipt

Some of these steps may be made concurrently, depending on the applicant's situation.

Eligibility

  • Financial — The ME worker determines an applicant's financial eligibility.
  • Medical — As part of the pre-enrollment home health assessment, the Home and Community Support Services (HCSS) agency nurse completes Form 3652-A, obtains the physician's signature, and transmits the form to Texas Medicaid and Healthcare Partnership (TMHP) to establish medical necessity.

Service Planning

  • The case manager coordinates with other members of the interdisciplinary team (IDT) in planning service for each CBA participant.
  • Casework procedures for the CBA program in AFC will track procedures in Community Care to Aged and Disabled (CCAD) adult foster care (AFC) to a limited extent.
  • The case manager discusses residential options with the participant who then chooses a home.
  • The case manager researches placement possibilities for the participant. If the participant chooses an adult foster care setting, the CBA AFC worker and case manager locate a suitable adult foster home for him. Consideration must be given to the participant's needs, including his needs for assistance in evacuation, for nursing care, and the provider's willingness and capability to perform nursing tasks. The case manager must inform the potential AFC provider if the participant can be left alone for up to three hours, based on the HCSS nurse's assessment. If the participant cannot be left alone, the provider will be responsible for providing, or arranging for, 24-hour supervision.
  • If a CBA AFC home is filled, the provider must maintain a waiting list. If the home is also enrolled for CCAD AFC, the provider must maintain two separate waiting lists. Those on the CBA waiting list will take priority over those on the CCAD waiting list.
  • The case manager is responsible for arranging the participant's visit to the home. Once agreement is reached, the case manager completes Form 2327, Individual/Member and Provider Agreement.
  • The case manager and AFC provider negotiate the starting date for services.
  • The case manager computes the initial copayment based on the starting date of residency.
  • If the applicant expresses an interest in money management, the case manager should document that the applicant expressed an interest in money management on Form 2067, that is sent to the AFC provider. The case manager must document that the applicant was offered money management, and he either accepted or refused the service. The request for money management services may also be documented on Form 2327.
  • The IDT completes the ISP, based on the applicant's choices and established needs for services.
  • The case manager faxes or mails the ISP (Form 3671, pages 1 through 3 and all attachments, Form 2060, and Form 2060-A) to the AFC provider for signature on Form 3671, page 2, that signifies the provider's agreement with the ISP and that the provider has agreed to serve the participant. The provider must mail the ISP, page 2, back to the case manager within two days of receipt. An AFC provider can decide if he can serve the particular applicant and may refuse to serve a CBA participant referred to his home. He would document the referral on Form 3671, page 2.
  • The case manager prepares and mails Form 2065-B, Notification of Community Based Alternatives (CBA) Services, and Form 3671, page 2 to the adult foster home provider authorizing CBA services, listing both initial and ongoing copayments. If the case manager has negotiated a service initiation date with the provider, he must also send Form 2067, Case Information, documenting the service initiation date negotiated with the provider.
  • Once the participant is residing in the adult foster home, the case manager visits and completes Form 2331, Client Monitoring – Adult Foster Care.

4230  Provider and Home Qualifications

Revision 02-4; Effective Upon Receipt

4231  CBA AFC Provider Qualifications

Revision 02-4; Effective Upon Receipt

STANDARD.

  1. All service providers must comply with all applicable state laws relating to medical and nursing practices.
  2. All Community Based Alternatives (CBA) adult foster care providers must meet the qualifications for the appropriate classification levels as specified in Section 4242.2, CBA Classification Levels of Adult Foster Care Homes.
  3. CBA adult foster care providers involved in the care of participants must be responsible, mature, healthy adults (18 years of age or older) capable of meeting the needs of the participants in the home.
  4. CBA adult foster care providers must be physically and mentally able to perform all the required duties.
  5. CBA adult foster care providers must be able to communicate directly with the participant and the participant's family.
  6. CBA adult foster care providers must show evidence of an examination for tuberculosis. This examination must be current within six months prior to the date of enrollment and must be obtained from a licensed physician or a local health department. If test results are positive, a physician's statement is required documenting that the disease is non-communicable.
  7. CBA adult foster care providers must not deliver direct services when they have a communicable disease or illness but ensure that participant needs are met by an approved substitute provider.
  8. CBA adult foster care providers must ensure that persons whose behavior or health status endangers the participants will not be allowed at the home.
  9. CBA adult foster care provider families must provide at the time of application three references from persons not related to the provider or substitute.
  10. CBA adult foster care providers may provide services to their own relatives as CBA participants.

"Relative" in this context is defined as someone other than the spouse. The relative must meet all qualifications for CBA AFC and may include grandparent, parent, aunt, uncle, brother, sister, cousin, or adult child.

  1. The CBA adult foster care provider must live in and share the same household (have common living areas) with the participants. Detached living quarters do not constitute the same living area.
  2. The CBA adult foster care provider must be the primary caregiver, personally performing the majority of the care for the participants, living and sleeping in the home.
  3. The CBA adult foster care provider must be the owner or lessee of the adult foster home.

For a description of verification procedures for the above requirement, refer to Section 2300 of this manual. The CBA adult foster care provider may work outside the home as long as he is the primary caregiver and has an approved substitute in residence when the provider is working.

  1. Individuals who are disqualified under Chapter 250, Health and Safety code may not provide CBA adult foster care services. The Department of Aging and Disability Services (DADS) will make a background check for criminal history.

DADS staff cannot request a background check for criminal history for a provider's spouse or other family members, unless the person in question is designated as a provider or a substitute.

  1. Each CBA adult foster care applicant must submit a statement providing information concerning any felony and/or misdemeanor convictions, and of any pending criminal charges.
  2. The following individuals may not provide CBA adult foster care:
    1. Anyone who has been identified by Adult Protective Services (APS) staff as a perpetrator in a validated case of abuse, caretaker neglect, or exploitation.

Anyone who has been identified by Child Protective Services (CPS) in a validated investigation has demonstrated a lack of responsibility in a caretaker role and should not be enrolled as a CBA adult foster care provider.

  1. Anyone against whom is returned:
    1. an indictment alleging commission of any felony classified as an offense against the person or family, or of public indecency, or of violation of the Texas Controlled Substances Act;
    2. an indictment alleging commission of any misdemeanor classified as an offense against the person or family, or of public indecency; or
    3. an official criminal complaint accepted by a district or county attorney alleging commission of a misdemeanor classified as an offense against the person or family, or of public indecency. The requirement shall remain in effect pending resolution of the charges. Notification of such action must be made to the department within 24 hours or the next work day.
  2. Anyone convicted of the following offenses:
    1. a felony or misdemeanor classified as an offense against the person or family;
    2. a felony or misdemeanor classified as public indecency; or
    3. a felony violation of any law intended to control the possession or distribution of any substance included as a controlled substance in the Texas Controlled Substance Act.
  1. Each CBA adult foster care provider must have at a minimum one approved substitute provider before the enrollment process is completed. Payment to the substitute is the responsibility of the primary provider. The substitute provider for a CBA AFC home must be able to perform any nursing delegated tasks according to the satisfaction of the supervising RN before assuming those duties.
  2. Substitute providers must meet requirements specified in subsections (a)–(p) of this section. DADS reserves the right to disapprove a substitute provider or attendant. The provider must orient any substitute caregiver to the participants and to the home, including the location of fire extinguishers; evacuation procedures; location of participants' records; location of telephone numbers for the participants' physicians, the provider, and other emergency contacts; location of medications; introduction to participants; and instructions for caring for each participant.
  3. Each CBA adult foster care provider must receive orientation conducted by DADS staff and covering the topics listed on the adult foster care orientation checklist before serving participants. The provider must ensure that he familiarizes all substitute providers with the topics.
  4. The CBA adult foster care provider must meet the training requirements outlined in Section 4242.2, CBA Classification Levels of AFC Homes. Training requirements do not apply to substitute providers, except for the training required to perform nursing delegated tasks.
  5. CBA adult foster care providers must demonstrate the ability to comprehend the client and provider agreements, individual plans of care, department directives, and the CBA Provider Manual.
  6. CBA adult foster care providers must demonstrate and maintain financial stability, independent of department provider payment, and the ability to meet existing financial obligations prior to enrollment and thereafter.
  7. Any other residential settings owned or operated by the provider must not be represented as DADS-enrolled homes. The provider must report Adult Protective Services or Department of State Health Services investigations of other settings to the CBA AFC specialist.
  8. CBA adult foster care providers agree to abide by all policies and procedures of the department.
  9. Grounds for denial of the application, disenrollment or non-renewal of enrollment include, but are not limited to, the submission of false information, subterfuge, or other means relating to an original or renewal application; habitual drunkenness, addiction to drugs, disorderly conduct, or the violation of any laws involving moral turpitude on the part of the home owner, family, or employees; the habitual consuming of alcoholic beverages; and willful or repeated action inconsistent with the health and safety of the participants; or repeated or gross failure to meet enrollment/licensure standards.

Whenever an AFC provider is without a substitute provider, they are out of compliance with the terms of the contract the first day the home is without a substitute.

A Level III provider must have licensed substitute providers for any Level III participants. If there are no Level III participants in the home, the substitute providers are not required to be licensed.

If a Level III provider loses a licensed substitute provider and another licensed substitute provider cannot be found, any Level III participants must be removed from the home prior to the time they would be left unsupervised or with an unlicensed substitute. A non-English speaking provider can qualify to provide CBA-AFC services if he is able to meet all the requirements of the program, which includes the ability to communicate directly with the participant and his family, and the ability to comprehend the client and provider agreements, CBA contract, ISPs, department directives, and the CBA Provider Manual.

The CBA AFC provider may be employed outside the home as long as he complies with all program requirements, including having qualified substitute providers.

4232  Excluded Personnel

Revision 02-4; Effective Upon Receipt

Effective September 1, 1989, Senate Bill 332 (House Bill 1466) passed by the 71st Legislature mandates that persons convicted of certain crimes may not be employed in most facilities and agencies providing care to persons who are aged or disabled. Therefore, providers must conduct criminal history checks on certain employees prior to an offer of permanent employment.

The provider must provide to the department the necessary information on a job applicant no later than the 72nd hour after the hour on which the person accepts temporary employment. Information is supplied on Form 5824, Request for Criminal History, which is submitted to the DADS regional data entry site. See the instructions for completing Form 5824 for further information on form completion and routing.

Providers may not employ or enter into a personal service agreement or subcontract with anyone who has been convicted of certain crimes. If a provider receives information that the individual attendant, employee, subcontractor, or personal service agreement provider is excluded because of a criminal history check, that individual may not deliver direct services to CBA participants.

The law requiring criminal history checks provides protection of confidentiality which prevents the provider or DADS from sharing with anyone the results of a criminal history check. Information obtained as a result of a criminal history check may not be shared with anyone except the employee (subcontractor, personal service agreement provider) affected and DADS.

If a provider receives inquiries from the participant, his family, potential employers, or other interested parties, the provider must explain the following:

  • that he is required by law to conduct criminal history checks on all employees,
  • that he is complying with the law, and
  • that DADS is monitoring compliance with the law.

If an AFC home loses a substitute provider, the AFC provider can employ someone on an emergency basis. The criminal history check must be done within 72 hours. The employee must furnish the employer a statement that they have not been convicted of an offense that would render them unemployable.

It is not acceptable to use local police criminal history checks in place of DADS procedure. Local police criminal history checks frequently are limited to offenses committed in their local area.

4233  Qualifications of Substitute Providers

Revision 02-4; Effective Upon Receipt

STANDARD.

All CBA substitute adult foster care providers must:

  • comply with all applicable state laws relating to medical and nursing practices;
  • be responsible, mature, healthy adults (18 years of age or older) capable of meeting the needs of the participants in the home;
  • be physically and mentally able to perform all the required duties and tasks;
  • be able to communicate directly with the participant and the participant's family;
  • show evidence of an examination for tuberculosis. This examination must be current within six months prior to the date of enrollment and must be obtained from a licensed physician or a local health department. If test results are positive, a physician's statement is required documenting that the disease is non-communicable;
  • not deliver services when they have a communicable disease or illness;
  • submit a statement providing information concerning any felony and/or misdemeanor convictions, and of any pending criminal charges; and
  • participate in the training required to perform delegated nursing tasks specified on the participant's plan of care.

Individuals who are disqualified under Chapter 250, Health and Safety Code, may not provide CBA adult foster care services. A background check for criminal history will be made.

Substitute Provider Qualifications for Levels I and II

Certain tasks provided in Levels I and II Foster Homes require the delegation and supervision of a registered nurse under applicable rules of the Board of Nurse Examiners in 22 TAC §218.1 et seq. The substitute providers for CBA adult foster care participants requiring delegated nursing tasks must be trained by the supervising RN delegating the nursing tasks.

If the substitute provider cannot be trained to perform the delegated nursing tasks to the satisfaction of the supervising RN, the CBA AFC Level I or II provider must hire a new substitute.

The substitute providers must demonstrate competence in performing the delegated nursing tasks to the satisfaction of the supervising RN prior to delivering services.

Substitute Provider Qualifications in Level III

Due to the complexity of need of the participants in Level III homes, delegation of nursing tasks is not allowed to unlicensed persons. Substitute providers must be licensed vocational nurses or registered nurses.

4234  CBA AFC Home Enrollment Requirements

Revision 02-4; Effective Upon Receipt

STANDARD.

All homes in which CBA adult foster care is provided must have:

  • bedrooms with at least 80 square feet of floor space in a single occupancy room, and at least 60 square feet of floor space per participant in a double occupancy room;
  • participant bedrooms close enough to the provider to alert the provider to night time needs or emergencies, or equipped with a call bell or intercom;
  • participant bedrooms constructed as sleeping areas when the home was built or remodeled under permit that meet local requirements;
  • participant bedrooms finished with walls or partitions of standard construction which go from floor to ceiling;
  • participant bedrooms ventilated and lighted with at least one window that will open freely and remain open from the inside without special tools;
  • a bed and sufficient drawer and closet space for each participant in the participant's bedroom;
  • no more than two beds in any room;
  • comfortable sleeping arrangements for participants;
  • at least one comfortable chair per participant in each bedroom;
  • at least one grab bar in the bathtub/shower area and a slip-proof surface in the bathtub/shower area;
  • adequate supplies of soap and toilet paper for each bathroom and individual towels and wash cloths for each participant;
  • a sketch of the home floor plan showing the dimensions and the purpose of all rooms and specifying where participants and household members will sleep. If arrangements change, the provider must give an updated floor plan to DADS staff;
  • a conspicuously posted emergency/disaster evacuation plan that specifies procedures participants follow in case of emergency, and evacuation drills at least every six months with at least one of the two required drills occurring during sleeping hours;
  • at least one working telephone available in the home for participants to make calls. The telephone number must be a listed number. Limitations on the use of the telephone must be specified in the house rules. Providers must not charge participants for the use of the telephone for local calls;
  • emergency telephone numbers including the CBA AFC specialist's number posted at or near the telephone;
  • an operational smoke detection system. Battery operated detectors are acceptable;
  • a portable A.B.C. type fire extinguisher charged and ready for use;
  • first aid supplies on the premises, as recommended by the American Red Cross;
  • at least one communal dining table with adequate seating for all participants at the same time;
  • space and furniture for participant visitors;
  • laundry service for the participants as part of the room and board rate;
  • met all applicable state and local building, zoning, and housing codes;
  • maintained, repaired, and cleaned so that they are not hazardous to participants in care (including yards). There shall be no accumulation of garbage, debris, rubbish, or offensive odors. If house pets are kept indoors, sanitation must be maintained. Swimming pools must be fenced;
  • screens on windows and doors used for ventilation;
  • equipment and furnishings that are safe for participants;
  • flammable and poisonous substances, explosives, and firearms stored and inaccessible to participants;
  • temperatures maintained at levels which are comfortable to participants. Heating and cooling systems must be in good working order. Hot water temperatures in participant areas must be between 100 and 125 degrees F;
  • food preparation areas and equipment clean, free of offensive odors, and in good repair. Utensils, dishes, and glassware must be washed in hot soapy water, rinsed, and stored to prevent contamination; and
  • soiled linens and clothing stored in containers in an area separate from food storage, kitchen, and dining areas.

4235  CBA AFC Provider Enrollment Requirements

Revision 02-4; Effective Upon Receipt

STANDARD.

For purposes of receiving payment from DADS, all CBA adult foster care homes and providers must:

  • meet all of the requirements in the CBA Provider Manual and provide care for no more than four adults, whether DADS participants or private pay residents. The home census may not exceed the capacity for which the home is enrolled;
  • serve only those CBA foster care, private pay residents, and CCAD adult foster care clients, approved by DADS;
  • not accommodate any individuals under 18 years of age who are unrelated to the provider;
  • not accommodate roomers, boarders, or other non-related residents except those individuals approved by the DADS CBA AFC specialist;
  • comply with all applicable fire, health, and safety laws, ordinances, and regulations;
  • obtain the necessary fire safety and health inspections and comply with any resulting requirements;
  • be inspected at least annually by fire safety authorities and meet or exceed the regulations. The provider must correct any hazardous conditions identified in the inspection within the time specified by the inspector, or before the department's enrollment or reassessment of the home, whichever is earlier;
  • be inspected at least annually by health authorities and meet or exceed the regulations. If local health authorities are unable to inspect the home, AFC staff may conduct the inspection using Form 2329, Health Inspection Checklist. The provider must correct any unsanitary and unsafe conditions identified by the inspection within the time specified by the inspector, or before the department's enrollment or reassessment of the home, whichever is earlier;
  • demonstrate the ability to evacuate all residents from the home within three minutes;
  • interview a prospective participant prior to or at the time of admission to determine whether the provider can meet the needs identified on the Individual Service Plan;
  • orient any new participant within 72 hours of arrival on fire safety, how to respond to a fire alarm, and how to exit from the home in an emergency; and
  • notify DADS of a change of residence prior to the change. The new home must meet all AFC requirements and be enrolled in the AFC program before payments can be made. Provider enrollment of new homes is not retroactive in non-emergency situations.

In the CBA program, the home must be enrolled prior to accepting participants, except in the case of emergency evacuations. If an emergency forces the evacuation of the CBA AFC home, the provider is to call the CBA AFC specialist by the next DADS work day to inform him of the move. The CBA AFC specialist must begin the enrollment process on the date of notification. The provider can continue to be paid for his current participants but may not accept new ones until the enrollment is completed.

The regions cannot limit provider enrollment for the CBA AFC program, in accordance with Medicaid regulations.

4236  Services Provided by CBA AFC Provider

Revision 02-4; Effective Upon Receipt

The AFC provider must provide 24-hour care in a home enrolled by DADS. Services may include, but are not limited to:

Personal care — help with activities related to the care of the participant's physical health that include but are not limited to bathing, dressing, preparing meals, feeding, exercising, grooming (routine hair and skin care), toileting, and transferring/ambulating.

Nursing tasks requiring delegation — certain nursing tasks that can only be delegated by a registered nurse in accordance with the rules promulgated by the Texas Board of Nurse Examiners.

Transportation — arranging for or directly transporting participants to meet their basic needs for food, clothing, toiletries, medications, medical care, and any necessary therapy.

Supervision — periodic checks or visits to the participant throughout the 24-hour period to assure the participant is well and safe. For some participants with more intensive medical needs or behavior problems, more supervision is required.

Meal preparation — preparation or provision of meals adequate to meet the needs of the client.

Housekeeping — activities related to housekeeping that are essential to the participant's health and comfort, such as changing bed linens, housecleaning, laundry, shopping, arranging furniture, washing dishes, and storing purchased items.

AFC services, with the exception of 24-hour supervision which is provided to all CBA participants in AFC, are provided on an "as needed" basis, with the flexibility to meet the participant's needs in the least restrictive way possible. CBA participants may not require assistance with medication, for example, or need help with transportation, but the services are available to all CBA participants in adult foster homes. Personal care tasks must be provided as identified on Form 2060, Needs Assessment Questionnaire and Task/Hour Guide. The provider may provide more services for the participant than are authorized, but not fewer.

CBA participants, as recipients of Medicaid, are entitled to medical transportation services. Transportation is provided to Medicaid-covered medical appointments. Access to scheduling medical transportation is available locally to participants.

STANDARD.

  1. Resident Care and Services. The CBA adult foster care provider must:
    1. Provide services to participants according to the Individual Service Plan (Form 3671) and the Individual/Member and Provider Agreement (Form 2327).
    2. Meet all requirements and conditions stated on the Individual/Member and Provider Agreement (Form 2327), Individual Service Plan (Form 3671) and the CBA Provider Contract (Form 3673).
    3. Ensure that an approved substitute provider is present if at least one participant remains in the home when the provider plans to be absent from the home for more than three hours in a 24-hour period. A participant whose Individual Service Plan specifies the need for 24-hour supervision may not be left without the supervision of an approved substitute provider for any period of time.
    4. Receive prior approval from the CBA AFC specialist or supervisor if the provider plans to be absent for more than 24 hours. The proposed substitute provider must have prior department approval and approval of the supervising registered nurse (RN) if delegated nursing tasks are to be performed. The provider must ensure that the substitute provider is aware of and takes responsibilities for meeting participant needs and providing services according to the participants' service plans and the requirements of the standards specified in this section. If two adults in the home have been approved as dual providers, (such as a husband and wife or mother and daughter working as a team) this notification is not necessary when one provider leaves for more than 24 hours.
    5. Ensure that participants are not abused, neglected, or exploited while in foster care. Validated reports of the provider, the provider's family, or employees willfully inflicting injury, physical suffering, intimidation, or mental anguish on any participant in the home shall constitute grounds for immediate disenrollment of the home.
    6. Notify the CBA AFC specialist when the provider, substitute provider, or a family member is the subject of an Adult Protective Services investigation. The provider must notify the CBA AFC specialist within 24 hours of the beginning of the investigation or the next work day. If the CBA AFC specialist is not available, the provider must notify the CBA AFC supervisor.
    7. Respond to, investigate, and document participant complaints; and report unresolved complaints to the AFC specialist within five days of receipt of the complaint.
    8. Have clearly defined house rules, including smoking policies. House rules must be shared with the participant before moving to the foster home.
    9. For Level I and Level II, CBA AFC providers deliver any delegated nursing tasks according to the instructions of the supervising RN.

CBA AFC Level I and Level II providers must deliver any delegated nursing tasks if the substitute provider cannot deliver the tasks according to the instructions of the supervising RN.

  1. Collect room and board payments according to the Individual/Member and Provider Agreement (Form 2327), and copayments/room and board according to Form 2065-B.
  2. Take appropriate action if the provider finds that a participant threatens the health and safety of others or himself.
  3. Provide the participant with a final accounting of the participant's funds and refund any monies owed to the participant within five days of discharge.
  1. Record Keeping.
    1. The CBA adult foster care provider must maintain for each participant a record with the following information:
      1. Records as required by the nurse on delegated nursing tasks;
      2. The name, address, and telephone numbers of the following:
        • The persons, other than DADS staff, to be notified in case of emergency, if any;
        • The participant's physician, if any; and
        • The participant's case manager and AFC specialist;
        • The registered nurse responsible for supervision for any delegated nursing task or designate substitute for the registered nurse.
      3. Current and past copies of Form 2327, Individual/Member and Provider Agreement, signed by the participant and/or responsible party, provider, and CBA AFC specialist;
      4. Current and past copies of Form 3671, Individual Service Plan (ISP);
      5. Current and past copies of Form 2065-B, Notification of Community Based Alternatives (CBA) Services;
      6. Current and past copies of Form 3252, Daily Service Delivery Record;
      7. Current and past copies of Form 3251, Daily Census Record;
      8. Current and past copies of Form 1290, Long Term Care Claim, or previous billing form;
      9. Any DADS communications regarding the participant; and
      10. If requested by the participant, personal papers of the participant, for instance, life insurance policies, burial arrangements, or savings account documentation.
    2. The CBA adult foster care provider must file claims for services according to DADS rules using the appropriate DADS forms and agree to accept the claimed amount as full payment for services provided, unless the community based alternatives participant is required to pay a copayment.

All claims must be filed before the end of the second fiscal year from the fiscal year in which the service was delivered.

  1. The CBA adult foster care provider must maintain copies of all reports and notifications made to the case manager or CBA case manager required in subsection (c) of this section.
  1. Reporting and Notification.
    1. The CBA adult foster care provider must report to the CBA case manager significant changes in the participant's physical health, mental and/or behavior status to the department within 24 hours or the next work day after awareness of the change.

During the course of a participant's stay in a foster home, he may experience changes in his condition or the care he requires. If the participant begins to need services that cannot be provided by the AFC provider, it will be necessary for the case manager, in consultation with the RN supervising the AFC provider's delivery of delegated nursing tasks to the participant, if any, to assure that the necessary care is obtained. An HCSS provider agency may provide skilled care in the AFC home for stabilization or rehabilitation.

If the short term services provided in the home by HCSS staff are not sufficient and other services are not available to support the participant in that AFC arrangement, the case manager, in conjunction with other members of the IDT, should explore alternatives. More long term chronic changes in service needs will likely require that the participant move to another AFC provider, AL/RC setting, or NF.

Physical restraints, such as leg restraints or lap belts intended to restrain a person in a chair, may be used in AFC settings only on an emergency basis. On an emergency basis, restraints may be used if written approval is obtained from the participant's physician and family and only if the restraints are for a short, limited period of time.

The AFC provider is expected to take actions necessary if the participant's condition has deteriorated and/or he has threatened the health and safety of himself or others. The provider is required to notify the case manager of actions taken on the same day of awareness. The case manager should follow the procedures identified in Section 4250, Discharge and Termination.

  1. The CBA adult foster care provider must report to the CBA case manager pending participant hospitalizations prior to the hospitalization and unplanned hospitalizations within 24 hours of the hospitalization or the next work day.
  2. The CBA adult foster care provider must report pending hospital discharges of approved participants to the CBA case manager prior to the actual discharge or on the day the participant returns to the foster care setting in order to ensure continued participant appropriateness.
  3. The CBA adult foster care provider must complete Form 3251, Daily Census Record, on a monthly basis, maintaining a record of the participants' presence or absences from the home.
  4. When a participant requests that services be terminated, the CBA adult foster care provider must notify the CBA case manager by the next work day.
  5. The CBA adult foster care provider must notify the CBA case manager immediately by phone upon becoming aware of the death of a participant, serious physical injury or distress, offense against the person or family, or public indecency. The provider must submit a written report within 48 hours of the verbal report. The provider must also notify the police of the death of a participant in the foster home, serious physical injury resulting from assault or battery, offenses against the person or family, or public indecency.
  6. The CBA adult foster care provider must notify the CBA case manager about serious occurrences involving the provider, the home, or the participants. These may include but are not limited to fire, accidents, altercations among participants, break-ins, or illness of the provider or participants. The provider must notify the CBA AFC specialist by telephone no later than the next calendar day after awareness of the occurrence.
  7. The CBA adult foster care provider must notify the CBA case manager before any participant receives home and community support services not provided through the waiver.
  8. If the CBA case manager is not available to speak with the provider, the provider must report to the specialist's supervisor or another CBA staff person any of the required notifications.
  1. Responding and Acting.
    1. The CBA adult foster care provider must, upon awareness, obtain medical attention for participants exhibiting signs of physical injury, pain or discomfort.
    2. The CBA adult foster care provider must seek medical attention or care on the same day of awareness for participants exhibiting acute changes in physical, mental, or behavior status.
    3. The CBA adult foster care provider must follow DADS adult foster care directives related to participant care within the specified time frames.
  2. Nutrition.
    1. Participants must be provided with at least three meals daily which meet each participant's dietary and nutritional needs. The same foods must be made available to the participant and provider unless a special diet is prescribed.
    2. CBA adult foster care providers must consider participants' food preferences and make reasonable accommodations within their dietary needs.
    3. The provider must serve a variety of foods within the participants' dietary needs.
    4. Special diets are to be followed as prescribed in writing by the participant's physician.
  3. Medications.

    The CBA adult foster care provider must comply with the following rules regarding the storage and management of medications.

    1. Prescription medication must be in the original container labeled with the participant's name, date, instructions, name of medication and dosage, and the physician's name.

The original container may be individual bottles, bubble packs, or med-packs, as received from the pharmacy or in med-packs as prepared by the registered nurse (RN) of the Home and Community Support Services (HCSS) agency.

  1. Medications requiring refrigeration must be separated from food in a clearly labeled, designated, and locked container.
  2. Medications must be transferred with the participant when the participant leaves the home. Medications must be disposed of when participant medication regimens are changed or when the medication is out of date. Medications must be disposed of by returning the unused medication to the dispensing pharmacist for destruction, as referenced in Texas State Board of Pharmacy Manual, page 392.
  3. Medications prescribed for one participant must not be taken by or given to any other participant.
  4. The provider must ensure that participants take over-the-counter medications according to the package directions. Excessive use of these medications must be reported to the case manager.
  5. The CBA adult foster care provider must ensure that all medications are taken as prescribed and in a timely manner according to the instructions on the medication label or instructions from the participant's physician.
  6. The CBA adult foster care provider may administer medications only as allowed by state law or regulation.
  7. Prescription medications in their original containers, must be kept in a locked container, unless a waiver from the requirement has been granted by the waiver manager.
  1. Participant Rights and Responsibilities
    1. The CBA AFC provider must inform the participant verbally and in writing, before or at the time of admission, of his rights and responsibilities. The rights and responsibilities include rules governing participant conduct, complaints, bedhold policies for hospital and personal leave, and eviction procedures. The policies must not violate the Community Based Alternatives Adult Foster Care rules of this title nor adversely affect the resident's health or safety. All policies must have an effective date. If the provider amends its policies, each participant must be informed before the change becomes effective. A written copy of these policies must be given to the participant to initial and date and must be filed in the participant's casefolder. A copy of the policies also must be given to the participant. If the participant is unable to understand the policies, a copy must be given to the person responsible for him, if there is such a person.
    2. The CBA AFC provider must
      1. allow the participant to manage his finances and/or trust funds. The provider must provide assistance to the participant in managing his finances only if the participant requests assistance in writing.
      2. within five work days from the receipt of the report investigate all problems or deficiencies and non-compliance with policies, procedures, and standards which are reported by the participant. A copy of the documented complaint and resolution must be submitted to the CBA AFC specialist within 30 days of the receipt of the report.
      3. provide all participants with a general orientation about their needs and tasks to be provided before or at the time service begins.
      4. not require participants to perform services for the provider or other participants.
    3. The participants are to be treated with dignity and respect. The provider must guarantee certain basic rights to participants living in their homes. Such rights include the right to privacy; humane care and environment; safety of personal possessions and funds; receipt of visitors; confidentiality of personal records; freedom of religion; freedom from physical or mental abuse, neglect and exploitation; freedom from physical or chemical restraints; freedom from financial exploitation; and the right to voice grievances without retribution or intimidation.
  2. Transportation.

    CBA adult foster care providers must provide or make arrangements to meet the transportation needs of participants for medical appointments and care, shopping for personal needs, and church activities as identified by the CBA AFC specialist. An escort for participants must also be provided if specified in Forms 2060 and 2060-A.

  3. Provider Rights.
    1. Each provider must post a providers' bill of rights in a prominent place in the foster home.
    2. The providers' bill of rights must state that the CBA adult foster care provider has the right to:
      1. be shown consideration and respect that recognizes the dignity and individuality of the provider;
      2. terminate the client/provider agreement after a written 30-day notice;
      3. refuse to perform services for the participant or the participant's family other than those specified in the client/provider agreement;
      4. refuse to accept a person referred to the foster home if the referral is inappropriate;
      5. refuse to allow the presence of illegal drugs and weapons in the home; and
      6. be made aware of a participant's problems, including aggressive or violent behavior, disease, alcoholism, or drug abuse.
  4. Termination of Services.

    CBA Adult Foster Care providers cannot terminate AFC services to participants without the prior approval of the case manager, and must follow established procedure of providing 30-day written notice with an exception for a participant whose behavior or condition threatens the health or safety of himself or others.

See Section 4250, Discharge and Termination.

If the nurse assessment determines a need for nursing tasks that can be delegated to an AFC provider, these nursing tasks will initially be provided by the registered nurse until the decision is made to delegate. If the RN will not delegate the nursing tasks, the case manager will consider the alternatives available.

Ongoing nursing intervention is available to CBA participants; however, if delegation of nursing tasks to the AFC provider is not possible, each case will be reviewed on an individual basis. The case manager will discuss the available options to the CBA participant. As long as the cost of care does not exceed the cap for services, the participant is free to choose how the service is delivered or the placement he prefers.

Any non-waiver services received by the CBA AFC participants must be reported to the case manager according to the requirements listed above in Item (c), Reporting and Notification, Subitem (8). Depending on the funding source for such service, non-waiver services could impact the participant's continued eligibility for the CBA program.

During the 30 days after written notice is served to the participant to vacate the adult foster home, the case manager will be responsible for working with the participant to assure alternative services will be available.

4237  Other Services Available to CBA AFC Participants

Revision 02-4; Effective Upon Receipt

Adaptive Aids and Medical Supplies — The CBA AFC participant is eligible to receive needed adaptive aids and medical supplies under the CBA program. Adaptive aids and medical supplies are defined as devices, controls, or medically necessary supplies which enable persons with functional impairments to perform activities of daily living or control the environment in which they live.

Nursing Services — Nursing services available through the CBA program will provide ongoing nursing intervention for Level I and Level II participants with chronic medical conditions and include activities related to the delegation of specific nursing tasks to designated attendants and AFC providers.

Minor Home Modifications — Minor home modifications are those services which are necessary to adapt the home environment to the individual's disability or medical condition. Minor home modifications will be limited to those modifications identified and approved by DADS on the ISP.

The CBA AFC provider will have to be willing to have modifications made to the home if the participant requires the minor home modifications be made so the home will meet the participant's needs. If the provider is the lessee of the home, the owner must be contacted and apprised of the needed modifications. Permission to make the modifications must be obtained from the home owner in writing and kept with Form 3671-D, in the HCSS's files.

If a CBA applicant or participant needs minor home modifications and wants to reside in an AFC home, the case manager must inform him of the special circumstances regarding the provision of modifications in an AFC home. Because the AFC provider's rights as a landlord are protected by law, the AFC provider must be told of any known modifications prior to the participant's move into the AFC home. The provider, or the owner of the home if the provider is a lessee, must agree, in writing, to any modifications planned for his home. The written permission must be kept with Form 3671-D, ISP Minor Home Modifications, by the HCSS provider delivering services to the participant.

If the AFC provider, or home's owner, refuses to allow the modification, the case manager must find an alternate living arrangement for the participant as the provider cannot be forced to accept the participant or make the modifications. If the AFC provider, or owner, agrees to the modifications, the participant and the provider include information on the proposed modifications in the Miscellaneous Arrangements section of Form 2327, Individual/Member and Provider Agreement.

The participant needs to understand that once a modification is made, it remains with the home regardless of the participant's movement from that residence for any reason. An AFC provider has the right to determine who lives in his home and may decide, as is his right, that the participant for whom the modification was installed can no longer live in the AFC home. The cost of the modification is deducted from the participant's $7500 program enrollment limit which will not increase because the participant moves to another location, unless the regional nurse has approved exceeding this limit.

In an effort to protect the participant and the provider, additional requirements include:

  • a minimum grace period of 30 days from the date the participant is authorized for services must be allowed prior to beginning any modifications; and
  • if modifications costing $1000 or more have been made to the home, the provider must agree not to request alternate placement for the participant for six months from the date the modification is completed, unless it is by mutual consent.

A waiver to the 30-day grace period can be made on a case-by-case basis if the health and/or safety of the participant is jeopardized without the necessary modifications upon entry into the AFC home, based on the recommendations of the IDT and approval by the case manager.

The agreement to keep the participant for six months should be addressed in the Miscellaneous Section of Form 2327, Individual/Member and Provider Agreement. All rules regarding unacceptable behavior or health and safety issues take precedence over the agreement. If the participant behaves in a way that endangers himself or others, the provider must take appropriate action, including eviction of the participant in extreme situations.

If more than one CBA participant in the same AFC home is in need of the same modification, such as a wheelchair ramp or bathroom modification, and the modification is identified on each participant's ISP, the cost of making the modification can be shared, with each participant's share of the total being applied to his cap for the service. If another participant moves into the AFC home after a modification has been installed and billed, he is not required to share in the cost and his ISP must not include this modification.

When the provider and participant meet to interview each other and complete Form 2327, Individual/Member and Provider Agreement, the minor home modifications should be listed in "Miscellaneous Arrangements." Both participant and provider should sign the form agreeing to all included information and stipulations.

To save the participant from spending his allocation for minor home modifications unnecessarily, a minimum grace period of 30 days should be allowed for adjustment of the placement before any modifications are begun.

If the health and/or safety of the participant is jeopardized without the necessary modifications upon entry into the AFC home, a waiver of the 30-day period can be made based on the recommendations of the IDT and approved by the case manager.

In the CBA program DADS will pay up to $7,500 for modifications. Once that cap is reached, only $300 per year per participant will be allowed for repair, replacement, or additional modifications.

If more than one participant is in need of the same minor home modifications, such as a wheelchair ramp or rails in the bathroom, and the modification is identified as a need in each participant's ISP, the cost of making the modification can be shared, with the participant's share of the total being applied to his cap for the service.

Minor home modifications remain in a CBA adult foster home even if the participant for whom the modifications were made permanently leaves the home.

Occupational Therapy — Occupational therapy services consist of the full range of activities provided by an occupational therapist, or a licensed occupational therapy assistant, if under the direction of a licensed occupational therapist and within the scope of his state licensure.

Physical Therapy — Physical therapy services consist of the full range of activities provided by a physical therapist or a licensed physical therapist assistant, under the direction of a licensed physical therapist and within the scope of his state licensure.

Speech Pathology Services — Speech pathology services consist of the full range of activities provided by a speech-language pathologist, or a licensed associate in speech-language pathology, under the direction of a licensed speech-language pathologist and within the scope of his state licensure.

Each of the above services will be provided according to the needs of the participant as identified on his ISP. The case manager will make referrals for the services and coordinate delivery.

If the CBA AFC participant has third party resources that can be used to provide any of the above services, the case manager will be responsible for accessing these resources for the participant.

A CBA AFC participant may not receive personal assistance services while a resident in a CBA AFC home.

4240  Provider Enrollment

Revision 02-4; Effective Upon Receipt

4241  Application to Become a CBA AFC Provider

Revision 02-4; Effective Upon Receipt

To be enrolled as an Adult Foster Home in the CBA program, both the provider and the provider's home must meet the following requirements. When an individual shows interest in becoming an AFC provider for the CBA program, the CBA AFC specialist provides the applicant Form 2324, Application to Provide DHS Adult Foster Care, Application for Participation in the CBA Program, contract certification forms, Form 3673, CBA Contract, and a copy of this section.

4241.1  Visit to Assess the Home

Revision 02-4; Effective Upon Receipt

The CBA AFC specialist is responsible for enrolling the provider to become a CBA AFC home. The worker completes Form 2323, Assessment of Provider and Adult Foster Care Home, and explains the deficiencies to the potential provider should the home not meet minimum standards and requirements.

4241.2  Enrollment of the Home

Revision 02-4; Effective Upon Receipt

When the prospective home has passed inspection for fire safety and health conditions and meets all DADS standards, the home is enrolled by the CBA AFC specialist. Form 3673, CBA Contract, is completed and signed. The provider must have a Payee Identification Number (PIN) to receive payment. Form 4109, Application for Payee Identification Number, is completed at the time of enrollment by the AFC specialist and is forwarded to fiscal division for the assignment of the PIN number. If a provider billing is submitted before the PIN number is assigned by Fiscal Division, the entire billing will be rejected.

4241.3  Reassessment of CBA AFC Provider

Revision 02-4; Effective Upon Receipt

The CBA AFC provider must be reassessed by the AFC specialist within 12 months from the date of the previous assessment. Form 2323, Certification/Assessment of Adult Foster Care Home, is used for reassessment of the home and provider. Fire safety and health inspections must be updated annually. The CBA Adult Foster home may not be reassessed until all necessary inspections have been performed.

If at the time of reassessment the provider fails to meet qualifications, the CBA AFC specialist must take appropriate action, which could include termination of the contract.

The CBA AFC contract is procured under provider enrollment. There is no termination date to the contracts. Therefore, there is no need to generate a renewal contract at the time of reassessment.

4242  CBA Payment Levels of Adult Foster Care Homes

Revision 02-4; Effective Upon Receipt

STANDARD. Reimbursement for Adult Foster Care services is based on the level of the participants' assessed need and the actual days of service delivery. Adult Foster Care providers must meet the qualifications for each classification of Adult Foster Care Home, as specified in Section 4242.2, CBA Classification Levels of AFC Homes. To receive the Adult Foster Care II reimbursement rate, the Adult Foster Care provider must directly provide the personal care or delegated nursing tasks that qualified the participant to be assessed for that payment level.

4242.1  Classification Levels of AFC Participants

Revision 02-4; Effective Upon Receipt

STANDARD. Classification of Adult Foster Care participants is based on their assessed needs for care as follows.

  1. Level I Adult Foster Care Participant. Certain tasks provided in Level I foster homes may require the delegation and supervision of a registered nurse under applicable rules of the Board of Nurse Examiners in 22 TAC §218.1 et seq. The participants need less complex assistance with tasks or supervision than those of Level II or Level III. Level I NF participants may require assistance with personal care tasks or one or more of the following nursing tasks which may require delegation by an RN.
    1. collecting, reporting, and documenting data including, but not limited to:
      1. vital signs, weight, intake and output, clinitest and hemetest;
      2. changes from baseline data established by the RN;
      3. behaviors related to the plan of care.
    2. reinforcement of health teaching planned and/or provided by the RN;
    3. non-invasive and non-sterile treatment/procedures; and
    4. ambulating.
  2. Level II Foster Care Participant. Certain skilled tasks in Level II foster homes may require the delegation and supervision of a registered nurse under applicable rules by the Board of Nurse Examiners in 22 TAC §218.1 et seq. These participants can require the same personal care tasks or delegated nursing tasks as in Level I with the same or increasing complexity and have in addition, medical conditions requiring at least one of the following more skilled tasks:
    1. direct administration of oral medications or administration of medications through permanently placed feeding tubes, or sublingually, including eye, ear, and nose drops, and vaginal or rectal suppositories;
    2. elimination procedures to include vaginal irrigations, cleansing enemas, and intermittent catheterizations;
    3. positioning and turning;
    4. feedings via permanently placed gastrostomy tube;
    5. non-sterile procedures, such as dressing or cleansing penetrating wounds and deep burns;
    6. care of broken skin other than minor abrasions or cuts generally classified as requiring only first aid treatment;
    7. sterile procedures involving a wound or an anatomical site which could potentially become infected;
    8. invasive procedures, such as inserting tubes in a body cavity or instilling or inserting substances into an indwelling tube (excluding a permanently placed gastrostomy tube); or
    9. participants who are determined by the RN to exhibit confusion, disorientation and behavior problems, as validated on the 3652-A (CARE) by having a "3" or "4" on field 60 and/or a "3" on one or more of fields 62–64.
  3. Level III Foster Care Participants. Skilled tasks in Level III homes must be provided by a licensed registered nurse, licensed vocational nurse, or substitute registered nurse or substitute licensed vocational nurse. These participants have a medical disorder, diseases, or both with a related impairment being so complex or of such sufficient seriousness that their needs exceed the care which may be delegated to an unlicensed person. These participants require timely assessment, planning, and intervention by a licensed nurse on a 24-hour basis.

The level of each CBA AFC home will be determined at the time of provider enrollment or reassessment, based on the level of the provider's experience and training. Once a provider is enrolled, he will be notified by letter of any change in the level of participants he may accept. A copy of the letter will become part of the contract file kept by the CBA AFC specialist.

Although a CBA AFC provider may be designated a Level I or Level II, he may not perform delegated nursing tasks until he has demonstrated his ability to perform such tasks to the satisfaction of the supervising RN. A licensed nurse that operates a Level I or Level II home must provide the nursing care directly to the participant. The licensed nurse would be paid at the participant's level, either Level I or II of the participant.

The licensed nurse of the AFC home determines if the level of the participant is Level III. If the case manager has a concern about whether a participant is classified as Level III, he must ask the regional DADS nurse to assess participation. The determination of DADS is final.

4242.2  CBA Classification Levels of AFC Homes

Revision 02-4; Effective Upon Receipt

STANDARD.

  1. Adult foster care providers must meet the requirements specified in the Adult Foster Care section of the Department of Aging and Disability Services' Community Based Alternatives Provider Manual, and have the following experience and training in order to be classified as a certain level home and to be able to accept participants appropriate to the home. All service providers must comply with all applicable state laws relating to medical and nursing practices.
    1. Level I Adult Foster Home. Certain tasks provided in Level I foster homes may require the delegation and supervision by a registered nurse under applicable rules by the Board of Nurse Examiners in 22 TAC §218.1 et seq. The provider must have six hours of training in AIDS/HIV, cultural diversity, CPR, and first aid, within twelve months of enrolling a CBA participant. Upon completion of the initial six hours of training, six hours of annual ongoing training are required from the following topics until all topics are covered:
      1. Medications and reactions.
      2. Vital signs.
      3. Behavior management.
      4. Diseases/illnesses of the elderly.
      5. Infection control.

After receiving training on the above listed topics, the provider may select training from the list of topics offered to Level II providers.

If an AFC provider does not provide any nursing tasks, either directly as a licensed nurse or through delegation from the HCSS RN, the AFC payment level is Level 1. If the AFC provider is no longer providing any delegated nursing tasks, as in the situation when the HCSS RN refuses to continue to delegate to the AFC provider, the AFC payment level reverts to Level 1, the ISP registration must be changed to AFC Level 1, and nursing hours delivered by the HCSS nurse are authorized on the ISP.

  1. Level II Adult Foster Home. Certain skilled services provided in Level II foster homes require the delegation and supervision of a registered nurse under applicable rules by the Board of Nurse Examiners in 22 TAC §218.1 et seq. The provider must have at least two years experience in direct participant care, have completed AIDS/HIV, cultural diversity training, CPR, and first aid, and twelve hours of ongoing training annually in at least three of the following topics:
    1. Medications and reactions
    2. Vital signs
    3. Behavior management
    4. Diseases/illnesses of the elderly
    5. Reality orientation
    6. Death and dying
    7. Working with difficult participants
    8. Special skin care needs
    9. The aging process
    10. Activities and exercise for the elderly and persons with disabilities
    11. Listening skills/communication

Two years experience in direct participant care is defined as hands-on experience caring for elderly or disabled people during a two- year time span. It does not have to be daily care for the two-year period. It does not have to be a paid position. However, if it is not a paid position, there must be written documentation, such as letters of reference, specifying what services the individual was providing.

In many AFC situations, the HCSS RN will delegate nursing tasks to the AFC provider. If the RN determines the nursing tasks cannot be delegated to the AFC provider, the nursing tasks may not be provided by the AFC provider. If the RN determines that the nursing tasks can no longer be delegated to the provider or the substitute provider, the delegation will cease immediately. Direct provision of nursing services by the HCSS agency will be provided to the participant to meet his identified nursing needs and are billed as nursing services. The RN notifies the case manager

  • by telephone on the next DADS work day after the delegation stopped or the decision to not delegate was made, and
  • within five work days via Form 2067 which documents the rationale for nondelegation and how the participant's nursing needs will be met.

The case manager must revise the ISP to authorize the nursing service hours requested by the HCSS provider effective the date the HCSS provider began providing the additional nursing hours.

If the substitute provider cannot be delegated to for reasons related to his competence, the AFC provider is responsible for locating another substitute to whom the RN can delegate.

The case manager must consider alternate arrangements after he has been notified that the nursing tasks cannot be delegated to the AFC provider. Alternate arrangements may include making a referral to Day Activity and Health Services (DAHS) services to provide nursing needs in the DAHS setting.

  1. Level III Adult Foster Home. The provider must be a licensed nurse with current CPR certification, and maintain proof of ongoing continuing education units as required by the Texas Board of Nurse Examiners or the Texas Board of Licensed Vocational Nurse Examiners.
  1. Providers with CBA participants may not care for more than one totally dependent participant. Level II participants cannot be served in Level I foster homes and Level III participants cannot be served in Level II or Level I foster homes.

If a licensed nurse wants to contract for an AFC Level II home, she does not have to meet the experience requirements for a Level II home.

The recommendations of the HCSS nurse regarding the appropriate level of AFC must be considered. An applicant can be placed at a higher level of home than the one recommended on Form 3671-C, but cannot be placed at a lower level home than the one recommended by the HCSS nurse. In the CBA program, the participant receives care in one of three levels of AFC based on his needs.

4242.3  Licensed Nurse Provider Options

Revision 12-1; Effective February 10, 2012

STANDARD.

  • A licensed nurse choosing to enroll as a Level I or Level II provider must meet all training requirements for that level home.
  • A licensed nurse choosing to operate a Level I or Level II home must perform all required nursing tasks and personal assistance services for individuals living in the home, no matter the level of the individual.

The nurse will only be paid at the level of the individual, Level I or Level II. There will not be any Home and Community Support Services Agency (HCSSA) involvement in supervision or training. A licensed RN operating a Level I or Level II home will be able to delegate to his substitute provider.

The only nursing services the HCSSA nurse will provide in any level CBA Adult Foster Care (AFC) home run by a licensed nurse is the Medical Necessity (MN) and Level of Care Assessment for a Resource Utilization Group (RUG) reset, the annual MN determination and the semiannual nursing assessment.

An individual residing in a Level III home may not attend a Day Activity and Health Services (DAHS) facility. An individual residing in a Level I or Level II home run by a nurse may attend a DAHS facility.

4250  Discharge and Termination

Revision 02-4; Effective Upon Receipt

Any participant whose medical condition or behavior threatens the health and/or safety of himself or others is subject to discharge without notice from a CBA Adult Foster Home.

The CBA AFC provider must take appropriate action if the participant's medical condition has deteriorated and he requires more skilled intervention to ensure his health and safety. Depending on the participant's condition, appropriate action could be calling Emergency Medical Services, the participant's physician or the RN working with the participant. If some action is taken by the AFC provider, the provider must inform the CBA AFC specialist and CBA AFC case manager on the same day of awareness.

The case manager must then work with the specialist, should another level of CBA AFC home be appropriate, or with providers of other services to arrange alternate placement where the participant's needs can be met.

The CBA AFC provider must take appropriate action if the participant's behavior has deteriorated and he threatens the health and safety of himself or others. Depending on the participant's behavior, appropriate action could be calling the police or sheriff's department, the participant's physician, the RN working with the participant, or the CBA AFC case manager. The participant must be removed from the home as soon as possible if he becomes a threat to the health or safety of himself or others.

In some instances, the CBA AFC case manager may call Adult Protective Services if hospitalization for psychiatric observation seems warranted.

The CBA AFC case manager must mail or give a completed Form 2065-B to the participant within three days of receiving information regarding the incident. The effective date on Form 2065-B is the date the form is dated and mailed/given to the participant, even if the decision is appealed. Though the participant may not be denied all services through CBA, he has a right to appeal the decision to remove him from the CBA Adult Foster Home.

The participant may not remain in the CBA Adult Foster Home during the appeal process. The CBA AFC case manager must work with APS or providers of other CBA services to arrange alternate placement for the participant.

4260  Monitoring Quality of Care

Revision 02-4; Effective Upon Receipt

STANDARD.

  1. The quality of care provided to waiver participants residing in Adult Foster Homes will be monitored at regular intervals by the case manager, the adult foster care specialist, and the registered nursed responsible for the delegation and supervision of nursing tasks.
  2. The case manager will contact waiver participants in adult foster care homes monthly for the first 90 days and quarterly thereafter. One of the initial contacts made during the first 90 days must be a visit.
  3. The registered nurse responsible for the delegation of nursing tasks will specify the interval required to supervise and monitor the adult foster care provider's performance of the nursing tasks in the nurse's delegation/treatment plan for each participant in accordance with applicable rules by the Board of Nurse Examiners in 22 TAC §218.1 et seq.

4270  Copayment and Leave Policies

Revision 02-4; Effective Upon Receipt

4271  CBA AFC Provider Copayment Procedures

Revision 02-4; Effective Upon Receipt

STANDARD. The CBA AFC provider must collect the copayment from the participant. The provider must keep receipts for all copayments collected. The provider must deduct the copayment amount (authorized on Form 2065-B) from reimbursement claims submitted to the department.

In CBA AFC, the copayment for each participant will be determined by CBA staff. The copayment amount is listed on both Form 3671 and Form 2065-B; Form 2065-B is used to report to the participant the amount of his copayment for the first month of authorized service and subsequent months. The CBA AFC provider will also receive a copy of Form 2065-B.

Couples entering an AFC home with incomes of less than twice the federal Supplemental Security Income (SSI) benefit rate for an individual do not have sufficient income to pay the full amount of room and board charges for two individuals. Providers will be encouraged to accept those individuals but retain the option of refusing to accept individuals who cannot pay the full room and board charges. If an individual does not have enough money to pay his full room and board payment, the AFC provider may choose to accept this individual as a resident of the home but is not required to do so.

4272  Participant Copayment and Room and Board Requirements

Revision 02-4; Effective Upon Receipt

STANDARD. The participant must pay his copayment and room and board charge by the eighth day of the month. If the participant does not pay the required fees, he may not be eligible for CBA Adult Foster Care services.

The room and board charge, as of January 1, 2002, for an individual, is fixed at $545.00, the SSI federal benefit rate minus a personal needs allowance of $85.00. The daily rate for room and board is fixed at $15.13. It must not be prorated to any other amount. If the room and board should change, the provider and the participant will be informed prior to the change.

The case manager must explain the copayment requirement and room and board charges. Every CBA AFC participant must pay room and board to the provider. Copayment is not required of SSI recipients. Copayment is required from those participants whose financial eligibility was determined under the special institutional criteria. The case manager must:

  • verbally notify the participant and the provider of the amounts to be collected and include this information on Form 2327, Individual/Member and Provider Agreement, and Form 2065-B; and
  • assist the participant and provider in resolving problems related to collection of the participant's copayment and room and board contributions.

The case manager must explain to the participant that failure to pay his room and board charges or copayment will result in termination of his CBA services.

If a CBA AFC participant does not pay his copayment and/or room and board, the case manager must investigate the participant's failure to pay. The case manager will contact the participant to learn the reason the fees were not paid. Even if there is a legitimate reason, such as the participant's income check has not been received by the 8th of the month, for the non-payment of the required fees, the participant is still under obligation to pay the fees. Grievances between the participant and the CBA AFC provider are not legitimate reasons for the participant to withhold payments due. Such grievances must be resolved through the intervention of the CBA AFC specialist and the case manager.

If the participant simply refuses to pay the fees, or there is no legitimate reason for his failing to pay, the case manager writes a letter to the participant or the participant's responsible party explaining the consequences of continued refusal to pay. If the participant does not pay his required fees within 30 days of the due date, the case manager can terminate AFC services to the participant. The participant can then be evicted from the home, according to local eviction ordinances and procedures.

4273  Hospital Leave

Revision 02-4; Effective Upon Receipt

STANDARD. To reserve his space during hospital stays, the Community Based Alternatives participant must pay his daily bedhold charge which is his room and board rate.

The CBA AFC provider does not bill the department for days the CBA participant is hospitalized. The participant's room and board charge constitutes the entire payment to the provider when a participant is hospitalized.

4280  General Billing and Claims Payment

Revision 02-4; Effective Upon Receipt

4281  CBA AFC General Billing and Claims Payment

Revision 02-4; Effective Upon Receipt

STANDARD.

  • The Community Based Alternatives (CBA) Adult Foster Care (AFC) provider may bill for the day a participant enters the AFC home but not for the day of discharge, unless discharge is due to the death of the participant.
  • The CBA AFC provider cannot bill DADS for the day the participant enters the hospital, but can bill the full rate for the day he returns from the hospital.
  • The CBA AFC provider is entitled to full payment for room and board and waiver service charges for up to 14 days of personal leave taken by the participant each calendar year.
  • The CBA AFC provider is not entitled to payment if services are not approved on Form 2065-B for CBA Adult Foster Care services.

The CBA AFC provider completes Form 1290, Long Term Care Claim, for all CBA AFC participants served during the month for which payment is requested. Form 3252, Daily Service Delivery Record, is completed for each CBA AFC participant served in the CBA AFC home during the month for which payment is requested.

4282  Reimbursement Rate

Revision 02-4; Effective Upon Receipt

STANDARD. The reimbursement rate for Community Based Alternatives (CBA) Adult Foster Care includes the amount paid by the Department of Aging and Disability Services (DADS), minus any participant copayments. In no case may the combined reimbursement from the department and the participant exceed the rate specified for CBA Adult Foster Care.

4283  CBA AFC Unit of Service Delivery

Revision 02-4; Effective Upon Receipt

STANDARD. The unit of service delivery in CBA adult foster care is one day.

4290  Documentation

Revision 02-4; Effective Upon Receipt

4291  CBA AFC Claims Payment Documentation

Revision 02-4; Effective Upon Receipt

STANDARD. The CBA AFC provider is liable for monetary exceptions if the monthly claims do not correspond with the provider's service authorization and service delivery records. The provider must maintain the following records:

  1. Form 3671, Individual Service Plan;
  2. Form 1290, Long Term Care Claim;
  3. Form 3252, Daily Service Delivery Record;
  4. Form 3251, Daily Census Record; and
  5. Form 2065-B, Notification of Eligibility for CCAD or CBA Services

The provider must document on these records

  1. that services were delivered consistently with the program requirements described in the Section 4200 of the CBA Provider Manual,
  2. the type and amount of service provided to participants, and
  3. when services were delivered.

4292  CBA AFC Trust Fund Records

Revision 02-4; Effective Upon Receipt

STANDARD. The CBA AFC provider must maintain trust fund records and

  1. have written permission from the participant to handle his personal financial affairs;
  2. keep participant trust accounts separate from the provider's operating accounts. The separate account must be identified "Trustee, (name of CBA AFC provider), Participants' Trust Fund Account";

If the AFC provider maintains a trust fund, the provider must

  • deposit the participant's monthly income into the account, and
  • write a check for the copayment and the room and board payment out of the trust fund account into the provider's operating account. Staff must not deposit the participant's monthly income into the operating account and then deposit the personal needs and room and board allowance into the trust fund account. See Appendix XI, Guidelines and Procedures for Setting Up Accounting Records for Participants' Trust Funds.
  1. make the participant trust fund records available for review by department staff during work hours without prior notice;
  2. not charge the participant for services that the provider is expected to provide for the participant;
  3. not charge the participant for banking service costs if the participant trust fund is in a pooled account;
  4. obtain and maintain current written individual records of all financial transactions involving the participants' personal funds that the provider is handling. The provider must include at least the following in the records:
    1. participant's name
    2. identification of participant's representative payee or responsible party,
    3. admission date,
    4. participant's earned interest, and
    5. transactions. The provider may choose one of the following options:
      1. Maintain records of the date and amount of each deposit and withdrawal, the name of the person who accepted the withdrawn funds, and the balance after each transaction. Each withdrawal must be signed by the participant. If the participant is unable to sign when funds are being withdrawn from his trust funds, the transactions or receipt must be signed by a witness.
      2. Maintain signed receipts indicating the purpose for which any withdrawn funds were spent, the date of expenditure, and the amount spent. The receipt must be signed by the person responsible for the funds and the participant. If the participant is unable to sign his name, a witness must sign the transaction or receipt.
  5. distribute the interest earned on any pooled interest banking account in one of the following options:
    1. prorated to each participant on an actual interest earned basis, or
    2. prorated to each participant on the basis of his end-of-quarter balance.

Trust fund receipts — The following information must be included on the receipt for all money that is received or deposited in the participant's trust fund:

  • name of participant;
  • date the money was received;
  • source of the money;
  • amount received; and
  • amount returned to the participant, if any.

All records pertaining to the participant's trust fund must be kept in the manner designated above, and available for monitoring without notice.

4293  CBA AFC Copayment and Miscellaneous Records/Receipts

Revision 02-4; Effective Upon Receipt

STANDARD. The provider must ensure that records include written receipts for all purchases and payments made by or for participants.

Copayment Receipts — The following information must be included on copayment and room and board receipts:

  • the name of the participant,
  • date receipt was written,
  • period covered by the copayment,
  • amount of money received, and
  • amount of money returned to the participant, if any.

Copayment and Room and Board Refunds — If the refund to the participant is made

  • in cash, the receipt must be signed by the participant or responsible party.
  • by check, the payee on the check or signed receipt must be the participant or responsible party.

If the signature of the participant cannot be obtained, the signature of a witness must be obtained. Receipts include cash register tapes or sales statements from a seller. Some exceptions to this requirement are items purchased from vending machines, for example, soft drinks, candy, cigarettes, and items costing less than one dollar.

4294  CBA AFC Client/Provider Agreement

Revision 02-4; Effective Upon Receipt

The case manager, before authorizing or reauthorizing (CBA) AFC, completes Form 2307 or 2307-S, and Form 2327, Client and Provider Agreement, and discusses it with the participant (and family/responsible person) and the provider in a joint meeting. All conditions of the agreement and the following topics must be covered in the discussion.

  • A full description of the care needs of the CBA participant and the services, and the schedule of care to be given to the participant by the CBA AFC provider, as well as the care to be delivered by a licensed registered nurse;
  • The beginning and ending date of the agreement;
  • A detailed description of the rights and responsibilities of the CBA participant and provider;
  • An explanation of the CBA participant's and the provider's right to privacy and confidentiality;
  • The monthly dollar amount the CBA participant agrees to pay the provider for room & board, as documented on Form 3671 and Form 2065-B, as well as trust fund arrangements should the CBA participant request such service from the provider;
  • An inventory of personal effects;
  • The names, addresses, and telephone numbers of the persons to be notified in an emergency, including the CBA participant's primary physician and family members/responsible person;
  • Any special conditions, habits, and needs of the CBA participant and any special arrangements or agreements between the CBA participant and the provider; and
  • The rights and responsibilities of both the CBA participant and the provider for notifying the case manager of all crises or problems, such as illnesses; the need for the RN to return to examine the CBA participant; hospitalizations; acts of violence; accidents; complaints about abuse, neglect, or exploitation; medication reactions; and other conditions that reflect changes in the CBA participant's condition and might affect the appropriateness of the placement. For CBA participants, any such changes or incidents must be reported within 24 hours of occurrence.

4295  Provider Contract File

Revision 02-4; Effective Upon Receipt

The following information should be kept in the provider's contract file:

  • Community Based Alternatives Contract
  • Application for Participation — Community Based Alternatives Program
  • Form 2031, Corporate Board of Directors Resolution (if applicable)
  • Form 2037, Contractors Accounting Questionnaire
  • Form 2046, Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion for Covered Contracts (if applicable)
  • Form 2047, Certification Regarding Federal Lobbying (if applicable)
  • Form 4732 and 4732-A (the latter only if applicable), Non-governmental Contractor Certification
  • HCFA Form 1513, Ownership and Control Interest Disclosure Statement
  • Form 2323, Assessment of Provider and Adult Foster Care Home
  • Form 2324, Application to Provide DHS Adult Foster Care
  • Form 2327, Individual/Member and Provider Agreement
  • Fire and health inspection reports
  • Documentation about the provider's references
  • Correspondence about complaints and documentation of subsequent investigations
  • Letters notifying the provider of noncompliance or termination
  • Case narrative, including information of the manner in which the provider will maintain the participant's trust fund (if applicable)
  • A roster of current and previous residents living in the home.
  • Documentation of all training received.
  • Copy of the floor plan of the home.
  • Copy of the deed, mortgage information, or lessee agreement for the home.

4300  Contracting to Provide Assisted Living and Residential Care Services

Revision 04-1; Effective April 16, 2004

4310  Subchapter A, Introduction

Revision 04-1; Effective April 16, 2004

46.1  Purpose

Revision 04-1; Effective April 16, 2004

This chapter establishes the requirements for facilities contracting to provide assisted living and residential care services to eligible clients through the Texas Department of Human Services Community Based Alternatives (CBA) Assisted Living/Residential Care (AL/RC) Program and the Community Care for the Aged and Disabled (CCAD) Residential Care (RC) Program. The requirements described in this chapter apply to both CBA AL/RC and CCAD RC, unless otherwise specified in the text.

46.3  Definitions

Revision 04-1; Effective April 16, 2004

The words and terms used in this chapter have the following meanings, unless the context clearly indicates otherwise.

(1)
Assisted living services — Services provided in an assisted living facility to eligible Texas Department of Human Services (DHS) clients under the Community Based Alternatives (CBA) Assisted Living/Residential Care (AL/RC) or the Community Care for Aged and Disabled (CCAD) Residential Care (RC) programs.
(2)
Assisted Living/Residential Care (AL/RC) Program — A 24-hour residential care program for CBA clients.
(3)
Attendant — A facility employee who provides direct care to clients. An attendant may have other duties in addition to direct client care.
(4)
Case manager — A DHS employee who is responsible for case management activities. Activities include eligibility determination, client registration, assessment and reassessment of client need, service plan development, and intercession on the client's behalf.
(5)
Client — A CCAD or CBA client, as defined in Chapter 48 of this title (relating to Community Care for Aged and Disabled), who is eligible to receive services under this chapter.
(6)
Community Based Alternatives (CBA) — A Medicaid program that provides services to eligible adults who are aged and/or disabled as an alternative to institutional care in a nursing facility. CBA services are provided in accordance with the waiver provisions of §1915(c) of the Social Security Act (42 U.S.C. §1396n(c)).
(7)
Community Care for Aged and Disabled (CCAD) — A group of DHS programs that provides a variety of Title XIX and Title XX-funded community-based services.
(8)
Contract — The formal, written agreement between DHS and an assisted living facility to provide services to DHS clients eligible under this chapter in exchange for reimbursement.
(9)
Contract manager — A DHS employee who is responsible for the overall management of the contract with the assisted living facility.
(10)
Contracted assisted living facility — An assisted living facility that contracts with DHS to provide CBA AL/RC services or CCAD RC services or both. Any reference to facility in this chapter means contracted assisted living facility, unless otherwise specified in the text.
(11)
Copayment — The amount of personal income a client must pay to the facility toward the cost of care.
(12)
Days — Any reference to days means calendar days, unless otherwise specified in the text. Calendar days include weekends and holidays.
(13)
Facility manager — The facility employee who is responsible for the day-to-day operation of a facility.
(14)
Licensed assisted living facility — A facility licensed by DHS Long Term Care Regulatory under the Health and Safety Code, Chapter 247.
(15)
Personal leave day — A continuous 24-hour period, measured from midnight to midnight, when the client is absent from the facility for personal reasons.
(16)
Representative — The client's spouse, other responsible party, or legal representative.
(17)
Residential Care (RC) Program — An assisted living and emergency care program for CCAD clients.
(18)
Room and board — The amount of personal income a client must pay to the facility toward the cost of lodging and food.
(19)
Signature — A person's name or a mark representing his/her name on a document to certify it is correct. Initials are not an acceptable substitute for a signature.
(20)
Trust fund — The services provided when the facility performs or assists with money management at the written request of the client or the client's representative.
(21)
Witness — A person who signs to verify distribution to or from a trust fund. A witness is identified in the client file by name, address, and relationship to the client, the client's representative, or the facility. A witness can be any person except:
(A)
the person(s) responsible for accounting for the client's trust fund;
(B)
the supervisor of the person(s) responsible for the client's trust fund;
(C)
a person supervised by the person(s) responsible for the client's trust fund; or
(D)
the person(s) who accepts the withdrawn funds.
(22)
Working days — Days DHS is open for business.

4320  Subchapter B, Provider Contracts

Revision 04-1; Effective April 16, 2004

46.11  Contracting Requirements

Revision 04-1; Effective April 16, 2004
(a)
General contracting requirements. A facility must meet all provisions described in this chapter and Chapter 49 of this title (relating to Contracting for Community Care Services).
(b)
Assisted living services contracting requirements. To qualify to provide assisted living services under contract with the Texas Department of Human Services (DHS), a facility must comply with the following requirements:
(1)
The facility must be licensed as defined in §92.4 of this title (relating to Types of Assisted Living Facilities). The facility must be allowed under licensure to provide the required services described in §46.41 of this chapter (relating to Required Services). Due to the licensure requirements, Type C and Type E facilities are not able to provide the required services under this chapter.
(2)
The facility must have a separate contract for each facility that provides assisted living services.
(3)
The facility must specify the number of beds for DHS clients in its contract, as follows:
(A)
The facility must ensure that the number of beds contracted are in rooms that meet the requirements in §46.13 of this chapter (relating to Housing Options).
(B)
The facility must ensure the number of DHS clients served by the facility does not exceed the number of contracted DHS beds.
(C)
The facility may adjust the number of beds for DHS clients by contract amendment.
(4)
The facility must comply with all other applicable DHS rules and regulations.
(c)
Disclosure statement requirements. The facility must ensure that the Assisted Living Disclosure Statement, as required by Chapter 92 of this title (relating to Licensing Standards for Assisted Living Facilities), does not conflict with the program requirements.
(d)
Client referrals. The facility must accept all DHS referrals unless:
(1)
the referral would cause the facility to exceed licensed capacity;
(2)
the referral would cause the facility to exceed the number of beds for DHS clients that the facility has specified in its contract; or
(3)
the facility is unable to meet the client's needs and has followed the procedures described in §46.35 of this chapter (relating to Interdisciplinary Team).
(e)
Contract assignment. In addition to the procedures described in §49.5 of this title (relating to Contract Assignment), the facility must follow the procedures described in §46.71 of this chapter (relating to Trust Fund Procedures for Client Discharge) for assignment of the trust fund account and records.

46.13  Housing Options

Revision 04-1; Effective April 16, 2004
(a)
Setting. A facility must specify in the contract the type(s) of setting(s) it uses to provide assisted living services according to the following guidelines:
(1)
Assisted living apartment. An assisted living apartment setting is a living unit that is a private space with living and sleeping areas, a kitchen, a bathroom, and adequate storage space. The bedroom must be single occupancy, except when the participant requests double occupancy in writing. The living unit must have private kitchen and bath facilities.
(A)
Size. Assisted living apartments must have a minimum of 220 square feet, not including the bathroom. Current contracted assisted living apartments that do not meet the square footage requirement may remain at their current size unless the apartment is remodeled. Remodeling includes:
(i)
the construction, removal, or relocation of walls and partitions;
(ii)
the construction of foundations, floors, or ceiling-roof assemblies;
(iii)
the expansion or alteration of safety systems, including:
(I)
sprinkler;
(II)
fire alarm; and
(III)
emergency systems; or
(iv)
the conversion of space in a facility to a different use.
(B)
Kitchen. The kitchen is an area equipped with a sink, refrigerator, a cooking appliance, adequate space for food preparation, and storage space for utensils and supplies. The cooking appliance must be a stove, microwave, or built-in surface unit. The cooking appliance must be able to be removed or disconnected.
(C)
Bathroom. The bathroom must be a separate room in the individual's living area with a toilet, sink, and an accessible bath.
(2)
Residential care apartment. A residential care apartment setting is a living unit that is a private space with connected sleeping, kitchen, and bathroom areas and adequate storage space. The bedroom must be double occupancy. The living unit must have private kitchen and bath facilities.
(A)
Size. Residential care apartments must have a minimum of 350 square feet of space per client. Indoor common areas used by Texas Department of Human Services (DHS) clients must be included in computing the minimum square footage. The portion of the common area allocated must not exceed usable square footage divided by the maximum number of individuals who have access to the common areas.
(B)
Kitchen. The kitchen is an area equipped with a sink, refrigerator, a cooking appliance, adequate space for food preparation, and storage space for utensils and supplies. The cooking appliance must be a stove, microwave, or built-in surface unit. The cooking appliance must be able to be removed or disconnected.
(C)
Bathroom. The bathroom must contain a toilet, sink, and an accessible bath.
(3)
Residential care non-apartment. A residential care non-apartment setting is a living unit that does not meet either the definition of an assisted living apartment or a residential care apartment. A residential care non-apartment must be double occupancy.
(A)
The facility that specifies the residential care non-apartment setting must be a freestanding building not physically attached to another licensed facility.
(B)
The facility must be licensed as an assisted living facility with a capacity of 16 or fewer beds.
(4)
Personal Care 3. A Personal Care 3 setting is only available in the Community Based Alternatives (CBA) Assisted Living/Residential Care (AL/RC) Program, and must meet the following qualifications:
(A)
The facility must be licensed for four to 16 beds in a residential care non-apartment setting.
(B)
The facility must provide 60% or more of its CBA clients with a single occupancy bedroom.
(C)
The facility must maintain a minimum staffing ratio of one direct care staff member for every:
(i)
four clients, including private pay clients, during the day and evening shifts; and
(ii)
eight clients, including private pay clients, during the night shift.
(D)
Sixty percent or more of the total clients served each month must require one-to-one staff assistance. One-to-one assistance is determined by a value of three or more on the DHS Client Assessment, Review, and Evaluation form in one or more of the following activities of daily living:
(i)
transferring;
(ii)
eating; or
(iii)
toileting.
(b)
Occupancy. The facility must provide each client with a private (singe occupancy) or semi-private (double occupancy) living unit.

46.15  Additional Services and Fees

Revision 04-1; Effective April 16, 2004
(a)
The facility may charge the client or the client's representative for additional items or services that the Texas Department of Human Services (DHS) does not require the facility to provide. The client or the client's representative must request and approve the additional items or services in writing.
(b)
The facility must not charge the client or the client's representative for any service provided to the client as required by its contract with DHS.
(c)
The facility must inform the client or the client's representative of the additional items or services and the charges for those items or services at the following times:
(1)
at admission;
(2)
before a change in the additional items, services, or charges; and
(3)
when the client requests the additional items or services.
(d)
The facility may charge the client or the client's representative for additional items or services, including:
(1)
private telephone;
(2)
television and/or radio for personal use;
(3)
cable television services;
(4)
personal comfort items, including smoking materials, notions and novelties, and confections;
(5)
cosmetics and grooming items and services in excess of those required;
(6)
personal clothing;
(7)
personal reading material;
(8)
gifts purchased on behalf of a client;
(9)
flowers and plants;
(10)
social events and entertainment outside the scope of the required activities program;
(11)
the cost of being a single occupant in a double occupancy room, except for:
(A)
a therapeutically required single occupancy room, such as isolation for infection control; or
(B)
services provided in the assisted living apartment setting, as defined in §46.13(a)(1) of this chapter (relating to Housing Options);
(12)
specially prepared or alternative food requested instead of the food generally prepared by the facility;
(13)
the actual amount of the fee charged by the bank for checks written by the client or the client's representative that are returned for non-sufficient funds;
(14)
charges for damage to the facility beyond expected wear and tear. The facility must not charge a security/damage deposit to DHS clients; and
(15)
pet deposit. A pet deposit does not apply to service animals. A service animal is any guide dog, signal dog, or other animal trained to provide assistance to an individual with a disability.

46.17  Termination of Contract

Revision 04-1; Effective April 16, 2004
(a)
General requirements for termination. The Texas Department of Human Services (DHS) will terminate the facility's contract as described in Chapter 49 of this title (relating to Contracting for Community Care Services) or as otherwise described in this chapter or the facility's contract with DHS.
(b)
Physical location. DHS will terminate the facility's contract if the facility loses the right to occupy the physical premises identified as the service delivery location. The contract termination is effective on the date the facility loses its right to occupy the physical premises, unless DHS notifies the facility of a later termination date. DHS will not pay for services provided after the termination date.
(c)
Payment suspension. DHS may suspend the facility's payments if the contract is terminated for any reason at any time other than the last day of a month. Payments will remain suspended until the facility has refunded all unearned copayment and room and board payments and all trust fund balances to all clients served.

46.19  Recordkeeping

Revision 04-1; Effective April 16, 2004
(a)
General documentation requirements. The facility must maintain the documentation described in Chapter 49 of this title (relating to Contracting for Community Care Services).
(b)
Record retention requirements. The facility must retain records for the time periods described in §69.205 of this title (relating to Contractor's Records).
(c)
Daily service delivery documentation. The facility must document the client's daily service delivery.
(1)
The daily service delivery documentation must contain the:
(A)
client name;
(B)
facility vendor number issued by Texas Department of Human Services (DHS);
(C)
coverage period of the daily service delivery documentation;
(D)
tasks assigned;
(E)
tasks performed during the coverage period;
(F)
signature of the facility manager or supervisor; and
(G)
date of signature of the facility manager or supervisor.
(2)
The daily service delivery documentation must be on a single document. If services delivered during the coverage period exceed the space on the single document, the facility may use multiple pages. The daily service delivery document must clearly indicate the number of pages used for the coverage period.
(d)
Daily census documentation. The facility must document the daily census of clients.
(1)
The daily census documentation must contain the:
(A)
name of the facility;
(B)
facility vendor number issued by DHS;
(C)
coverage period of the daily census documentation;
(D)
name of each client served during the coverage period;
(E)
daily status of each client for each day during the coverage period. Types of daily status are:
(i)
admission;
(ii)
discharge;
(iii)
present;
(iv)
personal leave;
(v)
institutional leave;
(vi)
emergency care (emergency care applies only to the Community Care for Aged and Disabled (CCAD) Residential Care (RC) program); and
(vii)
ineligible emergency care (ineligible emergency care applies only to the CCAD RC program);
(F)
total of each type of daily status during the coverage period;
(G)
signature of the authorized timekeeper; and
(H)
date of the authorized timekeeper's signature.
(2)
The daily census documentation must be on a single document. If the number of clients served during the coverage period exceeds the space on the single document, the facility may use multiple pages. The daily census document must clearly indicate the number of pages used for the coverage period.
(e)
Financial records. The facility must maintain financial records:
(1)
to support its billings to DHS for payment under §46.21 of this chapter (relating to Reimbursement);
(2)
to document reimbursements made by DHS. The documentation must include:
(A)
amount of reimbursement;
(B)
voucher number;
(C)
warrant number;
(D)
date of receipt; and
(E)
any other information necessary to trace deposits of reimbursements and payments made from the reimbursements in the facility's accounting system.
(3)
in accordance with generally accepted accounting principles (GAAP) and DHS procedures. A facility's financial records must include but are not limited to the following:
(A)
deposit slips, bank statements, cancelled checks, and receipts;
(B)
purchase orders;
(C)
invoices;
(D)
journals and ledgers;
(E)
timesheets and payroll and tax records;
(F)
inventory records for food and other supplies;
(G)
Internal Revenue Service, Department of Labor, and other government records and forms;
(H)
records of insurance coverage, claims, and payments (for example, medical, liability, fire and casualty, and worker's compensation);
(I)
equipment inventory records;
(J)
records of the facility's internal accounting procedures;
(K)
chart of accounts, as defined by GAAP; and
(L)
records of the facility's company policies.
(f)
Subcontractor records. If a provider agency utilizes a subcontractor, the provider agency must maintain records of the subcontractor's activities. Maintenance of all records to support subcontractor claims is the responsibility of the provider agency.
(g)
Registered nurse access. The facility must allow the home and community support services agency's registered nurse access to the client's medical and service plan records for use in the assessment.

46.21  Reimbursement

Revision 04-1; Effective April 16, 2004
(a)
The facility must bill for services provided as described in Chapter 49 of this title (relating to Contracting for Community Care Services).
(b)
The Texas Department of Human Services (DHS) will pay for eligible services provided and billed in compliance with this chapter.
(c)
A unit of service is one billable day of authorized service delivered to a client.
(d)
The facility must agree to accept the unit rate authorized by DHS, plus any applicable room and board payments, as payment in full for services required by DHS.
(e)
The unit rate reimbursed by DHS includes any copayment. The combined reimbursement from DHS and the client or the client's representative for the required services described in §46.41 of this chapter (relating to Required Services) must not exceed the unit rate plus room and board specified for each type of setting. The unit rate does not include charges for services described in §46.15 of this chapter (relating to Additional Services and Fees).
(f)
The facility must deduct the copayment amount from reimbursement claims submitted to DHS.
(g)
The facility must not bill DHS for the day of discharge, unless the discharge is due to the death of the client.
(h)
The facility must bill the double occupancy (Residential Care Apartment) rate for clients in the single occupancy (Assisted Living Apartment) setting who request double occupancy.
(i)
The facility must bill DHS for the balance of the bedhold charge for any clients whose daily copayment is less than the maximum bedhold charge allowed by DHS.
(1)
The facility must determine the client's daily copayment amount by dividing the client's monthly copayment charge by the number of days in the month.
(2)
The facility must deduct the client's daily copayment amount from the bedhold rate and submit the claim to DHS.
(3)
This subsection does not apply to the Community Based Alternatives (CBA) Assisted Living/Residential Care (AL/RC) Program.
(j)
The facility may bill DHS for emergency care provided to clients for:
(1)
up 60 days per authorization for eligible clients; or
(2)
five days for a client ineligible for emergency care.
(k)
The facility must not bill for services provided before or after the authorized effective dates for CBA AL/RC or Community Care for Aged and Disabled (CCAD) Residential Care (RC) services, as those dates are determined by DHS.
(l)
When the facility requests a Texas Index of Level of Effort (TILE) reset, the facility may bill DHS at the new TILE level effective the date of the TILE assessment. The facility may request only two TILE resets during each calendar year for each CBA client for the following time periods:
(1)
January through June; and
(2)
July through December.
(m)
CCAD RC services will be reimbursed at the double occupancy rate, regardless of the actual occupancy.

46.23  Monitoring Reviews

Revision 04-1; Effective April 16, 2004

Monitoring reviews are conducted through an on-site review and in accordance with Chapter 49 of this title (relating to Contracting for Community Care Services). The Texas Department of Human Services (DHS) reviews records on a regular and systematic basis, and as often as DHS deems necessary. DHS conducts the following types of monitoring:

(1)
Compliance monitoring. Compliance monitoring is a review to determine if the facility is delivering services according to the rules in this chapter. Compliance monitoring includes:
(A)
review of consumer satisfaction surveys conducted;
(B)
review of client records;
(C)
interviews with clients and staff;
(D)
observation of clients and staff; and
(E)
consultations with others as appropriate.
(2)
Fiscal monitoring. Fiscal monitoring is a review of documentation that supports the facility's billing. The facility is liable for recoupment of payment if monitoring errors indicate the monthly claims do not correspond with the daily census documentation and daily service delivery documentation. Fiscal monitoring includes:
(A)
Financial errors. DHS applies the error to the entire unit of service. Financial errors include:
(i)
The facility is reimbursed for services, but the daily census documentation and the daily service delivery documentation are missing for the period for which services are reimbursed. DHS applies the error to the total number of units reimbursed for the billing period for which forms are missing.
(ii)
The facility is reimbursed for units that exceed the units recorded on daily census documentation and daily service delivery documentation. DHS applies the error to the total number of units reimbursed in excess of units recorded.
(iii)
The facility is reimbursed for units of service and the client did not receive services. DHS applies the error to the total number of units reimbursed for the days the client did not receive services.
(iv)
The facility is reimbursed for units of service and the client was Medicaid ineligible. DHS applies the error to the total number of units reimbursed for the days the client was Medicaid ineligible. This does not apply to the Community Care for Aged and Disabled (CCAD) Residential Care (RC) program.
(B)
Administrative errors. Documentation is reviewed for administrative errors as they exist at the time DHS staff arrive to conduct the monitoring review. DHS applies the error to the administrative portion of the unit of service. The administrative portion is 12% of the paid unit rate. Administrative errors include:
(i)
The facility enters a date of signature on the daily census documentation that is before the date the last day services are provided. DHS applies the error to the total number of units reimbursed after the signature date.
(ii)
The facility fails to sign the daily census documentation. DHS applies the error to the total number of units reimbursed on the unsigned form.
(iii)
The facility fails to enter a date of signature on the daily census documentation to certify total number of units provided to the client. DHS applies the error to the number of units reimbursed on the undated form.
(iv)
The facility corrects the date of signature on the daily census documentation, but fails to initial the correction. DHS applies the error to the total number of units reimbursed after the earliest signature date.
(v)
The facility uses a signature stamp on the daily census documentation, but fails to initial the stamped signature. DHS applies the error to the total number of units reimbursed on the signature stamped form.
(vi)
The facility makes an illegible entry or illegible correction to any portion of the record of time on the daily census documentation. DHS applies the error to the total number of units reimbursed for the days in which entries are illegible.
(vii)
The facility enters an illegible date of signature or makes an illegible correction to the date of signature on the daily census documentation. DHS applies the error to the total number of units on the form.
(viii)
The facility fails to complete the entire daily census documentation in ink, as described in §49.11(d) of this title (relating to Record Documentation Requirements). DHS applies the error to the total number of units reimbursed that were not completed in ink.
(ix)
The facility uses a method other than crossing out and initialing to change an entry on the daily census documentation. DHS applies the error to the total number of units reimbursed that were corrected in a manner other than crossing out and initialing.
(x)
The facility fails to list the client on the daily census documentation, but the client was listed on the daily service delivery documentation. DHS applies the error to the total number of units reimbursed for the period the client was left off the daily census documentation.
(xi)
The facility leaves the daily status blank on the daily census documentation, but daily activity can be verified on the daily service delivery documentation. DHS applies the error to the total number of units reimbursed for which the daily status is left blank on the daily census documentation.

46.25  Complaints

Revision 04-1; Effective April 16, 2004

A facility must comply with the complaint procedures described in §49.13 of this title (relating to Client Rights and Responsibilities) and §49.14 of this title (relating to Complaint Procedures).

46.27  Reimbursement Methodology for Residential Care

Revision 04-1; Effective April 16, 2004
(a)
General requirements. The Texas Department of Human Services (DHS), or its designee, applies the general principles of cost determination as specified in §20.101 of this title (relating to Introduction).
(b)
Cost reporting.
(1)
Providers must follow the cost-reporting guidelines as specified in §20.105 of this title (relating to General Reporting and Documentation Requirements, Methods, and Procedures).
(2)
All contracted providers must submit a cost report unless the number of days between the date the first DHS client received services and the provider's fiscal year end is 30 days or fewer.
(3)
The provider may be excused from submitting a cost report if circumstances beyond the control of the provider make cost report completion impossible, such as the loss of records due to natural disasters or removal of records from the provider's custody by any regulatory agency. Requests to be excused from submitting a cost report must be received by the Texas Health and Human Services Commission's (HHSC) Rate Analysis department before the due date of the cost report.
(c)
Reimbursement determination.
(1)
Reporting and verification of allowable costs.
(A)
Providers are responsible for reporting only allowable costs on the cost report, except where cost report instructions indicate that other costs are to be reported in specific lines or sections. Only allowable cost information is used to determine recommended reimbursements. DHS or its designee excludes from reimbursement determination any unallowable expenses included in the cost report and makes the appropriate adjustments to expenses and other information reported by providers. The purpose is to ensure that the database reflects costs and other information that are necessary for the provision of services and that are consistent with federal and state regulations.
(B)
Individual cost reports may not be included in the database used for reimbursement determination if:
(i)
there is reasonable doubt as to the accuracy or allowability of a significant part of the information reported; or
(ii)
an auditor determines that reported costs are not verifiable.
(C)
When material pertinent to proposed reimbursements is made available to the public, the material will include the number of cost reports eliminated from reimbursement determination for the reason stated in subparagraph (B)(i) of this paragraph.
(2)
Residential care reimbursement. Recommended per diem reimbursement for residential care is determined as follows.
(A)
Reported allowable expenses are combined into four cost areas:
(i)
attendant;
(ii)
other direct care;
(iii)
facility; and
(iv)
administration and transportation.
(B)
Facility, transportation (vehicle), and administration expenses are lowered to reflect expenses for a provider at the lower of:
(i)
85% occupancy rate; or
(ii)
the overall average occupancy rate for licensed beds in facilities included in the database during the cost-reporting periods included in the base. The occupancy adjustment is applied if the provider's occupancy rate is below 85% or the overall average, whichever is lower. The occupancy adjustment is determined by the individual provider occupancy rate being divided by .85 or the average occupancy rate of all providers in the database.
(C)
Payroll taxes and employee benefits are allocated to each salary line item on the cost report on a pro rata basis based on the portion of that salary line item to the amount of total salary expense for the appropriate group of staff. Employee benefits will be charged to a specific salary line item if the benefits are reported separately. The allocated payroll taxes and employee benefits are Federal Insurance Contributions Act or Social Security, Medicare contributions, Workers' Compensation Insurance, the Federal Unemployment Tax Act, and the Texas Unemployment Compensation Act.
(D)
Allowable salaries paid to the director, administrator, assistant administrator, owner, or partner who works for the Residential Care contracted provider may be limited to the 90th percentile of an array of salary costs for the director, administrator, assistant administrator, owner, or partner.
(E)
The attendant cost area from subparagraph (A)(i) of this paragraph will be calculated as specified in §20.112 of this title (relating to Attendant Compensation Rate Enhancement).
(F)
The following applies to the cost areas from subparagraph (A)(ii)-(iv) of this paragraph:
(i)
Each provider's total reported allowable costs, excluding depreciation and mortgage interest, are projected from the historical cost-reporting period to the prospective reimbursement period as described in §20.108 of this title (relating to Determination of Inflation Indices). The prospective reimbursement period is the period of time that the reimbursement is expected to be in effect.
(ii)
Cost area per diem expenses are calculated by dividing total reported allowable costs for each cost area by the total days of service. Cost area per diem expenses are rank ordered from low to high to produce projected per diem expense arrays.
(iii)
Reimbursement is determined by selecting from each cost area the median day of service and the corresponding per diem expense times 1.07. The resulting cost area amounts are totaled to determine the per diem reimbursement.
(iv)
The client is required to pay the room and board portion of the per diem reimbursement. DHS will pay the services portion of the per diem reimbursement.
(3)
Exceptions to the reimbursement determination methodology. Reimbursement may be adjusted in accordance with §20.109 of this title (relating to Adjusting Reimbursement When New Legislation, Regulations, or Economic Factors Affect Costs) when new legislation, regulations, or economic factors affect costs.
(d)
Authority to determine reimbursement. The authority to determine reimbursement is specified in §20.101 of this title.
(e)
Allowable and unallowable costs. In determining whether a cost is allowable or unallowable, providers must follow the guidelines as specified in §20.102 of this title (relating to General Principles of Allowable and Unallowable Costs) and §20.103 of this title (relating to Specifications for Allowable and Unallowable Costs). In addition to these sections, the following allowable and unallowable costs are applicable in the Community Care for Aged and Disabled Residential Care program.
(1)
Allowable costs. Medical supplies required to provide residential care services are allowable. Allowable medical costs include supply costs associated with the administration of medications, such as medication cups, syringes for insulin injections, stethoscopes, blood pressure cuffs, and thermometers.
(2)
Unallowable costs. Unallowable costs include prescription drugs; non-legend drugs; medical records costs; and compensation for physicians, pharmacists, and medical directors.
(f)
Reporting revenue. Revenues must be reported on the cost report in accordance with §20.104 of this title (relating to Revenues).
(g)
Reviews and field audits of cost reports. Desk reviews or field audits are performed on cost reports of all contracted providers. The frequency and nature of the field audit are determined by DHS or its designee to ensure the fiscal integrity of the program. Desk reviews and field audits will be conducted in accordance with §20.106 of this title (relating to Basic Objectives and Criteria for Audit and Desk Review of Cost Reports), and providers will be notified of the results of a desk review or a field audit in accordance with §20.107 of this title (relating to Notification of Exclusions and Adjustments). Providers may request an informal review and, if necessary, an administrative hearing to dispute an action taken under §20.110 of this title (relating to Informal Reviews and Formal Appeals).

4330  Subchapter C, Provider Requirements

Revision 04-1; Effective April 16, 2004

46.31  Staff Requirements

Revision 04-1; Effective April 16, 2004

The facility must have staff as described in §92.41 of this title (relating to Standards for Type A, Type B, and Type E Assisted Living Facilities).

46.33  Staff Training

Revision 04-1; Effective April 16, 2004
(a)
General training requirements. The facility must provide all staff with training as described in §92.41 of this title (relating to Standards for Type A, Type B, and Type E Assisted Living Facilities).
(b)
Facility manager. In addition to the requirements described in subsection (a) of this section, the facility must train the facility manager on the following topics:
(1)
facility requirements for the Community Care for Aged and Disabled (CCAD) Residential Care (RC) or Community Based Alternatives (CBA) Assisted Living/Residential Care (AL/RC) programs or both, as applicable; and
(2)
client characteristics and needs.
(c)
Attendants. In addition to the requirements described in subsection (a) of this section, the facility must train the attendant in performing the tasks identified on the service plan described in §46.39(d) of this chapter (relating to Service Initiation).
(d)
Training of new staff. The facility must provide training to new staff hired after the initial orientation described in §49.3(b) of this title (relating to General Contractual Requirements).

46.35  Interdisciplinary Team

Revision 04-1; Effective April 16, 2004
(a)
Interdisciplinary Team (IDT). The IDT is a designated group that includes the following individuals who meet when the need arises to discuss service delivery issues:
(1)
the client or the client's representative, or both;
(2)
a facility representative; and
(3)
a Texas Department of Human Services (DHS) representative. A DHS representative may be:
(A)
the case manager (or designee);
(B)
the contract manager (or designee); or
(C)
the regional nurse (or designee).
(b)
Convening an IDT meeting.
(1)
The facility must convene an IDT meeting within three working days of the date the facility identifies a service delivery issue.
(2)
If the facility is unable to convene an IDT meeting with all the members described in subsection (a) of this section, the facility must send the documentation of the IDT meeting described in subsection (e) of this section to the Regional Administrator for the DHS region in which the client resides.
(A)
The documentation must be sent within five working days of the date of the IDT meeting.
(B)
Further action may be required by the facility, based on a review of the IDT meeting documentation.
(c)
IDT meeting.
(1)
The IDT meeting may be conducted by telephone conference call or in person.
(2)
The IDT must:
(A)
evaluate the issue;
(B)
identify any solutions to resolve the issue; and
(C)
make recommendations to the facility.
(d)
IDT meeting outcome. The facility must do one of the following within two working days after the IDT meeting:
(1)
implement the recommendations of the IDT; or
(2)
discharge the client from the facility and refer the case back to the case manager for referral to another facility.
(e)
Documentation of the IDT meeting. The facility must document the IDT meeting in the client file, including the:
(1)
specific reasons for calling the IDT meeting;
(2)
participants of the IDT meeting. If all members described in subsection (a) of this section are unable to participate, the facility must document all efforts made to convene an IDT meeting with all the members;
(3)
recommendations of the IDT;
(4)
efforts made to resolve the issue;
(5)
facility's action as a result of the IDT recommendations; and
(6)
reasons for the facility's actions.

46.37  Copayment and Room and Board

Revision 04-1; Effective April 16, 2004
(a)
Amount. The facility must collect the copayment and room and board amounts indicated on the Texas Department of Human Services' (DHS's) Notification of Community Care Services form or DHS's Notification of Community Based Alternatives (CBA) Services form. This subsection does not apply to clients who receive Community Care for Aged and Disabled emergency care service.
(b)
Due date.
(1)
The facility must designate a due date for copayment and room and board in writing. The due date must be during the same month the copayment and room and board is applied.
(2)
The facility must collect the entire copayment and room and board on or before the due date. If the due date falls on a weekend or a holiday, the facility must collect the entire copayment and room and board on or before the first working day thereafter.
(3)
If the client or the client's representative fails to pay the entire copayment and room and board by the due date, the facility must notify the client or the client's representative and the case manager in writing no later than the first working day after the due date.
(c)
Credit balances.
(1)
A credit balance is an amount due to the client or the client's representative when there is an overpayment by the client or the client's representative.
(2)
The facility must handle credit balances as follows:
(A)
The facility must provide written notice of a credit balance (client notice) to the client or the client's representative within 35 days of receipt of the payment resulting in a credit balance. The client notice may be the first monthly statement following the receipt of the payment resulting in a credit balance, if the monthly statement specifies the credit balance.
(B)
The facility must offer the client or the client's representative the following options in the client notice:
(i)
the client or the client's representative may choose to provide the corrected payment, and the facility will return the original amount paid;
(ii)
the facility will provide the client or the client's representative with a refund of the credit balance; or
(iii)
the client or the client's representative may choose to have the credit balance applied to the following month's payment. The client may choose to spread the credit balance over several months.
(C)
If the client or the client's representative fails to contact the facility within 35 days of the date of the client notice, the facility must, on the 35th day:
(i)
provide the client or the client's representative with a refund of the credit balance or apply the credit balance to the following month's payment; and
(ii)
provide written notice of the facility's choice of action to the client or the client's representative. The written notice of the facility's choice of action may be a monthly statement if the monthly statement specifies the facility's choice of action.
(d)
Copayment and room and board receipts.
(1)
The facility must provide receipts for all copayment and room and board payments received from or on behalf of clients at the time the payment is received.
(2)
The facility must keep a copy of all copayment and room and board receipts.
(3)
Copayment and room and board receipts must contain the following elements if the elements are not contained in the copayment and room and board ledger described in subsection (e) of this section:
(A)
the name of the client;
(B)
the month, day, and year the payment was received;
(C)
the total amount collected;
(D)
the specific amounts of copayment and room and board collected; and
(E)
the month and year of the coverage period for the payment received.
(4)
Copayment receipts may be in any format.
(e)
Copayment and room and board ledger. The facility must maintain a copayment and room and board ledger system in any format for each client.
(1)
The facility may keep the copayment and room and board ledger systems as separate ledgers, or the facility may combine both ledgers into a single ledger system. If the facility chooses to keep a single ledger system, a separate entry must be made for each copayment and room and board entry.
(2)
The copayment and room and board ledger system must reflect the following:
(A)
all charges for copayment and room and board by client;
(B)
all payments for copayment and room and board made by or on behalf of a client;
(C)
all credits for copayment and room and board by client, including the:
(i)
specific amount credited;
(ii)
month and year of the coverage period of the credit;
(iii)
type of payment credited; and
(iv)
reason for the credit; and
(D)
a running balance by client.
(3)
The facility must record all activities on the copayment and room and board ledger system within 35 days or by the next billing cycle, whichever is sooner.
(4)
The copayment and room and board ledger must be maintained in accordance with generally accepted accounting principles (GAAP).
(f)
Refunds upon discharge. The facility must refund the client's copayment and room and board for the remaining days of the month following the date of discharge or death. The refund must be made within ten working days of awareness that the client will be discharged or is deceased. The facility must document the date of awareness of the client's discharge from the facility.

46.39  Service Initiation

Revision 04-1; Effective April 16, 2004
(a)
Negotiated move-in date. The facility must negotiate a move-in date with the Texas Department of Human Services (DHS) case manager and the client or the client's representative.
(b)
Reserved space. The facility must reserve a living unit for three days from the agreed upon move-in date for each referred client. The facility may request another referral after three days if the move-in date is not re-negotiated.
(c)
Client and facility agreement. The facility must have a written agreement with the client or the client's representative. Both parties must sign the written agreement before or at the time of admission. The written agreement must include the following:
(1)
bedhold policies for hospital and nursing facility stays;
(2)
personal leave policies and charges;
(3)
eviction procedures;
(4)
all available services in the facility; and
(5)
charges for services not paid by DHS and charges not included in the facility's basic daily rate, as described in §46.15 of this chapter (relating to Additional Services and Fees).
(d)
Health assessment and service plan.
(1)
The facility must complete a health assessment and develop an individual service plan as described in §92.41(c) of this title (relating to Standards for Type A, Type B, and Type E Assisted Living Facilities).
(2)
In addition to the items described in §92.41(c) of this title, the health assessment developed by the facility must contain the following items:
(A)
vision patterns;
(B)
skin conditions;
(C)
body control problems; and
(D)
vital signs, height, and weight.
(3)
The health assessment and individual service plan must be completed:
(A)
within 72 hours of admission to the facility; and
(B)
by the appropriate person(s).
(i)
The facility manager or a nurse must complete the health assessment and individual service plan.
(ii)
A nurse must complete the medication administration portion of the health assessment for Community Based Alternatives (CBA) Assisted Living/Residential Care (AL/RC) clients. If the nurse is a licensed vocational nurse (LVN), a registered nurse (RN) must sign off on the medication administration portion of the health assessment.

46.41  Required Services

Revision 04-1; Effective April 16, 2004
(a)
Service delivery. The facility must provide services according to the service plan completed for the client.
(b)
Required services. Services include:
(1)
Personal care. The facility must provide or assist with personal care services identified on the service plan completed for the client. Personal care services are activities related to the care of the client's physical health that include at a minimum:
(A)
bathing;
(B)
dressing;
(C)
grooming;
(D)
routine hair and skin care;
(E)
exercising;
(F)
toileting;
(G)
medication administration, including injections. This does not apply to the Community Care for Aged and Disabled (CCAD) Residential Care (RC) Program;
(H)
transferring/ambulating. This does not apply to clients residing in a Type A assisted living facility;
(I)
twenty-four-hour supervision. The facility must conduct and document in the client file checks or visits to each client to ensure that each client is safe and well. The checks or visits must be made as identified on the service plan completed for the client; and
(J)
meal services. The facility must:
(i)
provide meal services as described in §92.41(m) of this title (relating to Standards for Type A, Type B, and Type E Assisted Living Facilities);
(ii)
offer dietary counseling and nutrition education to the client;
(iii)
modify food texture, including:
(I)
chopping, grinding, and mashing foods for clients who have trouble chewing; and
(II)
cutting up food into bite size pieces for clients who have trouble cutting food; and
(iv)
assist with eating, including:
(I)
assistance with spoon-feeding in instances when the client is temporarily ill;
(II)
bread buttering; and
(III)
opening containers or pouring liquids for clients with hand deformities, paralysis, or hand tremors.
(2)
Home management. The facility must provide or assist with activities related to housekeeping that are essential to the client's health and comfort, including:
(A)
changing bed linens;
(B)
housecleaning;
(C)
laundering;
(D)
shopping;
(E)
storing purchased items in the client's living unit. This includes medical supplies delivered to Community Based Alternatives (CBA) Assisted Living/Residential Care (AL/RC) clients; and
(F)
washing dishes.
(3)
Transportation and escort.
(A)
The facility must provide the client with transportation, escort, or both to:
(i)
local community areas where a client may purchase items to meet his or her personal needs or conduct personal business according to the facility's published schedule;
(ii)
recreational activities, field/community trips according to the facility's published schedule; and
(iii)
the nearest available medical provider for medical appointments, therapies, and other medical care.
(B)
The facility must make arrangements for other transportation for the client to the medical care provider of the client's choice if the client's medical provider is not the nearest available provider.
(4)
Social and recreational activities. The facility must provide a minimum of four scheduled social and recreational activities per week.
(A)
Activity requirements. The social and recreational activities must be:
(i)
planned to meet the social needs and interests of the clients; and
(ii)
listed on a monthly calendar that is posted in plain view at the facility at least one week in advance.
(B)
Types of activities. Social and recreational activities include:
(i)
activities that require group and client-initiated activities;
(ii)
opportunities to interact with other people;
(iii)
interaction, cultural enrichment, educational, or recreational activities; and
(iv)
other social activities on site or in the community.
(5)
Participation in the client assessment. The facility must designate someone who is familiar with the CBA AL/RC client's needs and service plan to participate with the client's assessment. The assessment will determine the Texas Index of Level of Effort (TILE) at both the annual assessment, and a requested re-TILE. Participation in the client assessment does not apply to the CCAD RC Program.
(6)
Emergency care. The facility must provide emergency care as authorized by the case manager.
(A)
Emergency care is assisted living services provided to clients while the case manager seeks a permanent living arrangement.
(B)
Emergency care services do not apply to the CBA AL/RC program.

46.43  Service Plan Changes

Revision 04-1; Effective April 16, 2004
(a)
The facility must complete a new service plan anytime there is a need for a change in the client's service plan.
(b)
The facility must implement service plan changes within seven days from the assessment date.

46.45  Required Notifications

Revision 04-1; Effective April 16, 2004
(a)
The facility must notify the Texas Department of Human Services (DHS) when one of the following happens:
(1)
significant changes in the client's health and/or condition;
(2)
the client temporarily enters an institution;
(3)
serious occurrences or emergencies involving the client or facility staff;
(4)
the client or the client's representative requests that services end;
(5)
the client refuses to comply with the service plan;
(6)
the client engages in discrimination in violation of applicable law;
(7)
the client or the client's representative fails to pay copayment;
(8)
the client uses ten personal leave days in the current calendar year;
(9)
the client or the client's representative requests to move to another facility; or
(10)
when the facility believes that a client's functional needs have changed such that it will impact the client's Texas Index of Level of Effort (TILE). This only applies to facilities providing assisted living services under the Community Based Alternatives (CBA) Assisted Living/Residential Care (AL/RC) Program that participate in the attendant compensation rate option.
(b)
The facility must notify the client's DHS case manager orally or by facsimile about the change no later than one DHS workday after the change happens. If the facility's first notification is oral, the facility must send written notification to the case manager within five working days of the initial notification.

46.47  Suspension of Services

Revision 04-1; Effective April 16, 2004
(a)
The facility must suspend services when one of the following happens:
(1)
the client dies;
(2)
the client moves from the facility;
(3)
the client is discharged because he threatens the health or safety of himself or other clients in the facility;
(4)
the client is permanently admitted to an institution;
(5)
the Texas Department of Human Services (DHS) enforces sanctions against the facility by terminating the contract;
(6)
the client's eligibility is denied; or
(7)
the case manager requests that services be suspended or terminated.
(b)
The facility must notify the client's DHS case manager orally or by facsimile about the suspension no later than one DHS workday after services are suspended. If the facility's first notification is oral, the facility must send written notification to the case manager within five working days of the initial notification.

46.49  Institutional Leave

Revision 04-1; Effective April 16, 2004
(a)
Institution. An institution is defined as a hospital, nursing facility, state school, state hospital, or intermediate care facility serving persons with mental retardation or a related condition.
(b)
Institutional leave. Institutional leave is when clients are absent from the facility because they temporarily enter an institution.
(c)
Bedhold. The facility must hold the client's bed:
(1)
for a Community Care for Aged and Disabled (CCAD) Residential Care (RC) client for:
(A)
60 days if the client is in a hospital; or
(B)
30 days if the client is in any other type of institution; and
(2)
for a Community Based Alternatives (CBA) Assisted Living/Residential Care (AL/RC) client for 60 days if the client is in any type of institution.
(d)
Bedhold charges. The facility must charge the client or the client's representative for bedhold during institutional leave.
(1)
Bedhold charges for a CCAD RC client are the bedhold rate established by the Texas Department of Human Services (DHS), plus room and board charges.
(2)
Bedhold charges for a CBA AL/RC client are the room and board charges.
(e)
Refund of copayment. The facility must not charge the client or the client's representative more than the maximum amount allowed by DHS for bedhold. The facility must refund the client's copayment for the days the client uses institutional leave.
(1)
The facility must refund any copayment paid by a CCAD RC client or the client's representative that is in excess of the bedhold amount. If the client's copayment amount is less than the bedhold charge, DHS pays the difference as described in §46.21 of this chapter (relating to Reimbursement).
(2)
The facility must refund all copayments paid by a CBA AL/RC client or the client's representative.
(3)
The refund must be made according to the procedures in §46.37(c) of this chapter (relating to Copayment and Room and Board).
(f)
Billing during institutional leave. The facility must charge the client or the client's representative only the bedhold amount for the date of admission to an institution. The facility must charge the client or the client's representative the full rate for date of return.
(g)
Notification of institutional leave. The facility must notify the DHS case manager of any institutional leave as described in §46.45 of this chapter (relating to Required Notifications).

46.51  Personal Leave

Revision 04-1; Effective April 16, 2004
(a)
Personal leave. A client is entitled to 14 days of personal leave per calendar year.
(b)
Client charges. The facility must collect the entire copayment and room and board charges for all personal leave days.
(c)
Texas Department of Human Services (DHS) payment during personal leave. The facility must not bill DHS for more than 14 days of personal leave taken by the client each calendar year.
(d)
Notification of personal leave days. The facility must notify the DHS case manager of personal leave days as described under §46.45 of this chapter (relating to Required Notifications).
(e)
Charge for exceeding personal leave days. The client is responsible for all charges for services if he exceeds the allowable limit of personal leave days.

46.53  Client Terminations

Revision 04-1; Effective April 16, 2004
(a)
Client discharge. The facility must convene an Interdisciplinary Team (IDT) meeting, as described in §46.35 of this chapter (relating to Interdisciplinary Team) before discharging a client, except when the client threatens the health or safety of others or himself. The facility must notify the DHS case manager as described under §46.47 of this chapter (relating to Suspension of Services).
(b)
Assistance with move. The facility must help the client prepare for transfer or discharge.
(c)
Refunds. The facility must refund the following:
(1)
copayment and room and board, as described in §46.37(f) of this chapter (relating to Copayment and Room and Board); and
(2)
trust fund balances, as described in §46.71 of this chapter (relating to Trust Fund Procedures for Client Discharge).

4340  Subchapter D, Trust Funds

Revision 04-1; Effective April 16, 2004

46.61  Trust Fund Management

Revision 04-1; Effective April 16, 2004
(a)
Clients have the right to:
(1)
perform their own money management;
(2)
request that the facility provide or assist with money management; or
(3)
designate another person to provide or assist with money management.
(b)
The case manager will inform the facility if a client wishes the facility to provide or assist with money management.
(c)
The facility must not require clients to request the facility provide or assist with money management. The facility must have the client's or the client's representative's written authorization to provide or assist with money management.
(d)
The facility must provide a written statement of the trust fund rights and responsibilities regarding the client's financial affairs. The written statement must:
(1)
be provided to each client or client's representative who chooses to have the facility provide or assist with money management;
(2)
be provided at the time of admission or request; and
(3)
include the following:
(A)
a statement that the facility must not require clients to allow the facility to provide or assist with money management;
(B)
the client or the client's representative's written request and authorization to provide or assist with money management; and
(C)
any charge by the facility for providing or assisting with money management is included in the facility's basic rate.

46.63  Trust Fund Bank Account

Revision 04-1; Effective April 16, 2004
(a)
Bank account.
(1)
The contracted assisted living facility must keep funds received from or on behalf of a client for a trust fund in a separate bank account from the facility's operating funds. The account must be identified as "Trustee, (Name of Facility), Client's Trust Fund Account."
(2)
The facility may use the following type of checking accounts for the trust fund:
(A)
a pooled checking account, which is a single checking account that contains all the personal funds received from each client utilizing the trust fund;
(B)
a client-choice individual checking account, which is a single checking account that contains only the personal funds of a single client. The client or the client's representative must request this type of trust fund in writing; or
(C)
a facility-choice individual checking account, which is a single checking account that contains only the funds of a single client. This type of trust fund is set up for the convenience of the facility.
(b)
Commingled funds. A facility may commingle the trust funds of private-pay clients and Texas Department of Human Services (DHS) clients.
(1)
Each private-pay client or the client's representative whose funds are commingled with DHS client funds must sign and date a permission form upon admission or at the time of request for trust fund services. The permission form must include:
(A)
permission for the facility to commingle the personal funds of the private pay client with DHS clients;
(B)
permission for the facility to maintain trust fund records of private-pay clients in the same manner as the DHS client's trust fund records; and
(C)
a provision allowing inspection of the private-pay client's trust fund records by DHS staff.
(2)
The facility must keep financial records of private pay clients with commingled funds in the same manner as the financial records of DHS clients as specified in this chapter.
(c)
Banking charges.
(1)
The facility is responsible for bank fees for the trust fund kept in a pooled checking account or in facility-choice individual checking accounts. The facility must not charge these fees to the client or the client's representative. The facility may report these fees as allowable costs on its cost report.
(2)
The client or the client's representative is responsible for bank fees for the trust fund kept in client-choice individual checking accounts.
(3)
The facility must not charge the client or the client's representative for the administrative handling of any allowable type of checking account. The facility may report these costs on its cost report.
(d)
Interest earned. The facility must distribute the interest earned on the pooled checking account, if the pooled checking account is interest-bearing, to all clients utilizing the trust fund. The facility must prorate the actual interest earned to each client's account:
(1)
at the time the financial institution pays the interest; and
(2)
on the basis of the client's balance at the time the financial institution pays the interest.

46.65  Trust Fund Transactions

Revision 04-1; Effective April 16, 2004
(a)
Transactions.
(1)
The facility must keep records of all trust fund transactions.
(2)
Facility staff must record on the client's trust-fund ledger or deposit/withdrawal document at least the following:
(A)
the date and amount of each deposit;
(B)
the source of each deposit;
(C)
the date and amount of each withdrawal;
(D)
the reason for each withdrawal;
(E)
the name of the person or entity who accepted the withdrawn funds; and
(F)
the balance after each transaction.
(3)
The client or the client's representative must sign for each withdrawal transaction at the time of the transaction.
(A)
The signature must be on the trust-fund ledger, deposit/withdrawal document, or trust fund receipt.
(B)
At least one witness must sign for each withdrawal transaction if the client or the client's representative cannot sign.
(C)
A signature is not required if the payment meets the definition of a recurring payment as described in subsection (c) of this section.
(4)
The facility must record transactions within 14 days of occurrence.
(b)
Bulk purchases. The facility may make bulk purchases for items used by multiple clients.
(1)
The bulk purchase must be traceable to individual clients.
(2)
The receipt for the bulk purchase must show the following:
(A)
the names of the clients for whom the purchase was made; and
(B)
the portion of the total price charged to each client.
(3)
The facility must not charge the client or the client's representative more than the actual cost of the client's portion of items that are purchased in bulk.
(c)
Recurring payments.
(1)
The facility must obtain the client's or the client's representative's written request and authorization to make recurring payments on behalf of the client. The written authorization must include the:
(A)
name of the business or entity to which the recurring payment is made;
(B)
amount of the recurring payment. If the recurring payment is not a set amount, the authorization must include the method for determining the amount of the recurring payment;
(C)
date the payment will begin; and
(D)
signature and signature date of the client or the client's representative.
(2)
The client or the client's representative must request and authorize the facility to stop recurring payments on behalf of the client.
(A)
The authorization may be oral or written.
(B)
The facility must document the request, including the:
(i)
name of the business or entity to which the recurring payment is made; and
(ii)
date the payment will stop.
(3)
The facility is not required to have a receipt for recurring payments made on behalf of the client.
(d)
Petty cash fund.
(1)
A petty cash fund is part of the pooled checking account trust fund kept on hand in cash by the facility. The petty cash fund is used for disbursement to clients for the purchase of minor items.
(2)
The facility must keep the petty cash fund locked.
(3)
The facility must set a dollar limit for petty cash transactions.
(A)
The facility must document:
(i)
the dollar limit of petty cash transactions; and
(ii)
a list of any exceptions to the petty cash transaction limit, if applicable.
(B)
The facility must follow the procedures in subsection (a) of this section for withdrawals that exceed the petty cash transaction limit.
(4)
The facility must keep records of all petty cash fund transactions. The petty cash fund record must be a:
(A)
petty cash fund ledger; or
(B)
petty cash fund receipt.
(5)
A petty cash fund ledger or receipt must include the:
(A)
name of the client;
(B)
date of the withdrawal;
(C)
amount of the withdrawal; and
(D)
signature of client or the client's representative, or at least one witness if the client or the client's representative cannot sign.
(6)
The facility must use the following guidelines to replenish the petty cash fund:
(A)
Count the money in the petty cash fund.
(B)
Determine the difference between amount in the petty cash fund and the amount needed in the petty cash fund.
(C)
Cash a check for the difference between the amount in the petty cash fund and the amount needed in the petty cash fund.
(i)
Write the check for cash on the appropriate checking account, either the:
(I)
pooled trust fund checking account; or
(II)
individual client trust fund checking account.
(ii)
Indicate "petty cash fund" in the "memo" line of the check.
(D)
Put the cash in the petty cash fund.
(7)
The facility must reconcile the petty cash fund at least monthly.
(8)
The facility must follow the requirements for transactions in subsection (a) of this section to post petty cash fund transactions to the trust fund ledger. However, the client's or the client's representative's signature is not required on the trust fund ledger or trust fund receipt if the client's or the client's representative's signature is on the petty cash fund ledger or receipt.
(e)
Receipts.
(1)
A trust fund receipt is required when a direct payment is made from the client's trust fund. The facility may use printed receipts from vendors as trust fund receipts only if:
(A)
all elements from paragraph (4) of this subsection are present; or
(B)
any missing elements from paragraph (4) of this subsection are added.
(2)
A trust fund receipt is required when a payment is received by the facility on behalf of a client. This is not applicable to funds direct-deposited to the trust fund account.
(3)
A trust fund receipt is not required when the client or the client's representative makes a direct purchase with funds withdrawn from the trust fund. The withdrawn funds must meet the requirements listed in subsection (a) of this section.
(4)
A trust fund receipt must contain the:
(A)
name of the client;
(B)
month, day, and year the receipt was written or created;
(C)
total amount of money spent or received for the client;
(D)
specific item(s) purchased; and
(E)
name of the business or entity from which the purchase was made or the payment received.
(5)
A trust fund receipt may contain the signature of the client or the client's representative for payments made from the trust fund. At least one witness must sign for each payment made if the client or the client's representative cannot sign.
(f)
Limitations on withdrawals. The facility must not use the client's personal funds to purchase any item or service that the Texas Department of Human Services requires the facility to provide. The facility must purchase additional items or service with the client's personal funds only as described in §46.15 of this chapter (relating to Additional Services and Fees).

46.67  Trust Fund Documentation

Revision 04-1; Effective April 16, 2004
(a)
Accounting and records.
(1)
The facility must keep written records of all financial transactions involving the client's personal funds that the facility is holding, safeguarding, and accounting. The written records may be in any format.
(2)
The facility must keep the accounting records in accordance with generally accepted accounting principles (GAAP).
(3)
The facility must keep records in accordance with its fiduciary duties for client trust funds.
(4)
The facility must include at least the following in the accounting records:
(A)
each client's name;
(B)
identification of each client's representative or person assigned to receive the client's income, if any;
(C)
admission date;
(D)
each client's earned interest, if any;
(E)
documentation of each transaction; and
(F)
receipts for purchases and payments, including cash register tapes or sales statements from a seller.
(b)
Quarterly statement. The facility must provide quarterly statements to the client or the client's representative, as described in §92.125(a)(3)(L) of this title (relating to Resident's Bill of Rights and Provider Bill of Rights).
(c)
Access to trust fund records.
(1)
The facility must make an individual client's financial record and supporting documents available at any time during working hours to the client, the client's representative, and the Texas Department of Human Services.
(2)
This review can be made without prior notification.

46.69  Trust Fund Refunds

Revision 04-1; Effective April 16, 2004
(a)
The facility must return the full balance of the client's personal funds held in the facility to the client or the client's representative immediately upon request if the request is made during normal business hours. For purposes of this subsection, normal business hours are 8:00 a.m. to 5:00 p.m. on working days, or at the beginning of the next normal business hours if the request is received during hours other than normal business hours.
(b)
The facility must return the full balance of the client's personal funds that the facility has deposited in any bank account to the client or the client's representative within ten working days of request. This refund must include any interest reported as of the date of the request.

46.71  Trust Fund Procedures for Client Discharge

Revision 04-1; Effective April 16, 2004
(a)
Client transfer.
(1)
The facility must write a check to the resident for all funds held in the pooled checking account. This must include any interest accrued.
(2)
The facility must complete the transfer within ten working days of the effective date of the transfer.
(3)
The facility must not make any payments out of a client's trust fund after the effective date of transfer, except as described in this subsection.
(4)
The cleared check will suffice as a receipt.
(b)
Client discharge.
(1)
The facility must refund the discharged client's personal funds and provide a final accounting of those funds to the client or the client's representative either:
(A)
in person; or
(B)
by mail via certified return receipt.
(2)
The facility must complete the refund and provide a final accounting within ten working days of the date of discharge, or the date of the facility's awareness of the client's discharge, whichever is later.
(3)
The facility must not make any payment out of a discharged client's trust fund, except as described in this subsection.
(4)
The facility must maintain the following documentation in the client's trust fund record:
(A)
a copy of the final accounting of the client's personal funds;
(B)
the amount refunded to the discharged client or the client's representative;
(C)
the date the refund was made. The date the refund was made is either:
(i)
the date the funds were refunded in person; or
(ii)
the date the certified return receipt shows the refund was mailed; and
(D)
the method of refund. The facility must:
(i)
obtain the signature of the client or the client's representative if the refund was in cash; or
(ii)
document the check number if the refund was made by check.
(c)
Client death.
(1)
The facility must refund the deceased client's personal funds and provide a final accounting of those funds to the beneficiary, heir, or executor of the deceased client's estate either:
(A)
in person; or
(B)
by mail via certified return receipt.
(2)
The facility must complete the refund and provide a final accounting within 30 days of awareness of the client's death, if the beneficiary, heir, or executor is known, located, or identified. The facility must make a bona fide effort to locate the beneficiary, heir, or executor of a deceased client's estate within 30 days.
(3)
The facility must not make any payments out of a deceased client's trust fund, except as described in this subsection.
(4)
The facility must maintain the following documentation in the client trust fund record:
(A)
a copy of the final accounting of the client's personal funds;
(B)
the amount refunded to the beneficiary, heir, or executor of the deceased client's estate;
(C)
the date the refund was made. The date the refund was made is either:
(i)
the date the funds were refunded in person; or
(ii)
the date the certified return receipt shows the refund was mailed; and
(D)
the method of refund. The facility must:
(i)
obtain the signature of the client or the client's representative if the refund was in cash; or
(ii)
document the check number if the refund was made by check.
(5)
The facility must use the following procedures to clear the client's account if it is unable to locate or identify the beneficiary, heir, or executor of a deceased client's estate within 30 days:
(A)
The facility must send the personal funds of the deceased client to the Texas Department of Human Services (DHS), Fiscal Division, P.O. Box 149055, Austin, Texas 78714-9055 with the following information:
(i)
the client's name;
(ii)
the client's social security number; and
(iii)
the amount of money being submitted to DHS for escheat.
(B)
The facility must maintain the following in the client trust fund record:
(i)
documentation of the facility's efforts to locate the beneficiary, heir, or executor of a deceased client's estate; and
(ii)
proof of submission of the personal funds of a deceased client to DHS.
(d)
Contract assignment.
(1)
The assignor (the facility transferring the contract) must transfer the bank balances of the trust fund to the assignee (the facility to which the contract assignment is made) either:
(A)
in person; or
(B)
by mail via certified return receipt.
(2)
The assignor must complete the transfer within five working days of the effective date of the contract assignment.
(3)
The assignor must not make any payments out of a client's trust fund after the effective date of the contract assignment, except as described in this subsection.
(4)
The assignor must provide the assignee with a list of the clients who are utilizing the trust fund and their balances.
(5)
The assignee must provide the assignor with a receipt for the transfer of these funds. The receipt must contain the following elements:
(A)
the date of the transfer of funds. The date the transfer was made is either the:
(i)
date the funds were refunded in person; or
(ii)
date the certified return receipt shows the refund was mailed;
(B)
the name of the assignor;
(C)
the amount received by the assignee; and
(D)
the check number for the transfer of funds.
(6)
The assignor must keep the receipt for audit purposes.

4400  Home and Community Support Services

Revision 11-2; Effective December 21, 2011

4410  Program Overview

Revision 02-4; Effective Upon Receipt

4411  Service Introduction

Revision 02-4; Effective Upon Receipt

The service array under the Community Based Alternatives (CBA) program is designed to offer home and community-based services as cost-effective alternatives to institutional care in Medicaid certified nursing facilities. Eligible participants receive services according to their specific needs, as defined by an assessment process, based on informed choice.

The majority of services offered under the CBA program will be delivered by licensed Home and Community Support Service Agencies (HCSS). HCSS agencies must comply with the terms of the contract, Texas Administrative Code (TAC) rules in this section, generic contracting rules found in Sections 2000 and 7000, generic billing rules found in Section 5000, and monitoring rules in Section 7000 of this manual. HCSS agencies provide services to participants living in their own home, adult foster homes, assisted living facilities, and other locations where service is needed. The services provided are identified on an Individual Service Plan (ISP) and are authorized by DADS.

§48.6050 — Service Array for Home and Community Support Services (HCSS).

HCSS agencies must provide the array of home and community support services identified in paragraphs (1)-(9) of this section in accordance with the individual service plan through their own employees, subcontractors, or personal service agreements with qualified individuals. Services include:

(1)
personal assistance services;
(2)
nursing services;
(3)
physical therapy;
(4)
occupational therapy;
(5)
speech pathology services;
(6)
adaptive aids;
(7)
medical supplies;
(8)
minor home modifications; and
(9)
respite care (in-home).

4412  General Contracting Requirements

Revision 02-4; Effective Upon Receipt

§48.6026 — Home and Community Support Services Provider Qualifications.

To be qualified as a home and community support services (HCSS) provider to deliver Community Based Alternatives (CBA) services under contract with the Texas Department of Human Services (DHS), a HCSS agency must:

(1)
have a separate contract to provide CBA services in each DHS region in which services are to be delivered;
(2)
deliver CBA services through the licensed home health category of licensure;
(3)
have the counties in the DHS contract for CBA services included in the identified licensed service area on file at DHS within the licensed home health category of licensure; and
(4)
be authorized by the secretary of state to do business in the State of Texas (if an out-of-state corporation).

Home and Community Support Services in the CBA program are provided under a licensed home health category of licensure. Skilled services available through the waiver include nursing, physical therapy, occupational therapy, and speech pathology.

§48.6028 — Provisional Contracts — Home and Community Support Services Agencies.

(a)
A provisional contract is limited to one year. The Texas Department of Human Services (DHS) may extend a provisional contract if:
(1)
the formal review, including any reexamination, has not been completed prior to the end of the provisional contract period, or
(2)
DHS is unable to successfully transfer all clients by the end of the provisional contract period.
(b)
Prior to applying for a DHS contract, the home and community support services agency (HCSSA) must:
(1)
hold the license used to qualify for the contract for at least one year;
(2)
have completed an on-site health survey; and
(3)
be eligible for that license to be renewed.
(c)
During the 12 months immediately preceding application for a DHS contract, the HCSSA must have provided attendant or home health services:
(1)
to at least ten clients, with at least two of these clients having received on-going services during a 60-day block of time; and
(2)
for a total of at least 500 hours.
(d)
The services in subsection (c) of this section must have been provided in the region in which the contract application is made or in a county contiguous to that region.
(e)
DHS will not enter into a provisional contract until the HCSSA has received a pre-contract orientation from DHS.
(f)
DHS will not enter into a provisional contract if a HCSSA is:
(1)
under a monitoring agreement, defined as a licensure action, mutually agreed upon by the service provider and DHS, in which the provider agrees to hire a consultant to assist in correcting problems identified in the survey;
(2)
has a license revocation action pending with DHS; or
(3)
has a Level II administrative penalty pending with DHS.
(g)
Any contracts entered into after the effective date of this rule will be provisional contracts, including contracts to existing HCSSAs expanding into a new region.
(h)
A HCSSA contracting under a new vendor number as a result of a contract assignment will receive a provisional contract, but is exempt from the requirements in subsections (b), (c), and (d) of this section.
(i)
DHS may choose not to contract with a HCSSA if, in the preceding 12 months, the HCSSA had any Level II administrative penalties imposed by departmental order.
(j)
DHS may not contract with a HCSSA if, in the preceding 24 months, the HCSSA had any community care program contract involuntarily terminated.
(k)
Notwithstanding other department rules regarding formal reviews, for provisional contracts, this subsection prevails.
(1)
DHS will formally review provisional contracts at least once during the contract's provisional status.
(2)
A HCSSA not in compliance with program-specific requirements after the formal review cannot enter into another Community Based Alternatives (CBA) contract with DHS for at least 24 months from the end date of the provisional contract. Twenty-four months after the end date of the prior provisional contract, the HCSSA may apply for another provisional contract.
(3)
A HCSSA choosing to withdraw from the provisional contract cannot enter into another CBA contract with DHS for at least 12 months from the end date of the provisional contract. Twelve months after the end date of the prior provisional contract, the HCSSA may apply for another provisional contract.
(4)
If DHS determines that a HCSSA is not in compliance with one or more program-specific requirements, the provider agency may request a re-examination of the determination.
(A)
The provider agency must submit the request in writing, and the appropriate DHS staff must receive it within ten calendar days of the date of the formal review exit conference.
(B)
The provider agency's written request must contain a concise statement of the specific actions or determinations it disputes and any supporting documentation the provider agency deems relevant to the dispute.
(C)
The lead DHS staff member coordinates a re-examination of the formal review determination with appropriate DHS staff. DHS staff may request additional information from the provider agency.
(D)
Within 30 days of the date DHS receives the request for re-examination or of the date DHS receives additional requested information, the lead staff member must send the provider agency its written decision.
(5)
If DHS determines that a HCSSA did not meet the requirements in subsection (c) of this section prior to obtaining a DHS contract, the provisional contract will be involuntarily terminated.

§48.6030 Current Contractors — Home and Community Support Services Agencies.

(a)
Conflict of rules. Notwithstanding other department rules regarding termination, this section prevails.
(b)
Voluntary termination of a contract. For a period of at least 12 months after a voluntary termination of a contract, the Texas Department of Human Services (DHS) will not recontract with the home and community support services agency (HCSSA) for Community Based Alternatives (CBA) services in the region covered by the terminated contract. At the end of the 12-month period, the HCSSA may apply for a provisional contract.
(c)
Involuntary termination of a contract.
(1)
For a period of at least 24 months after a contract was involuntarily terminated, DHS will not enter into a CBA contract with:
(A)
the HCSSA anywhere in the state; or
(B)
any HCSSA with a person with a controlling interest, who also had a controlling interest in the HCSSA which was involuntarily terminated.
(2)
If a HCSSA contract is involuntarily terminated for failure to deliver community care services for six consecutive months, the HCSSA may not recontract with DHS to provide services in the region covered by its terminated contract for six months after the involuntary termination.
(3)
The involuntary termination of a CBA contract in one region will not automatically result in the involuntary termination of CBA contracts held by the same HCSSA in other regions. DHS will review the HCSSA's contracts in other programs/regions to determine if there is cause for further terminations.
(4)
If a HCSSA contract is involuntarily terminated, the HCSSA must demonstrate to DHS that the conditions which caused the involuntary termination have been resolved prior to entering into another contract.
(d)
Reasons for termination. In addition to the reasons specified in §49.19(b)(3) of this title (relating to Sanctions), DHS may terminate the existing contract of a HCSSA if, in the preceding 12 months, the HCSSA had any Level II administrative penalties imposed by departmental order.
(e)
Formal reviews. DHS will conduct a formal review of each HCSSA contract at least once every two years.

4413  General Requirements for Participation

Revision 13-1; Effective March 1, 2013

STANDARD. General Requirements for Participation.

Home and Community Support Services Agencies (HCSSAs) must:

  1. Provide the array of HCSS identified below in accordance with the Individual Service Plan (ISP), Form 3671-1, Individual Service Plan, Form 3671-2, Individual Service Plan, Form 8598, Non-Waiver Services, and as applicable, Form 3671-B, Therapy Service Authorization, Form 3671-C, Nursing Service Plan, Form 3671-C-Alternate, CBA Individual Service Plan – Nursing Service Plan for Consumer Directed Services (CDS) and/or Specialized Nursing or Health Maintenance Activities (HMAs), Form 3671-D, Minor Home Modifications, Form 3671-E, Adaptive Aids and Medical Supplies, Form 3671-H, Dental Services, Form 3671-J, Dental Services – Proposed Treatment Plan, Form 2060, Needs Assessment Questionnaire and Task/Hour Guide, and Form 2060-A, Addendum to Form 2060 for Personal Assistance Services, through its own employees, subcontractors, or personal service agreements with qualified individuals. Services include:
    1. adaptive aids
    2. dental
    3. medical supplies
    4. minor home modifications
    5. nursing services
    6. occupational therapy
    7. personal assistance services
    8. physical therapy
    9. respite care (in-home)
    10. speech, hearing and language therapy
  2. Provide Form 3671-K, Service Backup Plan, for program services, as needed.
  3. Provide trained and competent staff to deliver services to the individual.
  4. Maintain documentation of the assessment and provision of services.
  5. Provide for the delegation and supervision of nursing tasks and personal care tasks.
  6. Access Medicare and other third party resources for any services that the case manager has identified on the individual’s ISP for non-waiver services, as needed by the individual.

HCSSAs may subcontract with a person or a group in order to provide the necessary services, as long as the group designates at least one signature authority for the contract. There needs to be some document that shows signature authority for the person signing. The HCSSA must meet the requirements in 97.289 of the Texas Administrative Code relating to Independent Contractors and Arranged Services.

If an HCSSA agency is not providing services, as authorized on the ISP or meeting the contract requirements, the case manager may authorize a change in the HCSSA agency providing services.

4413.1  Utilization of Other Resources

Revision 02-4; Effective Upon Receipt

The HCSS agency must work with the participant's case manager to ensure that, if the participant is eligible for Medicare (Title XVIII) or Medicaid (Title XIX) home health services or any other third- party resources, the resources are used to meet the participant's need for services. Federal regulations require these resources to be accessed before CBA services are provided. It is the responsibility of the HCSS agency to know when to access Medicare and Medicaid.

In developing the participant's ISP, the case manager must take into consideration any third-party resources the participant is receiving or is eligible to receive and will work with the HCSS agency to access these resources to pay for services the participant needs. If the participant is eligible to receive services from any third-party resource, the case manager will identify on the ISP for non-waiver services the services the HCSS will provide to the participant and bill to the third-party resource.

If the services provided through the third-party resource are not sufficient to meet the participant's need, waiver services may be provided to the participant, even on the same day, to meet the participant's need. The waiver services will be authorized on the ISP. The HCSS agency must not bill DHS for services that have not been authorized on the participant's ISP for waiver services.

Using Other Resources

For Medicare/Medicaid recipients, Medicare must be used as the primary resource for payment of home health benefits.

For recipients with MQMB coverage, Medicaid pays the deductible and coinsurance on claims that cross over from Medicare, whether or not the service is a benefit of Medicaid.

For recipients who have Medicare and Medicaid (but not MQMB), Medicaid pays the deductible. In addition, Medicaid pays the coinsurance if the service is a benefit of Medicaid (according to Medicaid benefits and limitations.)

Medicare services should always be accessed first before seeking coverage through Medicaid or CBA.

Medicaid Home Health Services

Service available under the Medicaid Home Health benefit include:

  • skilled nursing services
  • home health aide services
  • physical and occupational therapy
  • durable medical equipment/medical supplies

To be eligible for Medicaid Home Health, a CBA applicant/participant must meet the following requirements:

  • Be an adult age 21 or over and meet the definition of homebound;
    • For an individual to be considered homebound, his physician must attest that he has a condition due to illness or injury that restricts his ability to leave home or makes leaving home taxing or require considerable effort, or medically contraindicated.
    • Texas Department of Health indicates that homebound requirement under Medicaid Home Health can be met when an individual would be homebound if not for the provision of durable medical equipment or supplies covered by home health services.
  • Be under the continuing care of a physician who has established a plan of care for the recipient. The recipient must be seen by his physician within 30 days of the start of services, or the physician visit may be waived for a year when a diagnosis already has been established by the physician;
  • Have a medical need for covered home health services, DME, or medical supplies documented in the recipient's plan of care or Home Health DME/Medical Supplies Physician Order Form;
  • Received prior authorization from TMHP; and
  • Receive services that meet the recipient's existing medical needs and that can safely be provided in the recipient's home.

All HCSS agencies participating in the CBA program must access Medicaid Skilled Home Health services for eligible CBA participants either directly as the Medicaid Home Health provider or by referral to a Medicaid Home Health provider.

CBA HCSS providers may contact Texas Medicaid and Healthcare Partnership (TMHP) at 1-800-626-4117 to enroll as a Medicaid Home Health provider or obtain a list of local home health providers who are contracted to provider Medicaid Home Health services. To be eligible to enroll as a Medicaid Home Health provider, the HCSS must be licensed and certified to be a Medicare provider.

HCSS agencies may call TMHP to inquire on benefits available through Medicaid Home Health. Prior authorization and benefit availability can be obtained by calling 1-800-925-8957. A Texas Medicaid Provider Procedures Manual may be requested by calling TMHP, Customer Service, at 1-800-626-4117.

If the DME vendor or the HCSS agency does not comply with their agreement with TMHP to accept Medicaid reimbursement rates, the case manager contacts the HHSC Office of Investigations (Medicaid Fraud) at (915) 424-6519.

4413.2  Self-Determination Act

Revision 02-4; Effective Upon Receipt

STANDARD. Self-Determination Act. The HCSS Agency must send, within three days, a copy of the participant's advance directives, if executed, to the Emergency Response Service (ERS) provider if ERS services are authorized for the participant.

Refer to Appendix I for information about meeting the requirements of the Patient Self-Determination Act. Copies of the attachment in the appendix can be made to:

  • provide information to participants, and
  • educate staff and people in the community.

4414  Procedures for Accessing Medicaid Home Health

Revision 02-4; Effective Upon Receipt

4414.1  Procedure for Accessing Medicaid Home Health Services at Pre-Enrollment

Revision 02-4; Effective Upon Receipt

For CBA HCSS agency providers who are providers of Medicaid Home Health services, the CBA HCSS agency must determine the applicant's homebound status. If homebound:

  • Enter "yes" on Form 3676 noting homebound status.
  • Identify on Form 3676 that prior authorization was requested. Submit copy of prior authorization request identifying the items that are being requested from Medicaid to case manager with the pre-enrollment packet.
  • Supply all items and services to the CBA participant as authorized through CBA during the interim period before supplying through Medicaid Home Health.
  • Initiate Medicaid Home Health services when authorized by TMHP.
  • Discontinue the provision of CBA services to be provided through Medicaid when Medicaid Home Health services are initiated so not to duplicate services.
  • Within five days of receipt of authorization from TMHP, submit a service plan change to the case manager deleting the services from the CBA service plan and a copy of the authorized claim from TMHP showing approval of the services.

If homebound requirement is not met, enter:

  • "no" on From 3676, and
  • rationale for not being homebound in comments.

For CBA HCSS agency providers who are not contracted to provide Medicaid Home Health services, determine the applicant's homebound status. If homebound:

  • Enter "yes" on Form 3676 and complete prior authorization requested and date, identifying the name, telephone number of agency notified to assess individual for Medicaid Home Health services.
  • Coordinate the provision of services with the Medicaid Home Health provider (ask the referred Medicaid Home Health provider to submit a copy of the prior authorization approval to them informing them of services being provided through Medicaid Home Health).
  • Within five days of receipt of copy of TMHP's prior approval authorization from the referred HCSS agency, submit a service plan change to the case manager deleting the Medicaid services from the CBA service plan. (These are the services that will be listed on the prior approval authorization receipt.)

Note: If not notified within 30 days that Medicaid Home Health Services were initiated, the CBA HCSS agency provider refers the individual to another Medicaid Home Health provider agency for follow up and documents the second referral, to include the name and telephone number of the agency, on Form 2067, Case Information, and sends to the case manager.

If not homebound:

  • enter "no" on Form 3676, and
  • document rationale in comments.

4414.2  Procedure for Accessing Medicaid Home Health Services When a Service Plan Change or an In-Patient Hospitalization is Needed Due to a Condition Change Following New Diagnoses or New Medications

Revision 02-4; Effective Upon Receipt

For CBA HCSS agency providers who are providers of Medicaid Home Health services, complete the necessary ISP attachment identifying the needed services to determine the participant's homebound status. If homebound:

  • Determine if identified services may be obtainable through Medicaid Home Health.
  • Request prior authorization.
  • Send copy of prior authorization with service plan change request to case manager. (This identifies services requested to be provided through Medicaid Home Health.)
  • Supply all authorized items and services to the CBA participant during the interim period awaiting authorization from TMHP.
  • Initiate Medicaid services when authorized by TMHP.
  • Discontinue the provision of CBA services to be provided through Medicaid when Medicaid Home Health services are initiated to avoid duplicate services.
  • Within five days of receipt of authorization from TMHP, submit a service plan change to the case manager deleting the services from the CBA service plan and a copy of the authorized claim from TMHP showing approval of the services.

If the participant is not homebound:

  • The CBA agency will write on Form 2067 that the participant is not homebound and provide the reason.
  • Form 2067 will be submitted to the case manager with the service plan change request.

For CBA HCSS agency providers who are not contracted to provide Medicaid Home Health services, complete the necessary ISP attachment identifying the needed services. Determine the participant's homebound status. If homebound:

  • Refer the participant to contracted Medicaid Home Health provider for Medicaid services.
  • Coordinate the provision of services with the Medicaid Home Health provider. Ask the referred Medicaid Home Health provider to submit a copy of the prior authorization approval to them informing them of services being provided through Medicaid Home Health.
  • Send the service plan change request annotating the items that may be authorized through Medicaid Home to the case manager with Form 2067 identifying the Medicaid Home Health agency and telephone number.
  • Within five days of receipt of a copy of TMHP's prior approval authorization from the referred HCSS agency, submit a service plan change to the case manager deleting the Medicaid services from the CBA service plan. (These are the services that will be listed on the prior approval authorization receipt.)

Note: If not notified within 30 days that Medicaid Home Health services were initiated, the CBA HCSS agency provider refers the individual to another Medicaid Home Health provider agency for follow up and documents the second referral, to include the name and telephone number of the agency, on Form 2067, Case Information, and sends to the case manager.

If the participant is not homebound:

  • the CBA HCSS agency will write on Form 2067 that the participant is not homebound and provide the reason.
  • Form 2067 will be submitted to the case manager with the service plan change request.

The CBA HCSS agency is responsible for the authorized provision of services until notified that Medicaid Home Health services are being provided.

If Form 3676 is marked "No," but the case manager believes the client to be homebound, the case manager may refer the applicant to the regional nurse for consultation. All rationales for not billing Medicaid Home Health are subject to review by DADS nurses upon request of the case manager.

When notified by the HCSS agency of a service plan change because the Medicaid Home Health provider is now providing covered item or services through Medicaid Home Health, the case manager will:

  • notify the participant on Form 2065 of the reduction in services, thus offering the right to appeal;
  • explain on Form 2065 the reason for the service reduction is to prevent duplication of services; and
  • modify the ISP reflecting the change in service plan.

Texas Medicaid and Healthcare Partnership (TMHP) has a 24-hour turnaround for prior authorization requests. If the prior authorization request is requested by fax, an approval response will be mailed to the HCSS within 24 hours of receipt of the prior authorization by Medicaid Home Health. If an approval is requested by phone, an approval may be given immediately or within 24 hours. TMHP sends written denial notices to clients only; they are not required to send denial notices to providers. With this procedure, the HCSS agency should have approval or denial information to the case manager within a reasonable amount of time.

TMHP makes the determination regarding homebound status based on information provided by the HCSS agency nurse or physician. The HCSS agency must inform the physician of the Texas Department of Health's interpretation of homebound status verbally or in written communication which may be attached to the Title XIX Home Health, DME/Medicaid Supplies Physician Order form when submitted to the physician for signature.

Prior authorization by TMHP will be issued for supplies and DME for up to six months based on diagnosis. An extension may be obtained from TMHP by requesting the extension up to 60 days prior to the start of the new authorization period.

If the HCSS agency submits a request for an item that appears to be covered under Medicaid Home Health but does not submit any documentation or rationale why Medicaid Home Health was not accessed, the case manager may request a review from the regional nurse. The regional nurse will follow up with the HCSS agency and send back the request to the HCSS agency if determined appropriate for a Medicaid referral. If an HCSS agency is told by TMHP that a requested item will not be approved, the HCSS agency should document the date and the name of the TMHP nurse who gave the verbal denial. This documentation provides proof of the attempt to provide purchase through Medicaid Home health for audit purposes. This information should be related to the case manager via 2067.

CBA may pay for adaptive aids and medical supplies that are denied by Medicare or Medicaid, because the participant does not meet Medicare for Medicaid medical necessity. The CBA participant must have a medical need for the item if purchased by CBA funds. CBA case managers may need to consult with the regional nurse on items that do not meet Medicare or Medicaid medical necessity, but possibly meet CBA criteria.

Medicaid providers, including DME companies, cannot refuse to supply items to a CBA participant because Medicaid does not pay the full cost of the item. Medicare and Medicaid suppliers are bound by Medicare/Medicaid assignment. HCSS agencies must not request any differences be paid for by CBA funds or the participant. Accepting full payment also applies to HCSS agencies contracting with TMHP to provide Medicaid Skilled Home Health. TMHP makes the determination for payment on a claim that Medicare paid part of the claim on a case-by-case basis, based on criteria found in the Texas Medicaid Provider Procedures Manual.

If a Medicaid provider refuses to supply items to a Medicaid recipient, a referral should be made. If the client is the one reporting the problem, they can call the Medicaid Hotline at 1-800-252-8263. If it is a matter of educating the provider and the reporting person is from DADS, they can call Texas Department of Health at 512-338-6520 or 512-338-6504 and request that the HCSS TMHP provider representative educate the provider regarding his assignment to Medicaid. If it is apparent to a DADS staff person that the Medicaid provider is aware of the assignment policy but still refuses to supply Medicaid products to Medicaid recipients, the DADS staff person will contact Health and Human Services, Medicaid Integrity Program, at 512-490-0421 or 512-490-0402 and make a referral to follow up.

4420  Description of Services

Revision 02-4; Effective Upon Receipt

HCSS agencies provide services to the participant living in his choice of care setting whether in his own home, an Assisted Living/Residential Care facility, an Adult Foster Care (AFC) home or other locations where he needs services.

Services and care provided, as identified and authorized on Form 3671, ISP, must assist the participant to attain or maintain the highest practicable physical, mental, and psychosocial well-being.

Services provided will be tailored to meet the participant's goals and needs based upon his medical condition, mental and functional limitations, ability to self-manage, and availability of family and other support.

The HCSS agency must assure that the participant's informed choice and convenience will be incorporated into the planning and provision of the participant's care by involved professionals. Participants must be encouraged and allowed to play an active role in determining their ongoing plan of care.

While providing care under the standards of professional practice, HCSS agencies must recognize and support the participant's right to a dignified existence, privacy, and self-determination.

4420.1 Service Backup Plans

Revision 13-1; Effective March 1, 2013

Effective March 1, 2013, all initial and reassessment packets completed by the Home and Community Support Services Agency (HCSSA) on or after March 1, 2013, must provide a service backup plan for each applicant/individual. The backup plan must be completed as part of the pre-enrollment home health assessment, the annual reassessment or anytime a revision to the service backup plan is needed. The plan is completed using Form 3671-K, Service Backup Plan.

HCSSAs must provide a service backup plan for program services, as needed, when normal service delivery is interrupted in the absence of the service provider or in an emergency. The HCSSA completes a service backup plan for each individual. The HCSSA must implement the services in the backup plan as described on Form 3671-K, if the need arises. The service backup plan must be maintained in the individual’s case record. If a change to the service backup plan is needed, the HCSSA nurse assessor completes a new Form 3671-K.

The case manager provides a copy of the individual service plan (ISP), which includes the service backup plan (Form 3671-K), to the individual receiving CBA waiver services.

The HCSSA is not responsible for creating a service backup plan for individuals residing in an adult foster care home or an assisted living facility, or when services are delivered through the Consumer Directed Services option. 

4421  Personal Assistance Services

Revision 02-4; Effective Upon Receipt

Personal assistance services provide assistance to the participant, as authorized on his ISP, Form 3671, with the performance of activities of daily living, household chores, and nursing tasks that have been delegated by a registered nurse (RN).

4421.1  Qualifications of Registered Nurse Supervisors

Revision 02-4; Effective Upon Receipt

STANDARD. Supervision of personal care attendants is provided by HCSS Agency registered nurses (RNs) who:

  1. have proof of a current license from the Board of Nurse Examiners for the state of Texas, and
  2. practice in compliance with the Nurse Practice Act according to the rules and regulations of the Board of Nurse Examiners.

Proof of licensure can be validated by viewing the nurse's original current license and recording in a log the nurse's name, license number, date of expiration, and initials of the individual who verified that the license is current. If necessary, licenses can be verified with the Board of Nurse Examiners by telephone or written request.

4421.2  Qualifications of Personal Assistance Services Attendants

Revision 02-4; Effective Upon Receipt

STANDARD. Personal Assistance Services are performed by personal care attendants who:

  1. are employed by a HCSS agency; and
  2. are not spouses of participants.

A common law spouse is excluded from being a paid attendant.

4421.3  Types of Personal Care Attendants

Revision 02-4; Effective Upon Receipt

STANDARD. The two types of personal care attendants are:

  1. regular attendants who perform all of the personal assistance services available within their scope of competency; and
  2. special attendants who may be used to initiate services, prevent a break in service, and provide on-going service.

4421.4  Required Training for Attendants

Revision 02-4; Effective Upon Receipt

STANDARD.

  • Before or when services begin, the attendant must meet the registered nurse (RN) supervisor at the participant's home to receive a general orientation with the participant as described in Section 4421.6, Orientation and Training Responsibilities of the RN Supervisor.
  • Although special attendants are required to receive the general orientation as described in Section 4421.6, they do not have to receive it in the participant's home as long as they meet the following requirements:
    • The special attendant must meet the requirements in Section 4421.2, Qualifications of Personal Assistance Services Attendants; and
    • Special Attendants must either:
      • meet the requirements described in §97.61 (a) and (c)-(g) of Title 40, Subchapter E (relating to Home Health Aides; Training course; Duties); or
      • meet the following requirements:
        • have six continuous months of experience in delivering personal care tasks in family care, primary home care, personal assistance services, client managed attendant services (CMAS); or
        • be listed as a nurses aide on the Texas Department of Health nurses aide registry.

4421.5  Documentation of Required Training

Revision 02-4; Effective Upon Receipt

The following documentation may be used to establish that a special attendant meets requirements.

Home Health Aide Documentation

  • A copy of the home health aide certificate, or attendant records that indicate that the home health aide meets the requirements specified in Section 4421.2, Qualifications of Personal Assistance Services Attendants; or
  • A diploma or form letter that includes the name of the person who received the training, the date he completed the program, and the name of the person certifying the completion of the course.

Home health aide training must be provided by individuals approved by the Texas Department of Health (TDH). The provider agency must have records that include the date and name of the person providing the home health aide training, the number of hours and topics covered in the training, and signatures of both the trainer and trainee.

Six Month's Experience Documentation

  • Attendant personnel records that indicate that he has six months of continuous (full or part-time) experience in providing family care, primary home care, personal assistance services, or client managed attendant services (CMAS); and
  • Written notes from the family care, primary care, or personal assistance supervisor, and orientation forms from the agency RN documenting that the attendant is competent to provide personal care services.

Nurses Aide Documentation

  • A copy of the nurses aide certificate issued by DADS.

A copy of the nurses aide certificate or a copy of the nurses aide registry in which the aide is listed must be filed in the attendant's personnel folder. To verify nurses aide certification or to get a copy of the nurses aide registry contact DADS at 1-800-425-3934.

An agency form containing the aide's license number, expiration date, aide name, and signature of agency staff verifying the information is not acceptable documentation in lieu of a nurse aide certificate.

Once oriented, the special attendant does not need to be reoriented if the participant's condition, tasks, and hours remain unchanged. There are no limits on the length of a time a special attendant may be used. The special attendant may serve the participant without retraining, as long as the participant's condition, tasks, and hours remain unchanged. In addition, there are no restrictions with respect to the amount of time between the special attendant's assignments.

4421.6  Orientation and Training Responsibilities of the RN Supervisor

Revision 02-4; Effective Upon Receipt

STANDARD.

  1. The registered nurse (RN) supervisor must provide orientation to the personal care attendants in the participant's home, on or before the service initiation date, in order to:
    1. provide them necessary training to deliver the personal assistance tasks, and document in the clinical record that the orientation/training was provided or initiated; and
    2. determine if the attendant is competent to deliver the authorized nursing tasks and document competency in the clinical record or on the teaching protocol, if utilized.
  2. The RN supervisor is not required to give onsite orientation to the special attendant if requirements are met for special attendants as specified in Section 4421.4, Required Training for Attendants, but must give the attendant verbal or written orientation before he goes to the participant's home.
  3. The RN supervisor will provide orientation to the personal care attendants on the following:
    1. information about the participants health condition and how it may affect the performance of tasks;
    2. tasks to be performed, work schedule, and safety and emergency procedures; and
    3. symptoms or changes in the participant's health status about which the unlicensed person should notify either the RN or the attending physician.
  4. During the time of the orientation visit, the RN must advise the participant and/or family of their right to file complaints against the individual provider or the HCSS agency.

Although the RN supervisor will make every attempt to complete orientation for the attendant on the service initiation date, circumstances such as difficult nursing tasks, unstable condition of the participant or instances in which an LVN will be providing the training for the delegated tasks, may necessitate the need for completion of orientation on the next day's visit.

If more than one attendant is needed to provide services to a participant, for instance, for a split shift schedule, the RN supervisor may orient the attendants at the same time.

Supervision is not a billable activity for HCSS agencies unless the RN is supervising the attendant in the delivery of delegated nursing tasks.

4421.7  Description of Personal Assistance Services

Revision 02-4; Effective Upon Receipt

STANDARD.

  1. Personal Assistance Services include, but are not limited to, the following:
    1. assisting with the activities of daily living, such as feeding, preparing meals, transferring, and toileting;
    2. assisting with personal maintenance, such as grooming, bathing, dressing, and routine care of hair and skin;
    3. assisting with general household activities and chore services which are necessary to maintain the home in a clean, sanitary, and safe environment, such as changing bed linens, housecleaning, laundering, shopping, storing purchased items, and washing dishes;
    4. providing protective supervision as temporary relief of the primary caregiver;
    5. providing extension of therapy services;
    6. providing ambulation and exercise;
    7. assisting with medications that are normally self-administered;
    8. performing nursing tasks delegated by registered nurses;
    9. escorting the participant on trips to obtain medical diagnosis, treatment, or both.
  2. The HCSS agency must provide Personal Assistance Services as identified on Forms 2060 and 2060-A to participants living in their own homes.
  3. The HCSS agency must notify the case manager on Form 2067 when protective supervision hours are authorized as personal assistance services before an unpaid caregiver becomes a paid attendant of the agency, and no other attendant will be providing protective supervision.

Because shopping is an authorized task, it may entail paying mileage to the attendant to perform the task. The participant cannot be charged for transportation costs incurred in performance of this task by either the attendant or the HCSS agency. Taking care of household pets and ironing are not included under general household activities or chore services and are not reimbursable under the CBA waiver.

To facilitate safe participant ambulation or movement, the attendant may need to arrange furniture, for example, for participants who use wheelchairs, walkers, or crutches, or for blind participants. The RN supervisor addresses this activity during orientation for an attendant who provides services to a participant needing this assistance.

Escorting a participant for medical diagnosis or treatment does not include the direct transportation of the participant by the attendant. Transportation for Medicaid recipients is available in every county through the Medical Transportation program. Transportation is not included as an activity in the escort task.

Licensed therapists may choose to instruct the attendants in the proper way to assist the participant in follow up on therapy sessions. This assistance and support provides reinforcement of instruction and aids in the rehabilitative process.

Protective supervision is authorized on Forms 2060 and 2060-A and assures supervision of the participant in instances when the primary caregiver is out of the home for short periods of respite, for instance, at a movie and the participant has a demonstrated or assessed need to be supervised. Protective supervision is supervision only and does not require the delivery of personal care tasks. Protective supervision is appropriate when it is necessary to protect the participant from injury due to his cognitive/memory impairment and/or physical weakness. If left unattended, for instance, the participant may wander outside, turn on electrical appliances and burn himself, or try to walk and then fall. Protective supervision is not routinely authorized due to the fact that the unpaid caregiver is encouraged to be out when the personal care attendant is providing care in the participant's home.

The purpose of protective supervision is to provide relief for the caregiver from the responsibility of supervising the participant. Because the purpose of protective supervision is to relieve a caregiver, the case manager must identify the caregiver on Form 2067, Case Information, submitted to the HCSS agency at the time of the referral acceptance or at the time of the written referral for services to notify the HCSS agency that the caregiver may not provide protective supervision if hired as the HCSS attendant. When protective supervision hours are authorized and a case manager is notified by an agency of an unpaid caregiver becoming a paid attendant and no other attendant will be providing the protective supervision hours, the case manager will reduce the authorized PAS hours on the participant's ISP, deleting the authorized protective supervision hours.

4421.8  Requirements for Supervision and Delegation

Revision 02-4; Effective Upon Receipt

STANDARD.

  • The RN supervisor is responsible for the delegation and supervision of nursing tasks to personal care attendants as allowed under the provider agency's licensure category as a Home and Community Support Services Agency from rules promulgated by the Texas Board of Nurse Examiners and referenced in Appendix II.
  • The RN supervisor must document the plan for return supervisory visits in the nurse's delegation/treatment plan for each participant.
  • During each visit for the monitoring of the performance of delegated tasks, the RN supervisor must perform the following and document in the progress notes in the participant's clinical record:
    • assess the participant's health and determine whether any changes have occurred in his health since the last visit;
    • review the adequacy of the participant's current service plan;
    • assess the quality of services provided by the attendant as authorized on Form 3671; and
    • determine the attendant's service delivery problems, training needs, and corrective action needs.

There is no regular required supervisory visit in CBA. The necessity for and scope of delegation, supervision, and monitoring of nursing tasks is dependent upon the RN's professional judgement in accordance with standards of practice as defined by the Texas Board of Nurse Examiners.

Although the administration of medications can be a delegable task, the preparation of med-packs for weekly administration of medications is only an acceptable practice for an RN if the nurse feels it is a safe and prudent practice for the situation.

The following circumstances are situations in which delegation would not be appropriate:

  • the participant's medical condition is not stable and predictable;
  • the criteria for delegation according to the rules promulgated by the Texas Board of Nurse Examiners are not met;
  • the physician assesses and orders tasks to be performed only by licensed nurses due to complexity and circumstances; or
  • the participant refuses delegation of nursing tasks.

Decisions to delegate tasks for CBA participants are documented for CBA purposes on Form 3671-C, ISP Nursing Service Plan, Form 2060-A, CBA Individual Service Plan Addendum to Personal Assistance Services, and in other documentation necessary for the provision of services. The time required for the attendant to perform the delegated tasks is authorized on Form 2060-A as personal assistance services.

The need for assistance in ambulation may be either a personal care task or a nursing task depending on the assessment by the nurse on Form 3671-C. When doing the functional assessment on Forms 2060 and 2060-A, the case manager must consider the HCSS nurse's assessment on the individual's need for ambulation, as documented on the nursing assessment on Form 3671-C. The case manager should not authorize ambulation as a personal assistance task on Form 2060 if it is being done as a nursing task. Ambulation, as a delegable nursing task (as identified in Item 10 on Form 3671-C) requires nursing intervention in response to a specific condition of the participant. The physician may or may not order specific ambulation orders.

As an example, the physician may order "ambulation or activity as tolerated" for a participant with congestive heart failure. This participant experiences increased shortness of breath when ambulating. The nurse intervenes and delegates how to perform the ambulation, "to walk no more than 10-15 steps without resting 1-2 minutes while taking several deep breaths before starting to walk again. Attendant to support the client on one side while walking by holding on to his elbow."

Ambulation as a personal care task involves non-skilled assistance with walking/transferring while taking the usual precautions for safety, i.e., standby assistance, gentle support of an elbow for balance or assuring balance of walker. This does not involve nursing intervention. No special precautions are needed other than for safety measures.

As part of the RN's responsibility to supervise the provision of delegated tasks, the RN will periodically assess the provider's ability to perform the delegated tasks and the participant's overall health status and response to the delegated tasks. If the RN's assessment is that the provider is not performing the tasks properly, the delegation to that particular provider must stop. The HCSS provider must continue to meet the nursing needs of the participant. If the unsatisfactory provider is an HCSS attendant, the HCSS provider must assure that the participant does not experience a break in service. The participant's desire to retain an attendant to whom the RN will not delegate must be considered; however, the case manager should help the participant understand the cost implications of the alternatives he selects on the revised service plan.

4422  Nursing Services

Revision 02-4; Effective Upon Receipt

Nursing services in the CBA program includes the direct delivery of care, the training of non-paid family members, neighbors and other informal support in administering care, and the delegation to and supervision of unlicensed persons, i.e., HCSS attendants and Adult Foster Care providers and provider substitutes of Levels I and II Adult Foster Care Homes.

An HCSS agency must carry out any skilled treatment or any service specified in the plan of care ordered by a medical doctor (MD), doctor of osteopathy (OD), or a practitioner. The practitioner definition includes a physician assistant (PA) and advanced practice nurse (APN).

The DADS case manager will authorize nursing services with Service Code 13, calculating the Individual Service Plan (ISP) using the registered nurse (RN) rate. In the event that a CBA applicant exceeds the cost ceiling due to a large amount of nursing hours, the case manager will request that the home and community support services (HCSS) agency provide an estimate of RN and licensed vocational nurse (LVN) hours the HCSS agency projects will be provided during the waiver year.

Licensed nurses may be AFC providers in any level AFC home but must be the provider in AFC Level III homes, as referenced in the CBA Provider Manual, Section 4422.4.1.

§48.6040 — Registered Nurse (RN) Delegation of Nursing Tasks.

Delegation and supervision of selected nursing tasks is permitted in the Community Based Alternatives:

(a)
by RNs employed by the Home and Community Support Service agencies to personal care attendants and adult foster care providers of Level I and II Adult Foster Care homes. Delegation will occur in accordance with the Texas Department of Health Home and Community Support services licensure rules for the provider agency's licensure category; or
(b)
by independent RNs to adult foster care providers of Level I and II, Adult Foster Care homes. Delegation will occur in accordance with the rules from Texas Board of Nurse Examiners, 22 TAC §218; or
(c)
by RNs who are adult foster care providers of a Level I or II Adult Foster Care home who delegate to substitute providers. Delegation will occur in accordance with the rules from Texas Board of Nurse Examiners, 22 TAC §218.

4422.1  Nurse Qualifications

Revision 02-4; Effective Upon Receipt

STANDARD. Nursing services are provided by licensed nurses meeting the following qualifications:

  • Registered nurses must:
    • have proof of a current license from the Board of Nurse Examiners for the state of Texas, and
    • practice in compliance with the Nurse Practice Act according to the rules and regulations of the Board of Nurse Examiners.
  • Licensed vocational nurses must:
    • have proof of a current license from the Board of Vocational Nurse Examiners of Texas, and
    • practice within the parameters of their educational preparation and rules and regulations of the Board of Vocational Nurse Examiners.

Proof of licensure can be validated by viewing the nurse's original current license and recording in a log the nurse's name, license number, date of expiration, and initials of the individual who verified that the license is current. If necessary, licenses can be verified with the Board of Nurse Examiners or Board of Vocational Nurse Examiners by phone or written request.

Texas RN licenses may also be verified online at:

www.bne.state.tx.us/olv/verification.html

4422.1.1  Role of the CBA Nurse with the TPR Nurse

Revision 02-4; Effective Upon Receipt

When an HCSS RN and an RN from a TPR, such as Medicare, share responsibility and care in a CBA case, each nurse is accountable for her own actions. If the CBA RN is sharing nursing tasks with the Medicare nurse then it is expected that the nurses will collaborate in determining the necessary interventions and performance of tasks, with Medicaid being the last payor. The CBA RN and the Medicare RN do not supervise each other.

4422.1.2  Role of the Licensed Vocational Nurse

Revision 02-4; Effective Upon Receipt

The licensed vocational nurse (LVN) from the HCSS agency may deliver nursing services, to include training attendants, AFC providers and provider substitutes on nursing tasks, after the RN has assessed the participant and established the plan of care. The LVN may not complete Form 3652-A, Client Assessment Review and Evaluation (CARE),or initiate any service plan changes.

4422.2  Nursing Services in Participants' Homes

Revision 02-4; Effective Upon Receipt

RN supervisors delegate, supervise, and monitor personal care attendants in the delivery of personal care and/or nursing tasks under personal assistance services. If nursing tasks cannot be delegated, for whatever reason, the HCSS agency must continue meeting the participants' identified needs for nursing care by direct delivery from licensed nurses.

4422.3  Nursing Services in Assisted Living Facilities

Revision 02-4; Effective Upon Receipt

Licensed nurses will directly deliver care, with the exception of medication administration, to participants requiring nursing services residing in assisted living facilities.

If an AL/RC participant's nursing needs are being met by a TPR such as Medicare, the HCSS RN will not be authorized any routine visit hours for monitoring the participant or his needs. When Medicare services terminate, an ISP change should be requested by the HCSS agency RN to add nursing hours for monitoring of the participant.

4422.4  Nursing Services in Adult Foster Care Homes, Levels I and II

Revision 02-4; Effective Upon Receipt

The HCSS agency RN will provide direct delivery of nursing services, as well as delegation of nursing tasks, in the AFC homes, Level I and II. The RN hours spent in performing delegation, including the training and supervision of the delegated tasks, are billable nursing hours.

The RN should orient and train the foster care provider and substitute provider simultaneously. This simultaneous training is intended to be cost-effective to avoid adverse impact on the participant's ISP cost ceiling. It is the foster care provider's responsibility to have the substitute provider available for the RN's training.

Following a condition change, a participant may need increased nursing tasks on a short term basis, for stabilization or rehabilitation to previous health status. These nursing tasks may exceed the skill and ability of the AFC provider caring for the participant and/or the AFC provider may not choose to learn these more complex nursing tasks or other criteria for delegation is not met. In these instances, to avoid disrupting the participant's living situation, the case manager may authorize short-term direct nursing services or will explore the possibility of accessing other resources for the provision of skilled care.

4422.4.1  Nursing Services in AFC Homes Operated by Licensed Nurses

Revision 12-1; Effective February 10, 2012

In serving an individual in any level CBA Adult Foster Care (AFC) home operated by a licensed nurse, the Home and Community Support Services Agency (HCSSA) registered nurse will complete the CBA program assessments as referenced in Section 4442.3, Pre-Enrollment Home Health Assessment, and initiate service as referenced in Section 4444, Authorization and Initiation of Services.

The HCSSA RN will also be authorized hours by the DADS case manager to complete the annual assessment and the semiannual nursing assessments. The AFC licensed nurse will verbally notify the HCSSA of any additional CBA services, other than nursing, the AFC individual needs. The HCSSA, after being made aware of the request, will submit to the DADS case manager Form 2067, Case Information, and the appropriate individual service plan attachment within seven days of being informed of the need and process a request for a service plan change as referenced in Section 4452.2, Requests for Routine Service Plan Changes. Upon being notified of an emergency request, the HCSSA will verbally notify the DADS case manager by the next DADS work day of the request and submit written notification within seven calendar days as referenced in Section 4424.4.2, Emergency Procurement of Adaptive Aids and Medical Supplies.

Direct nursing services, excluding assessments, in any CBA AFC home operated by a licensed nurse will be provided by the AFC licensed nurse.

4422.5  Orientation/Training and Delegation/Supervision of the Adult Foster Care Provider

Revision 02-4; Effective Upon Receipt

STANDARD.

  1. The registered nurse must provide orientation in the Adult Foster Care Home, Levels I and II, to the foster care provider and provider substitute on or before the day the participant is determined eligible for CBA services, or becomes a resident of the home unless the provider is a licensed nurse.
  2. The registered nurse will provide orientation to the foster care provider and foster care provider substitutes on the following and document on the progress notes in the participant's clinical record:
    • information about the participant's health condition and how it may affect the performance of tasks;
    • nursing tasks to be performed, if delegated; and
    • symptoms or changes in the participant's health status about which the AFC provider should notify either the RN or the attending physician.
  3. The registered nurse is responsible for the delegation and supervision of nursing tasks to the Adult Foster Care provider and provider substitute in Levels I and II, as allowed under the provider agency's licensure category as a Home and Community Support Services Agency from rules promulgated by the Texas Board of Nurse Examiners and referenced in Appendix II.

In instances in which an AFC provider is a relative of a participant needing nursing tasks, the RN will delegate (if appropriate) and supervise the relative who is providing the care for pay.

The licensed nurse will provide training according to the specific nursing needs of participants. Licensed vocational nurses may provide training to AFC providers and provider substitutes on nursing tasks delegated by the HCSS RN and after the RN has assessed the participant's condition and determined the plan of care.

The necessity for, and scope of, delegation, supervision and monitoring of nursing tasks is dependent upon the RN's professional judgement in accordance with standards of practice as defined by the Board of Nurse Examiners for Texas.

The AFC provider is responsible for the delivery of all personal care tasks needed by the participant. Personal care tasks do not routinely need to be delegated.

4422.6  Reserved

Revision 02-4; Effective Upon Receipt

4422.7  Documenting Non-Delegation of Nursing Tasks in Adult Foster Care Homes

Revision 02-4; Effective Upon Receipt

STANDARD.

  1. The registered nurse must document in the clinical record the rationale for non-delegation of nursing tasks. Non-delegation may occur when:
    1. the criteria for delegation is not met;
    2. the physician assesses and orders tasks to be performed only by licensed nurses due to complexity and circumstances; or
    3. the participant refuses the delegation of nursing tasks.
  2. The reason identified nursing tasks are not delegated must be communicated to the case manager by telephone by the next DADS work day after the decision not to delegate has been made.
  3. Form 2067, Case Information, must be sent to the case manager within five DADS working days of the telephone call and must contain:
    1. the rationale for non-delegation; and
    2. documentation on how the participant's nursing needs will be met.

If the RN determines the nursing tasks cannot be delegated to the AFC provider for reasons stated in (a) above, for instance, the foster care provider is now expected to use judgement in providing the nursing task, and the delegation to that unlicensed person will cease immediately. Direct provision of nursing services will be provided to the participant to meet his identified needs and billed as a nursing service. The case manager must revise the ISP to authorize the nursing service hours requested by the HCSS provider. The effective date of the change is the date the HCSS provider began delivering the additional nursing hours.

The case manager must consider alternate arrangements after being notified that the nursing tasks cannot be delegated to the AFC provider. Alternate arrangements may consist of making a referral to an independent RN on contract or to DAHS services. If the substitute provider cannot be delegated to, it is the responsibility of the AFC provider to recruit another substitute.

4422.8  Training of Unpaid Family Members, Neighbors, or Other Informal Support

Revision 02-4; Effective Upon Receipt

STANDARD.

  1. The HCSS agency licensed nurse may choose to train unpaid family members, neighbors, or other informal support in the provision of nursing tasks and personal assistance service, as documented in the clinical record:
    1. upon participant's request for such an arrangement; and
    2. the individual's agreement to perform the needed nursing task(s);
  2. The licensed nurse, if training the unpaid individual to perform nursing tasks or personal assistance tasks must document the following:
    1. the task(s) was demonstrated; and
    2. a return demonstration was performed satisfactorily.
  3. The licensed nurse will obtain the unpaid family member, neighbors or other informal support's signature on Form 3671-C, if contributing to the participant's care by performing nursing tasks.
  4. If the licensed nurse finds noncompliance of the trained unpaid individual to the agreed upon nursing or personal care tasks, she must:
    1. verbally report to the case manager by the next DADS work day after becoming aware of the situation, and
    2. make arrangements for the necessary tasks to be delivered by an alternate source, and
    3. submit a service plan change as referenced Section 4452.1, Requests for Service Plan Change in Emergencies.

In certain instances, the licensed nurse from the HCSS agency may choose to work closely with the participant's family or other informal support in the provision of certain nursing and personal care functions. By training the unpaid individual to perform certain nursing functions, the HCSS agency is able to contribute to the individual's desire to remain in his own home or AFC home, Levels I or II, and provide cost-effective services. For example, the licensed nurse may teach the family member to do a dressing change to a wound in instances where the physician orders the dressing change to be done twice a day. The agency personnel may do the dressing change in the morning and the family member may do the dressing change in the evening.

With family members and other informal support offering and documenting such agreement to provide personal care and certain nursing functions, an individual's care can be provided, which would otherwise, not be cost-effective. The case manager must obtain the signature of informal support performing care on Forms 2060 and 2060-A, and the HCSS nurse must obtain signatures on Form 3671-C. The case manager will list all informal support agreeing to provide personal care and nursing tasks on page 3 of Form 3671.

The decision of the nurse to train the unpaid individuals on nursing tasks is dependent upon the participant and the participant's wishes, and the nurse's experience and professional judgement in accordance with standards of practice and the nurse's ability to work with the unpaid individual.

Licensure issues related to family members or caregivers who are also licensed nurses and provide gratuitous care should be referred to the Board of Nurse Examiners.

4422.9  Semiannual Nursing Assessments

Revision 12-1; Effective February 10, 2012

To assure quality of care for participants in the CBA program by identifying significant changes in conditions and initiating appropriate interventions on a timely basis, the Home and Community Support Services Agency (HCSSA) registered nurse (RN) must perform semiannual nursing assessments on all current CBA individuals.

The semiannual nursing assessment must be performed in the fourth month of the individual service plan (ISP) year. There is no longer a requirement to complete the initial nursing assessment within 14 days of the waiver service initiation date.

The second semiannual nursing assessment is replaced with the annual reassessment skilled nursing visit and may be performed when the HCSSA RN is doing a supervisory visit for individuals receiving delegated nursing tasks. Form 3751, CBA Semiannual Nursing Assessment, Form 3751-A, CBA Semiannual Nursing Assessment Attachment, and Form 3752, Evaluation of RN Semiannual Assessment, are completed during the semiannual nursing assessment, but are not completed during the annual reassessment.

The chart below outlines how nursing assessments are handled depending upon the month in which the ISP expires.

ISP Expiration Dates Semiannual Assessment Due Date

Annual Assessment Packet Due Date

Packet Due to Case Manager Between

Jan. 31

May 1 - May 31

Nov. 1 - Nov. 30

Feb. 28 or 29

June 1 - June 30

Dec. 1 - Dec. 31

March 31

July 1 - July 31

Jan. 1 - Jan. 31

April 30

Aug. 1 - Aug. 31

Feb. 1 - Feb 28 or 29

May 31

Sept. 1 - Sept. 30

March 1 - March 31

June 30

Oct. 1 - Oct. 31

April 1 - April 30

July 31

Nov. 1 - Nov. 30

May 1 - May 31

Aug. 31

Dec. 1 - Dec. 31

June 1 - June 30

Sept. 30

Jan. 1 - Jan. 31

July 1 - July 31

Oct. 31

Feb. 1 - Feb. 28 or 29

Aug. 1 - Aug. 31

Nov. 30

March 1 - March 31

Sept. 1 - Sept. 30

Dec. 31

April 1 - April 30

Oct. 1 - Oct. 31

Copies should not be sent to the DADS case manager. The HCSSA RN uses the results of the semiannual nursing assessments to develop the nursing plan of care and initiate appropriate interventions. The HCSSA RN consults with the Adult Foster Care and Assisted Living Service providers to obtain information regarding the individual's current condition and service plan.

DADS reimburses HCSSAs for the number of RN hours used to perform each semiannual nursing assessment. HCSSAs must bill for the actual time spent doing the assessment as they would for any other type of nursing visit. The HCSSA can still bill for a minimum of one hour of nursing for each nursing visit.

The following are examples of how claims should be submitted:

Example 1
An RN spends 1 hour and 15 minutes to perform the semiannual nursing assessment and 15 minutes for wound care.

The HCSSA submits a claim for 1 1/2 hours of nursing.

Example 2
An RN spends 1 hour to perform the semiannual nursing assessment and 45 minutes for the annual reassessment.

The HCSSA submits a claim for 1 3/4 hours of nursing.

Example 3
An RN spends 1 hour and 30 minutes to perform the semiannual nursing assessment.

The HCSSA submits a claim for 1 1/2 hours of nursing.

DADS case managers authorize four hours annually on Form 3671-C, Nursing Service Plan, Page 2, at the time of enrollment and annual reassessment to cover time spent doing the semiannual nursing assessments.

The HCSSA is entitled to reimbursement when a third semiannual nursing assessment occurs within the ISP year, if the visit was done within the required time frames.

4423  Therapy Services

Revision 02-4; Effective Upon Receipt

Therapy services include the evaluation, examination, and treatment of physical, functional, speech, and hearing disorders and/or limitations. Therapy services include the full range of activities under the direction of a licensed therapist within the scope of his state licensure. Therapy services are provided directly by licensed therapists or by assistants under the supervision of licensed therapists in the participant's own home, or the participant may receive the therapy in a rehabilitative center. If the therapy is provided outside the participant's residence based on the participant's choice, the participant is responsible for providing his own transportation or accessing the Medicaid medical transportation system. If residing in Adult Foster Care or an Assisted Living/Residential Care setting and therapy is provided in a rehabilitative center, etc., the Residential Care provider is responsible for arranging for transport or directly transporting the participant.

If the therapy is provided outside the participant's residence because of the convenience of the HCSS provider, the HCSS provider is responsible for providing the participant's transportation. In this instance, allowable transportation expenses may be included in the "Texas Community Based Alternatives Cost Report" and reported in the appropriate Therapy Services Cost area.

STANDARD.

  1. Occupational therapy, physical therapy, and speech pathology services are covered by the Community Based Alternatives only after the participant has exhausted his therapy benefit under Titles XVIII, XIX, or other third-party resources.
  2. The HCSS agency will provide the occupational therapy, physical therapy, and speech pathology services as identified on the participant's Individual Service Plan, Form 3671-B.
  3. Individuals providing therapy services must be licensed in Texas in their profession or be licensed as assistants and employed directly or through sub-contract or personal service agreements with a HCSS agency.

Physical therapy is defined as specialized techniques for evaluation and treatment related to functions of the neuro-musculo-skeletal systems provided by a licensed physical therapist or a licensed physical therapy assistant, directly supervised by a licensed physical therapist.

Occupational therapy is defined as specialized restorative techniques for evaluation and treatment of problems interfering with an individual's functional performance, provided by a registered occupational therapist or a certified occupational therapy assistant, directly supervised by a registered occupational therapist.

Speech therapy is defined as evaluation and treatment of impairments, disorders, or deficiencies related to an individual's speech and language provided by a speech-language pathologist or a licensed associate in the speech-language pathology, under the direction of a licensed speech-language pathologist.

4423.1  Initiation of Assessment and Therapy

Revision 02-4; Effective Upon Receipt

The case manager, upon recommendation from the HCSS nurse for a therapy assessment, authorizes four hours on the initial service plan for the assessment and the service initiation, if applicable. If therapy is initiated on the assessment visit, further direct service hours must be requested by the therapist on the same Form 3671-B.

4423.2  Responsibilities of Licensed Therapists in CBA

Revision 02-4; Effective Upon Receipt

STANDARD. Responsibilities of the licensed therapists include, but are not limited to, the following:

  • assessing the participant's need for therapy, adaptive aids, and minor home modifications;
  • completing Form 3671-B upon evaluating the participant, requesting authorization for direct service delivery;
  • delivering of direct therapy as authorized in the ISP;
  • supervising delivery of therapy rendered by the therapy assistant as authorized in the plan of care;
  • informing physician and other team members of changes in participant's health status requiring a service plan change;
  • training the participant with the utilization of adaptive aids; and
  • participating in the IDT meetings when appropriate and requested by the case manager.

4424  Adaptive Aids and Medical Supplies

Revision 11-2; Effective December 21, 2011

Adaptive aids and medical supplies, necessary for the individual to have optimal function, independence and well-being, will be identified and approved by DADS on the individual's Form 3671-1, Individual Service Plan (ISP).

Definitions:

Adaptive aids are devices that are medically necessary to treat, rehabilitate, prevent or compensate for medical conditions resulting in disability or loss of function. Adaptive aids enable persons with functional impairments to perform the activities of daily living or control the environment in which they live.

Medical supplies are items that either have therapeutic or diagnostic benefits specific to the individual's diagnosis that are necessary in carrying out the ISP.

Limit adaptive aids and medical supplies to the most cost-effective items that can:

  • meet the individual's needs;
  • directly aid the individual avoid premature nursing facility (NF) placement; and
  • provide NF residents an opportunity to return to the community.

The CBA program is not intended to provide every individual with any and all adaptive aids or medical supplies the individual may receive as an NF resident.

For example, all NF residents have their clothes washed and dried by the NF, while CBA individuals should not expect the CBA program to pay for a clothes washer and dryer for each individual.

4424.1  Documentation of Necessity

Revision 11-2; Effective December 21, 2011

STANDARD

  1. Documentation of necessity for all of the adaptive aids and medical supplies (excluding prescriptions) identified on the individual service plan (ISP), Form 3671-E, Adaptive Aids and Medical Supplies, must be provided to the DADS case manager by the Home and Community Support Services Agency (HCSSA).
  2. The documentation must:
    1. specify the item requested, describe why the item is necessary and how it relates to the individual's disability or medical condition;
    2. be provided by a physician, physician's assistant, nurse practitioner, registered nurse, physical therapist, occupational therapist or speech pathologist; and
    3. be provided once per ISP period for medical supplies needed on an on-going basis.

Form 3671-F, Rationale for Adaptive Aids, Medical Supplies, Dental Services and Minor Home Modifications, may be used to document necessity. Use of Form 3671-F is optional as long as the required documentation as specified on Form 3671-F is provided with the request for adaptive aids and medical supplies on the ISP, Form 3671-E. The medical professional that completes the documentation, in most instances, will be an employee of the HCSSA.

Repair, maintenance and installation of authorized items do not require separate documentation from a medical professional.

Multiple medical supplies may be grouped on Form 3671-F using one rationale for the following types of care:

  • Catheter care
  • Diabetic care
  • I.V. therapy
  • Ostomy care
  • Tube feedings
  • Ventilator care
  • Wound care

STANDARD.

Adaptive aids and medical supplies will be approved as a waiver service if documentation supports the requested item(s) as being necessary, related to the individual's disability or medical condition and meets all service plan requirements.

The DADS case manager should not approve an adaptive aid or medical supply that was delivered to the individual if the item was not authorized to be purchased before the item was delivered.

The DADS regional nurse (RN) may be consulted by the DADS case manager in making the decision as to whether an adaptive aid or medical supply is necessary and related to the individual's condition based on the documentation submitted by the HCSSA. The HCSSA medical professional may be contacted by the DADS RN to discuss the necessity or relationship of a requested item for an individual's condition. If this occurs, the DADS RN will make the decision if the purchase is necessary.

Individual service plans (ISPs) should be individualized and items requested to meet the specific needs of each individual. As an example, electric toothbrushes should not be ordered for individuals unless there is a documented necessity for such. CBA does not pay for such products without documented need. DADS is not able to provide items that can benefit every individual, such as an electric toothbrush, without evidence that such an item meets an individual's specific need related to his disability or medical condition.

To avoid delaying the provision of necessary supplies or adaptive aids to the individual, the DADS case manager should authorize the HCSSA's estimate for approved items on the ISP registered on the Service Authorization System (SAS). If the DADS case manager feels that the HCSSA is not obtaining medical supplies or adaptive aids in a cost-effective manner, he may refer the situation to the DADS contract manager for investigation, along with appropriate documentation to explain his concerns. The DADS contact manager should conduct a review of the purchase records to see if there is justification for the specific purchase and purchase history. The amount of the authorization on the ISP should be reduced if the HCSSA requests a reduction of the authorization after the DADS contract manager's investigation or DADS administrative staff direct the DADS case manager to reduce the dollar amount of the authorization.

The DADS case manager should not retroactively change the ISP to include an adaptive aid that was delivered to the individual without the item and its cost, first being authorized by the DADS case manager. The DADS case manager may change the ISP retroactively in emergencies where the HCSSA has followed the procedures described in Section 4452.1, Requests for Services Plan Changes in Emergencies, or after Medicare and Medicaid Home Health has denied the adaptive aid. Since in these instances the item has already been delivered before the DADS case manager has authorized the item, the HCSSA does not need to get specifications or bids for the item. The HCSSA still must document the medical necessity for the item and complete Form 3848, CBA Documentation of Completion of Purchase, for the item.

The DADS case manager may add additional adaptive aids or medical supplies to Form 3671-E if he and the individual determine that there is an unmet need for these items which were not included in the original pre-enrollment home health assessment. When the ISP attachments are sent to the HCSSA with the proposed plan of care, the DADS case manager should document on Form 2067, Case Information, any changes to the original assessment and request that the HCSSA evaluate the necessity for the item and develop the documentation on Form 3671-F, or alternate documentation.

If the HCSSA does not agree with the initial Form 3671-E because, for example, the HCSSA has identified new needs, he completes a new Form 3671-E and submits it to the DADS case manager along with Form 3671-F or similar documentation in another format, which specifies the item requested and describes why the item is necessary and how it relates to the individual's disability or medical condition. Following approval by the interdisciplinary team (IDT), the HCSSA will be responsible for obtaining the necessary items in the most cost effective manner, documenting the purchase and delivery of the items, and following the procedures outlined in Section 4441, Referrals for the Pre-Enrollment Home Health Assessment.

4424.2  List of Adaptive Aids and Medical Supplies

Revision 11-2; Effective December 21, 2011

STANDARD.

  1. Adaptive aids, medical supplies and prescriptions are covered by the waiver only after the individual has exhausted any third-party resources, including Medicare and Medicaid Home Health that he is eligible to receive.
  2. Adaptive aids, including repair and maintenance (to include batteries) not covered by the warranty, consist of the following:
    1. Lifts
      1. wheelchair lifts
      2. porch or stair lifts
      3. hydraulic, manual or other electronic lifts
      4. stairway lifts
      5. bathtub seat lifts
      6. ceiling lifts with tracks
      7. transfer bench
    2. Mobility aids, including batteries and chargers
      1. manual/electric wheelchairs and necessary accessories
      2. three-wheel scooters
      3. mobility bases for customized chairs
      4. braces, crutches, walkers, and canes
      5. forearm platform attachments for walkers and motorized/electric wheelchairs
      6. prescribed prosthetic devices
      7. prescribed orthotic devices, orthopedic shoes, and other prescribed footwear
      8. prescribed exercise equipment and therapy aids
      9. portable ramps
    3. Respiratory aids
      1. ventilators/respirators
      2. back-up generators
    4. Positioning devices
      1. standing boards, frames, and customized seating systems
      2. electric or manual hospital beds, tilt frame beds, and necessary accessories
      3. egg crate mattresses, sheepskin, and other medically-related padding
      4. trapeze bars
      5. lift recliners
    5. Communication aids (including repair, maintenance, and batteries)
      1. augmentative communication devices
        1. direct selection communicators
        2. alphanumeric communicators
        3. scanning communicators
        4. encoding communicators
        5. speaker and cordless phones for persons who cannot use conventional telephones
      2. speech amplifiers, aids, and assistive devices
      3. interpreters
    6. Control switches/pneumatic switches and devices
      1. sip and puff controls
      2. adaptive switches/devices
    7. Environmental control units
      1. locks
      2. electronic devices
      3. voice activated, light activated, and motion activated devices
    8. Medically necessary durable medical equipment not covered in the state plan for the Texas Medicaid Program
    9. Temporary lease/rental of medically necessary durable medical equipment to allow for repair, purchase, replacement of essential equipment or temporary usage of the equipment
    10. Payment of premium deductibles and co-insurance {for items covered under the waiver}, including rentals for Medicare or Third Party Health Insurance, if not covered under the Qualified Medicare Beneficiary (QMB) or the Medicaid Qualified Medicare Beneficiary (MQMB) programs
    11. Modifications/additions to primary transportation vehicles
      1. van lifts
      2. driving controls
        1. brake/accelerator hand controls
        2. dimmer relays/switches
        3. horn buttons
        4. wrist supports
        5. hand extensions
        6. left-foot gas pedals
        7. right turn levers
        8. gear shift levers
        9. steering spinners
      3. medically necessary air conditioning unit prescribed by a physician for individuals with respiratory or cardiac problems or people who can't regulate temperature
      4. removal or placement of seats to accommodate a wheelchair
      5. installation, adjustment or placement of mirrors to overcome visual obstruction of wheelchair in vehicle
      6. raising the roof of the vehicle to accommodate a participant riding in a wheelchair
      7. installation of frames, carriers, lifts, for transporting mobility aids
    12. Sensory adaptations
      1. eyeglasses
      2. hearing aids
      3. auditory adaptations to mobility devices
    13. Adaptive equipment for activities of daily living
      1. Assistive Devices
        1. reachers
        2. stabilizing devices
        3. weighted equipment
        4. holders
        5. feeding devices including:
          1. electric self-feeders
          2. food processors and blenders — only for individuals with muscular weakness in upper body or who lack manual dexterity and are unable to use manual conventional kitchen appliances
          3. variations of everyday utensils
            • shaped, bent, built-up utensils
            • long-handled equipment
            • addition of friction covering
            • coated feeding equipment
        6. count-a-dose medication systems
        7. walking belts and physical fitness aids
        8. specially adapted kitchen appliances
        9. toilet seat reducer rings unless participant resides in an AL/RC facility
        10. hand-held shower sprays unless participant resides in an AL/RC facility
        11. shower chairs unless participant resides in AL/RC facility
        12. electric razors
        13. electric toothbrushes
        14. water piks
        15. service animals
        16. overbed tray tables unless participant resides in an AL/RC facility
      2. Safety restraints and safety devices
        1. bed rails
        2. safety padding
        3. helmets
        4. safety restraints
        5. flutter boards
        6. life jackets
        7. elbow and knee pads
        8. visual alert systems
    14. medically necessary heating and cooling equipment for individuals with respiratory or cardiac problems, people who cannot regulate temperature, or people who have conditions affected by temperature.

The CBA program does not pay for central air conditioning and heat. CBA funds can be used to purchase window air conditioners, etc., for an individual's principal living area, such as a bedroom. CBA does not pay for multiple air conditioners to cover an individual's residence.

  1. Medical supplies, necessary for therapeutic or diagnostic benefits, for:
    1. tracheostomy care
    2. decubitus care
    3. ostomy care
    4. pulmonary, respirator/ventilator care
    5. catheterization

    Other types of supplies include:
    1. diapers, linens and other incontinence supplies
    2. nutritional supplements
    3. enteral feeding formulas and supplies
    4. diabetic supplies (strips, lancelets, syringes)
    5. Transcutaneous Electrical Nerve Stimulation (TENS) units/supplies/repairs
    6. stethoscopes, blood pressure monitors, and thermometers for home use
    7. blood glucose monitors
  2. prescribed medications beyond the three-per-month limit under the Texas Medicaid Program

DADS will authorize liquid nutritional supplements such as Ensure (including Ensure puddings), Boost, Resource, Jevity, and Glucerna (which is used primarily by diabetics), as well as Arginaid (which is used primarily for individuals with burns or wound care) when HCSSAs provide documentation that these supplements are medically necessary to meet the needs of the individual. These nutritional supplements must have either a therapeutic or a diagnostic benefit specific to the individual's diagnosis that is necessary to carry out the individualized service plan. Medical necessity does not include situations when an individual chooses a nutritional supplement in place of eating a meal for reasons of personal preference or convenience. DADS authorizes nutritional supplements as medical supplies, and HCSSAs will bill for these items as such.

DADS will not approve products such as Carnation Instant Breakfast, V-8 Juice, Slim Fast, fruit juices, flavored water, vitamin enhanced water, and bottled water for CBA participants. In addition, DADS will not approve nutrition bars, protein bars, and breakfast cereals, including those marketed to individuals with specific medical conditions (e.g., Glucerna Cereal and Glucerna Snack Bars marketed to individuals with diabetes). Since these products are available to individuals for overall health benefits and convenience, they are not covered by the CBA program.

HCSSAs may not deliver nutritional supplements before receiving written authorization for the nutritional supplements, even if those items cost $200 or less.

HCSSAs are still required to request approval from DADS when a nutritional supplement, even if the HCSSA does not agree that the item is medically necessary. In these situations, the HCSAA will continue to follow current procedures and document that the individual is requesting the item and that the HCSSA does not agree that the product is medically necessary.

DADS case managers send all requests for nutritional supplements to DADS regional nurses. The DADS regional nurse reviews the information and determines if the nutritional supplement will be approved or denied.

Since nutritional supplements are intended to be used under medical supervision, DADS has developed clinical guidance for the DADS regional nurse to determine when a nutritional supplement must be approved. The DADS regional nurse will only approve nutritional supplements when there is a demonstrated medical need as supported by the required documentation.

Diagnoses, medications, chewing and swallowing problems, unplanned weight loss, and recent hospitalizations are some of the factors to be considered in the determination of the medical necessity for nutritional supplements. Medical supervision related to nutritional supplements is especially important for individuals with particular medical conditions. For example, some nutritional supplements can cause undesired effects for individuals who are taking blood thinning medication or who are on dialysis.

Required Documentation for Nutritional Supplement Requests

To support the medical need for the nutritional supplement, the HCSSA must complete Form 3671-F, Rationale for Adaptive Aids, Medical Supplies, Dental Services and Minor Home Modifications. The documentation on this form must address the following:

  • the individual's diagnosis and medical condition;
  • the individual's specific medical need for the nutritional supplement; and
  • how the requested nutritional supplement will meet the identified medical need(s) and will benefit the individual's health status.

A diagnosis alone is not sufficient information to support the need for a nutritional supplement. Stand alone generic statements, such as "to increase oral intake," "to prevent weight loss," "to improve nutritional status" and "to maintain weight" do not support an individual's specific need for a nutritional supplement. In order to be sufficient to support the need for a nutritional supplement, HCSSAs must provide documentation about the individual's health condition and how the requested nutritional supplement will specifically treat the listed condition. The DADS regional nurse may authorize a quantity or a duration of less than what is being requested if the documentation does not support the requested amount.

Examples of Nutritional Supplement Documentation

The following are examples of documentation that do not support an individual's specific need for a nutritional supplement.

  • Individual has diabetes. She is requesting Glucerna due to poor appetite. Her height is 5 feet and her weight is 170 pounds. Her daughter states Glucerna makes her mother feel better and keeps her from feeling weak.
  • Individual has congestive heart failure. He reports that he has a "weak stomach." His wife states that he has always been a picky eater and has very firm food preferences. He requests Boost to help maintain adequate nutritional status and prevent hospitalizations.
  • Individual has a history of a stroke and has left-sided weakness. Her caregiver reports that she doesn't eat much. The individual is 5 feet 7 inches and weighs 149 pounds. She is requesting a nutritional supplement to obtain daily requirements of vitamins and minerals.

The following are examples of documentation that do support an individual's specific need for a nutritional supplement.

  • Individual is on hospice. He has limited mobility and spends the majority of time in bed or sitting in a chair, placing him at risk for skin breakdown. He is 5 feet 10 inches and weighs 225 pounds. His daughter reports that he eats only a few bites of food at each meal. Drinking a high protein nutritional supplement in between meals will provide the individual with needed nutrients and help to prevent skin breakdown.
  • Individual has cancer. He is currently on a two-month round of radiation treatments which have caused mouth sores. He has a decreased appetite and has lost seven pounds in the last month. The requested supplement will help meet his nutritional needs while not irritating the mouth sores. Note: In this case, the DADS regional nurse will consider authorizing a time-limited supply of the supplement.
  • Individual is a diabetic who recently had a leg amputation. She has not regained her appetite since surgery and has lost eight pounds in the past month. The individual requests two cans of Glucerna per day to prevent further weight loss and aid in the healing process. Note: In this case, the DADS regional nurse will consider authorizing a time-limited supply of the supplement.

Reference: Information Letter 2009-144, Authorization of Nutritional Supplements; published Dec. 9, 2009.

Bedside commodes may be purchased as an adaptive aid.

Toiletry items such as toothpaste, mouth swabs, waterless soap, shampoo, lotions, powders, deodorant, etc. are personal hygiene items and are not covered under the waiver.

Vitamins cannot be purchased as a medical supply.

Other types of incontinence supplies that may be purchased as medical supplies are skin barrier products, enemas and antiseptic wipes.

Dental treatment includes:

  • emergency dental treatment procedures that are necessary to control bleeding, relieve pain and eliminate acute infection;
  • operative procedures that are required to prevent the imminent loss of teeth;
  • treatment of injuries to the teeth or supporting structures; and
  • dentures and cost of fitting and preparation for dentures, including extractions, molds, etc.

A licensed dentist must determine the medical necessity for dental treatment. Approvals for dental treatment may be granted based on one price quote from a dentist.

Dental treatments must be approved by the case manager and authorized on the individual service plan, unless they are provided in an emergency. In this case, the HCSSA must meet the requirements under Section 4424.4.2, Emergency Procurement of Adaptive Aids and Medical Supplies. If the HCSSA does not get prior approval or does not follow the procedures in Section 4424.4.2, DADS will not pay for the dental treatments.

When the case manager approves dental treatments for the participant, he should send a copy of Form 3671-F, Rationale for Adaptive Aids, Medical Supplies, Dental Services and Minor Home Modifications, and Form 3671-E, Adaptive Aids and Medical Supplies, to the Medicaid eligibility specialist so the specialist will know the expense is being paid through CBA and is not an allowable incurred medical expense.

4424.3  Responsibilities Pertaining to Adaptive Aids and Medical Supplies

Revision 11-2; Effective December 21, 2011

§48.6052 — Cost-Effective Purchases of Adaptive Aids.

The Home and Community Support Services Agency (HCSSA) RN identifies the individual's needs and preferences on the individual service plan (ISP) Form 3671-E, Adaptive Aids and Medical Supplies, at the time of the pre-enrollment and annual assessment and any time there is an identified need for an adaptive aid necessitating a service plan change. The fees for obtaining adaptive aid specifications and inspections are authorized upon approval of the adaptive aid; specifications and inspection fees must not be authorized before approving an adaptive aid. A specification fee must not be approved for the repair of an adaptive aid.

CBA will not pay for specifications or an evaluation for an adaptive aid being paid by Medicare/Medicaid Home Health.

If Medicare/Medicaid Home Health denies an adaptive aid, or if an adaptive aid is delivered following emergency procedures as outlined in Section 4424.4.2, Emergency Procurement of Adaptive Aids and Medical Supplies, the DADS case manager changes the ISP to include the adaptive aid and authorizes payment for the item. Since, in this case, an item has already been delivered before the DADS case manager has authorized the item, the HCSSA does not need to get specifications or bids for the item. The HCSSA still must document the medical necessity for the item and complete Form 3848, CBA Documentation of Completion of Purchase.

Form 3671-F, Rationale for Adaptive Aids, Medical Supplies, Dental Services and Minor Home Modifications, or another alternate form of documentation must be used to substantiate the medical necessity of the item to the individual's condition or disability.

Rental of equipment will allow for repair, purchase, replacement of the essential equipment, or temporary usage of the equipment, such as renting a wheelchair while an individual's wheelchair is being repaired. The length of time for rental of equipment should be based on the individual circumstances of the individual. If a wheelchair repair is requested, the case manager and the HCSSA work together to minimize the time an individual is without his wheelchair. If the medical professional and/or the individual is not certain the medical equipment will be useful, the equipment should be rented for a trial period or short term before purchasing the equipment. The length of time for rental of equipment should be based on the individual circumstances of the applicant/individual.

In renting equipment, the cost of rental versus purchase must be explored. Rentals can be more cost-effective than direct purchase of an item. The expected duration of the use of equipment must be considered in the decision to rent or purchase. It may be more cost- effective, after renting for a period of time, to purchase the equipment instead of continuing to rent.

Used adaptive aids can be purchased if the individual prefers to buy used equipment and documentation verifies that the equipment is appropriate, functions properly and that the used equipment is the choice of the individual.

If it is more cost efficient to replace an adaptive aid rather than to repair it, the adaptive aid may be requested on the ISP. The number of times an adaptive aid can be replaced rather than repaired is limited, and must be determined on a case-by-case basis by the DADS case manager and HCSSA.

If an adaptive aid is defective, its repair or replacement should be sought through the warranty. If the adaptive aid must be replaced, approval by the DADS case manager prior to replacement is required for CBA to pay.

When using a price list, HCSSAs should keep the actual price list as proof of cost-effectiveness considered in the selection process. When using a price list or when obtaining comparative price quotes, agencies must document the price quote, date of the quote, name of the agency and name of the person giving the quote.

If the agency chooses to annually select a supplier for all the adaptive aids it will purchase during a calendar year, the HCSSA must select a supplier based on the lowest prices from the quotes/price list for the main type of adaptive aids the HCSSA has been purchasing. If the HCSSA annually selects a supplier, it is not required to comply with §48.6052(b)(1)(D), getting three bids but are required to comply with §48.6052(b)(1)(A), getting written specifications for aids that cost more than $500. The HCSSA must purchase all adaptive aids from this supplier. If the single supplier that has been selected does not have an adaptive aid during the year, the HCSSA can get the adaptive aid from the second lowest bidder.

In determining the supplier for adaptive aids, the HCSSA staff should consider the overall cost of the item, plus any other costs that could be incurred during the life span of the item. For example, the routine maintenance and needed repair for oxygen concentrators and feeding pumps will be ongoing. A local supplier may be able to respond quickly to a repair call while an out-of-town supplier cannot. Some suppliers will loan the individual a substitute item while the item is being repaired.

The reason each selection is made and the considerations for making each selection must be documented and attached to the comparative price quotes, price lists or the bids. Form 3848 is used by the HCSSA staff to verify that the adaptive aid meets the individual's needs, individual's satisfaction, that orientation was provided, and delivery of purchase of the requested and authorized item(s) as required in §48.6052(a)(1)(G). This form is not completed for the purchase of batteries. This form is completed based on a telephone contact or face-to-face home visit, if applicable. The telephone contact or home visit to provide orientation/training must be made within 10 DADS workdays of delivering the adaptive aid. When making a telephone contact, the HCSSA staff must document the date and name of the person (individual or individual's responsible party) whom the HCSSA representative spoke to regarding the authorized purchase. Telephone contacts are not a billable contact. If an HCSSA purchases the adaptive aids from a company it owns, it cannot charge DADS more than it charges other individuals.

If determined via telephone contact that a face-to-face home visit is not needed, Form 3848 must be completed and submitted to the DADS case manager within seven DADS workdays of initiating the telephone contact.

If determined via the telephone contact that additional orientation/training, adjustments to the adaptive aid are needed or the individual states that the adaptive aid was not what he had expected or he is dissatisfied with the adaptive aid, a therapist, nurse or durable medical equipment (DME) vendor must conduct a home visit within 14 DADS workdays of the telephone contact to provide additional orientation/training or adjustments to the adaptive aid. Form 3848 must be completed and submitted to the DADS case manager within seven DADS workdays of the home visit. This home visit is a billable activity at the hourly rate of professional services for therapists and nurses doing the visit for orientation or training, making adjustments, or finding the reason the individual is not satisfied with the adaptive aid, and completing Form 3848.

Form 3848 should be completed for every adaptive aid where CBA pays all of the cost of the item. In instances where CBA only pays a portion of the cost, such as a copay, CBA does not monitor for the completion of purchase, the individual's satisfaction or the need for any training or orientation.

If the HCSSA determines that home visit hours are needed for the nurse to develop specifications or orient or train the applicant or individual on the use of the adaptive aid, then this request must be documented on Form 3671-C, Nursing Service Plan, item 16. If therapy hours are needed to develop specifications or orient or train the applicant on the use of the adaptive aid, then this request must be documented on Form 3671-B, Therapy Service Authorization, Item 45.

If no hours for the visit are initially requested, the visit can still be conducted without prior approval of the case manager if a need for the visit is determined when the individual is contacted. If the provider believes that the existing estimated hours for the service category of the professional that will conduct the visit is insufficient to cover the visit, the provider should inform the case manager on Form 3848 in Section I, Item 9, Description of Job or Item, of the number of hours the provider spent conducting the visit. The DADS case manager will then register the increase in hours on the individual's ISP and send Form 2065-B, Notification of Waiver Services, to the provider and the individual.

If the HCSSA follows the process described above, no fiscal exceptions will be taken for billing for the home visits to orient the individual.

If any problem is identified during the orientation/training visit, the agency staff must attempt to resolve the problem before submitting Form 3848 to the case manager. Examples of possible solutions would be adjustments needed for operational use of an adaptive aid, or return of a DME if the shipment did not deliver what was ordered.

The individual may verbalize dissatisfaction over the purchase in some instances, but if the purchase was based on the specifications and the individual agreed to the adaptive aid before it was ordered, the agency can still submit a claim for the item. However, the HCSSA must assure notification to the DADS case manager by documenting in Section IV of Form 3848 the individual's voiced dissatisfaction and reason. The case manager will call or visit the individual to investigate the reason for the dissatisfaction and determine what next steps need to be taken.

If a claim is submitted for a professional visit to provide needed orientation or determine why the individual is not satisfied, the documentation must substantiate the billing and include the reason for the visit, assessed findings and plans for intervention in the situation. This documentation should be written on Form 3670, CBA Documentation of Services Delivered, in the comments section. Additionally, documentation must support the intervention as being priority or an emergency and that it could not wait until the next scheduled nursing visit. A home visit by the DME vendor in performing orientation or making adjustments to an adaptive aid is not a billable activity.

A maximum fee of $500 may be paid on assessments for computers, environmental control units and augmentative communication devices to assure optimal technology assistance. This fee will be paid to appropriate professionals, such as rehabilitation engineers or licensed physicians for an assessment, writing of the specifications, and a follow-up training visit to assure optimal operation and owner usage of the adaptive aid. The professional who does the specifications also can submit a bid for the adaptive aid. This fee should be entered on the ISP, Form 3671-E. The DADS case manager will enter this fee amount on Form 3671-1, Individual Service Plan, under service code 41-C, Specifications – Adaptive Aids. This fee amount will not impact the $10,000 adaptive aid/medical supplies limit.

The professional who wrote the specifications must maintain documentation and provide it to the HCSSA.

If the three solicited bids are not returned, documentation must support making the decision on only two bids or on the only bid that was returned. Examples of appropriate documentation are the following:

  • the provider sent out reminder letters to the contractors who did not return a bid package (this can be documented by a certified mail receipt);
  • the provider sent bid packages to more than three contractors (as evidenced by certified mail receipt); and
  • the provider called contractors to follow up why bids were not returned and the calls are documented.

Soliciting only one bid because an individual insists on using a particular type of adaptive aid or supply from a particular company is not acceptable. Individual preferences should not be the only factor in making purchasing decisions. HCSSAs must solicit bids from at least three companies and make the decision to purchase based on the most cost-effective purchase that meets the individual's needs.

The HCSSA must do the following:

  • maintain documentation on repairs authorized for payment under the waiver that fall outside the scope of any existing warranty for the item to be repaired;
  • assure that all adaptive aids and DME purchased for the CBA individual remain with the individual if services are terminated or with the individual's estate upon death;
  • make vehicle modifications in accordance with the Texas Rehabilitation Commission Standard for Automotive Adaptive Equipment and Vehicle Modifications; and
  • assure that the CBA waiver is the last payor for identified items.

§48.6058 — Cost-Effective Purchases of Medical Supplies.

When making purchases based on the lowest prices quoted for the main types of supplies, agencies must maintain documentation supporting the rationale used to select the "main types" of supplies, such as per volume or dollars spent on certain supplies for the last six months or year.

When using a price list, agencies should keep the actual price list from the vendors as proof of cost-effectiveness considered in the selection process. When using a price list or when obtaining comparative price quotes, agencies must document the price quote, date of the quote, name of the agency and name of the person giving the quote. If the HCSSA houses or owns its own medical supply company, it still needs to obtain three price quotes.

The HCSSA is required to have knowledge of services available through Medicare and Medicaid Home Health and not request services through CBA when the individual is eligible to receive services from other resources. The HCSSA may use Form 3672, Medicare/Medicaid/Third-Party Resources Utilization Report, when submitting purchase requests to the CBA case manager.

Medicaid Home Health can refer individuals to independent DME Medicaid Home Health contractors for needed supplies and durable equipment. A form to document the medical necessity of the time and the individual's homebound status must be obtained from the medical supplier and completed by the individual's physician.

If an individual independently contacts a DME vendor and has an adaptive aid delivered without consulting the HCSSA and approval by the case manager, the adaptive aid should not be authorized on the ISP. Any contacts made with the DME by the individual for purchase of an adaptive aid through private insurance, Medicare or Medicaid is between the individual and the DME vendor and is not added to the ISP.

HCSSAs should not submit adaptive aid requests to the DADS case manager until a denial is received from Medicare or Medicaid, or the HCSSA documents the individual does not meet the homebound requirements. When a denial is received, the HCSSA may then submit a change request for authorization for payment of the item through CBA.

Adaptive aids and durable medical equipment are a one-time purchase and should not be authorized through CBA for individuals potentially eligible for Medicaid Home Health, unless Texas Medicaid and Healthcare Partnership (TMHP) has denied the coverage or the HCSSA specifically documents that the individual does not meet Medicaid Home Health eligibility requirements. Adaptive aids and durable medical equipment may be rented through CBA in the interim, or provided on an emergency basis to assure health and safety.

If an item payable through Medicare costs more than the HCSSA can buy through CBA, the item can be purchased through CBA. The cost of both CBA and Medicaid Home Health services are included in the federal report of cost-effectiveness for the CBA program. (Example: A toilet chair through Medicare costs $105. The HCSSA can purchase one through CBA for $30. CBA should be used to purchase the toilet chair.)

For lift chairs, Medicare may pay 80% of the lift mechanism. The lift chair should not be incorporated into the ISP until approval is obtained from Medicare for the cost of the lift mechanism.

If an individual meets the medical necessity for an adaptive aid not covered by Medicaid Home Health, such as a recliner, and it is authorized through CBA and purchased through a DME company, the individual may pay the difference between a lower cost adaptive aid and a model that costs more. The manufacturer would be responsible for providing a warranty on the adaptive aid.

A CBA individual who receives diapers from Medicaid through a DME vendor or an HCSSA, but prefers a more expensive brand, does not pay an extra amount to the DME vendor or HCSSA. If the Medicaid reimbursement rate is too low, the case manager can authorize a two- to three-month supply of medical supplies to assure the individual's needs are being met while the HCSSA finds a vendor that accepts the TMHP Medicaid rate for supplies.

Medicare will pay for glucose monitors, test strips and lancets for all diabetic individuals at 80% of the cost. CBA can cover the 20% co-insurance if no other resources are available. In instances when the individual is not covered by Qualified Medicare Beneficiary (QMB), Medicaid Qualified Medicare Beneficiary (MQMB) or a third-party resource for items covered through CBA and identified on the ISP, the co-insurance can be authorized under Adaptive Aids, on Form 3671-E, for payment through CBA. See Section 4424.6, Co-Insurance and Deductibles.

Insulin syringes and needles are obtained by the individual through the Vendor Drug Program of the Texas Department of State Health Services, not through the CBA program.

4424.4  Requesting Items Not on Approved List

Revision 11-2; Effective December 21, 2011

To request adaptive aids and medical supplies not listed in this section, the case manager must request in writing by memo or on Form 2067, Case Information, from the regional nurse, approval to authorize the needed item(s). Although the Home and Community Support Services Agency (HCSSA) must certify as to the availability of resources, it is the case manager's responsibility to assure that other resources are utilized before requesting items from the waiver. The written request must contain:

  • a copy of Form 3671-E, Adaptive Aids and Medical Supplies, identifying the needed items;
  • documentation of necessity as described on Form 3671-F, Rationale for Adaptive Aids, Medical Supplies, Dental Services and Minor Home Modifications. Documentation identifying all items needed and the necessity and relationship to the individual's disability/medical condition must be completed by the individual's physician, occupational or physical therapist, or speech pathologist, agency RN, nurse practitioner or physician's assistant;
  • the cost estimate; and
  • a statement indicating that the item is not covered by Medicare, Medicaid or other third-party resource.

If a request is made to purchase item(s) not on the approved list, it is not necessary for the case manager to delay enrolling an applicant until being notified by the waiver section manager. The item requested may be deleted on the individual service plan (ISP), and the ISP may be approved based on other eligibility factors.

If the documentation of necessity prepared by the HCSSA is incomplete or not descriptive of how the requested item is pertinent to the individual's disability or medical condition, authorization for the identified services will be delayed. Additional, more descriptive information may be requested by the DADS case manager from the agency to support the medical necessity and in some instances, to resubmit the request.

4424.4.1  Requesting State Office Approval to Exceed Individual Service Cap

Revision 11-2; Effective December 21, 2011

The $10,000 individual service cap on adaptive aids and medical supplies may be waived by the regional nurse. The case manager must send a written request by memo or on Form 2067, Case Information, to the regional nurse along with appropriate documentation, or use optional Form 3671-F, Rationale for Adaptive Aids, Medical Supplies, Dental Services and Minor Home Modifications, identifying all items needed, and the necessity and relationship to the individual's disability/medical condition. In addition, the request must contain:

  • the cost estimate;
  • assurance that the service plan is within the individual's overall cost limit and adequate to meet the needs of the individual (as shown on copy of Form 3671-1, Individual Service Plan (ISP); and
  • the case manager's telephone number, Mail Code, and regional director's name and Mail Code.

The DADS regional nurse reviews all materials submitted and consults with the case manager, HCSSA, and other resources as appropriate, to make a professional judgment to approve or deny the request on a case-by-case basis. The criteria used to approve or deny the request is the same as for any exception to the list of adaptive aids and medical supplies, such as if there is a medical need for the adaptive aid, that it is a cost-effective purchase, etc. If the item meets all requirements, then it should be approved; do not deny the request just because it is over the $10,000 limit.

The DADS case manager counsels the individual of the possible risk of exceeding the annual $10,000 cost limit during the ISP year. If additional funds are used during the ISP year to purchase adaptive aids that could be purchased later, without placing the individual's health and safety at risk, funding may not be available during the current ISP year to meet the individual's unforeseen needs.

4424.4.2  Emergency Procurement of Adaptive Aids and Medical Supplies

Revision 13-2; Effective June 5, 2013

§48.6062 — Time Frames for Emergency Purchases of Medical Supplies.

If the case manager or the Home and Community Support Services Agency (HCSSA) identifies a need for the emergency purchase and delivery of a medical supply, the HCSSA must deliver the item within two DADS workdays of identifying the need for the medical supply.

The HCSSA may procure adaptive aids and medical supplies not currently authorized on the individual service plan (ISP) only in situations that place the individual's health and/or safety at risk.

An emergency purchase is defined as a purchase precipitated by a change in the individual's condition to meet his acute care needs brought about by the condition change. Examples of emergency purchases would be supplies and durable medical equipment (DME) needed to provide suctioning as ordered by the practitioner due to being notified of an individual's respiratory distress or emergency dental treatments. Incontinent supplies needed due to a condition change can be purchased as an emergency with a practitioner's order to provide diapers as an emergency for individual's incontinency in providing necessary hygiene. However, the lack of planning of an agency to order supplies should not necessitate an emergency order from physicians for necessary and routine supplies nor take the place of requesting supplies from other resources, such as Medicaid Home Health.

STANDARD.

  1. If procuring emergency adaptive aids and medical supplies, the HCSSA must:
    1. obtain written agreement from the participant or caregiver that the item is needed by obtaining his signature on Form 3671-E, Adaptive Aids and Medical Supplies, and Form 3671-2, Individual Service Plan;
    2. verbally notify the case manager by the next DADS workday after purchasing the necessary item(s);
    3. submit the following documentation to the case manager within seven days of the verbal notification of purchase of the emergency items:
      1. the revised Form 3671-E and Form 3671-2, with the individual's or individual's caregiver's signature showing that the purchase was needed;
      2. Form 2067, Case Information, explaining why the emergency purchase was necessary and submit Form 3671-F, Rationale For Adaptive Aids, Medical Supplies, Dental Services and Minor Home Modifications; describing why the item is necessary and how it is related to the individual's disability or medical condition; and

If the HCSSA follows the notification procedures outlined above, the case manager must submit an ISP change, if necessary, to authorize the emergency services and/or purchases and increase the ISP authorizations in order for the agency to be paid for purchases or services already delivered.

      1. a practitioner's statement that the adaptive aid or medical supply was for an emergency. This order can be obtained from the practitioner when receiving orders for interventions to meet the individual's change in condition. (Telephone orders will be accepted but must be signed in a timely fashion, and kept on file as proof of compliance to this emergency procedure.)
    1. ensure delivery of the emergency item within two DADS workdays of identifying the need.

A practitioner's statement is not needed for emergency repairs of adaptive aids or durable medical equipment previously authorized through CBA for purchase.

4424.4.3  Effects of Changing Providers on Adaptive Aid Procurements

Revision 11-2; Effective December 21, 2011

If an individual wishes to change to another HCSSA while an adaptive aid remains on order, the individual must be offered a choice of waiting on the adaptive aid to be delivered through the transferring agency or canceling the order if the item has not been ordered. If the individual chooses to transfer before the adaptive aid is delivered, the receiving agency initiates service and the transferring agency will bill for the adaptive aid upon delivery of the adaptive aid to the individual's house using the service termination date as the billing date.

4424.4.4  Time Frames for Adaptive Aids/Medical Supplies

Revision 11-2; Effective December 21, 2011

§48.6054 — Time Frames for Adaptive Aids Costing Less Than $500.

§48.6056 — Time Frames for Adaptive Aids Costing $500 or More.

Form 3671-E, Adaptive Aids and Medical Supplies, authorizing the purchase of the requested adaptive aid, must be date stamped upon receipt. The agency has 14 or 30 DADS workdays counting from either the effective date entered on Form 3671-E, or the date the form is received, whichever is later, to purchase and deliver the adaptive aid.

If there will be a delay in the delivery, the agency must provide written notice to the individual and the case manager on Form 2067, Case Information, of the expected delay in the delivery and provide notification of the new proposed delivery date prior to the date the adaptive aid should have been delivered. Form 2067 must be mailed by the day the date the adaptive aid is required to be delivered. Compliance to this delivery schedule is documented on Form 3848, Documentation of Completion of Purchase, item 3, Date Completed/Delivered.

If the adaptive aid requested will not be delivered in the current individual service plan (ISP), the item must be transferred to the new ISP. If the transfer of the adaptive aid to the new ISP causes the ISP to exceed the adaptive aid/medical supplies limit, approval must be obtained from the regional nurse to exceed the service category limit. If the authorization on the new ISP causes the service plan to exceed the annual cost limit, the regional nurse may authorize using the date the item was ordered by the HCSSA as the date of service delivery and the HCSSA may bill against the previous ISP.

§48.6060 — Time Frames for Medical Supplies.

If there is an existing supply of medical supplies on the service initiation date, the agency RN must write in progress notes "existing supply of needed medical supplies on hand" as verification that supplies were available to the individual and did not require delivery at this time. The waiver service initiation date will be documented on Form 3670, CBA Documentation of Services Delivered. Form 3671-E authorizing the purchase of the requested medical supply must be date stamped upon receipt.

Stock piling of medical supplies should not occur. Supplies, such as incontinent and wound care supplies not covered through Medicaid Home Health and needed on an on-going basis, should be delivered so that there is no more than a three-month supply in the individual's home at a time.

The agency must document the delivery date of the medical supplies ordered on Form 3670.

4424.5  Prescriptions

Revision 11-2; Effective December 21, 2011

CBA individuals obtain all of their prescribed medications through the Texas Medicaid Vendor Drug program. CBA individuals can receive more than three prescriptions per month; however, the Medicaid Vendor Drug program formulary does not cover certain drugs and many over-the-counter medications.

CBA individuals are responsible for purchasing any medications not covered through the Medicaid Vendor Drug program.

The CBA individual will receive a Medicaid card monthly that is marked "can receive more than three prescriptions." The HCSSA staff must check the individual's Medicaid card monthly to assure that the individual remains eligible for Medicaid. If an individual's card does not contain the statement, "can receive more than three prescriptions," pharmacists may verify the CBA individual's eligibility for more than three prescriptions by calling Pharmacy Billing. If eligibility cannot be verified, the HCSSA staff should notify the case manager of the situation.

4424.6  Co-Insurance and Deductibles

Revision 11-2; Effective December 21, 2011

Reimbursement for the cost of co-insurance for the purchase or rental of adaptive aids or the purchase of medical supplies reimbursed by Medicare or private health insurance is available if the following conditions are met:

  1. the CBA individual does not have coverage under the Qualified Medicare Beneficiary (QMB) or the Medicaid Qualified Medicare Beneficiary (MQMB) programs;
  2. the adaptive aid or medical supply is listed in the service definition in the CBA Provider Manual or has been prior authorized by the state office CBA section manager; and
  3. documentation submitted supports the necessity of the item(s) for the individual's disability or medical condition.

Reimbursement for the co-insurance amount to Medicare or private health insurance for therapy services or the rental of any adaptive aids is a cost-effective way for the CBA program to utilize third-party resources.

The cost of any co-insurance payment must be billed under Adaptive Aids.

In instances when an individual is not covered under the QMB or MQMB program and he cannot pay his premium deductible under a third-party resource for items covered under the waiver and identified on the individual's individual service plan, the deductible can be listed under Adaptive Aids, on Form 3671-E, Adaptive Aids and Medical Supplies, for payment through CBA.

4424.7  Temporary Lease and Equipment Rental

Revision 11-2; Effective December 21, 2011

Rental of equipment will allow for repair, purchase, replacement of the essential equipment, or temporary usage of the equipment. The length of time for rental of equipment should be based on the individual circumstances of the individual. If the medical professional and/or the individual is not certain the medical equipment will be useful, the equipment should be rented for a trial period or short term before purchasing the equipment. The length of time for rental of equipment should be based on the individual circumstances of the applicant/individual.

In renting equipment, the cost of rental versus purchase must be explored. Rentals can be more cost-effective than direct purchase of an item. The expected duration of the use of equipment must be considered in the decision to rent or purchase. It may be more cost effective after renting for a period of time to then purchase the equipment instead of continuing to rent.

Used adaptive aids can be purchased if the individual prefers to buy used equipment and documentation verifies that the equipment is appropriate, functions properly, and that the used equipment is the choice of the individual.

4424.7.1  Bulk Purchase of Medical Supplies

Revision 11-2; Effective December 21, 2011

The HCSSA may choose to buy medical supplies in bulk. The cost of storing supplies can be reported on the annual cost report as an allowable expense. The medical supply would be billed at the unit rate based on the invoice cost of the bulk purchase divided by the number of units purchased.

4424.7.2  Reporting Medical Supplies on the Cost Report

Revision 11-2; Effective December 21, 2011

The cost for medical supplies used in the nurse assessment process or in the delivery of nursing services, such as thermometers, thermometer covers, gloves for universal precautions and alcohol swabs, should be reported on the cost report in the appropriate cost area, per cost report instructions. HCSSAs are responsible for providing these items on a routine basis.

If an individual has a condition requiring frequent use of such medical supplies, the requested items may be authorized for purchase by the case manager as a medical supply. The requested items must be left in the individual's home to be used by his family, informal support or attendant in providing care.

4424.7.3  Freight and Delivery Charges

Revision 11-2; Effective December 21, 2011

§48.6066 — Freight Charges for Medical Supplies and Adaptive Aids.

Documentation must substantiate the need to access overnight delivery for emergency purchases. Overnight delivery fees will not be paid for routine deliveries.

The shipping cost or freight expense charged by the manufacturer or supplier is part of the invoice and is to be included in the actual cost of the adaptive aid or medical supply.

The cost of delivering adaptive aids or medical supplies to individuals when not done through a commercial carrier (i.e., the attendant delivering the medical supply) cannot be charged to DADS.

4424.8  Oxygen

Revision 11-2; Effective December 21, 2011

Equipment necessary to provide oxygen, including but not limited to concentrators, tanks and regulators, is considered medically necessary durable equipment not covered in the state plan for the Texas Medicaid program and must be billed under adaptive aids.

Tubing, masks, cylinder refills and distilled water are examples of some medical supplies necessary for pulmonary and respirator or ventilator care and are to be billed under medical supplies.

Paying the co-insurance for oxygen provided on a rental basis through Medicare or private insurance is a cost-effective way of providing service to an individual when purchase is not considered or the oxygen can be rented with the option to buy. If this is the case, the oxygen co-insurance is billed under adaptive aids.

4425  Minor Home Modifications

Revision 11-2; Effective December 21, 2011

Minor home modification services will be limited to those services identified and approved by DADS on the individual's Form 3671-1, Individual Service Plan (ISP).

The HCSSA is authorized to provide the specific minor home modifications within the estimated amounts included on Form 3671-D, Minor Home Modifications. If additional modifications are necessary, or the identified modifications will cost more than was estimated, the HCSSA must submit an ISP change and obtain the case manager's approval of the modification or increased costs prior to providing the modification.

STANDARD.

Minor home modifications are those services which assess the need for, arrange for, and provide modifications and/or improvements to an individual's home or an Adult Foster Care home to enable individuals to reside in the community and facilitate mobility, function, accessibility and safety. Limit minor home modifications to the most cost-effective modifications that meet the individual's needs. Ensure that minor home modifications directly aid the individual to avoid premature nursing facility (NF) placement and provide NF residents an opportunity to return to the community. Minor home modifications may be made to an individual's residence when he is receiving out-of-home respite services.

The CBA program is not intended to provide every individual with any and all modifications that would make his home comparable to the living conditions in an NF. For example, every NF individual resides in a facility where the roof does not leak. The CBA program pays for necessary repairs related to the individual's disability or medical condition; it does not pay for roof repairs for every CBA individual.

Minor home modifications can also be provided to individuals residing in Assisted Living/Residential Care facilities, Type A only. Minor home modifications do not include major home renovations, remodeling or construction of additional rooms.

If an NF resident is approved for CBA services, the HCSSA can begin doing minor home modifications to the applicant's home before the individual is discharged from the NF. In this case, the date of service is the date of completion of the modification and date of discharge from the NF.

All modifications under construction must be completed on the individual's home before the effective date of a provider change. This is to assure follow-through and compliance with the original contract/work agreement between the contractor and the agency or individual.

4425.1  Documentation of Necessity

Revision 11-2; Effective December 21, 2011

STANDARD.

  1. Documentation of necessity for all of the minor home modifications identified on the individual service plan (ISP), Form 3671-D, Minor Home Modifications, and listed in Section 4425.2, List of Minor Home Modifications, must be provided to the DADS case manager by the HCSSA for authorization to purchase prior to procuring the modification(s).
  2. The documentation must:
    1. specify the modification requested, describe why the modification is necessary and how it relates to the individual's disability or medical condition;
    2. be provided by the physician, physician's assistant, nurse practitioner, registered nurse, physical therapist, occupational therapist or speech pathologist.

Form 3671-F, Rationale for Adaptive Aids, Medical Supplies, Dental Services and Minor Home Modifications, may be used to document necessity. Use of Form 3671-F is optional as long as the required documentation as specified on Form 3671-F is provided with the request for minor home modifications on the ISP, Form 3671-D.

Minor home modifications require documentation of necessity when identified. Repair, maintenance and installation of authorized modifications do not require separate documentation from a medical professional unless the modification was not paid for through the waiver. If a home owner has completed modifications before CBA enrollment that now need some repair, the repair can be authorized if a special request is submitted by the case manager to the waiver section manager. (See Section 4425.6, Requesting Minor Home Modifications Not on the Approved List.)

Minor home modifications should be approved by the case manager only if documentation supports the requested item(s) as being necessary and related to the individual's disability or medical condition. Approved modifications must be to existing structures, and must not increase the square footage of the dwelling.

If the individual requests an item that the HCSSA medical professional believes is not medically necessary or related to the individual's disability or medical condition, the medical professional puts the comments in Section B of Form 3671-F. The case manager determines whether the justification is sufficient for denial.

The DADS nurse may be consulted by the case manager in making the decision as to whether a minor home modification is necessary and related to the individual's condition based on the documentation submitted by the HCSSA. The HCSSA medical professional may be contacted by the DADS RN to discuss the necessity or relationship of a requested item for an individual's condition. If this occurs, the DADS nurse will make the decision if the purchase is necessary.

4425.2  List of Minor Home Modifications

Revision 11-2; Effective December 21, 2011

STANDARD.

  1. The following minor home modifications include the installation, maintenance and repair of approved items not covered by warranty:
    1. Purchase of wheelchair ramps
      1. protective awnings over ramps
    2. Modifications/additions for accessible bathroom facilities
      1. wheelchair accessible showers
      2. sink modifications
      3. bathtub modifications
      4. toilet modifications
      5. water faucet controls
      6. floor urinal and bidet adaptations
      7. plumbing modifications and additions to existing structures necessary for accessibility adaptations
      8. turnaround space modifications
    3. Modifications/additions for accessible kitchen facilities
      1. sink modifications
      2. sink cut-outs
      3. turnaround space modifications
      4. water faucet controls
      5. plumbing modifications/additions to existing structures necessary for accessibility adaptations
      6. work table/work surface adjustments/additions
      7. cabinet adjustments/additions
    4. Specialized accessibility/safety adaptations/additions, including repair and maintenance
      1. door widening
      2. electrical wiring
      3. grab bars and handrails
      4. automatic door openers, doorbells, door scopes and adaptive wall switches
      5. fire safety adaptations and alarms
      6. medically necessary air filtering devices
      7. light alarms, doorbells for the hearing and visually impaired
      8. floor leveling, only when the installation of a ramp is not possible
      9. vinyl flooring or industrial grade carpet necessary to ensure the safety of the individual, prevent falling, improve mobility and adapt a living space occupied by a beneficiary who is unable to safely use existing floor surface
      10. medically necessary steam cleaning of walls, carpet, support equipment and upholstery
      11. widening/enlargement of garage and/or carport to accommodate primary transportation vehicle and to allow persons using wheelchairs to enter and exit their vehicles safely
      12. installation of sidewalk for access from non-connected garage and/or driveway to residence, when existing surface condition is a safety hazard for the person with a disability
      13. porch/patio leveling, only when the installation of a ramp is not possible
      14. safety glass, safety alarms, security door locks, fire safety approved window locks and security window screens, for example, for persons with severe behavioral problems
      15. security fencing for residence, for those persons with cognitive impairment or persons whose safety would be compromised if they wandered
      16. protective padding and corner guards for walls for individuals with impaired vision and mobility
      17. recessed lighting with mesh covering and metal dome light covers to compensate for violent aggressive behavior, for example, for persons with autism or mental illness
      18. noise abatement renovations to provide increased sound proofing, for example, for persons with autism or mental illness
      19. door replacement for accessibility only
      20. motion sensory lighting
      21. intercom systems for individuals with impaired mobility
      22. lever door handles

Ramps may be installed for improved mobility for use with scooters, walkers, canes, etc., or for individuals with impaired ambulation as well as for wheelchair mobility. In some instances and according to supporting documentation, multiple modifications may be needed for accessibility and mobility, such as ramps and hand rails for individuals with impaired ambulation.

Carbon monoxide detectors cannot be purchased under CBA as a "fire safety adaptation and alarm."

4425.3  Responsibilities Pertaining to Minor Home Modifications

Revision 11-2; Effective December 21, 2011

§48.6068 — Cost-Effective Purchases of Minor Home Modifications.

The Home and Community Support Services Agency (HCSSA) registered nurse (RN) identifies the individual's needs and preferences for any minor home modifications on the individual service plan (ISP) Form 3671-D, Minor Home Modifications, at the time of:

  • pre-enrollment,
  • annual assessment, and
  • any time there is an identified need for a minor home modification necessitating a service plan change.

The fees for obtaining minor home modification specifications and inspections are authorized upon approval of the modification; specifications and inspection fees must not be authorized before approving a minor home modification. The HCSSA is also responsible for obtaining specifications, performing inspections and providing a one-year guarantee on a modification when part of the cost will be paid through a non-waiver service. Form 3671-F, Rationale for Adaptive Aids, Medical Supplies, Dental Services and Minor Home Modifications, or another alternate form of documentation must be used to substantiate the need of the item to the individual's condition or disability.

Form 3849, CBA Specifications for Minor Home Modifications, must be completed prior to procuring bids for any single minor home modification costing $1,000 or more. A fee of up to $200 can be charged by an individual with experience in home building for writing specifications. The HCSSA must document the experience of the individual writing the specifications and maintain this documentation. The HCSSA must obtain an invoice from the individual writing the specifications, which is the amount the HCSSA can bill under service code 41-D, Specifications – Minor Home Modifications. The HCSSA cannot bill for a specification fee that has not been authorized by the case manager, or bill for more than the amount authorized by the case manager. The specification fees are excluded from the total modification cost when determining if the modification is within the $7,500 limit.

The HCSSA may obtain separate specifications when the modifications will be completed by different contractors (Example: A minor home modification that will require plumbing, electrical and carpentry). The HCSSA can claim specification fees for each bid packet that is prepared. In the above example, if one contractor does a bid packet for all three modifications, the HCSSA can only bill one fee for specifications.

The HCSSA is entitled to reimbursement for specifications when the individual writing the specifications determines the modification is not feasible, the bids received determine the modification would cost under $1,000, or the minor home modification is eventually disapproved by the case manager.

An HCSSA refusing to provide a minor home modification is non-compliant with the terms of the contract, unless the specifications provided by an individual qualified to perform the specifications indicate that the structure of the home is unsafe.

Upon completion of the written specifications, the form is signed and dated by the individual writing the specifications, the individual and the landlord (if applicable). These signatures are obtained before beginning the modifications to show agreement of the work to be done.

One bid should be solicited for multiple minor home modifications done as one job, if one contractor will be doing all the modifications.

If the three solicited bids are not returned, documentation must support making the decision on only two bids or on the only bid that was returned. Examples of appropriate documentation are the following:

  • the provider sent out reminder letters to the contractors who did not return a bid package (this can be documented by a certified mail receipt);
  • the provider sent bid packages to more than three contractors (as evidenced by certified mail receipt); and
  • the provider called contractors to follow up why bids were not returned and the calls are documented.

Within seven DADS workdays of completion of the modifications, an inspection must be completed to document completion in compliance with the written specifications, if applicable, and to document acceptance of the modifications by the individual, landlord (if applicable), the HCSSA and the inspector. Form 3848, CBA Documentation of Completion of Purchase, must be signed by the individual or the responsible party for every minor home modification. This inspection may be performed by the individual preparing the specifications, but not by the contractor nor the attendant. The HCSSA is responsible for selecting an inspector who is qualified to determine that the minor home modification conforms to specifications and Texas Accessibility Standards (TAS). The HCSSA must determine what qualifications the inspector must meet to assure that he is competent to perform inspections and document what the qualifications were and that the inspector met the qualifications.

An inspection fee of up to $150 may be charged for the inspection. The HCSSA must maintain documentation supporting what was done on the inspection to bill for the inspection fee. The inspection fee is added on Form 3671-D to the cost of the modification and computed based on this total. The fees for obtaining minor home modification inspections are requested by the HCSSA on Form 3671-D and authorized by the case manager upon approval of the modification. The HCSSA cannot bill for an inspection fee that has not been authorized on Form 3671-D, or bill for more than the amount authorized on Form 3671-D.

The provider can bill the maximum of $150 for an inspection for each minor home modification, no matter if more than one visit was done to inspect the job. If the inspector makes one home visit to inspect two jobs by different contractors, the provider can bill up to $150 maximum for both jobs. Example: If an individual had a ramp with railings done by a carpenter and installation of an accessible bath by a plumber, the HCSSA can charge up to $150 for inspecting two jobs done by different contractors. In this example, if inspection visits were done on different jobs on different days, the HCSSA can bill up to $150 for each job.

Completion of a minor home modification with or without written specifications must be documented on Form 3848. This form must be submitted to the case manager by the HCSSA within seven DADS workdays of completing the inspection.

If the modification does not meet the specifications, the inspector must notify the HCSSA that adjustments are necessary to bring the modification in compliance with the agreed upon specifications. If the adjustments will not be completed within the 30 days for modifications costing less than $1,000 or 60 days for modifications costing more than $1,000, the HCSSA must notify the case manager on Form 2067, Case Information, why the job is not being completed on time and provide another job completion date.

If the individual is not satisfied with the completed job, the HCSSA should send an RN to determine why the individual is not satisfied and attempt to resolve the situation. This is a billable activity as long as there is documentation of the nurse's intervention on Form 3670, CBA Documentation of Services Delivered, in the comments section. The DADS case manager must be informed by the RN if the individual has a problem with the modification. The DADS case manager should contact the individual to discuss the situation. However, spending time with the individual prior to the initiation of the modifications to assure understanding by the individual of what is to be done and that he does agree and understand is a more cost-effective approach for all involved.

If an individual meets the medical necessity for a minor home modification, the individual is allowed to pay for enhancements to the modification. The CBA program normally pays for wheelchair ramps made of treated lumber unless there is a justifiable reason to pay for a more expensive ramp. (Example: A steel ramp lasts many years longer than a treated lumber ramp.) A treated lumber ramp meets the individual's needs, meets American with Disabilities Act (ADA) requirements and is a cost-effective purchase.

If the individual wants a ramp made of another material, such as redwood just so it can match a redwood deck, the CBA program only pays for ramps made of treated lumber. The contractor must give the HCSSA a bid only for a treated lumber ramp. The DADS case manager explains to the individual, with written documentation, the work for which he authorizes CBA to pay. Written documentation is necessary to prevent any misunderstandings. The DADS case manager ensures that the individual and contractor have a written agreement that outlines what the contractor will provide to the individual and how much the individual will pay directly to the contractor.

If alternative solutions exist, modifications will be approved by DADS based on considerations of cost and comparable functionality. If more than one option is available, DADS will approve the amount equivalent to the least costly option of comparable functionality. If the individual selects a more costly option, the individual shall be responsible for any costs that exceed those approved by DADS.

The HCSSA must:

  1. make modifications in accordance with TAS. Having merged the federal and state standards, TAS are specifically concurrent with ADA specifications;
  2. Local building inspectors must adhere to TAS. If there are no building inspectors available, copies of TAS are available for purchase from:

    Texas Register
    P.O. Box 12887
    Austin, TX 78711-3824
    512-463-5561
    512-463-5569 (Fax)
    Email: register@sos.state.tx.us

    Copies are $10 each.

    Providers may order their own copies.

  3. use A117.1-1986 as the basis of specifications for any other home adaptive or modification;
  4. make improvements or modifications in accordance with local and state housing codes;
  5. maintain documentation that any home modifications meet any applicable standards and/or codes;
  6. maintain documentation that repairs authorized for payment under the waiver fall outside the scope of any existing warranty for the item to be repaired;
  7. maintain documentation that homes to be repaired meet applicable health, safety, and fire codes or state inspection criteria;
  8. select a contractor who meets the applicable city and local ordinances and other requirements;
  9. obtain from the contractor an invoice for the work done up to the date the individual expired or was determined ineligible and bill for payment only the portion for the modification completed at the time of death or ineligibility determination;
  10. pay the sub-contractor directly for services rendered and agreed upon in the contract; and
  11. not hire the spouse of an individual to do a minor home modification.

Modifications that result in deviations from ADA must be approved by the commissioner. However, if the deviation is being made as a reasonable accommodation for the particular individual, prior approval from the commissioner is not required but the rationale for the deviation must be well documented and in an agreement signed by all involved individuals.

The HCSSA and the individual should be satisfied with the quality of the modification before the contractor is paid. The modification should be completed as agreed in the written work agreement that the individual, contractor and provider signed prior to the work being started. If the modification meets ADA requirements, the specifications and the job was completed as documented in the written agreement signed by all parties before the job was initiated, the HCSSA should be paid for the completed job.

4425.4  Minor Home Modification Procurement

Revision 11-2; Effective December 21, 2011

STANDARD.

  1. HCSSA employees may do minor home modifications for their own individuals as long as the HCSSA obtains three bids and the bid the employee submits is the most cost-effective of the three bids.
  2. The HCSSA must select a bidder to provide the services based on cost and record of quality services, as well as the ability and availability to provide routine maintenance and repair (see Appendix XVI, Procurement Pointers for Home Modifications – Adaptive Aids and Medical Supplies, for procurement pointers).
  3. The HCSSA must specify in the bid specifications any additional requirements, applicable to all bidders.
  4. If the HCSSA is bidding on a modification, the HCSSA must not have any information not available to other bidders which would create an unfair advantage in bidding.

The HCSSA may require contractors per contractual agreement to meet other requirements in excess of local requirements, such as requiring a particular level of insurance or being bonded.

4425.5  Minor Home Modifications in AFC

Revision 11-2; Effective December 21, 2011

In providing minor home modifications in Adult Foster Care (AFC) homes, the agency must allow a minimum grace period of 30 days from the date the individual is authorized for services before beginning any modifications. A waiver to the 30-day grace period can be made on a case-by-case basis by the case manager in situations where the modifications would be a necessity for individual placement and as based on recommendations of the interdisciplinary team (IDT).

4425.6  Requesting Minor Home Modifications Not on the Approved List

Revision 11-2; Effective December 21, 2011

To request minor home modifications not listed in this section, the case manager must send a written request to the DADS regional nurse for approval to authorize the needed modification(s). The written request must contain:

  • a copy of Form 3671-D, Minor Home Modifications, identifying the needed items;
  • documentation of necessity as described on Form 3671-F, Rationale for Adaptive Aids, Medical Supplies, Dental Services and Minor Home Modifications. Documentation identifying all items needed and their necessity and relationship to the individual's disability/medical condition must be completed by the individual's physician, occupational or physical therapist, or speech pathologist, agency RN, nurse practitioner or physician's assistant;
  • the cost estimate; and
  • a statement indicating that the item is not covered by Medicare, Medicaid or other third-party resource.

If a request is made to the DADS regional nurse for items not on the approved list, it is not necessary for the case manager to delay enrolling an applicant until being notified by the DADS regional nurse. The modification requested may be deleted on the individual service plan (ISP) and the ISP can be approved based on other eligibility factors.

If the documentation of necessity prepared by the HCSSA is incomplete or not descriptive of how the requested item is pertinent to the individual's disability or medical condition, authorization for the identified services will be delayed. Additional more descriptive information may be requested by the case manager from the HCSSA to support the medical necessity and in some instances, to resubmit the request.

4425.7  Requesting State Office Approval to Exceed the ISP Service Cap

Revision 11-2; Effective December 21, 2011

Individual service cap for minor home modifications of $7,500 represents the total allocation during CBA participation for minor home modifications necessary to improve mobility, accessibility, function and safety. This lifetime cost cap can be waived by the DADS regional nurse with appropriate documentation. The case manager must send a written request by memo or on Form 2067, Case Information, to the DADS regional nurse along with appropriate documentation or use optional Form 3671-F, Request for Adaptive Aids, Medical Supplies, Dental Services and Minor Home Modifications, identifying all modifications needed, and their necessity and relationship to the individual's disability/medical condition. In addition, the request must contain:

  • the cost estimate;
  • assurance that the service plan is within the individual's overall cost limit and adequate to meet the needs of the individual, (as shown on a copy of Form 3671-1, Individual Service Plan (ISP)); and
  • the case manager's telephone number, Mail Code and regional director's name and Mail Code.

The DADS regional nurse will review all materials submitted, consult with the case manager, HCSSA and other resources, as appropriate, to make a professional judgment to approve or deny the request on a case-by-case basis. The criteria used to approve or deny this request is the same as for any exception to the list of minor home modifications, such as if there is a medical need for the modification that is a cost effective purchase, etc. If the items meets all requirements, then the modification should be approved; do not deny it just because it is over the $7,500 limit.

The case manager counsels the individual of the possible risk of exceeding the lifetime minor home modification limit. If additional funds are used during the ISP year to purchase minor home modifications that could be purchased later, without placing the individual's health and safety at risk, funding may not be available during the current ISP year to meet the individual's unforeseen needs.

Once the $7500 cap or a higher amount approved is reached, only $300 per year per individual, including the fees, will be allowed for repairs, replacement or additional modifications.

4425.8  Minor Home Modifications

Revision 11-2; Effective December 21, 2011

4425.8.1  Time Frames for Minor Home Modifications

Revision 11-2; Effective December 21, 2011

§48.6070 — Time Frames for Minor Home Modifications Costing $1,000 or More.

§48.6072 — Time Frames for Minor Home Modifications Costing Less Than $1,000.

Form 3671-D, Minor Home Modifications, authorizing the purchase of the requested minor home modification must be date stamped upon receipt. The agency has 30 DADS workdays counting from the effective date entered on Form 3671-D or the date the form is received, whichever is later, to complete a modification for minor home modifications costing less than $1,000. For modifications costing $1,000 or more, the agency has 60 DADS workdays counting from the effective date entered on Form 3671-D, or the date the form is received, whichever is later.

If an individual's service plan authorizes several minor home modifications (some estimated to cost less than $1,000 and some more than $1,000), the time frame that needs to be met for completion of the modifications is dependent on whether the modifications are considered one job with one bid packet or several jobs.

If there will be a delay in the completion of the modification, thereby exceeding the 30 or 60 day time frame allowed for completion, the agency must provide written notice to the individual and the case manager on Form 2067, Case Information, before the end of the 30 or 60 day time frame and provide the new proposed completion date. The case manager will call the agency upon receipt of Form 2067 if the explanation doesn't seen reasonable and will refer repeated extensions to the contract manager. Compliance to this delivery schedule is documented on Form 3848, CBA Documentation of Completion of Purchase, Item 3, Date Completed/Delivered.

§48.6074 — Landlord Approval for Minor Home Modifications.

This approval is documented on Form 3849, CBA Specifications for Minor Home Modifications, and must be obtained prior to the initiation of any requested modification when the individual has a landlord or when the owner of the home is not the individual.

4425.8.1.1  Accountability for Minor Home Modifications

Revision 11-2; Effective December 21, 2011

§48.6076 — Accountability for Minor Home Modifications.

4425.9  Requests for Home Remodeling and Major Renovations

Revision 11-2; Effective December 21, 2011

Requests for home remodeling or major renovation is not a covered service under the CBA program. A home modification authorization requires an existing structure to be modified to improve the individual's safety and accessibility.

If the case manager isn't sure whether to approve a minor home modification because it may be considered home remodeling or a major renovation, he should request approval from the regional nurse before authorizing the work.

4425.9.1  Changing Providers During a Home Modification

Revision 11-2; Effective December 21, 2011

All modifications under construction must be completed on the individual's home before the effective date of a provider change. This is to assure follow through and compliance with the original contract or work agreement between the contractor and the agency or individual. If the individual desires to change providers and the construction has not begun, he may do so. The agency will transfer copies of all obtained bids to the receiving agency, and it will be up to the receiving agency to renegotiate any current bids.

4426  In-Home Respite Care

Revision 11-2; Effective December 21, 2011

In-home respite care are services provided by the Home and Community Support Agencies (HCSSAs), on a short-term basis, to individuals unable to care for themselves because of the absence or need of relief for their unpaid caregiver.

STANDARD.

  • In-home respite care is provided in the individual's own home, as authorized on the individual's Form 3671-1, Individual Service Plan (ISP), when the unpaid primary caregiver needs relief either on an emergency or planned short-term basis.
  • The HCSSA is responsible for providing to the individual the tasks authorized on the individual's ISP and Form 2060, Needs Assessment Questionnaire and Task/Hour Guide and Form 2060-A, Addendum to Form 2060 for Personal Assistance Services, during the time he is receiving in-home respite care.
  • The HCSSA must document in the individual's clinical record:
    • the fact that the in-home respite service provider was given a briefing on the individual's status, needs and preferences prior to delivering services, and
    • the dates and duration of services delivered.

In-home respite care helps prevent individual and/or family or support breakdown and the consequent institutionalization which may result from the physical burden and emotional stress of providing continuous support and care to a dependent person.

Respite can be authorized as often as needed for caregiver relief or emergency absences of the caregiver, up to the 30-day or 720 hours maximum per ISP year.

The in-home respite service provider must deliver the personal assistance services (PAS). The HCSSA RN has the option of either directly providing any needed nursing services or delegating the nursing task(s) to the in-home respite provider. Additional waiver services, such as speech therapy and adaptive aids, authorized on Form 3671-1 and delivered by the HCSSA during the time the individual is receiving respite services, will be billed at the authorized rate for the service.

The caregiver who is a paid attendant can never be hired as the respite provider, as respite is intended for caregiver relief or short-term emergency absences of the caregiver. If the caregiver is the paid attendant who also provides uncompensated care, in-home respite may be provided during those hours the caregiver would be providing care to the individual without compensation. If the caregiver is the paid attendant and will be absent during hours for which they are normally paid, respite cannot be provided during this time period. It is the HCSSA's obligation to provide a substitute attendant during this time period. The same applies if the caregiver is a back-up provider.

In-home respite is not intended to be used when the caregiver needs to be out of the house for short periods of time. The caregiver should be encouraged to be out of the house for brief respite when the attendant is providing the PAS services.

4430  Reserved

Revision 11-2; Effective December 21, 2011

4440  Service Initiation

Revision 11-2; Effective December 21, 2011

4441  Referrals for the Pre-Enrollment Home Health Assessment

Revision 11-2; Effective December 21, 2011

§48.6020 — Pre-Enrollment Home Health Assessment.

Referrals for the pre-enrollment home health assessment will be based on the following priorities:

  • applicant's/individual's choice; and
  • on a rotation basis from a list of contracted CBA providers, unless the applicant is receiving Medicare skilled services.

At the time of the initial contact with the applicant, the case manager determines if the applicant is receiving Medicare home health services and follows the following procedures:

  • If the applicant is receiving Medicare home health services and the Medicare provider is also a CBA provider, the case manager will inform the applicant that he can choose this agency to conduct the pre-enrollment home health assessment or he can select another agency from the list of contracted CBA providers if he wants CBA services to be provided by another agency;
  • If the applicant is receiving Medicare home health services and his Medicare provider is not a CBA provider, the applicant should be informed that he has the option to change his Medicare provider so both CBA and Medicare services can be coordinated and provided by the same agency. If he chooses to continue to receive his Medicare services from his current provider, he selects another agency from the list of contracted CBA providers; or
  • If the applicant is not receiving Medicare home health services, he chooses an agency or prioritizes his choices of agencies from a list of contracted CBA providers presented by the case manager. If he has no preference, the next agency on the rotation list is authorized to complete Form 3676, CBA Pre-Enrollment Home Health Assessment Authorization.

The DADS case manager will prepare and send Form 3676 to authorize the HCSSA to perform the assessment.

For a priority status applicant (immediate or expedited referrals) or for an individual eligible to bypass the CBA interest list, the case manager will negotiate for an assessment completion date, not to exceed 14 calendar days, with the HCSSA of the applicant's choice, as selected from the list of providers. The case manager also will negotiate for an assessment completion date for an individual who has bypassed the interest list. If the selected provider is unable to agree to complete the pre-enrollment home health assessment within an acceptable time frame for the applicant and case manager, the case manager will call other agencies selected from a rotation list of providers. Following the verbal authorization to the agency, the case manager completes Section A of Form 3676 and faxes the authorization to the agency. The case manager enters the date negotiated for the completion of the assessment in item 14 of Form 3676.

For a routine status applicant, the DADS case manager enters "14 days" as the time frame for completion of the assessment in item 14 of Form 3676. The agency has 14 calendar days to complete the assessment and assure that it is received by the case manager. The case manager completes Section A of Form 3676 and mails it to the agency. The agency date stamps the authorization form on the day of receipt and has 14 calendar days after the date of receipt to complete all components of the assessment, and return the assessment packet to the CBA case manager.

HCSSAs must complete an initial Medical Necessity and Level of Care (MN/LOC) Assessment. While the individual is in a nursing facility (NF), if both the NF and the HCSSA submit a Minimum Data Set (MDS) for MN determination and an MN/LOC Assessment at the same time, the DADS case manager must use the MN determination and Resource Utilization Group (RUG) resulting from the MN/LOC Assessment submitted by the HCSSA.

For those individuals, the DADS case manager will indicate on Form 2067, Case Information, that the MN/LOC Assessment is required as part of the pre-enrollment assessment, which is sent with Form 3676.

For questions regarding this information, contact DADS Policy Development and Oversight at CBA@dads.state.tx.us.

Reference: Information Letter 2011-41, Procedure Changes for Money Follows the Person Applicants and Individuals Submitting the Medical Necessity and Level of Care Assessment Temporarily Residing in a Nursing Facility; published July 15, 2011.

4442  Verbal Referrals

Revision 11-2; Effective December 21, 2011

The HCSSA will receive a verbal referral for the pre-enrollment home health assessment from the DADS case manager for priority status applicants. The case manager will inform the agency of the applicant's general medical condition and verbally authorize the agency to perform a pre-enrollment home health assessment.

Applicants with priority status need immediate and expedited access to personal or nursing care. The applicant's HCSSA of choice will be given the initial referral and the opportunity to negotiate a time frame in which to perform the pre-enrollment home health assessment. If the assessment cannot be completed in an expedient time frame, the DADS case manager will call the applicant's next choice of agency or the next provider on the rotation list.

Following the verbal referral, the HCSSA will receive Form 3676, CBA Pre-Enrollment Home Health Assessment Authorization, by fax from the DADS case manager authorizing the assessment. Priority referrals will have the "negotiated time frame" entered in Item 14 of Form 3676.

Verbal referrals are not made for routine status applicants. Routine referrals are those that do not meet the criteria for priority status. The HCSSA will receive Form 3676 by mail for routine status applicants. Routine referrals will have 14 calendar days after the receipt of Form 3676 to complete the pre-enrollment home health assessment.

Note: If the individual is being removed from the interest list and does not meet the exception criteria for bypassing the interest list, the referral is considered a routine referral.

4442.1  Pre-Enrollment Home Health Assessment Authorization

Revision 11-2; Effective December 21, 2011

The pre-enrollment home health assessment authorization, Form 3676, CBA Pre-Enrollment Home Health Assessment Authorization, Section A, authorizes the HCSSA to perform a pre-enrollment home health assessment on the individual identified on the form.

4442.2  Receipt of Authorization

Revision 11-2; Effective December 21, 2011

STANDARD.

The HCSSA must date stamp Form 3676, CBA Pre-Enrollment Home Health Assessment Authorization, on the day of receipt.

The day of receipt is considered to be "day zero."

In addition to receipt of Form 3676, the HCSSA will receive Form 2060, Needs Assessment Questionnaire and Task/Hour Guide, and Form 2060-A, Addendum to Form 2060 for Personal Assistance Services, with Form 2060 completed by the case manager for the personal assistance needed.

4442.3  Pre-Enrollment Home Health Assessment

Revision 13-1; Effective March 1, 2013

This face-to-face assessment is performed with the individual and the legally authorized representative by the Home and Community Support Services Agency (HCSSA) registered nurse (RN). This assessment:

  • collects data pertinent for the individual's eligibility for the CBA program;
  • identifies the individual's needs for care plan developing;
  • gathers information for completion of the service backup plan; and
  • provides a data base for the case manager to use in projecting an annual service plan for the individual.

Information regarding the delay of the pre-enrollment may be found at §48.6021 — Delay of Pre-Enrollment Home Health Assessment.

In order to complete the pre-enrollment home health assessment, the following forms (Form 3671-B, Form 3671-C, Form 3671-D, Form 3671-E, Form 3671-F, Form 3671-H, Form 3671-J or Form 3671-K) must be completed, as applicable, along with Form 3676, by the appropriate and qualified staff:

  • Form 3671-B, Therapy Service Authorization, to
    • record the assessment of the applicant's or individual's needs for therapy;
    • provide a worksheet for the initial and ongoing development of the individual service plan (ISP); and
    • identify therapy services.
  • Form 3671-C, Nursing Service Plan, to
    • determine the level of Adult Foster Home — Level I or II placement, or recommend Level III placement;
    • recommend to the case manager if the individual can be left alone for up to three hours at a time;
    • identify nursing tasks to be delegated, directly provided or provided through Medicare, Medicaid Home Health, third-party resources and family and informal support;
    • provide a worksheet for the initial and ongoing development of the ISP;
    • request delegation and training hours; and
    • project hours per month needed to perform nursing tasks.
  • Form 3671-D, Minor Home Modifications, to
    • record the estimated cost of each modification;
    • record the total estimated annual cost;
    • serve as a worksheet for the initial and ongoing development of the ISP; and
    • identify specific minor home modifications needed by the individual.
  • Form 3671-E, Adaptive Aids and Medical Supplies, to
    • record the needs of the applicant or individual for adaptive aids and medical supplies;
    • record the estimated monthly cost of adaptive aids and medical supplies; and
    • serve as a worksheet for the initial and ongoing development of the ISP.
  • Form 3671-F, Rationale for Adaptive Aids, Medical Supplies, Dental Services and Minor Home Modifications, or other appropriate forms of documentation for purchases identified in Form 3671-D, Form 3671-E and Form 3671-H, as referenced in Section 4424.1, Documentation of Necessity, to provide documentation.
  • Form 3671-H, Dental Services.
  • Form 3671-J, Dental Services – Proposed Treatment Plan.
  • Form 3671-K, Service Backup Plan, to document the service backup plan for program services, as needed, when normal services delivery is interrupted in the absence of the regular service provider, or in an emergency.
  • The HCSSA RN must complete the pre-enrollment home health assessment and sign Form 3676, CBA Pre-Enrollment Home Health Assessment Authorization, HCSSA Report, Section B, indicating comments pertinent to the care plan development and sign Form 2060-A, Addendum to Form 2060 for Personal Assistance Services (PAS), to indicate agreement with the PAS services identified on Form 2060, Needs Assessment Questionnaire and Task/Hour Guide, and 2060-A, or indicate on Form 2067, Case Information, what changes in PAS services are needed. All completed forms must be submitted to the DADS case manager according to the time frame entered in Item 14 of Form 3676 or 14 days after receipt of Form 3676, whichever is sooner, unless the decision to initiate Medicare services is still pending or there is a delay in getting a Medical Necessity/Level of Care (MN/LOC) Assessment, signed by the physician.

If the completed packets are not received by the due date, regional contract staff may place a hold on individual referrals or take other corrective actions.

The DADS case manager will review the pre-enrollment home health assessment for completeness upon receipt and:

  • send Form 2067 to the HCSSA if the assessment is not complete;
  • when the completed assessment is received, complete Section C of Form 3676 to authorize payment to the HCSSA and send a copy of Form 3676 signed by the DADS case manager to the HCSSA within five workdays after receipt of the completed assessment; and
  • register the authorization for payment on the Service Authorization System (SAS).

The HCSSA must send the documented locator number (DLN) and a copy of the signed Physician's Signature Page to the DADS case manager.

DADS requires a physician's signature on the Physician's Signature Page when the type of assessment (field A0310 on the MN/LOC Assessment) is marked Initial Assessment. By signing the Physician's Signature Page, the physician is certifying the individual requires nursing facility services or alternative community based services under the supervision of a Medical Doctor/Doctor of Osteopathy. There is no DADS requirement for a physician to attest to the accuracy of an MN/LOC Assessment.

Reference: Information Letter 2011-36, Procedure Changes for Submitting the Medical Necessity and Level of Care Assessment; published April 27, 2011.

The pre-enrollment home health assessment is considered complete when the DADS case manager has received:

  • Form 2060-A signed by the HCSSA RN to indicate agreement with the PAS identified on Form 2060 and Form 2060-A, or Form 2067, indicating what changes in PAS services are needed;
  • ISP attachments, Form 3671-B, Form 3671-C, Form 3671-D, Form 3671-E, Form 3671-H, Form 3671-J and Form 3671-K, including sufficient documentation on Form 3671-F or other documentation which identifies each adaptive aid, medical supply or minor home modification; why it is necessary and how it is related to the applicant's disability or medical condition;
  • Form 3676 with Section B completed;
  • Form 3671-C signed by HCSSA staff, the individual and any informal support who has agreed to provide delegated nursing or PAS tasks; and
  • Form 3671-2, Individual Service Plan, with the individual's signature choosing CBA and agreeing with the service plan and HCSSA signatures agreeing with the service plan and accepting the individual with the proposed service plan.

The DADS case manager will question the HCSSA RN before approving payment for the assessment if there are inconsistencies in the assessment. For example, if Form 3676 indicates the applicant is receiving Medicare home health services, but the nursing assessment on Form 3671-C does not indicate the applicant is receiving any nursing services through Medicare, the DADS case manager should ask the HCSSA RN to explain the inconsistency. If the assessment does not include sufficient documentation to support the necessity for each identified adaptive aid, dental service, medical supply or minor home modification listed on Form 3671-D, Form 3671-E or Form 3671-H, the DADS case manager will request the additional documentation.

If Form 3671-K is not filled out completely, the pre-enrollment home health assessment is considered incomplete and the DADS case manager will return the pre-enrollment assessment to the HCSSA to complete.

HCSSAs must complete an initial MN/LOC Assessment while the individual is in a nursing facility, if both the nursing facility and HCSSA submit a minimum data set (MDS) for MN determination and an MN/LOC Assessment at the same time. The DADS case manager must use the MN determination and resource utilization group (RUG) resulting from the MN/LOC Assessment submitted by the HCSSA.

For those individuals, the DADS case manager will indicate on Form 2067 that the MN/LOC Assessment is required as part of the pre-enrollment assessment, which is sent with Form 3676.

Reference: Information Letter 11-41, Changes for Money Follows the Person Applicants and Individuals Submitting the Medical Necessity and Level of Care Assessment Temporarily Residing in a Nursing Facility; Published July 15, 2011.

The HCSSA cannot submit a claim for the pre-enrollment home health assessment until it has received Form 3676 with the DADS case manager's signature. The DADS case manager has five workdays after receipt of Form 3676 from the HCSSA to sign Form 3676 in acknowledgement of receipt of the completed assessment and return the form to the agency.

4442.3.1  Authorization for Second Pre-Enrollment Home Health Assessment

Revision 13-1; Effective March 1, 2013

The DADS case manager may authorize a second pre-enrollment home health assessment prior to an applicant's enrollment in the CBA program if the applicant's condition and need for services has changed significantly since the first assessment and the individual service plan (ISP) does not adequately address his current needs. If a second pre-enrollment home health assessment has been authorized, the case manager must send a copy of Form 2060, Needs Assessment Questionnaire and Task/Hour Guide, and Form 2060-A, Addendum to Form 2060 for Personal Assistance Services (PAS), to the Home and Community Support Services Agency (HCSSA). The HCSSA is expected to complete the assessment components (Medical Necessity/Level of Care (MN/LOC) Assessment, ISP attachment Form 3671-B, Therapy Service Authorization, Form 3671-C, Nursing Service Plan, Form 3671-D, Minor Home Modifications, Form 3671-E, Adaptive Aids and Medical Supplies, Form 3671-H, Dental Services, Form 3671-J, Dental Services – Proposed Treatment Plan, and Form 3671-K, Service Backup Plan, as appropriate, including documentation of Form 3671-F, Rationale for Adaptive Aids Medical Supplies, Dental Services and Minor Home Modifications, or similar documentation to justify adaptive aids, medical supplies or minor home modifications, and Section B of Form 3676, CBA Pre-Enrollment Home Health Assessment Authorization) unless directed otherwise by the case manager on Form 2067, Case Information, attached to the authorization. The HCSSA RN should sign and return Form 2060-A to the case manager, or Form 2067, indicating changes in PAS tasks services requested, along with the rest of the assessment packet.

Within five DADS workdays after the second completed assessment has been received, the case manager may write "For Second Assessment" next to the words "C. Payment Authorization" when he completes the bottom section of Form 3676, before he sends a copy of the form to the HCSSA to authorize the payment for the assessment.

The DADS case manager should not authorize a second assessment to obtain a second medical necessity (MN) determination because the first MN has expired before the applicant has been enrolled in the CBA program. The DADS Long Term Care regional nurse may complete a new MN/LOC Assessment to update the MN determination if the applicant's MN has expired or will expire before the CBA eligibility is established.

The DADS case manager may not authorize a second pre-enrollment home health assessment solely because the initial HCSSA has refused to accept the referral of a CBA applicant. When the initial HCSSA has refused to accept an applicant, the DADS case manager should share the previous Form 3676 and ISP, Form 3671-1 and Form 3671-2, and all attachments with the second HCSSA.

4442.3.2  Delay in Completion of the Pre-Enrollment Assessment

Revision 11-2; Effective December 21, 2011

If the HCSSA cannot meet the time frame for the pre-enrollment home health assessment and does not verbally notify the case manager as specified in Section 4442.3, Pre-Enrollment Home Health Assessment, the case manager will verbally contact the agency within two DADS workdays after the due date of the assessment to determine the status of the assessment. After the case manager obtains from the HCSSA the reason for the delay, he confers with the applicant so the applicant can decide whether he wants the referral cancelled and a referral made to another agency or if he agrees to wait until the agency can complete the referral.

If the applicant wishes to cancel the referral to the first agency who made the assessment, the case manager will call the agency to cancel the referral by the next DADS workday and follow up by sending Form 2067, Case Information, to the agency within five DADS workdays of the telephone call. If a referral is cancelled by an applicant for a delay in completing an assessment, payment for the pre-enrollment home health assessment will not be authorized by the case manager.

4442.4  Selecting the Paid Attendant

Revision 11-2; Effective December 21, 2011

The HCSSA is responsible for selecting and hiring attendants for individuals living in their own homes. Selection of the paid attendant is based on the individual's needs and the available attendant best able to meet those needs. The case manager will not recommend specific individuals be hired as attendants for specific individuals. The case manager and the HCSSA must be responsive to the preferences and expressed interest of the individual.

Individuals who want specific persons to be considered as attendants will be encouraged by the case manager to discuss this with the HCSSA. If the individual requests or suggests that certain individuals be considered as attendants, the case manager communicates this request to the provider on Form 2067, Case Information, and states that the potential attendants were suggested by the individual. If DADS is aware of any restrictions on employment of any individual, such as the particular attendant is a spouse or has abused, neglected or exploited other individuals or the caregiver, if hired as the paid attendant, cannot provide protective supervision. The restrictions will be conveyed to the HCSSA on Form 2067 by the case manager when the service plan is submitted for concurrence. (See Section 4443, Service Plan.)

The individual's or HCSSA's choice of attendants is not limited unless:

  • the case manager has specified that a particular attendant should not be employed by the HCSSA; or
  • the RN supervisor or the case manager has determined that the attendant is not providing adequate care.

If an HCSSA hires attendants who have been identified as inappropriate or undesirable, meet with agency staff to discuss the issues and resolve the problem. If the problems occur regularly or cannot be resolved through discussion, report this to your supervisor, who will contact the contract manager and the program director.

At reassessment, do not specify that the current paid attendant should not continue in that capacity unless:

  • there is evidence to indicate that the attendant has abused, neglected or exploited the individual or others;
  • the attendant has been providing inadequate care and you have not been able to resolve the issue with the provider agency; or
  • you discover that the attendant is the spouse of a CBA individual.

Criminal background checks are required for HCSSAs. Except in emergency situations, HCSSAs are required to obtain a criminal history check before offering permanent employment to unlicensed employees having direct contact with individuals.

A person must be barred from employment if he has been convicted for a criminal offense for which an administrative review is not available. A person may request an administrative review for some criminal offenses that may potentially bar employment.

Appendix XVIII, Criminal History Check of Employees in Certain Agencies/Facilities Serving the Elderly or Persons with Disabilities, outlines the procedures regarding criminal history checks.

If you are asked by anyone, including the individual, about the results of the check, explain that:

  • all provider agencies must conduct criminal history checks on attendants;
  • either DADS or the Texas Department of State Health Services is monitoring compliance with the law; and
  • confidentiality requirements prevent sharing information obtained as a result of a criminal history check with anyone except the employee.

4443  Service Plan

Revision 13-1; Effective March 1, 2013

The service plan as presented on Form 3671-1 and Form 3671-2, Individual Service Plan (ISP), Form 2060, Needs Assessment Questionnaire and Task/Hour Guide, and Form 2060-A, Addendum to Form 2060 for Personal Assistance Services (PAS), and attachments, Form 3671-B, Therapy Service Authorization, Form 3671-C, Nursing Service Plan, Form 3671-D, Minor Home Modifications, Form 3671-E, Adaptive Aids and Medical Supplies, Form 3671-F, Rationale for Adaptive Aids, Medical Supplies, Dental Services and Minor Home Modifications, Form 3671-H, Dental Services, Form 3671-J, Dental Services – Proposed Treatment Plan, and Form 3671-K, Service Backup Plan, will be faxed or hand-delivered to the Home and Community Support Services Agency (HCSSA) by the DADS case manager along with Form 2067, Case Information, if applicable. Form 2067 will document if a specific attendant cannot be hired, or any other communication to the HCSSA pertinent to the individual's care.

STANDARD.

  1. Upon receipt of the service plan from the DADS case manager, an HCSSA RN must sign Form 3671-2, in certification that the ISP accurately reflects the needs of the individual.
  2. In addition, the HCSSA representative must do one of the following upon receipt of the service plan:
    1. Acknowledge agreement with the service plan by signing Form 3671-2 and faxing to the DADS case manager within two DADS workdays of receipt of the service plan; or
    2. Refuse to serve the applicant based upon licensure limitations by:
      • identifying a "no" under Referral Acceptance, on Form 3671-2, and document the specific licensure rule(s) the agency cannot comply with in the space allowed for not agreeing to serve the individual; and
      • faxing Form 3671-2 to the case manager within two DADS workdays of receipt of the service plan; or
    3. Negotiate for a change in service plan by:
      • calling the DADS case manager within one DADS workday of the receipt of the service plan;
      • completing the appropriate ISP attachment, Form 3671-B, Form 3671-C, Form 3671-D, Form 3671-E, Form 3671-H, Form 3671-J, identifying the requested service plan change, or Form 3671-K, identifying changes to the service backup plan, or use Form 2067 for requesting a service plan change for PAS; and
      • fax the service plan request and the appropriate ISP attachment back to the case manager within two DADS workdays of receipt of the faxed tentative service plan.
  3. For service plans in which service changes have been negotiated, the HCSSA must return Form 3671-2 to the DADS case manager, in agreement or refusal as referenced in items (b) (1) and (2), within one DADS workday of receipt.

The HCSSA RN, in addition to the RN who performed the pre-enrollment home health assessment, may sign Form 3671-2, in certification that the ISP accurately reflects the needs of the applicant.

The DADS case manager will consider requests for changes in service plans and may authorize the services.

For service plans that are returned to the DADS case manager for changes, the DADS case manager will consider the requests to authorize the services if it is within the individual's cost limit. The DADS case manager will fax the updated service plan to include Form 2060 and Form 2060-A, the appropriate ISP attachment (Form 3671-B, Form 3671-C, Form 3671-D, Form 3671-E, Form 3671-H, Form 3671-J, Form 3671-K) and Form 3671-2, to the HCSSA within two DADS workdays for approval or refusal of services.

4443.1  Individual Agreement for Services

Revision 11-2; Effective December 21, 2011

HCSSAs may choose to provide services through Medicare, private insurance or through private pay arrangement with individuals awaiting determination of CBA eligibility. Services arranged for by the agency and the applicant and implemented prior to the determination of a CBA eligibility date will not be reimbursed by DADS and are provided at the agency's own risk.

The HCSSA cannot be held responsible for deficits or failure in areas not included in the HCSSA portion of the individual's service plan when gratuitous care or care by other resources is being provided. The HCSSA nurse is responsible for the nature and quality of care that an individual receives under his direction as set forth by the Board of Nurse Examiners for the State of Texas.

4443.2  Refusal to Serve Applicants

Revision 11-2; Effective December 21, 2011

If an agency refuses to serve an applicant based on licensure limitation, the reason the agency will not be able to adequately meet the needs of the individual must be stated. The reason must be related to the individual himself and not previous efforts.

§97.401(b) of the Standards for Licensed Home Health states an agency "shall accept an individual for home health services on the basis of a reasonable expectation that the individual's medical, nursing and social needs can be met adequately in the individual's residence. An agency has made a reasonable expectation that it can meet an individual's needs if, at the time of the agency's acceptance of the individual, the individual and the agency have agreed as to what needs the agency would meet (i.e., the agency and the individual could agree that some needs could be met but not necessarily all needs)." §97.404(f)(2) of the Standards of Personal Assistance Services states the individual file shall include "an individualized service plan developed, agreed upon and signed by the individual or family and the agency to include, but not limited to … (A) types of service, supplies, and equipment to be provided." This licensure service plan is similar but not the same as the CBA individual's service plan. Both plans must be signed in agreement of the services to be provided.

The statement, "licensure limitations," is not sufficient as a reason for declining to accept a CBA applicant or to continue providing HCSSA services to a CBA individual. The HCSSA must provide a specific reason in writing for declining to accept or serve a CBA individual.

Examples of legitimate licensure reasons for declining acceptance of care include:

  • The lack of a specialty nurse(s) available for a medically complex case. Such a case could include an applicant who is ventilator dependent and the agency does not employ a licensed nurse or a sufficient number of licensed nurses with ventilator experience.
  • An individual who requests attendant services during the time the HCSSA is not open for business.
  • An agency contracted to provide CBA services in a remote county that loses the only attendant available to provide services to an individual in that area who requests services.

The HCSSA should have documentation to show that efforts to bring attendants to the area, such as newspaper advertising, contacting family members and requesting individual recommendations, have failed. If the agency repeatedly declines to accept individuals for care who live in an isolated county because "no attendants are available," the agency should change its contract geographic boundaries. If the agency provides attendant services to other individuals before or after business hours or is able to meet the personal care needs of other individuals in the same remote area, quoting "licensure limitations" is not a legitimate reason for declining to accept or to continue to provide contract services.

The HCSSA can refuse an individual only after the initial assessment. Once an HCSSA accepts an individual for care, the HCSSA cannot refuse to serve its portion of the ISP unless there is danger to staff. HCSSAs must provide services according to licensure service plans, which is similar but not the same as the CBA ISP.

The HCSSA licensing rules (§97.295) define the steps an agency must take to transfer or discharge an individual.

Patterns of provider agencies refusing to provide services to individuals will be referred to the contract manager. The contract manager will evaluate the patterns to determine if the reasons are limited to being unable to meet the needs of the individual as allowed under licensure. If patterns are limited to a certain county, the contract manager can recommend that the county be deleted from the agency's contract. If patterns are not due to the circumstances allowed under licensure, the contract manager must take appropriate corrective action.

4444  Authorization and Initiation of Services

Revision 11-2; Effective December 21, 2011

No later than two DADS workdays after determining that the applicant is eligible for CBA services, the case manager must fax to the HCSSA:

  • a copy of the ISP, Form 3671-2, Individual Service Plan (ISP); and
  • a copy of Form 2065-B, Notification of Waiver Services, which authorizes the HCSSA to deliver the services identified on the ISP.

If the case manager has negotiated a service initiation date with the provider, he must also fax Form 2067, Case Information, documenting the service initiation date negotiated with the provider.

§48.6092 — Initiation of Community Based Alternatives (CBA) Home and Community Support Services Agency (HCSSA).

Form 2067 sent to the case manager must list the names of all the attendants who were hired to initiate services. If more than one attendant was hired when services were initiated, not all the attendants have to begin working within the required time frame to be in compliance with this rule.

DADS will not reimburse a provider for any services delivered before the effective date in the provider authorization on Form 2065-B.

4445  Reserved

Revision 11-2; Effective December 21, 2011

4446  Delay of Initiation of Authorized Services by the HCSSA

Revision 11-2; Effective December 21, 2011

§48.6094 — Delay of Community Based Alternatives (CBA) Home and Community Support Services (HCSS) Initiation.

If the case manager is notified that services were not initiated within the required time frame, he must determine if it is appropriate to negotiate a new service date with the agency or cancel the authorization and authorize another agency to provide services. The case manager will confer with the applicant so that he can decide whether he wants to wait on the first provider agency to initiate services or whether he wants to change to another agency. In working with the applicant to make this decision, the case manager must assure that services are initiated within 30 days of waiver eligibility.

If the applicant chooses to remain with the first agency, the case manager will call the agency and negotiate a new service initiation date.

If the applicant wishes to cancel the referral to the first agency, he selects another agency. The DADS case manager will call the first HCSSA to cancel the authorization and follow up by sending Form 2065-B, Notification of Waiver Services, to the HCSSA. The HCSSA will not be paid for the pre-enrollment home health assessment if the applicant chooses to cancel the referral.

The DADS case manager will notify the selected agency of the referral and negotiate a new service initiation date. The HCSSA will receive the following from the DADS case manager:

  • faxed individual service plan and attachments; and
  • Form 2065-B containing the effective date of the authorization.

If the individual is not in the home and the HCSSA cannot initiate services as authorized, then the HCSSA must initiate waiver services as soon as the individual returns home. In this instance, the agency should verbally notify the case manager of the delay by the next DADS workday after services were to have been initiated. A new service date is not negotiated nor is a new provider authorized when the service initiation is caused by the individual's absence.

4450  Service Provision

Revision 13-1; Effective March 1, 2013

The Home and Community Support Services Agency (HCSSA) who performed the pre-enrollment home health assessment, in most instances, will become the applicant's provider if the individual is approved for service. Examples of instances when another HCSSA may be authorized to provide the initial CBA services are:

  • when the HCSSA completing the pre-enrollment home health assessment refuses to serve the applicant;
  • when the applicant and the HCSSA mutually agree; and
  • when the agency fails to initiate services within the required time frame and the applicant desires to change to another agency.

If an individual requests to change providers, and if another appropriate provider is available, the DADS case manager will negotiate an effective date for the change with the providers.

The DADS case manager will fax or mail a copy of the following to the new provider for referral acceptance:

The applicable attachments will be annotated to identify services and items that have already been delivered.

Upon receipt of the referral packet, the HCSSA must make the decision whether it will accept the referral. If the new provider decides to serve the referred individual, the agency must sign Form 3671-2 and return it to the case manager.

Upon receipt of the returned ISP and signature of the new agency in agreement to serve the individual, the case manager will prepare and send Form 2065-B, Notification of Waiver Services, to the:

  • "old" provider to inform the provider of the termination date of the service authorization, and
  • "new" provider to notify the provider of the effective date of service authorization.

If the selected provider refuses to accept the referral, the case manager will work with the individual to select another provider.

4450.1  Complaints About Service Providers

Revision 11-2; Effective December 21, 2011

The individual has the right to file complaints against individual providers or the HCSSA.

STANDARD.

The HCSSA must investigate any complaint received from the case manager and submit a response on Form 2067, Case Information, to the case manager within five DADS workdays of receipt of the complaint.

Depending on the nature of the complaint, the case manager may also refer the complaint to the Texas Department of Family and Protective Services, the Texas Board of Nurse Examiners, the contract manager or local law enforcement agencies.

4451  Service Breaks

Revision 13-1; Effective March 1, 2013

§48.6096 — Service Breaks

The individual service plan (ISP) includes Form 2060, Needs Assessment Questionnaire and Task/Hour Guide, Form 2060-A, Addendum to Form 2060 for Personal Assistance Services; Form 3671-1 and Form 3671-2, Individual Service Plan, and Form 3671-B, Therapy Service Authorization, Form 3671-C, Nursing Service Plan, Form 3671-D, Minor Home Modifications, Form 3671-E, Adaptive Aids and Medical Supplies, Form 3671-H, Dental Services, Form 3671-J, Dental Services – Proposed Treatment Plan, and Form 3671-K, Service Backup Plan.

§48.6096 (1) pertains to circumstances identified in §48.6100, §48.6098, and §48.6106, found in Appendix XXV, Rules Pertaining to Suspension or Termination of Services to Active CBA Participants.

§48.6096 (2) pertains to circumstances identified in §48.6102 and §48.6104, found in Appendix XXV.

The individual and the Home and Community Support Services Agency (HCSSA) may agree to modify the schedule for personal assistance services hours in order to meet the individual's needs (see below Section 4451.1, Schedule Flexibility/PAS Outside the Home).

There is no requirement that the HCSSA call the individual to determine if there is a service break.

If a special attendant is assigned to prevent a service break, the special attendant must stay for the time the regular attendant was scheduled to be at the home and complete all the authorized tasks.

Repetitive use of licensed personnel to prevent service breaks will be considered grounds for service evaluation by the DADS contract manager.

4451.1  Schedule Flexibility/PAS Outside the Home

Revision 13-2 Effective June 5, 2013

CBA policy allows scheduling flexibility for the specific personal assistance services (PAS) tasks performed. Except for a schedule implied by the individual's need for particular services, (for example, assistance with breakfast) due to special individual circumstances or at the request of the individual, the CBA case manager will pass on a specific schedule to the provider agency. Otherwise, DADS does not identify a specific schedule for the delivery of services.

Home and Community Support Services Agencies (HCSSAs) and CBA individuals may negotiate a mutually agreeable schedule for delivery of services, and change the actual tasks to be delivered if the:

  • changes do not increase the monthly authorized units of service, as authorized on Form 2060-A, Addendum to Form 2060 for Personal Assistance Services;
  • tasks are allowable tasks in the program; and
  • flexibility does not violate compliance with practitioner's orders, nursing practice standards and HCSSA licensure.

If the individual is scheduled to receive services on certain days of the week, and services are not provided on scheduled days, services to the individual can be provided on a subsequent day if the individual agrees to the change.

Examples:

  • An individual is scheduled to receive services on Monday, Wednesday and Friday. The individual has a doctor's appointment on Wednesday. Services to the individual could essentially be provided on Tuesday or Thursday.
  • An individual is authorized to receive 30 hours/week, for a monthly total of 130 hours (30 × 4.33 = 130). The individual was discharged from the hospital and needs services seven days per week the first two weeks of the month. The individual could receive seven hours/day for two weeks (14 days) for a total of 98 hours during the two week period. The remaining 32 hours could be distributed the remainder of the month.

As long as the total hours are within the maximum hours authorized for that month, as authorized on Form 2060-A, you do not need to notify the case manager or obtain approval from the case manager:

  • if tasks are performed on a regular basis less frequently than the number of times per week agreed by the individual and the case manager; or
  • to change a schedule.

Individuals who receive PAS are allowed flexibility in choosing where they can receive PAS. CBA individuals can choose to receive PAS outside the home, up to the maximum amount of hours authorized per month on Form 2060-A.

Hours diverted so the individual can receive services in alternative locations may not be added back into the service plan. For example, an individual approved for 28 hours of PAS per week, four hours per day, may elect to spend 10 hours at the beginning of the week going to church, out to eat and to the movies. While at these locations, the attendant performs the usual duties of:

  • transferring,
  • toileting assistance,
  • escorting,
  • reminding to take medications,
  • feeding, etc.

This is an acceptable use of attendant care hours. Provider agencies still are not required to transport the individual.

The case manager continues to allocate hours based solely on hours needed as measured by Form 2060, Needs Assessment Questionnaire Task/Hour Guide. Hours are based solely on services assumed to be provided within the home environment. The case manager does not authorize additional hours to the service plan if the delivery of services in an alternate location uses hours the attendant requires to provide the tasks the individual needs. For example, the attendant in the case above is not able to deliver any tasks on the last day of the week because four additional hours were needed to deliver personal care tasks during the two days the individual went to church, out to eat and to the movies.

Provider agencies must make a reasonable effort to meet an individual's request to have services provided in alternate locations. Provider agencies must document when an individual requests services be provided in alternate locations and if the request was granted. If the request was not granted, written justification must support why it was not within the power of the agency to comply with the request.

Provider agencies still are not required to transport individuals or to pay expenses the attendant incurs while delivering services in alternate locations. CBA HCSSAs must not violate compliance with practitioner's orders, nursing practice standards or HCSSA licensure.

The flexibility for schedules and specific tasks delivered is intended to better meet the individual's needs and is not for the convenience of the provider agency or to be applied retroactively to justify the absence of an HCSSA attendant. The negotiated schedule must be documented to meet the requirements for HCSSA licensure and agency policy. The schedule is based on the individual's needs and not agency staff resources. The provider agency must have a backup system to assure provision of all PAS services for the negotiated schedule. The backup system must prevent a service break, even if there are unexpected changes in personnel.

The flexibility in schedules and tasks does not apply to protective supervision if the caregiver is hired as the PAS attendant. The reason is that protective supervision is intended to relieve the caregiver of the responsibility of supervising the individual.

If there is a need for a reduction of hours of service, the HCSSA cannot reduce hours without notifying the case manager and must request a service plan change. When services are to be reduced, the case manager must notify the individual of the reduction in services to offer an appeal process even though the individual has signed the agreed upon service plan including the reduction. The reduction in services cannot be effective until 10 days after the date of the notification to the individual, or until a decision is made by the appeals officer if the individual requests an appeal.

PAS Services Without Delegated Nursing Tasks

Documentation in the provider agency's files must support the agreement reached for the individual initiated requests to change services to specific days or at different times during the same day. Any temporary changes or deviations from the original schedule must be documented in the individual's record.

An example where documentation needs to support a change in scheduled services is when the attendant calls in the day before saying he cannot work the next day. The agency must then notify the individual before the attendant is due at the individual's house and present the following options:

  • another attendant can be sent at the regular scheduled time;
  • another attendant can be sent at a different time than the regularly scheduled time; or
  • the schedule can be changed for the week.

Documentation Requirements for §48.6096(4)-(5) Involving Service Flexibility for PAS Services Without Delegated Nursing Tasks

Provider agency compliance with the service break standard is based on the agency's documentation of:

  • the number of hours authorized by DADS staff;
  • the schedule mutually agreed to by the individual and the agency;
  • documentation of changes or deviations from the written schedule; and
  • the hours of service as documented on the time sheet.

PAS Services with Delegated Nursing Tasks: Service Flexibility in CBA

When individuals with delegated nursing tasks initiate requests that services not be provided on certain days or time as authorized in the current schedule, the agency registered nurse must be notified before the agency agrees to any schedule change requested by the individual. The HCSSA RN should assess the individual's service flexibility request for compliance with the practitioner's orders, nursing practice standards, HCSSA licensure and any health and safety concerns the CBA individual may have.

Documentation Requirements for §48.6096(4)-(5) Involving Service Flexibility with Delegated Nursing Tasks

The criteria listed previously under documentation requirements for §48.6096(4)-(5) involving service flexibility for PAS service without delegated nursing tasks also applies to service breaks involving service flexibility when delegated nursing tasks are involved. In addition, the HCSSA must:

  • maintain documentation substantiating that prior notification was given to an HCSSA RN for any individual initiated schedule change; and
  • have the HCSSA RN sign the documentation within five calendar days of receiving notification of an individual initiated schedule change, validating the following:
    • prior notification of the individual initiated schedule change was provided to the RN; and
    • the service flexibility remained in compliance with practioner's orders, nursing practice standards and HCSSA licensure.

4451.1.1  Schedule Flexibility/Protective Supervision and the Unpaid Caregiver

Revision 11-2; Effective December 21, 2011

Flexibility in scheduling does not apply to protective supervision as the purpose of protective supervision is to relieve the caregiver of the responsibility of supervising the individual. If protective supervision is needed, the caregiver cannot be hired as the attendant or another attendant must be hired to provide the protective supervision hours. If the unpaid caregiver becomes the paid attendant and there is not a relief caregiver to provide the protective supervision hours, the protective supervision hours will no longer be authorized.

STANDARD.

  1. If protective supervision hours are authorized by the DADS case manager and the unpaid caregiver is hired by the HCSSA for protective supervision hours, the HCSSA must initiate a service plan change to the DADS case manager to reduce the personal assistance services (PAS) hours before the caregiver becomes a paid attendant.
  2. The HCSSA must assign another attendant for the PAS hours within two weeks of receipt of Form 2067, Case Information, from the DADS case manager requesting that the protective supervision hours be provided by another attendant.

If the DADS case manager determines that a previously unpaid caregiver is providing the protective supervision hours, the case manager will discuss with the individual that he must be willing to have the protective hours provided by someone else; if not, the protective supervision hours must be discontinued. If the individual is willing, the DADS case manager will notify the HCSSA on Form 2067 that he must assign another attendant within two weeks to provide the protective supervision hours. If the individual is not willing to have someone else provide the protective supervision hours, the case manager must reduce the individual's previously authorized PAS services by the number of hours previously authorized for protective supervision hours and give the individual the right to appeal the reduction in services.

4452  Changes and Disagreements Over Service Plan

Revision 11-2; Effective December 21, 2011

4452.1  Requests for Service Plan Change in Emergencies

Revision 11-2; Effective December 21, 2011

In meeting the needs of waiver individuals experiencing crises, the HCSSA intervenes to meet the unanticipated medical needs, unexpected or sudden changes in medical condition or health status of the individual, or loss of the individual's caregiver.

STANDARD.

  1. In emergencies and crises, the HCSSA must deliver:
    1. all the nursing and personal assistance services necessary to meet the needs of waiver individuals living in their own homes;
    2. all nursing services except medication administration necessary to meet the needs of individuals living in Assisted Living/Residential Care Facilities; and
    3. all nursing services necessary to meet the needs of individuals living in Adult Foster Care, Level I and II, if the home is not operated by a licensed nurse.
  2. When providing emergency interventions, the HCSSA must verbally notify the DADS case manager or the case manager's supervisor about any emergency interventions by the next DADS workday after providing the necessary services.
  3. Written communication must be sent to the case manager within seven calendar days of the verbal notification, to include:
    • Form 2067, Case Information, containing the rationale for the emergency intervention, the type and amount of additional personal assistance services needed and the anticipated duration or any personal assistance service;
    • the appropriate individual service plan (ISP) attachment, Form 3671-B through E, that identifies the service plan change, signed by the individual or the individual's caregiver and HCSSA RN; with
      • Form 3671-F, Rationale for Adaptive Aids, Medical Supplies, Dental Services and Minor Home Modifications, if appropriate;
      • Form 3671-2, Individual Service Plan, signed by the individual or responsible party in agreement to the submitted service plan change; and
      • a physician's statement of emergency for adaptive aids and medical supplies. (See Section 4424.4.2, Emergency Procurement of Adaptive Aids and Medical Supplies.)

Three hours of nursing service is authorized on the initial ISP for the HCSSA nurse to provide emergency interventions in crises.

If the HCSSA follows the notification procedures outlined above, the case manager must submit an ISP change, if necessary, within 14 calendar days of the documented verbal request for the service plan change, to increase the authorized hours to cover the services already delivered, with an effective date of the service initiation date. Any ongoing services the HCSSA has been providing after notification to the case manager must also be authorized for payment on the ISP.

The HCSSA may purchase adaptive aids and medical supplies not currently authorized on the ISP only if the individual's health and/or safety is at risk. (Refer to Section 4424.4.2)

4452.2  Requests for Routine Service Plan Changes

Revision 11-2; Effective December 21, 2011

§48.6023 — Routine Service Plan Changes.

§48.6024 — Changes to Personal Assistance Services.

STANDARD.

Within seven calendar days of receiving the revised individual service plan (ISP), and appropriate attachment page from the case manager, the HCSSA will:

  1. acknowledge approval of the revised ISP by signing the attachments and returning to the case manager; and
  2. initiate the authorized services.

Upon receipt of the request for service plan change, the case manager must assess what impact the changes will have on the individual's eligibility.

If the request is for a reduction in the service plan, the case manager will notify the individual to offer an appeal process even though the individual has signed the agreed upon service plan.

If the case manager approves the request, he will submit an ISP change to the HCSSA within 14 calendar days of the written request to authorize the service plan change.

Any time the individual has a need for medical supplies or adaptive aids not listed on Form 3671-E, Adaptive Aids and Medical Supplies, or has a condition change and the ISP does not reflect the individual's current needs, the agency must prepare a service plan change (complete Form 3671-F, Rationale for Adaptive Aids, Medical Supplies, Dental Services and Minor Home Modifications, if necessary) and forward to the case manager.

The HCSSA should also request a change in the service plan, including a reduction in services, when there is a significant improvement in the individual's condition and the ISP does not reflect the individual's current needs.

It is not appropriate to request a Resource Utilization Group "reset" if the individual's condition improves because the service plan should be based on the individual's needs, not his cost limit.

The HCSSA has seven calendar days after receipt of the revised ISP to initiate the changed service, except for adaptive aids, medical supplies or minor home modifications, and acknowledge receipt by signing and returning the signed ISP attachment form(s). For adaptive aids, medical supplies and minor home modifications, the HCSSA will provide the needed items or modifications by the dates required.

4452.3  Individual Service Plan Disagreements

Revision 11-2; Effective December 21, 2011

If the HCSSA RN and/or other licensed professionals on the interdisciplinary team (IDT) have doubts about the adequacy or appropriateness of the proposed individual service plan (ISP) these concerns should be expressed in an IDT meeting and documented in the IDT meeting notes. The case manager may involve other professional staff, such as his supervisor and the regional nurse, in the development of the ISP for applicants with ongoing needs for life sustaining care or those in questionable living situations.

4453  Notifications

Revision 11-2; Effective December 21, 2011

STANDARD.

  1. The Home and Community Support Services Agency (HCSSA) must notify the case manager when one or more of the following circumstances occur:
    1. The individual leaves the state for more than 90 days. DADS retains the authority to extend this time in extraordinary circumstance.
    2. The individual has been legally confined or has resided in an institutional setting for longer than 120 days. An institution includes legal confinement, an acute care hospital, state hospital, rehabilitation hospital, state supported living center, nursing home or intermediate care facility for persons with intellectual disability (ICF-ID). DADS retains the authority to extend this time in extraordinary circumstances.
    3. The individual is not financially eligible for Medicaid benefits.
    4. The individual does not meet the medical necessity (MN) criteria for nursing facility care.
    5. The estimated costs of the CBA services necessary to adequately meet the needs of the individual exceeds the CBA cost limit.
    6. HCSSAs have refused to serve the individual on the basis of a reasonable expectation that the individual's medical and nursing needs cannot be met adequately in the individual's residence.
    7. The individual or someone in the individual's home refuses to comply with mandatory program requirements, including the determination of eligibility and/or the monitoring of service delivery.
    8. The individual fails to pay his qualified income trust copayment.
    9. The situation, individual or someone in the individual's home is hazardous to the health and safety of the service provider, but there is no immediate threat to the health and safety of the provider.
    10. The individual or someone in the individual's home openly uses illegal drugs or has illegal drugs readily available within sight of the service provider.
    11. The individual requests services end.
    12. If the DADS case manager determines that documentation supports initiation of denial, the case manager provides written notification of denial to the individual and provider agency within two DADS workdays. The written notification must specify the reason for denial, the effective date of the denial, the regulatory reference and provide written notice of the right to appeal.

      If the individual appeals the notification of denial within 10 days of written notification, the CBA provider agency continues CBA services until notification of the decision by the Health and Human Services Commission (HHSC) hearings officer. The CBA provider agency must not reduce waiver services until the outcome of the appeal is known.

  2. The HCSSA must verbally notify the DADS case manager by the next DADS workday of the reason for denial and follow up with written documentation on Form 2067, Case Information, within two DADS workdays of the verbal notification.
  3. If one or both circumstances specified in Paragraphs (1) and (2) of this subsection occur, the HCSSA must provide written documentation to DADS to support the reason for the denial of services.
    1. The individual or someone in the individual's home has a substantial and demonstrated pattern of verbal abuse and harassment of service providers, not related to the individual's disability, which results in an inability to provide service(s) to the individual.
    2. The individual or someone in the individual's home has a substantial and demonstrated pattern of discrimination against the service providers on the basis of race, color, national origin, age, sex or disability that has not improved with appropriate intervention and which results in an inability to provide service(s) to the individual.
  4. The case manager must provide advance written notification of denial of services to the individual with written notice of the right to appeal.
  5. If the individual appeals the denial of services within 10 days of written notification, the CBA HCSSA must continue CBA services until notification of the decision by the HHSC hearing officer. The CBA provider agency must not reduce or suspend services until the outcome is known.

Immediate Suspension or Reduction of Services

  1. If the individual or someone in the individual's place of residence exhibits reckless behavior that may result in imminent danger to the health and safety of service providers, the DADS case manager and HCSSA are required to make an immediate referral for appropriate crisis intervention services to the Department of Family and Protective Services (DFPS) and/or the police and suspend services. Suspension of services is defined in §48.6002 of this title (relating to CBA Definitions).
  2. The DADS case manager must immediately provide written notice of temporary suspension to the individual, and the right of appeal to a fair hearing must be explained to the participant. The written notification must specify the reason for denial or suspension, the effective date, the regulatory reference, and the right of appeal.
  3. The HCSSA must verbally inform the DADS case manager by the following DADS workday of the reason for the immediate suspension and follow up with written notification to DADS within two DADS workdays of verbal notification.
  4. The DADS case manager must make a face-to-face visit to initiate efforts to resolve the situation. If the temporary suspension of services constitutes a threat to the health and safety of the individual, then community alternatives or placement in an institutional setting must be offered and facilitated by the case manager.
  5. With prior authorization by DADS, the CBA HCSSA may continue providing services to assist in the resolution of the crisis. This service will be reimbursed as an administrative expense.
  6. If the crisis is not satisfactorily resolved, the DADS case manager provides notification of denial of services and offers the right of appeal. Services do not continue during the appeal process.

4453.1  Service Re-Initiation

Revision 11-2; Effective December 21, 2011

STANDARD. When services are re-initiated following a hospital stay, the HCSSA must:

  1. re-initiate services based on the approved service plan.
  2. notify the case manager or staff in the case manager's office by telephone by the first DADS workday to:
    • inform them of the service re-initiation date; and
    • inform them of any changes needed in the service plan.
  3. mail to the case manager within five calendar days of the service re-initiation date the following:
    • Form 2067, Case Information, documenting the service initiation date, the rationale for a service plan change, if needed, the type and amount of additional services needed and the anticipated duration; and
    • the appropriate Form 3671-2, Individual Service Plan (ISP), and attachment pages, both signed by the individual or the individual's caregiver requesting the service plan change, if needed.

The HCSSA should re-initiate services to meet the individual's needs. The agency should work with the individual's physician, hospital discharge planner and other service providers, including Medicare and informal providers, to assure that services are available upon discharge.

Depending on the individual's situation, Medicare, Medicaid Home Health, or other third-party resource may be available to be used at this time. The case manager and the HCSSA will collaborate on the utilization of all available resources as explained in Section 4413.1, Utilization of Other Resources.

4454  Monitoring Medicaid Eligibility

Revision 11-2; Effective December 21, 2011

STANDARD. The Home and Community Support Services Agency (HCSSA) must verify monthly that the individual has received a current Medicaid Identification card.

As the HCSSA is responsible for the provision of needed services and supplies to CBA individuals, on going eligibility status must be checked prior to delivering services each month. If the agency does not provide services on a monthly basis, which may be the case in an Adult Foster Home, the HCSSA can verify receipt of a current Medicaid Identification card by calling the Adult Foster Home provider.

4455  Clinical Records and Supplemental Documentation

Revision 11-2; Effective December 21, 2011

STANDARD.

  1. Clinical notes in accordance with licensure and professional standards documenting the individual's mental and physical status, performed interventions by paid and unpaid individuals as applicable in individual's care, and Resource Utilization Group (RUG) items claimed on the Medical Necessity/Level of Care (MN/LOC) Assessment, as instructed in the MN/LOC instructions, must be maintained by:
    1. licensed nurses and therapists; and
    2. unlicensed persons performing delegated nursing tasks.
  2. The rationale for all services assessed as necessary for the individual's care must be documented in the clinical notes.
  3. The following documentation, which is not all-inclusive, in addition to that required according to professional standards, must be maintained and available for review:
    1. Form 2067, Case Information;
    2. Form 3671-1, Individual Service Plan;
    3. Form 2060, Needs Assessment Questionnaire and Task/Hour Guide;
    4. Form 2060-A, Addendum to Form 2060 for Personal Assistance Services;
    5. Form 3671-B, Therapy Service Authorization;
    6. Form 3671-C, Nursing Service Plan;
    7. Form 3671-D, Minor Home Modifications;
    8. Form 3671-E, Adaptive Aids and Medical Supplies;
    9. Form 3676, CBA Pre-Enrollment Home Health Assessment Authorization;
    10. Form 2065-B, Notification of Waiver Services;
    11. Registered nurse (RN) supervisory notes and other medical records pertinent to the individual's care;
    12. MN/LOC Assessment; and
    13. Form 3671-F, Rational for Adaptive Aids, Medical Supplies, Dental Services and Minor Home Modifications, or other forms of documentation supporting the necessity of adaptive aids (excluding prescriptions), medical supplies and minor home modifications.

4456  Practitioner's Orders

Revision 13-2; Effective June 5, 2013

STANDARD.

  1. Practitioner’s orders are obtained by the licensed nurse or therapist according to professional practice and licensure.
  2. The licensed nurse or therapist receiving a practitioner’s verbal order must record it immediately for services to begin as soon as possible and be followed by a signed and dated practitioner’s order.  
  3. Receipt of the signed and dated practitioner’s order must include the practitioner’s credentials and meet the Home and Community Support Services Agency (HCSSA) written policy, as described in Title 40 of the Texas Administrative Code (TAC), Part 1, Chapter 97, Subchapter C, Division 4, Rule §97.297 Receipt of Physician Orders.

A practitioner is:

  • A person who holds a doctor of medicine or doctor of osteopathy degree and is currently licensed and practicing medicine under the laws of the state of Texas, Oklahoma, New Mexico, Arkansas or Louisiana;
  • Military physicians with a medical license from any state, the District of Columbia, or U.S. territory practicing at a healthcare facility of the Department of Defense (DOD), a civilian facility affiliated with the DOD, or any other location authorized by the Secretary of Defense;
  • a podiatrist currently licensed in Texas;
  • a dentist currently licensed in Texas;
  • a physician assistant (PA) currently licensed in Texas; or
  • an advanced practice registered nurse (APRN) currently licensed from the Texas Board of Nursing to practice as an APRN.

HCSSA licensure standards do not require practitioner’s orders for minor home modifications; therefore, practitioner’s orders are not required for minor home modifications for CBA individuals.

For temporary permits with no number, the license number may be the date of issue and expiration.

For physicians assigned to military facilities, use the military number assigned.

4456.1  Practitioner's Signature Stamps

Revision 13-2; Effective June 5, 2013

Practitioner's signature stamps are acceptable under the following conditions:

  • If the signature stamp is a facsimile of the practitioner's signature, then neither initials nor a countersignature are needed. Documentation from the practitioner approving the stamp should be available. The authorization must be signed by the practitioner and must include a copy of the stamped signature that will be used.
  • If the signature stamp is typewritten or block print, the stamped orders must be initialed or countersigned by the practitioner. Initials are accepted if they are the practitioner's usual signature. If initials are used, the practitioner's name must be typed or printed above or below the signature line.

4456.2  Faxing of Practitioner's Orders

Revision 13-2; Effective June 5, 2013

The use of a fax machine to transmit orders from the practitioner to the licensed nurse or therapist is permissible. When the fax is used, it is not necessary for the prescribing practitioner to countersign the order at a later date. Extra precautions are advised when thermal paper is used to ensure that a legible copy of the practitioner’s order is retained as long as the individual's order is current.

4457  Excluded Waiver Providers

Revision 11-2; Effective December 21, 2011

STANDARD.

  1. Licensed nurses and therapists who are excluded from Medicare and/or Medicaid participation must not provide waiver services to individuals.
  2. Physicians who are excluded from Medicare and/or Medicaid participation must not order or prescribe services for waiver individuals.

Under the terms of the Medicare and Medicaid Patient and Program Protection Act of 1987, an excluded provider (physician) must not order or prescribe services for Title XIX or XX individuals. DADS no longer furnishes providers with the Directory of Texas Licensed Physicians for the approved Medicaid providers.

Although DADS will no longer furnish the Directory of Texas Licensed Physicians, the directory is available through the Texas Medical Board by writing to:

Texas Medical Board
P.O. Box 2018
Mail Code 240
Austin, TX 78768-2018

or at the following website: http://reg.tmb.state.tx.us/OnLineVerif/Phys_NoticeVerif.asp?.

4458  Medical Necessity

Revision 11-2; Effective December 21, 2011

§48.6005 — Level-of-Care/Medical Necessity Determinations.

Medical necessity (MN) is a prerequisite for participation in the CBA program. The determination of MN is based on a completed Medical Necessity and Level of Care (MN/LOC) Assessment. An applicant's/individual's service plan cost limit is calculated on the MN/LOC Assessment information.

Home and Community Support Services Agencies (HCSSAs) registered nurses complete and submit the MN/LOC Assessment to Texas Medicaid and Healthcare Partnership (TMHP) for CBA applicants and individuals. TMHP will process MN/LOC Assessments for CBA applicants and individuals to determine MN and calculate a Resource Utilization Group (RUG). A RUG is a measure of nursing facility staffing intensity and is used in waiver programs to:

  • categorize needs for applicants and individuals;
  • establish the service plan cost limit; and
  • identify provider reimbursement rates.

When TMHP processes an MN/LOC Assessment, an alphanumeric three-digit RUG will appear in the TMHP Long Term Care (LTC) Online Portal. An MN/LOC Assessment with incomplete information may result with a BC1 code instead of a RUG value. An MN/LOC Assessment resulting with a BC1 code does not have all of the information necessary for TMHP to accurately calculate a RUG for the consumer. Code BC1 is not a valid RUG to determine CBA eligibility.

The HCSSA nurse may correct the information on the MN/LOC Assessment within 14 calendar days of submitting the assessment that resulted in a BC1 code. After 14 calendar days, the HCSSA nurse must inactivate the MN/LOC Assessment and resubmit the assessment with correct information to TMHP.

General qualifications and specific criteria are utilized to determine if the individual has medical necessity. Qualifications and criteria specific to MN are explained in Appendix III, Qualifications for At-Risk Assessments and Medical Necessity Determinations.

For individuals living in the community, an MN decision is made prior to CBA admission as part of the assessment and eligibility process.

For CBA applicants whose MN has expired or will exceed the 120-day expiration standard before CBA eligibility is established, the MN must be updated by a DADS regional nurse. The DADS regional nurse should complete a new MN/LOC Assessment to update the MN determination. The updated MN/LOC Assessment, completed and signed by the regional nurse to validate continued MN, should be attached to the original MN/LOC Assessment with the Physician's Signature page and filed in the case record.

If the DADS regional nurse believes that the applicant does not meet MN, the DADS case manager should authorize the HCSSA to do a second MN/LOC Assessment and submit as Purpose Code 3-SCSA. The Significant Change in Status Assessment (SCSA) submittal of the MN/LOC Assessment will process the MN determination and/or reset the applicant's RUG based on the MN/LOC Assessment information submitted.

The MN/LOC Assessment should be completed for the CBA applicant and individual as it is for the nursing facility individual. When assessing applicants/individuals for inclusion in the CBA program, RUG is to be assessed based on the applicant's/individual's total needs, regardless of payment source. The individual service plan (ISP) will identify and coordinate the benefits available to the applicant and individual that are to be reimbursed by Medicaid and any other payment source.

Applicants from nursing facilities will require a CBA pre-enrollment home health assessment by the HCSSA nurse before enrollment in the CBA in order to develop the ISP.

If the applicant has a valid MN determination, the DADS case manager proceeds with the CBA eligibility determination. If the individual does not have a valid MN determination, or CBA services will not begin within 60 days of his discharge from the nursing facility, the DADS case manager requests a pre-enrollment home health assessment by the HCSSA nurse and completion and submittal of the MN/LOC Assessment to TMHP for an MN determination.

HCSSAs must submit the MN/LOC Assessment through the LTC Online Portal to process a determination of MN and reimbursement rates. HCSSAs submit the MN/LOC Assessment as:

  • Purpose Code 1 – Admission Assessment, submitted at enrollment when authorized on Form 3676, CBA Pre-Enrollment Home Health Assessment Authorization;
  • Purpose Code 2 – Annual Assessment; or
  • Purpose Code 3 – SCSA, submitted when authorized by the DADS case manager due to changes in the consumer's medical condition.

STANDARD.

  1. The HCSSA registered nurse, who is registered at TMHP as having completed a RUG training within the last two years, must complete the MN/LOC Assessment at a face-to-face visit:
    1. as part of the pre-enrollment home health assessment, see Section 4442.3, Pre-Enrollment Home Health Assessment;
    2. on the annual reassessment along with the ISP attachment forms; and
    3. on RUG resets as requested by the DADS case manager.
      1. A RUG reset must be performed by the HCSSA registered nurse within three DADS workdays of receipt of Form 2067, Case Information, from the DADS case manager requesting the RUG reset.
      2. The HCSSA must fax or take the MN/LOC Assessment to the DADS case manager within two DADS workdays of the visit to do the RUG reset.
  2. The HCSSA must submit to the DADS case manager a copy of the weekly status report showing that the individual was granted or denied MN within two DADS workdays of receipt from TMHP.
  3. The HCSSA must call TMHP within three DADS workdays of receipt of a pending denial status report.
  4. The HCSSA must electronically submit the MN/LOC Assessment to the TMHP Long-Term Care Portal after it has been signed by the physician. The HCSSA sends the DADS case manager the Document Locator Number (DLN) of the transmitted MN/LOC Assessment.

The status report reveals if the individual has been approved or denied MN and the individual's RUG.

If an individual's name appears on the status report as "pending denial," the HCSSA RN who completed the assessment or another agency RN must call TMHP to provide any additional information that may contribute to the individual's MN determination, answer any questions regarding assessment data, or verify that all relevant information has been provided. If the HCSSA RN does not call TMHP, the MN will be denied. If the applicant's/individual's MN is denied, the applicant and individual will be notified of the right to appeal and, if he/she appeals, an HCSSA RN must be present at the appeal hearing if requested by the hearing officer. (See Section 4458.5, Medical Necessity Denials/Appeals.)

4458.1  CBA Program Exceptions for Medical Necessity Determination

Revision 11-2; Effective December 21, 2011

A CBA applicant and individual must have a valid medical necessity (MN) determination before admission into the CBA program. The determination of MN is based on a completed Medical Necessity and Level of Care (MN/LOC) Assessment.

The Home and Community Support Services Agency (HCSSA) completes the MN/LOC Assessment.

As part of the pre-enrollment home health assessment:

  1. Enter Purpose Code 1. A physician's signature is required. (Faxed physician's signatures are accepted.)
  2. Submission of the MN/LOC Assessment completed on the pre-enrollment home health assessment visit.

The HCSSA must electronically transmit the MN/LOC Assessment to Texas Medicaid and Healthcare Partnership (TMHP) for MN determination with the following exceptions. If the applicant is in a nursing facility and has a valid MN determination, the MN/LOC Assessment will not be completed and transmitted to TMHP. The DADS case manager will inform the HCSSA on Form 2067, Case Information, that an MN/LOC Assessment is not necessary. However, if the individual does not have a valid MN, or CBA services will not begin within 60 days of discharge from a nursing facility, the DADS case manager will request that the MN/LOC Assessment be completed as part of the pre-enrollment home health assessment and submitted to TMHP.

Physicians Assistants (PAs) working in collaboration with a physician may sign for the physician on the MN/LOC Assessment. The PA will enter his name below the physician's name after entering in the physician's name and license number. Documentation should be available from the physician authorizing the PA to sign his name. A copy of this authorization must be retained by the HCSSA on file if accepting the MN/LOC Assessment signed by a PA.

Refusal of physicians to sign in certification of the individual requiring nursing facility care under the supervision of an MD/DO may be encountered. Utilization of Medicaid services requires that a physician certify at admission the individual's need for inpatient care in a nursing facility. This signature requirement is often less objectionable when "APPLICATION TO ESTABLISH MEDICAL NECESSITY FOR THE COMMUNITY BASED ALTERNATIVES PROGRAM" is written at the top of the form. The procedure used in obtaining the physician's signature is the HCSSA's choice and a combination of methods is often necessary, from a cover letter to a verbal explanation to the physician.

For the annual MN review:

Enter Purpose Code 2. A physician's signature is not required on the annual review. Submit the annual MN/LOC Assessment electronically to TMHP for MN determination according to the reassessment due date as based on the ISP expiration date and explained in Appendix XIX, CBA Reassessment Packet Due Dates.

On RUG resets:

Resource Utilization Group (RUG) resets are done before initiating a denial for CBA services when the individual's condition deteriorates to the extent that the service plan cannot be accommodated within the individual's current cost limit. RUG resets are done by the HCSSAs only when authorized by the DADS case manager. There is no limit on the number of RUG resets that can be authorized for an individual residing at home. For individuals residing in an Assisted Living/Residential Care (AL/RC) facility that participates in the enhanced rate option, there is a limit of two RUG resets during each calendar year.

RUG resets are not done when an individual's condition improves, except if he resides in an AL/RC facility, because the individual's service plan should be based on the services needed and not on the individual's cost limit.

4458.1.1  Electronic Submission of the MN/LOC Assessment to TMHP

Revision 11-2; Effective December 21, 2011

STANDARD. The Home and Community Support Services Agency (HCSSA) must submit the Medical Necessity and Level of Care (MN/LOC) Assessment through the Long Term Care (LTC) Online Portal to process a determination of MN and reimbursement rates.

  1. HCSSAs must submit electronically the MN/LOC Assessment to Texas Medicaid and Healthcare Partnership (TMHP) through the Long Term Care (LTC) Online Portal to process MN determination. HCSSAs submit the MN/LOC Assessment as:
    1. Purpose Code 1 – Admission Assessment, submitted at enrollment when authorized on Form 3676, CBA Pre-Enrollment Home Health Assessment Authorization;
    2. Purpose Code 2 – Annual Assessment; and
    3. Purpose Code 3 – Significant Change in Status Assessment (SCSA), submitted when authorized by DADS case manager due to changes in the consumer's medical condition.
  2. HCSSAs must begin electronically transmitting to TMHP within 30 days of the effective date of their contract.
  3. MN/LOC Assessment Purpose Code 1 must be signed by the physician before the MN/LOC Assessment can be transmitted to TMHP.

HCSSAs may contact TMHP at 1-800-626-4117 for information on obtaining and operating the software necessary for electronic submission.

4458.2  Changing of Physician's Name and License Number on the MN/LOC Assessment

Revision 11-2; Effective December 21, 2011

STANDARD.

The Home and Community Support Services Agency (HCSSA) must enter the correct currently attending physician's name and license number on every Medical Necessity/Level of Care (MN/LOC) Assessment submitted to Texas Medicaid and Healthcare Partnership (TMHP).

The entering of the correct attending physician's name and license number is necessary for TMHP to notify a physician that MN has been denied. The physician must receive TMHP's denial letter in a timely manner for the physician to submit any additional information, if appropriate, in support of MN before the individual is denied MN or before the appeal hearing is held.

If the HCSSA determines that MN/LOC Assessment was transmitted to TMHP without the correct current attending physician's name, the HCSSA must call TMHP at 1-800-626-4117 to request that the correct physician's name and license number be changed on a previously transmitted MN/LOC Assessment.

If the DADS regional nurse identifies on a utilization review that the wrong physician's name was transmitted to TMHP, the HCSSA must call TMHP and make the correction. For TMHP to make the corrections, the HCSSA must provide the individual's name, Medicaid number, and Social Security number, physician's name and license number. This request would be in instances where the DADS regional nurse found no changes other than the wrong physician's name was transmitted to TMHP.

If the DADS regional nurse identifies changes on a utilization review, in addition to the wrong physician's name having been transmitted, the changes as well as the entering of the correct physician and license number must be made.

4458.3  Required Training for Completion of MN/LOC Assessment

Revision 11-2; Effective December 21, 2011

STANDARD.

  1. Home and Community Support Services Agency (HCSSA) registered nurses (RNs) completing the Medical Necessity/Level of Care (MN/LOC) Assessment and Resource Utilization Group (RUG) must complete a RUG training course.
  2. All HCSSA RNs completing the RUG training course must be registered with the Texas Medicaid and Healthcare Partnership (TMHP) as having completed a RUG training within the last two years.

The Health and Human Services Commission (HHSC) developed additional avenues to minimize costs to HCSSAs while continuing to provide quality education and meet the mandates of state law. In coordination with Texas State University, HHSC has developed a long-distance learning program to include a correspondence course and an online web-based training module for the fraud and abuse prevention program and the RUG training course. Access to both methods of delivery is available through the HHSC website and is offered at no cost to the RNs. RNs that do not have access to the HHSC website may request a copy of the correspondence course by writing to the Texas State University address below.

Both training programs are offered free; however, RNs who do not pass the required proficiency test on their first submission or do not complete the course within 90 days, must pay a fee for subsequent enrollments. RNs may also obtain continuing education credits through Texas State University.

Additional information about this training can be found at the following websites:
www.dads.state.tx.us/providers/mds/introduction/step1.html
www.hhsc.state.tx.us

Texas State University, in cooperation with the Office of Inspector General has made this training available through its long-distance training program.
www.txstate.edu/continuinged/

For more information contact Texas State University – San Marcos at 512-245-7118

Information may also be requested by writing Texas State University at:

Texas State University
Clevenger House
601 University Drive
San Marcos, TX 78666
continuinged@txstate.edu

Telephone numbers are:

Correspondence Course – 512-245-2507 or 512-482-3280
Online Training – 512-245-3150

4458.3.1  Waiver Request

Revision 11-2; Effective December 21, 2011

A 60-day waiver may be requested from the Utilization, Assessment and Review staff in order to process forms prior to attending a Resource Utilization Group (RUG) training. Requests for this time limited waiver may be faxed to: Utilization, Assessment and Review (UAR) at 512-245-3173 containing the following information:

  • nurse's name and license number,
  • agency name and address,
  • agency telephone number,
  • four-digit site identification number assigned by the CBA program at DADS,
  • agency fax number,
  • reason for waiver request, and
  • signature of the agency administrator.

The nurse will be notified by fax of the decision to approve or not approve the 60-day waiver. If the nurse does not request a 60-day waiver prior to submitting the Medical Necessity/Level of Care Assessment to Texas Medicaid and Healthcare Partnership, the form will be remanded and the nurse will be instructed on how to apply for a waiver. This delay in requesting a waiver will unnecessarily prolong an applicant's eligibility process.

4458.4  Submitting the MN/LOC Assessment to the DADS Case Manager

Revision 11-2; Effective December 21, 2011

Home and Community Support Service Agencies (HCSSAs) must send the Medical Necessity and Level of Care (MN/LOC) Assessment Document Locator Number (DLN) to the DADS case manager. The DLN is a unique number assigned to each MN/LOC Assessment submitted on the Texas Medicaid and Healthcare Partnership (TMHP) Long-Term Care (LTC) Portal. Upon receipt of the DLN, the DADS case manager (or designee) will log on to the TMHP LTC Portal to access and print the MN/LOC Assessment for the waiver individual's case record. In some instances, DADS may request the HCSSAs to send a copy of the completed MN/LOC Assessment to the DADS case manager for an Annual Assessment or a Significant Change in Status Assessment (SCSA).

For initial pre-enrollment assessments only, the HCSSA must send the DLN and a copy of the signed Physician's Signature Page to the DADS case manager.

Initial Assessment — DADS requires a physician's signature on the Physician's Signature Page when the type of assessment (Field A0310 on the MN/LOC Assessment) is marked Initial Assessment.

Annual Assessment — The physician's signature is optional when the type of assessment is marked Annual Assessment or SCSA.

By signing the Physician's Signature Page, the physician is certifying the individual requires nursing facility services or alternative community-based services under the supervision of a Medical Doctor/Doctor of Osteopathy. There is no DADS requirement for a physician to attest to the accuracy of an MN/LOC Assessment.

Reference: Information Letter 2011-36, Procedure Changes for Submitting the Medical Necessity and Level of Care Assessment; published April 27, 2011.

4458.5  Medical Necessity Denials/Appeals

Revision 11-2; Effective December 21, 2011

Should an applicant's/individual's medical necessity be denied, the individual and his physician will be notified of the denial by Texas Medicaid and Healthcare Partnership (TMHP) within two working days of making the denial determination. The agency is notified of the denial via the weekly status report transmitted to the agency by TMHP. Following is the text of the generic letter that is sent to the individual and the physician:

TMHP is the organization that decides, for the Department of Aging and Disability Services (DADS), whether an applicant or individual has a medical necessity for Community Based Alternatives (CBA) services. This letter advises you of the initial determination made on your request for CBA services.

Based on the medical information given to TMHP by <<vendname>>, it has been determined that you do not meet the medical necessity criteria to be eligible for the CBA program, according to guidelines defined by DADS. Medical necessity means that an individual has a medical condition that is serious enough that his needs exceed the routine care which may be given by an untrained person, and requires the skills of a licensed nurse to assess, plan, supervise and provide treatment on a regular basis. Medical necessity does not mean custodial care, such as assistance with bathing, grooming, toileting, eating or mobility, because these services do not require the skills of a licensed nurse. Based on the medical information we have available at this time, we have determined that you do not meet medical necessity for licensed nursing care because you do not require the services of a licensed nurse on a regular basis. If you would like a more detailed explanation about your case, you may contact TMHP at 1-800-626-4117 and select option 1.

This determination will affect your eligibility for benefits available through the CBA program. The physician who has been treating you for your medical condition has been notified of this determination and has been given the opportunity to give us more information regarding whether you need licensed nursing care. If you feel any of your other physicians have additional information to support your need for licensed nursing care, please have them fax this information to TMHP at 512-514-4223 or ask them to call 800-626-4117, selecting option 1, within 21 days of receipt of this letter. You can expect your DADS case manager to contact you by mail advising you of the final determination regarding your eligibility for CBA benefits and inform you of your right to appeal this decision.

Sincerely,

Consulting Physician
Nurse Analyst

CBA providers will be notified by the DADS case manager of the individual's termination of CBA services via Form 2065-C, Notification of Ineligibility of Suspension of Waiver Services. If the individual files a timely appeal, the provider agency will be notified by the case manager on Form 2067, Case Information, to continue services until the outcome of the appeal is determined.

STANDARD.

  1. The HCSSA RN completing the Medical Necessity and Level of Care (MN/LOC) Assessment, or an alternate HCSSA RN if the assessing RN cannot be present, must attend the individual's MN appeal hearing, if requested by the HHSC hearings officer.
  2. The HCSSA must deliver CBA services through the effective date of the termination on Form 2065-C unless otherwise notified by the case manager.

If after the hearing officer renders a decision that substantiates the denial of MN, and only if the case manager believes a change in the individual's medical condition now requires routine nursing care and the individual service plan (ISP) has not expired, follow these steps:

  • have the DADS nurse confirm that the individual's medical condition has changed since the date of the hearing and the individual may now meet MN criteria;
  • authorize the HCSSA to complete a new MN/LOC Assessment and have the HCSSA transmit the completed form to TMHP with a Purpose Code 3;
  • approve the continuation of services if TMHP approves the MN and the individual meets all other eligibility criteria.

If the individual's ISP expires before the MN determination is made, CBA services terminate on the last day of the ISP.

If the case manager feels the individual's condition has changed to the point he may now meet MN criteria, the hearing has been held but the hearings officer has not made a decision, the case manager must contact the hearings officer immediately so this new information can be considered.

If at the time of the annual reassessment, the denial of the MN determination is sustained by the hearings officer and CBA services continued because the individual had filed a timely appeal, the case manager will immediately verbally notify HCSSA to stop delivering CBA services the day of the verbal notification or the date specified by the hearings officer.

If the denial is reversed, the case manager will submit written notification on Form 2067 within two workdays to the HCSSA to continue CBA services because the denial was reversed.

For pre-admission MN denials, if the original MN denial is overturned at the hearing and MN is granted, the MN effective date is the date of the appeal officer's decision. The case manager will have 120 days from this decision date to make the CBA eligibility determination.

For annual MN denials, if the denial is overturned at the hearing, the MN approval date will go back to the date of the re-assessment and as documented on the MN/LOC Assessment.

If an MN denial is overturned before a scheduled hearing for MN only, the hearing officer will send a written copy of his hearing decision to the HCSSA, cancelling the scheduled hearing.

TMHP will not accept additional information from the HCSSA after the individual has been notified that MN has been denied. However, if additional information is identified by the HCSSA, the HCSSA should submit this information to the hearings officer before the decision.

4458.6  Roles and Responsibilities of the DADS Regional Nurse

Revision 11-2; Effective December 21, 2011

The role of the DADS regional nurse in the medical necessity denial appeal process is to continue to improve the accuracy of the information on Medical Necessity/Level of Care (MN/LOC) Assessment, through the utilization review and the six-month individual satisfaction face-to-face interview with individuals. The DADS regional nurse will focus on the accuracy of the current attending physician's name entered on the MN/LOC Assessment, Purpose Code 3, by the agency nurse. Accuracy of the current attending physician is necessary in order for Texas Medicaid and Healthcare Partnership (TMHP) to contact an individual's physician for additional information should an individual's MN be denied.

The DADS regional nurse will:

  • Participate in MN denial appeal hearings for MN/LOC Assessment, Purpose Code 1, when contacted by the hearings officer.
  • Verify with the individual that the physician listed on the recently completed MN/LOC Assessment, Purpose Code 3, is the individual's current attending physician. If the physician listed is not the current attending physician, the DADS nurse will ask the individual who his current attending physician is and enter the change on the MN/LOC Assessment.
  • Verbally notify the HCSSA that the physician entered on the MN/LOC Assessment, Purpose Code 3, was incorrect and inform them of the change in the current attending physician's name on the form and:
    • if there are no changes on a Purpose Code 1 review, instruct the agency to call TMHP at 1-800-626-4117, option 2, and report the current physician and his license number; or
    • if there are changes in the Purpose Code 1 review, enter the identified physician's name on the Purpose Code 1 and ask that the agency enter the physician's license number on the MN/LOC Assessment prior to transmitting the Purpose Code 1 to TMHP.
  • Notify the contract manager if the HCSSA has not entered the correct physician's name on the MN/LOC Assessment, Purpose Code 3, so that corrective action can be taken if agencies show a pattern in failure to assure the entry of the current attending physician's name on the MN/LOC Assessment.

4458.7  Termination of CBA Services if the Individual Does Not Appeal

Revision 11-2; Effective December 21, 2011

For terminations of CBA services when an individual does not meet the medical necessity at the reassessment and if the individual does not request an appeal hearing, all CBA providers are authorized to deliver CBA services through, but not later than, the end of the current individual service plan (ISP) period or 10 days after the notice is sent to the individual, whichever is later.

For all other types of terminations, if the individual does not request an appeal, all CBA providers are authorized to deliver CBA services through 10 days after the notice is sent to the individual. This date is the effective date of the denial entered on the notification form sent to individuals and to CBA providers.

If the ISP effective period ends before the 12-day notification period expires, the case manager will notify the providers, via Form 2067, Case Information, to continue services as authorized on the ISP through the 10th day of the notification period.

4459  Annual Individual Service Plan Activities

Revision 12-1; Effective February 10, 2012

Timely completion of the annual re-assessment is necessary to assure continuity of services and payment. Gaps in the individual service plan (ISP) coverage periods will result in loss of individual eligibility and loss or delay in provider payment.

STANDARD.

  1. The Home and Community Support Services Agency (HCSSA) RN must conduct an annual face-to-face home visit for all individuals to complete the following:
    • Form 3671-1, Individual Service Plan, and attachments B-F, H and J;
    • Form 3671-F, Rationale for Adaptive Aids, Medical Supplies, Dental Services and Minor Home Modifications, or other optional documentation of necessity for purchases identified on Form 3671-D, Minor Home Modifications, and Form 3671-E, Adaptive Aids and Medical Supplies; and
    • the Medical Necessity/Level of Care (MN/LOC) Assessment.
  2. The ISP attachments and MN/LOC Assessment must be completed and received at the case manager's office during the second month before the month the ISP expires, according to reassessment due dates listed in Appendix XIX, CBA Reassessment Packet Due Dates.
  3. Upon receipt of the completed annual ISP from the case manager, an HCSSA RN must sign Form 3671-2, Individual Service Plan, to certify that the ISP accurately reflects the current needs of the individual, and it continues to accept to serve the individual.
  4. In addition to the above, the HCSSA must do one of the following upon receipt of the annual service plan:
    1. Fax the signed Form 3671-2 to the case manager within two DADS workdays of receipt of the service plan;
    2. Refuse to serve the individual based upon licensure limitations as explained in Section 4443, Service Plan, (2); or
    3. Negotiate for a change in service plan as explained in Section 4443, Service Plan, (3).

Compliance with the reassessment time frames will be monitored by the DADS regional staff. Failure to comply will be considered a contract compliance issue and may result in adverse action.

If the HCSSA nurse conducts the home visit to complete the reassessment MN/LOC Assessment more than 120 days before the effective date of the reassessment ISP, the case manager should return MN/LOC Assessment to the provider so it can be redone and transmitted again to TMHP, within the correct time frame, without additional compensation.

If the case manager is delinquent in recertifying the CBA case and the MN is more than 120 days old, the DADS nurse should update the MN/LOC Assessment.

DADS reimburses HCSSAs for the number of RN hours used to complete the annual reassessment.

4459.1  Role of the HCSSA in the Review Process

Revision 11-2; Effective December 21, 2011

STANDARD.

  1. The HCSSA must:
    1. provide all requested documentation for the reviewer(s);
    2. provide review space as requested to accommodate the reviewer(s); and
    3. comply with any requested corrective action plan.

If problems are identified during monitoring, referrals may be made to the following agencies:

  • Texas Department of Family and Protective Services, Adult Protective Division;
  • Texas Department of State Health Services, Licensure and Certification Division;
  • Texas Board of Nursing; or
  • local law enforcement agencies.

Repeated citations for non-compliance with contract or program standards, or for deficiencies issued by other regulatory or licensure agencies, threaten the viability of the agency's CBA contract.

4459.2  Utilization Review Process

Revision 11-2; Effective December 21, 2011

Utilization reviews are performed by DADS regional nurses on a sample of the Medical Necessity/Level of Care (MN/LOC) Assessment, completed by HCSSA RNs. The purpose is to:

  • verify assessment information used to determine medical necessity;
  • assure the accuracy of the Resource Utilization Group (RUG) payment levels used to establish the individual cost limit for the CBA service plan; and
  • identify training/corrective action needs of HCSSA nurses.

The results of the utilization review (UR) should be submitted to state office, CBA Unit manager, on the Regional Monthly CBA Utilization Review Report by the end of the month following the month listed on the report. Each DADS region should do a minimum of 15 cases each month, but should attempt to do 20 cases each month. Factors to consider in deciding which cases should be reviewed can include the following:

  • Select a cross-range of individuals from the least to the more impaired.
  • Select cases from different agencies whose assessments were done by different nurses.

Depending on the frequency and severity of the findings of the UR, appropriate next steps to be taken by regional staff could be:

  • Follow-up targeted reviews of assessments done by HCSSA nurses that have had previous assessments changed by the DADS nurse.
  • Work with contract staff to develop a corrective action plan with the HCSSA to address inaccurate assessments being completed, with follow-up to ensure continued accuracy.
  • Training provided by the DADS nurse to the HCSSA nurses on the proper completion of the MN/LOC Assessment.

STANDARD. The following are responsibilities of the HCSSA in the UR process:

  1. Perform the annual reassessment face-to-face home visit and transmit the MN/LOC Assessment, Purpose Code 3, to TMHP according to the time frames specified in Section 4459, Annual Individual Service Plan Activities.
  2. Submit the original the MN/LOC Assessment, Purpose Code 3 to the case manager along with the individual service plan (ISP) attachments, B-F, to the DADS case manager immediately upon completion and after transmitting to TMHP according to the time frames specified in Section 4459.
  3. Electronically transmit or mail (if without transmittal capabilities) the MN/LOC Assessment, Purpose Code 1, to TMHP within one DADS workday of receipt from the DADS regional nurse. (If mailed, the agency RN must complete all blank fields on the MN/LOC Assessment, Purpose Code 1,; with the data from the most recent Purpose Code 3, and sign/date in the bottom left corner of the purpose code "1").
  4. Fax the transmitted copy of the MN/LOC Assessment, Purpose Code 1, or a copy of the mailed purpose code "1" to the DADS regional nurse within one DADS workday of receiving the Purpose Code 1 from the DADS regional nurse.

Accessing the MN/LOC Assessment resubmission in the software instructions will provide instructions on how to submit the Purpose Code 1 after the Purpose Code 3. If an agency in transmitting for the first time, (mailed in the Purpose Code 3), the entire MN/LOC Assessment must be completed according to the software instructions.

The HCSSA nurse may be contacted by the DADS regional nurse when clarification is needed over rationale for assessment values.

4460  Claims and Payment

Revision 11-2; Effective December 21, 2011

4461  Home and Community Support Services Agency Billable Activities

Revision 11-2; Effective December 21, 2011

§48.6078 — Billable Units.

4461.1  HCSSA Non-Billable Time and Activities

Revision 11-2; Effective December 21, 2011

§48.6080 — Non-Billable Time and Activities.

Attending a medical necessity appeal hearing is considered an administrative meeting and is a non-billable activity.

HCSSAs are not entitled to reimbursement of the specification or inspection fees if they do not complete the appropriate form. To receive reimbursement, the DADS case manager must approve the fees before the item is purchased or the modification done.

When billing for assessments, the HCSSA RN must not bill for the time spent processing paperwork or completing records or reports.

4461.2  Additional Claims Limits

Revision 12-1; Effective February 10, 2012

§48.6084 — Service Limits and Claim Limits.

An HCSSA is entitled to reimbursement when a third nursing assessment occurs within the individual service plan year, if the visit was done within the required time frames.

4462  Duplicate Home and Community Support Services

Revision 11-2; Effective December 21, 2011

STANDARD. An individual provider may deliver and bill for only one service at a time.

Examples include:

  • A personal care attendant who is also a licensed vocational nurse helps an individual with some personal care tasks for one hour. The provider may bill for one unit of personal assistance. The provider should bill the time under the service definition that most closely matches the activity.
  • A personal care attendant spends one hour bathing and grooming an individual while relieving the regular provider and during that time does household chores in the individual's home. The provider may bill for one unit of personal assistance, not two.

4463  Mutually Exclusive Home and Community Support Services

Revision 11-2; Effective December 21, 2011

§48.6082 — Mutually Exclusive Services.

4464  Home and Community Support Services, Unit of Service Definitions

Revision 11-2; Effective December 21, 2011

STANDARD.

  1. A billable unit of service is the method for calculating the amount that the HCSSA may bill to DADS. Units are measured by increments of time or by the cost of the item provided.
  2. The following services use time as the measure.
    1. One unit of service is defined as:
    2. personal assistance one hour
      nursing one hour
      occupational therapy one hour
      physical therapy one hour
      speech pathology one hour
      in-home respite one day
    3. For each nursing visit, the HCSSA can bill for a minimum of one hour, as either an RN or LVN visit, using the appropriate billing code.
  3. The following services are measured by the cost of the item provided:
    1. adaptive aids;
    2. medical supplies; and
    3. minor home modifications.

All services measured by the hour use the following formula to calculate the billable unit, with the exception of in-home respite. The basic formula is:

Number of providers × time spent delivering services ÷ number of individuals served = billable unit of service
Examples:
1 provider × 1 hour of service ÷ 1 individual = 1 billable hour
1 provider × 1 hour of service ÷ 2 individuals = 1/2 hour billable per individual
1 provider × 1 hour of service ÷ 3 individuals = 1/3 hour billable per individual
2 providers × 1 hour of service ÷ 3 individuals = 1/2 hour billable per individual

Note: There must be a separate Form 3670, CBA Documentation of Services Delivered, for each individual, as in the third example above, a time sheet showing 20 minutes (1/3 hour) of service must be prepared of each of the three individuals.

The unit of service for in-home respite is defined as one day. All in-home respite is billed on a daily or partial daily rate.

Examples   Billable Unit of Service
1 individual receives in-home respite for 15 hours on Feb. 20 = 3/4 (.62) of day of in-home respite
1 individual receives in-home respite from 8 pm on Feb 21 until 8 pm on Feb. 22 = 1 day of in-home respite
1 individual receives in-home respite from 8 pm on April 20 until 3 pm on April 21 = .87 of day of in-home respite

4465  Billing Partial Units

Revision 11-2; Effective December 21, 2011

When billing for all services measured by time except respite, add all units of a particular type of service provided to an individual by all providers of that type during the month to arrive at a monthly total. Services may be billed in unit increments. If the monthly total is not a whole number or unit increment, round the total up to the nearest quarter unit (for in-home respite, round to the nearest hour and use the fractional equivalent for that number of hours). Convert the partial unit to the decimal equivalent when billing.

1–15 minutes of service = 1/4 unit (.25)
15.1 minutes to 30 minutes = 1/2 unit (.5)
30.1 minutes to 45 minutes = 3/4 unit (.75)
45.1 minutes to 60 minutes = 1 unit (1.0)

Example: Total Time Provided to Individual in a Month

Attendant A = 12 hours and 12 minutes
Attendant B = 5 hours
Attendant C = 4 hours and 15 minutes
Total attendant time for Month = 21 hours and 27 minutes
Billable units of service for Month = 21.5 (twenty-one and one-half)

Billing Partial Units of In-Home Respite

1 hour of service = 1/24 unit (.04)
2 hours of service = 2/24 unit (.08)
3 hours of service = 3/24 unit (.12)
4 hours of service = 4/24 unit (.17)
5 hours of service = 5/24 unit (.21)
6 hours of service = 6/24 unit (.25)
7 hours of service = 7/24 unit (.29)
8 hours of service = 8/24 unit (.33)
9 hours of service = 9/24 unit (.37)
10 hours of service = 10/24 unit (.42)
11 hours of service = 11/24 unit (.46)
12 hours of service = 12/24 unit (.50)
13 hours of service = 13/24 unit (.54)
14 hours of service = 14/24 unit (.58)
15 hours of service = 15/24 unit (.62)
16 hours of service = 16/24 unit (.67)
17 hours of service = 17/24 unit (.71)
18 hours of service = 18/24 unit (.75)
19 hours of service = 19/24 unit (.79)
20 hours of service = 20/24 unit (.83)
21 hours of service = 21/24 unit (.87)
22 hours of service = 22/24 unit (.92)
23 hours of service = 23/24 unit (.96)
24 hours of service = 24/24 unit (1.0)

All in-home respite services provided in a month are added together. If the total is not a whole number or 1/4 unit increment, round up to the nearest 1/4 unit increment. Convert the partial unit to its decimal equivalent for billing.

4466  Minor Home Modification and Adaptive Aid Purchases

Revision 11-2; Effective December 21, 2011

4466.1  Minor Home Modification Purchases

Revision 11-2; Effective December 21, 2011

Minor home modifications have a maximum expenditure cap of $7,500 per individual unless waived by the regional nurse. Once the cap is reached, only $300 per year per individual will be allowed for repair, replacement or additional modifications. The first $300 for repair, replacement, or additional modifications can be spent during the same individual service plan effective period that the cap was reached.

Employees of HCSSAs who perform minor home modifications must submit bids which document the cost effectiveness of the service provided as compared with other bidders.

Copies of written approval from the owner of the dwelling and/or rental agreement authorizing modifications, as well as copies of any applicable building permits are required. The cost of any building permit required for the construction of the authorized modification should be included in the estimate of the total cost and can be billed as a cost of construction.

All documentation required above must be maintained according to requirements for monitoring and audit purposes.

4466.2  Adaptive Aid Purchases

Revision 11-2; Effective December 21, 2011

Adaptive aids and medical supplies have a $10,000 maximum expenditure cap per individual per individual service plan year unless waived by the regional nurse.

The individual's need for adaptive aids and medical supplies is documented on Form 3671-E, Adaptive Aids and Medical Supplies.

4467  Claims and Payment Documentation

Revision 11-2; Effective December 21, 2011

§48.6086 — Claims and Service Delivery Records.

The provider must document claims on these records:

  • that services were delivered consistently with the program requirements described in Section 4400, Home and Community Support Services;
  • the amount of service provided to individuals; and
  • when services were delivered.

4467.1  Documentation of Services Delivered

Revision 11-2; Effective December 21, 2011

§48.6088 — Required Documentation for Service Delivery.

4468  Payment of Claims

Revision 11-2; Effective December 21, 2011

The HCSSA may bill for waiver services if any of the following occurs:

  • Waiver services were provided to an individual on the day of admittance to a hospital or institution. Example: The attendant provides services to the participant in the morning and the individual is hospitalized or institutionalized in the afternoon.
  • Waiver services were provided to an individual in the individual's home the day of discharge from the hospital or institution.
  • A payroll check was issued to the attendant but not deposited, the attendant cannot be located, and
    • there is a valid Form 3671-1, Individual Service Plan, authorizing services, and
    • the valid Form 3670, CBA Documentation of Services Delivered, covering the pay period was completed and signed by the attendant.
  • If an attendant is no longer employed, and the agency is unable to obtain the signature on Form 3670, the RN can certify through verification with the individual that services were provided by that attendant. The RN can then sign Form 3670 as the supervisor of the attendant, as long as the RN's supervisory position is indicated on the form.

4500  Out-of-Home Respite Services

Revision 11-2; Effective December 21, 2011

4510  Introduction

Revision 11-2; Effective December 21, 2011

Out-of-home respite services provide a 24-hour living arrangement in a DADS-enrolled Adult Foster Home, a licensed personal care facility or a licensed nursing facility for persons who, because of the unavailability of their primary caregiver, have no one to meet their needs on a short-term basis. Services may include meal preparation, housekeeping, personal care and nursing tasks, help with activities of daily living, supervision, the provision of or arrangement of transportation.

Nursing tasks may be directly provided by licensed nurses in out-of-home respite services or may be delegated as determined by the professional judgment of the HCSSA RN unless facility licensure prohibits delegation.

4520  Individual Eligibility

Revision 11-2; Effective December 21, 2011

STANDARD.

In order to receive out-of-home Community Based Alternatives (CBA) respite services, the applicant or individual must:

  • meet all the eligibility criteria, as specified in §48.6003 of this title (relating to Client Eligibility Criteria);
  • reside in his own home,
  • have a primary caretaker that needs relief either on an emergency or planned short-term basis; and
  • not reside in Adult Foster Care or a Personal Care Facility.

The case manager is responsible for authorizing the respite care services needed by the individual. The individual must be given the opportunity to choose from the contracted providers which are appropriate considering his needs and the licensed capabilities of the provider.

Respite services can be authorized as often as needed for caregiver relief or emergency absences of the caregiver, up to the 30-day maximum per individual service plan year. Both in-home and out-of-home respite may be used in hourly increments and billed by the provider in hourly increments. The annual limit on respite services is 30 days, equivalent to 720 hours (30 days times 24 hours per days), unless a waiver is approved.

The applicant for CBA respite services must complete the same eligibility determination process as other CBA applicants. An individual, whose caregiver is providing uncompensated care and is also the HCSSA paid attendant, may receive out-of-home respite.

4530  Provider Qualifications

Revision 11-2; Effective December 21, 2011

STANDARD.

Out-of-home Community Based Alternatives (CBA) respite services providers must be:

  • a licensed nursing facility;
  • a licensed assisted living facility; or
  • a Department of Aging and Disability Services (DADS) enrolled Adult Foster Care home.

To deliver CBA out-of-home respite services, the contract must be signed by both the provider and DADS before the provider serves individuals.

4540  Description of Services

Revision 11-2; Effective December 21, 2011

The CBA individual may receive out-of-home respite services in a nursing facility, an assisted living facility, or a DADS enrolled adult foster home, with services to be delivered as authorized on the individual service plan (ISP) and in accordance with facility licensure and contract requirements.

The CBA individual may take any adaptive aids he is using to the out-of-home respite setting.

The DADS case manager will provide the out-of-home respite provider with the ISP attachments pertinent to the services the individual will receive while in the facility/home. The provider must deliver services as identified on the individual's ISP attachments.

4550  Respite Service in a Personal Care Facility or Adult Foster Care Home

Revision 11-2; Effective December 21, 2011

The CBA individual receiving respite services in a Personal Care Facility or Adult Foster Care Home may receive nursing services or therapy services from outside providers while residing in the respite setting. The individual's need for any service must be authorized on his individual service plan before he receives the service.

The waiver services the individual receives from outside providers while receiving respite services in a Personal Care Facility or Adult Foster Care Home are considered separate services and are billed separately.

The CBA individual receiving respite services in an Adult Foster Care Home must qualify for placement in the particular level of adult foster home by meeting the specific criteria for that level of home.

Nursing services provided in an Adult Foster Care Home, Levels I or II, may be delegated, according to the professional judgment of the HCSSA RN.

Personal Care Facility licensure prohibits delegation of nursing tasks. In Assisted Living/Residential Care Out-of-Home Respite settings, nursing services will have to be provided directly by licensed nurses.

4560  Respite Service in a Nursing Facility

Revision 11-2; Effective December 21, 2011

The CBA individual receiving respite services in a nursing facility may receive therapy services from outside providers. His need for any service must be authorized on his individual service plan before receiving the service. The nursing facility will be responsible for providing the needed nursing services to the individual.

Costs for all services are included in the Resource Utilization Group (RUG) rate of payment to the facility and are not to be billed separately. Unless there has been a significant change in the individual's condition, a new RUG will not be requested.

4570  Room and Board

Revision 11-2; Effective December 21, 2011

STANDARD.

Room and board charges are not allowable charges to the CBA individual receiving out-of-home respite services.

Room and board charges are included in the rates for the services.

4580  Billing Documentation

Revision 11-2; Effective December 21, 2011

The nursing facility provider completes Form 1290, Long Term Care Claim; Form 3251, Assisted Living and Residential Care/CBA Foster Care Daily Census Record; and Form 3252, Assisted Living and Residential Care/ CBA Foster Care Service Delivery Record, for all individuals during the month for which payment is requested.

Providers of Adult Foster Care respite care and Assisted Living/Residential Care respite care follow the billing procedures for submitting and maintaining records established in Section 4200, Adult Foster Care, and Section 4300, Contracting to Provide Assisted Living and Residential Care Services.

The facility/provider must document on these records:

  • that services were delivered consistently with program requirements described in Section 4500, Out-of-Home Respite Services;
  • the amount of service provided to individuals; and
  • when services were delivered.

No payment will be made to providers delivering out-of-home respite services for bedhold or personal leave days. Billable time for the provider will be based solely on time spent by the individual in the respite facility. Respite is billed on a daily basis.

If an individual is at home in the morning and receives two hours of attendant services, then enters a respite setting in the afternoon, the HCSSA can bill for the two hours of service delivery provided by the attendant, and the respite provider can bill for the actual time spent in the respite setting that day.

4581  Billing Units of Respite Services

Revision 11-2; Effective December 21, 2011

Partial units of respite are calculated as follows:

1 hour of service = 1/24 unit (.04)
2 hours of service = 2/24 unit (.08)
3 hours of service = 3/24 unit (.12)
4 hours of service = 4/24 unit (.17)
5 hours of service = 5/24 unit (.21)
6 hours of service = 6/24 unit (.25)
7 hours of service = 7/24 unit (.29)
8 hours of service = 8/24 unit (.33)
9 hours of service = 9/24 unit (.37)
10 hours of service = 10/24 unit (.42)
11 hours of service = 11/24 unit (.46)
12 hours of service = 12/24 unit (.50)
13 hours of service = 13/24 unit (.54)
14 hours of service = 14/24 unit (.58)
15 hours of service = 15/24 unit (.62)
16 hours of service = 16/24 unit (.67)
17 hours of service = 17/24 unit (.71)
18 hours of service = 18/24 unit (.75)
19 hours of service = 19/24 unit (.79)
20 hours of service = 20/24 unit (.83)
21 hours of service = 21/24 unit (.87)
22 hours of service = 22/24 unit (.92)
23 hours of service = 23/24 unit (.96)
24 hours of service = 24/24 unit (1.0)

All respite services provided in a month by the same provider are added together.

4600  Home-Delivered Meals

Revision 11-2; Effective December 21, 2011

4610  Chapter 55, Contracting to Provide Home-Delivered Meals

Revision 11-2; Effective December 21, 2011
§55.1  Purpose
§55.3  Definitions
§55.5  Contracting Requirements for Provider Agencies
§55.9  Training Requirements
§55.11  Nutrition Education
§55.13  Compliance with Laws and Regulations
§55.15  Menus
§55.17  Standard Recipes
§55.19  Modified Diets
§55.21  Frozen, Chilled, or Shelf-Stable Meals
§55.23  Meal Packaging
§55.25  Service Initiation
§55.27  Service Requirements
§55.29  Significant Changes
§55.31  Provider Agency Quality Control Measures
§55.33  Suspension of Services
§55.35  Service Plan Changes
§55.37  Termination of Services
§55.39  Recordkeeping
§55.41  Billing and Claims Payment
§55.43  Complaints
§355.511  Reimbursement Methodology for Home-Delivered Meals