Texas Department of Aging and Disability Services
Case Manager Community Based Alternatives Handbook
Revision: 13-2
Effective: June 3, 2013

Section 4000

Specific CBA Services

4100  Home and Community Support Services

Revision 12-4; Effective December 3, 2012

4110  Program Overview

Revision 12-2; Effective June 1, 2012

4111  Service Introduction

Revision 09-9; Effective December 1, 2009

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 consumers 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 Services Agencies (HCSSA). HCSSAs must comply with the terms of the contract, Texas Administrative Code (TAC) rules in this section, generic contracting rules and monitoring rules found in the Community Based Alternatives Provider Manual. HCSSAs provide services to consumers living in their own homes, adult foster homes, personal care facilities and other locations where service is needed. The services provided are identified on an individual service plan (ISP) and are authorized by the Department of Aging and Disability Services.

HCSSAs must provide the array of services identified in this section in accordance with the ISP through its 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. dental services;
  9. minor home modifications; and
  10. respite care (in-home).

4111.1  Service Locations for Home and Community Support Services Agencies (HCSSAs)

Revision 09-9; Effective December 1, 2009

All HCSSA services, except minor home modifications, can be provided to consumers in locations of their choice whenever services are needed, as long as the location is not an unlicensed personal care facility or an institutional setting. Nursing services, therapy services, dental services, adaptive aids and medical supplies may be provided as HCSSA services to a Community Based Alternatives (CBA) resident residing in a licensed personal care facility that is contracted to provide CBA services.

4112  General Contracting Requirements

Revision 12-2; Effective June 1, 2012

§48.6026 — Home and Community Support Services Provider Qualifications.

(a)
A HCSSA that contracts to provide CBA services must:
(1)
maintain a license under Chapter 97 of this title (relating to Licensing Standards for Home and Community Support Services Agencies) in the licensed home health services category;
(2)
have a separate contract to provide CBA services in each DADS region in which services are to be delivered;
(3)
be in compliance with Chapter 49 of this title (relating to Contracting for Community Care Services);
(4)
have the counties in the DADS contract for CBA services included in the identified licensed service area on file at DADS; and
(5)
be authorized by the secretary of state to do business in the State of Texas (if an out-of-state corporation).
(b)
A HCSSA that contracts to provide CBA services may maintain a license in the personal assistance services category in addition to the licensed home health services category for the purpose of providing personal assistance services that do not require nurse delegation.

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 therapy.

For additional information on General Contract Requirements see the Community Based Alternatives Provider Manual.

4113  General Requirements for Participation

Revision 09-9; Effective December 1, 2009

STANDARD. General Requirements for Participation.

Home and Community Support Services Agencies (HCSSAs) must:

  1. Provide the array of services identified below in accordance with Form 3671-1, Individual Service Plan, through its 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,
    9. dental services, and
    10. respite care (in-home).
  2. Provide trained and competent staff for consumer care.
  3. Maintain documentation of the assessment and provision of services.
  4. Provide for the delegation and supervision of nursing tasks and personal care tasks.
  5. Access Medicare and other third party resources for any services that the case manager has identified on the consumer's individual service plan (ISP) for nonwaiver services as needed by the consumer.

Agencies may subcontract with an individual 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.

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

4114  Service Plan

Revision 09-9; Effective December 1, 2009

The service plan, as presented on the individual service plan (ISP), Form 3671-1, Individual Service Plan, Form 3671-2, Individual Service Plan, Form 8598, Non-Waiver Services, Form 2060, Needs Assessment Questionnaire and Task/Hour Guide, Form 2060-A, Addendum to Form 2060 for Personal Assistance Services, 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-H, Dental Services, and Form 3671-J, Dental Services – Proposed Treatment Plan) will be faxed or hand-delivered to the Home and Community Support Services Agency (HCSSA) by the 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 assessment of the consumer for medically necessary services, the registered nurse (RN) who completed the assessment must sign Form 3671-2 to certify that the proposed 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 it to the case manager within two Department of Aging and Disability Services (DADS) business days 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 reason and 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 business days of receipt of the service plan; or
    3. Negotiate for a change in service plan by:
      • calling the DADS case manager within one DADS business day of the receipt of the service plan;
      • completing the appropriate ISP attachment, (Form 3671-B, Form 3671-C, Form 3671-D, Form 3671-E) identifying the requested service plan change, or use Form 2067 for requesting a service plan change for personal assistance services; and
      • faxing the service plan request and the appropriate ISP attachment back to the case manager within two DADS business days 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 case manager, in agreement or refusal as referenced in items (b) (1) and (2), within one DADS business day of receipt.

The HCSSA may sign to accept or refuse the applicant/consumer based on the assessment completed by the HCSSA nurse, or after receipt of the developed ISP by the DADS case manger. Any HCSSA representative or RN, in addition to the RN who performed the pre-enrollment home health assessment, may sign Form 3671-2 to accept or refuse the individual.

For service plans that are returned to the case manager for changes, the case manager will consider the requests and if able to authorize the services within the individual's cost limit, will re-fax the service plan to include Form 2060, Form 2060-A and the appropriate ISP attachment forms to the HCSSA within two DADS business days for approval or refusal of services.

4115  Individual Agreement for Services

Revision 03-4; Effective Upon Receipt

Home and Community Support Services Agencies (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 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 client's individual 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 a client receives under his direction as set forth by the Board of Nurse Examiners for the State of Texas.

4116  Refusal to Serve an Applicant or Individual

Revision 13-1; Effective March 1, 2013

If a Home and Community Support Services Agency (HCSSA) refuses to serve an applicant or individual based on licensure limitation, the reason why the provider will not be able to adequately meet the needs of the applicant or individual must be stated. The reason must be related to the applicant or individual himself and not previous efforts.

In accordance with Texas Administrative Code, Title 40, Chapter 97, Subchapter D (relating to Standards Specific to Licensed Home Health Services), an agency "must accept a client for home health services based on a reasonable expectation that the client's medical, nursing, and social needs can be met adequately in the client's residence. An agency has made a reasonable expectation that it can meet a client's needs if, at the time of the agency's acceptance of the client, the client and the agency have agreed as to what needs the agency would meet, for instance, the agency and the client could agree that some needs would be met but not necessarily all needs." In addition (relating to Standards Specific to Agencies Licensed to Provide Personal Assistance Services), the client record shall include "an individualized service plan developed, agreed upon, and signed by the client or family and the agency. The individualized service plan must include, but not be limited to... (A) types of services, supplies, and equipment to be provided."

This licensure service plan is similar but not the same as the Community Based Alternatives (CBA) individual service plan (ISP). 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 an applicant or to continue providing services to an individual. The HCSSA must provide a specific reason in writing for declining to accept an applicant or serve an individual.

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

  • the lack of a specialty nurse(s) available for an individual who has medically complex needs. For example, an applicant who requires a ventilator and the provider 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.
  • a provider contracted to provide CBA services in a remote county that loses the only attendant available to provide services to an individual in that area.

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

Once an HCSSA accepts an applicant or individual for care, the HCSSA cannot refuse to serve its portion of the ISP unless there is danger to staff. An HCSSA must provide services according to the licensure service plan, 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.

§97.295 – Client Transfer or Discharge Notification Requirements.

(a)
Except as provided in subsection (e) of this section, an agency intending to transfer or discharge a client must:
(1)
provide written notification to the client or the client's parent, family, spouse, significant other, or legal representative; and
(2)
notify the client's attending physician or practitioner if he is involved in the agency's care of the client.
(b)
An agency must ensure delivery of the written notification no later than five days before the date on which the client will be transferred or discharged.
(c)
The agency must deliver the required notice by hand or by mail.
(d)
If the agency delivers the written notice by mail:
(1)
the notice must be mailed at least eight working days before the date of discharge or transfer; and
(2)
the agency must speak with the client by telephone or in person to ensure the client's knowledge of the transfer or discharge at least five days before the date of discharge or transfer.
(e)
An agency may transfer or discharge a client without prior notice required by subsection (b) of this section:
(1)
upon the client's request;
(2)
if the client's medical needs require transfer, such as a medical emergency;
(3)
in the event of a disaster when the client's health and safety is at risk in accordance with provisions of §97.256 of this chapter (relating to Emergency Preparedness Planning and Implementation);
(4)
for the protection of staff or a client after the agency has made a documented reasonable effort to notify the client, the client's family and physician, and appropriate state or local authorities of the agency's concerns for staff or client safety, and in accordance with agency policy;
(5)
according to physician orders; or
(6)
if the client fails to pay for services, except as prohibited by federal law.
(f)
An agency must keep the following in the client's file:
(1)
a copy of the written notification provided to the client or the client's parent, family, spouse, significant other, or legal representative;
(2)
documentation of the personal contact with the client if the required notice was delivered by mail; and
(3)
documentation that the client's attending physician or practitioner was notified of the date of discharge.

HCSSA patterns of refusing to provide services to an applicant or individual 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 applicant or 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 HCSSA's contract. If patterns are not due to the circumstances allowed under licensure, the contract manager must take appropriate corrective action.

4120  Description of Services

Revision 10-3; Effective June 1, 2010

Home and Community Support Services Agencies (HCSSAs) provide services to the consumer living in his choice of care setting whether in his own home, an Assisted Living/Residential Care (AL/RC) facility, an Adult Foster Care (AFC) home or other locations where the consumer needs services. For example, Personal Assistance Services (PAS) and nursing services may be provided in other settings, such as school or work.

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

Services provided will be tailored to meet the consumer'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 HCSSA must assure that the consumer's informed choice and convenience will be incorporated into the planning and provision of the consumer's care by involved professionals. A consumer must be encouraged and allowed to play an active role in determining his ongoing plan of care.

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

4121  Personal Assistance Services

Revision 13-2; Effective June 3, 2013

Personal Assistance Services provide assistance to the individual, as authorized on Form 3671-1, Individual Service Plan, provided by an attendant that includes:

  • personal care and household tasks (tasks identified on Form 2060, Needs Assessment Questionnaire and Task/Hour Guide);
  • protective supervision;
  • extension of therapy; and
  • delegated nursing tasks, health maintenance activities or non-delegated nursing tasks (tasks identified on Form 3671-C, Nursing Service Plan, or 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)).

4121.1  Description of Personal Assistance Services

Revision 13-2; Effective June 3, 2013

STANDARD.

  1. Personal Assistance Services (PAS) includes tasks provided by an attendant that includes:
    • personal care and household tasks (tasks identified on Form 2060, Needs Assessment Questionnaire and Task/Hour Guide);
    • protective supervision (documented on Form 2060-A, Addendum to Form 2060 for Personal Assistance Services);
    • extension of therapy (documented on Form 2060-A); and
    • delegated nursing tasks, health maintenance activities or non-delegated nursing tasks (tasks identified on Form 3671-C, Nursing Service Plan, or 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), and documented on Form 2060-A).
  2. The Home and Community Support Services Agency (HCSSA) must provide PAS as identified on Form 2060 and Form 2060-A to an individual living in his own home.
  3. The HCSSA must notify the case manager on Form 2067, Case Information, when protective supervision hours are authorized as PAS before an unpaid caregiver becomes a paid attendant of the provider and no other attendant will be providing protective supervision.

Because shopping may be an authorized task, it may entail paying mileage to the attendant to perform the task. The individual must not be charged for transportation costs incurred in the performance of this task by either the attendant or the HCSSA. Taking care of household pets and ironing are not included under general household activities or chore services and are not reimbursable under the Community Based Alternatives (CBA) waiver.

To facilitate safe ambulation or movement for the individual, the attendant may need to, for example, rearrange furniture for an individual who uses a wheelchair, walker or crutches, or for an individual with a visual impairment. The HCSSA nurse addresses this activity during orientation for an attendant who provides PAS to an individual needing this assistance.

Ambulation may be either a personal care task or a nursing task depending on the assessment by the HCSSA nurse. Ambulation, as a delegable nursing task (as identified in Item 10 on Form 3671-C or Form 3671-C-Alternate) requires nursing intervention in response to a specific condition of the individual. The physician may or may not prescribe specific ambulation orders. For example, the physician may prescribe "ambulation or activity as tolerated" for an individual with congestive heart failure. The individual 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 one to two minutes while taking several deep breaths before starting to walk again, the attendant must support the individual on one side while walking by holding on to the individual’s elbow."

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

If ambulation is being delegated as a nursing task on Form 3671-C or Form 3671-C-Alternate, the case manager should not authorize ambulation as a non-skilled task on Form 2060. Authorization of ambulation as a nursing task and at the same time as a non-skilled task may be a duplication of services. When completing the functional assessment on Form 2060 and Form 2060-A, the case manager must consider the HCSSA nurse's assessment of the individual's need for ambulation, as documented on the nursing assessment on Form 3671-C or Form 3671-C-Alternate. If it appears the individual needs both skilled and non-skilled ambulation assistance, the case manager must discuss this with the HCSSA nurse. If the case manager and HCSSA nurse agree the individual needs ambulation as a personal care task and as a nursing task, the case manager must document in the case record why and how the individual requires both. The case manager may authorize both tasks if there is no duplication.

Escorting an individual for medical diagnosis or treatment does not include the direct transportation of the individual by the attendant. Transportation for an individual who receives Medicaid is available in every county through the Medical Transportation Program. Transportation is not included as an activity in the escort task.

A licensed therapist may choose to instruct the attendant in the proper way to assist the individual in follow up on therapy sessions. This assistance and support provides reinforcement of instruction and aids in the rehabilitative process.

Protective supervision may be authorized to assure the health and welfare of an individual with cognitive impairment, memory impairment or physical weakness. The PAS attendant’s responsibility is to supervise the individual. Protective supervision is authorized when the caregiver is not available to supervise the individual on a routine basis. Protective supervision is supervision only and does not include the delivery of personal care tasks. Protective supervision is appropriate when it is necessary to protect the individual from injury due to his cognitive impairment, memory impairment or physical weakness. If left unattended, for instance, the individual may wander outside, turn on electrical appliances and burn himself, or try to walk and then fall.

The purpose of protective supervision is to provide relief for the caregiver from the responsibility of supervising the individual. When protective supervision hours are authorized and a case manager is notified by the HCSSA of the caregiver becoming a paid attendant and no other attendant will be providing protective supervision hours, the case manager will reduce the authorized PAS hours on the individual service plan, deleting the authorized protective supervision hours.

Example 1: An individual requires assistance with personal care and household tasks Monday through Friday. The caregiver is available in the afternoon to supervise the individual Monday through Thursday but attends a class every Friday afternoon. If left unattended, the individual may try to walk and is at risk of falling due to physical weakness. In this situation, the case manager may include time for protective supervision for Friday afternoon when authorizing PAS.

Example 2: The caregiver works eight hours a day, Monday through Friday. The case manager completes Form 2060 and determines the individual needs five hours for assistance with personal care and household tasks. If left unattended, the individual may wander outside and is at risk of getting lost or injured due to a cognitive impairment. In this situation, the case manager may add time for protective supervision daily in addition to the time for personal care and household tasks to authorize eight hours of PAS per day. The attendant may provide protective supervision, personal care and household tasks intermittingly throughout the eight hours of PAS per day.

When protective supervision is authorized, the case manager must:

  • document in the case record that the individual has a cognitive impairment, memory impairment or physical weakness; and
  • identify the caregiver on Form 8598, Non-Waiver Services, in item 5, Family and Community Supports.

Refer to Section 3311.4.4, Authorization of Protective Supervision as a Personal Assistance Service Task, for additional information about protective supervision.

4121.2  Qualifications for Registered Nurse Supervisors

Revision 02-0; Effective April 4, 2002

STANDARD. Supervision of personal care attendants is provided by HCSSA 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.

4121.3  Qualifications of Personal Assistance Services Attendants

Revision 13-2; Effective June 3, 2013

STANDARD. Personal Assistance Services are delivered by a personal care attendants who is:

  1. employed by a Home and Community Support Services Agency (HCSSA); and
  2. not the individual's spouse.

4121.4  Types of Personal Care Attendants

Revision 13-2; Effective June 3, 2013

STANDARD. A personal care attendant is a:

  1. regular attendant who performs all personal assistance services tasks available within his scope of competency; or
  2. special attendant who may be used to initiate services, prevent a break in service, and provide on-going service.

4121.5  Orientation and Training Responsibilities of the RN Supervisor

Revision 03-4; 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 4121.6, 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 participant's 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 HCSSA.

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 HCSSAs unless the RN is supervising the attendant in the delivery of delegated nursing tasks.

4121.6  Required Training for Attendants

Revision 02-0; Effective April 4, 2002

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 the CBA Provider Manual, 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 4121.3, 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 Department of State Health Services nurses aide registry.

The HCSSA must maintain documentation on the training of attendants as outlined in Section 4421.5 of the CBA Provider Manual.

4121.7  Training of Unpaid Family Members, Neighbors or Other Informal Support

Revision 07-3; Effective March 16, 2007

STANDARD.

  1. The Home and Community Support Services Agency (HCSSA) 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 consumer'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 obtains the unpaid family member's, neighbor's or other informal support's signature on Form 3671-C, Nursing Service Plan, if contributing to the consumer'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 business day after becoming aware of the situation;
    2. make arrangements for the necessary tasks to be delivered by an alternate source; and
    3. submit a service plan change as referenced in Section 3610.3, Emergency Service Plan Changes to the Individual Service Plan.

In certain instances, the licensed nurse from the HCSSA may choose to work closely with the consumer'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 HCSSA is able to contribute to the individual's desire to remain in his own home or adult foster care (AFC) home, levels I or II, and provide cost-effective services. Example: The licensed nurse may teach the family member to change a wound dressing when the physician orders the dressing be changed twice a day. The provider 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 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 documents informal support(s) performing care on Form 2060, Needs Assessment Questionnaire and Task/Hour Guide, Form 2060-A, Addendum to Form 2060 for Personal Assistance Services, or Form 8598, Non-Waiver Services. The case manager obtains informal support agreements and signatures, as applicable. Refer to Section 3311.4.2, Family Members and Informal Supports. The HCSSA nurse must obtain signatures on Form 3671-C. The decision of the nurse to train the unpaid individuals about nursing tasks depends on the consumer and the consumer's wishes, the nurse's experience and professional judgment 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 also are licensed nurses and provide gratuitous care should be referred to the Board of Nurse Examiners.

4122  Nursing Services

Revision 09-3; Effective February 27, 2009

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

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

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, verification of licenses can be made with the Texas BON online or by telephone or written request.

The Texas Medicaid & Healthcare Partnership (TMHP) will verify that nurses who complete and transmit a Medical Necessity and Level of Care (MN/LOC) Assessment have a current registered nurse (RN) license. Verification will be with the Texas BON for nurses who have a Texas RN license. For nurses who have a license with a compact state, TMHP will verify licensure with the BON in the state that issued the compact license. TMHP will reject any MN/LOC Assessments if the nurse's license number is either invalid or inactive.

4122.1  Role of the CBA Nurse with the TPR Nurse

Revision 08-10; Effective September 1, 2008

When a Home and Community Support Services Agency (HCSSA) registered nurse (RN) and an RN from a third party resource (TPR), such as Medicare, share responsibility and care in a Community Based Alternatives (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 payer. The CBA RN and the Medicare RN do not supervise each other.

4122.2  Role of the Licensed Vocational Nurse

Revision 08-10; Effective September 1, 2008

The licensed vocational nurse (LVN) from the Home and Community Support Services Agency (HCSSA) may deliver nursing services to include training attendants, Adult Foster Care providers and provider substitutes on nursing tasks, after the registered nurse has assessed the consumer and established the plan of care. The LVN may not complete the Medical Necessity and Level of Care Assessment or initiate any service plan changes.

4122.3  Nursing Services in Participant's Homes

Revision 02-0; Effective April 4, 2002

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 HCSSA must continue meeting the participants' identified needs for nursing care by direct delivery from licensed nurses.

4122.4  Nursing Services in Personal Care Facilities

Revision 02-0; Effective April 4, 2002

Licensed nurses will directly deliver care, with the exception of medication administration, to participants requiring nursing services residing in personal care facilities. Delegation of nursing tasks by HCSSA RNs to facility attendants is not allowed by DADS licensure.

If an AL/RC participant's nursing needs are being met by a TPR such as Medicare, the HCSSA 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 HCSSA RN to add nursing hours for monitoring of the participant.

4122.5  Nursing Services in Adult Foster Care Homes, Levels I and II

Revision 02-0; Effective April 4, 2002

The HCSSA 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.

4122.5.1  Nursing Services in AFC Homes Operated by Licensed Nurses

Revision 08-10; Effective September 1, 2008

In serving a consumer in any level Community Based Alternatives (CBA) program Adult Foster Care (AFC) home operated by a licensed nurse, the Home and Community Support Services Agency (HCSSA) registered nurse (RN) will complete the CBA program assessments as referenced in the Community Based Alternatives Provider Manual, 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 from the case manager to assess for the annual medical necessity (MN) and individual service plan (ISP) attachments and assessments related to the individual's cost limit.

The AFC provider RN will verbally notify the HCSSA of any additional CBA services other than nursing that the AFC consumer needs. The HCSSA, after being made aware of the request, will submit to the case manager Form 2067, Case Information, and the appropriate ISP attachment within seven days of being informed of the need and process a request for a service plan change as referenced in the Community Based Alternatives Provider Manual, Section 4452.2, Requests for Routine Service Plan Changes. Upon notification of an emergency request, the HCSSA will verbally notify the case manager by the next business day of the request and submit written notification within seven calendar days as referenced in the Community Based Alternatives Provider Manual, Section 4424.4.2, Emergency Procurement of Adaptive Aids and Medical Supplies.

Direct nursing services in any CBA AFC home operated by an RN will be provided by the AFC provider RN.

4122.5.2  Orientation/Training and Delegation/Supervision of the Adult Foster Care Provider

Revision 02-0; Effective April 4, 2002

STANDARD.

  1. The registered nurse must provide orientation in the Adult Foster Care (AFC) 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 (HCSSA) from rules promulgated by the Texas Board of Nurse Examiners and referenced in Appendix II, Board of Nurse Examiners Rules Pertaining to Delegation, of the CBA Provider Manual.

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 HCSSA 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.

4122.5.3  Documenting Non-Delegation of Nursing Tasks in Adult Foster Care Homes

Revision 02-0; Effective April 4, 2002

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 business 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 business 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 HCSSA. The effective date of the change is the date the HCSSA 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.

4122.6  Semiannual Nursing Assessments

Revision 12-2; Effective June 1, 2012

To assure quality of care for individuals in the Community Based Alternatives (CBA) program by identifying significant changes in conditions and initiating appropriate interventions on a timely basis, the Home and Community Support Services Agency (HCSSA) must perform semiannual nursing assessments on all individuals. A nursing assessment can be performed in conjunction with the annual reassessment skilled nursing visit, including when the registered nurse (RN) is doing a supervisory visit when the individual is receiving delegated nursing tasks.

If an individual transfers to another HCSSA, a nursing assessment must be performed by the gaining HCSSA within 14 calendar days of the transfer effective date.

The semiannual nursing assessment does not replace the Medical Necessity and Level of Care (MN/LOC) Assessment, which must be used to determine medical necessity at the time of pre-enrollment and annually thereafter.

HCSSAs use Form 3751, CBA Semiannual Nursing Assessment, Form 3751-A, CBA Semiannual Nursing Assessment Attachment, and Form 3752, Evaluation of RN Semiannual Assessment, to perform the semiannual nursing assessment. Completed nursing assessments are to be maintained by the HCSSA in each individual's file. Copies should not be sent to the Department of Aging and Disability Services (DADS) case manager. The HCSSA nurse should use the results of the nursing assessment to develop the nursing plan of care and initiate appropriate interventions. The HCSSA nurse should consult with 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 nursing assessment. DADS case managers authorize four hours annually on Form 3671-C, Nursing Service Plan, page 2, at the time of initial enrollment and annual reassessment to cover time spent doing the semiannual nursing reassessments. The HCSSA is entitled to reimbursement when an additional nursing assessment is required within the individual service plan year, if the visit was done within the required time frames.

4122.7  Utilization of Other Resources

Revision 02-0; Effective April 4, 2002

All HCSSAs 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 HCSSAs may contact Texas Medicaid & Healthcare Partnership (TMHP) at 1-800-925-9126 to enroll as a Medicaid home health provider or obtain a list of local home health providers who are contracted to provide Medicaid Home Health Services. To be eligible to enroll as a Medicaid home health provider, the HCSSA must be licensed and certified to be a Medicare provider.

HCSSAs 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 1-800-925-9126.

If the DME vendor or the HCSSA 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.

4122.7.1  Self-Determination Act

Revision 02-0; Effective April 4, 2002

STANDARD. Self-Determination Act. The HCSSA 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, Patient Self-Determination Advanced Directives, 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.

4122.8  Post-Hospital Assessment Visits

Revision 09-9; Effective December 1, 2009

The Community Based Alternatives (CBA) program will pay for post-hospital assessment visits completed by Home and Community Support Services Agency (HCSSA) nurses. The HCSSA should use existing crisis intervention nursing hours authorized on Form 3671-C, Nursing Service Plan, Section IV, Item 3, to conduct a post-hospital assessment visit. If crisis hours have been exhausted and a post-hospital visit has been completed, the HCSSA should submit the following documentation to the CBA case manager within seven days of the post-hospital assessment visit:

  • Form 3671-C, which includes the actual number of nursing hours used to conduct the post-hospital assessment visit in Section IV, Item 3, Column B.
  • Form 2067, Case Information, which includes the hospital release date and the date the post-hospital assessment visit was conducted.

The case manager is not required to verify there has been a hospital stay before authorizing the hours.

The HCSSA may use nursing hours to perform a post-hospital assessment for consumers released from a nursing facility, rehabilitation unit, psychiatric hospital and/or any other institutional setting.

4123  Specialized Nursing

Revision 10-4; Effective September 1, 2010

Specialized Nursing (SN) services delivered by a Registered Nurse (RN) or Licensed Vocational Nurse (LVN) are available through the Community Based Alternatives (CBA) program. SN services may be used when a consumer requires, as determined by a physician, daily skilled nursing to:

  • cleanse, dress and suction a tracheostomy; or
  • provide assistance with ventilator or respirator care.

The consumer must be unable to do self-care and require the assistance of a nurse for the ventilator, respirator or tracheostomy care.

The Home and Community Support Services Agency (HCSSA) is required to maintain documentation of the use of SN services, but is not required to provide the case manager with the written documentation or a physician's order. The HCSSA sends the following documents to the CBA case manager to include SN services in the individual service plan (ISP):

  • Form 2067, Case Information, requesting authorization of SN services; and
  • 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), detailing the nursing service plan.

Form 2067 and Form 3671-C-Alternate are sent for ISP changes. Form 2067 is not necessary at initial certification or annual reassessment. For changes, SN services are added to the ISP effective the date the request is processed. The addition of SN services cannot be retroactive.

SN codes are SN RN – 13C, and SN LVN – 13D. SN hours are authorized on the ISP as requested by the HCSSA on Form 3671-C-Alternate. The HCSSA must document the request for SN services in Section II, Column H, Direct Nursing Performed by HCSSA, by checking the "Specialized" box.

When SN is used, nursing hours required to complete orientation (Section II, Item 17), annual reassessments (Section II, Item 18), delegation/training (Section III, Item 4B) and mandatory hours (Section IV, 5, B) must always be authorized as specialized RN hours under Service Code 13C. Based on the consumer's need, the HCSSA may request all nursing hours as specialized RN on Form 3671-C-Alternate in Section II, Column H, RN column. In some cases the HCSSA may deliver some nursing tasks as SN RN and some as SN LVN. Along with the RN column, the HCSSA completes Section II, Column H, LVN column to document the number of SN LVN hours needed. The SN LVN hours are authorized as Service Code 13D.

Nursing hours required to complete orientation, annual reassessments, delegation/training and mandatory hours are also authorized as specialized RN hours under Service Code 13C when SN hours are performed totally by informal support or other third-party resource.

If the case manager becomes aware of an HCSSA using SN services for a CBA consumer who does not require skilled respiratory nursing tasks, a report should be made to the contract manager.

Non-SN hours are authorized on the ISP as CBA Nursing, Service Code 13. Form 3671-C, Nursing Service Plan, Section II, Column H, is used to request non-specialized hours. The HCSSA may deliver nursing services via an LVN and/or an RN. The HCSSA bills for nursing hours under Service Code 13 but uses a different bill code for LVN and RN on payment claims to designate the type of nursing services delivered.

4130  Therapy Services

Revision 02-0; Effective April 4, 2002

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 HCSSA, the HCSSA 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 HCSSA 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 an HCSSA.

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.

4130.1  Initiation of Assessment and Therapy

Revision 02-0; Effective April 4, 2002

The case manager, upon recommendation from the HCSSA 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.

4130.2  Responsibilities of Licensed Therapists in CBA

Revision 02-0; Effective April 4, 2002

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.

4140  Adaptive Aids and Medical Supplies

Revision 10-1; Effective March 11, 2010

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 consumer's service plan, Form 3671-1, Individual Service Plan.

Definitions

Adaptive aids and medical supplies are specialized medical equipment and supplies, which include devices, controls or appliances specified in the plan of care, that enable individuals to increase their abilities to perform activities of daily living or perceive, control or communicate with the environment in which they live. Adaptive aids and medical supplies are reimbursed with waiver funds with the goal of providing individuals a safe alternative to nursing facility (NF) placement. Items that are not of direct remedial benefit (providing a remedy to cure or restore health) or medical benefit to the individual are excluded from reimbursement.

Adaptive aids and medical supplies are limited to the most cost-effective items that can:

  • meet the consumer's needs;
  • directly aid the consumer to avoid premature NF placement; and
  • provide NF residents an opportunity to return to the community.

The Community Based Alternatives (CBA) program is not intended to provide every consumer with any and all adaptive aids or medical supplies the consumer may receive as an NF resident.

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

4141  List of Adaptive Aids and Medical Supplies

Revision 13-1; Effective March 1, 2013

STANDARD.

  1. Adaptive aids and medical supplies are covered by the Community Based Alternatives (CBA) waiver only after the individual has exhausted all available third-party resources, including Medicare and Medicaid home health the individual is eligible to receive.
  2. Adaptive aids and medical supplies are approved for purchase as a waiver service only if the documentation supports the requested item(s) as being necessary and related to the individual's disability or medical condition.

A list of items that Medicaid will not pay for is located in Appendix XVIII, Acute Medicaid List of Adaptive Aids and Medical Supplies. Prior to authorization of adaptive aids and medical supplies, the case manager must refer to the list in Appendix XVIII to determine if an item can be considered through the CBA program or should be accessed through Medicaid.

Section 4141 provides four lists:

  • List of Adaptive Aids Approvable by the Case Manager
  • List of Medical Supplies Approvable by the Case Manager
  • List of Adaptive Aids and Medical Supplies that Require Regional Nurse Review for Authorization Determination
  • List of Items Excluded from Coverage by the CBA program

The case manager must use the following lists to determine the approval process for requests for adaptive aids and medical supplies.

List of Adaptive Aids Approvable by the Case Manager

Adaptive aids that can be approved by the case manager include the following items, including batteries, maintenance, and repair not covered by the warranty. Service calls for repair of adaptive aids on the approved list may be considered as part of repair and maintenance of the adaptive aid. Before authorizing a service call, the case manager should determine if warranty for the item will pay for the service call.

  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 and wall lifts with tracks
    7. lift recliners (excluding lift recliners with heat and/or massage)

    Refer to Section 4142.1, Lift Chair Approvals, for additional procedures related to authorizing lift chairs.

  2. Mobility aids, including batteries and chargers
    1. non-customized manual and electric wheelchairs and necessary wheelchair accessories including arm pad replacement and weather protective covers
    2. three-wheel scooters, four-wheel scooters
    3. crutches, walkers (including those with seats, brakes and rollers) canes, replacement glides, tips and grips
    4. forearm platform attachments for walkers
    5. prescribed prosthetic devices
    6. prescribed orthotic devices including braces, inserts, orthopedic shoes and other prescribed shoes (including diabetic shoes)
    7. portable ramps

    Wheelchairs and scooters that primarily enable the individual to increase his abilities to perform activities of daily living in the home and in the community are reimbursable as a CBA adaptive aid. Wheelchairs and scooters for the purpose of facilitating participation in recreational activities and sports do not meet waiver requirements and are not covered by the CBA program.

    Diabetic shoes are paid for through Medicare if there is a physician order. If the individual does not have Medicare, the case manager may approve diabetic shoes if there is a documented medical need and a physician order for the shoes.

  3. Respiratory aids
    1. ventilators/respirators
    2. oxygen concentrators
    3. continuous positive airway pressure (CPAP) and bilevel positive airway pressure (BiPAP) machines including CPAP and BiPAP headgear
    4. backup generators, (including necessary wiring)
    5. nebulizers
    6. portable air purifier and filters for an individual with a chronic respiratory diagnosis such as asthma, Chronic Obstructive Pulmonary Disease (COPD) bronchitis, emphysema
    7. suction pumps
    8. incentive spirometers, peak flow meters

    Equipment necessary to provide oxygen is covered by Medicare and Medicaid.

    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.

  4. Positioning and support devices
    1. standing boards, standing frames
    2. standard electric or manual hospital beds
    3. replacement mattresses for standard electric or manual hospital beds
    4. egg crate mattresses, mattress overlays, sheepskin
    5. wheelchair cushions
    6. elbow, knee and heel protectors, hand rolls for positioning
    7. trapeze bars
    8. arm slings, arm braces, wrist splints
    9. abdominal binders
    10. Geri-chair if the individual is alert, oriented and able to remove the tray table without assistance and as desired. Otherwise, the Geri-chair is considered a restraint and the CBA program does not cover restraints.

    Necessary items related to hospital beds could include electric controls, manual cranks or other items related to the use of the bed. Medicare and Medicaid cover hospital beds and specialty mattresses for skin breakdown. Specialty sheets, such as hospital bed sheets, may be covered through the CBA program.

  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. speech amplifiers, aids and assistive devices
    2. large button telephones or speaker phones (for an individual with significant functional visual or hearing impairment)
  6. Control switches/pneumatic switches and devices
    1. sip and puff controls
    2. adaptive switches/devices
  7. Environmental control units
    1. remotely operated locks for use by an individual unable to use a traditional lock  
    2. voice-activated, light-activated and motion-activated devices
  8. Temporary lease/rental of medically necessary durable medical equipment to allow for repair, purchase, replacement of essential equipment or temporary usage of the equipment
  9. Payment of premium deductibles and co-insurance (for items covered under the waiver), including rentals for Medicare or third-party resources, if not covered under the Qualified Medicare Beneficiary (QMB) or the Medicaid Qualified Medicare Beneficiary (MQMB) programs
  10. Modifications/additions to primary transportation vehicles (does not include vehicle repairs or vehicle maintenance)
    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 an individual with respiratory or cardiac problems or an individual who can't regulate temperature
    4. removal or placement of seats to accommodate a wheelchair
    5. purchase and installation, adjustments or placement of mirrors to overcome visual obstruction of wheelchair in vehicle
    6. raising the roof/lowering the floor of the vehicle to accommodate an individual riding in a wheelchair
    7. purchase and installation of frames, carriers, lifts, for transporting mobility aids
    8. purchase and installation of heavy duty shock absorbers, if required to support a wheelchair lift or vehicle modification
    9. trailers (including sales tax) for transporting wheelchairs or scooters may be approved with documentation of medical necessity (title, license and registration are not included)
    10. purchase and installation of trailer hitches for trailers used to transport wheelchairs or scooters

    Vehicle repairs are part of normal maintenance and cannot be covered. Refer to Section 4142.4, Vehicle Modification Requirements, for additional procedures related to reviewing requests for vehicle modifications.

  11. Sensory adaptations
    1. eyeglasses with standard frames and lenses
    2. hearing aids
    3. hand-held magnifying glasses
  12. Adaptive equipment for activities of daily living
    1. assistive devices
      1. reachers, including sock aids
      2. stabilizing devices including transfer poles, metal bathtub bars
      3. holders including baskets for walkers and wheelchairs to transport medically necessary items
      4. feeding devices including:
        1. food processors and blenders — only for an individual who requires modified textured foods and with muscular weakness in upper body or lacking manual dexterity, causing the individual to be unable to use manual conventional kitchen appliances
        2. variations of everyday utensils
          • shaped, bent, built-up utensils
          • long-handled equipment
          • addition of friction covering
          • coated feeding equipment
          • weighted equipment
          • stabilizing place mat
      5. medication devices including manual medication reminder systems, pill organizers, medication boxes, pill planners, pill splitters, pill crushers, Count-A-Dose® and similar types of medication systems designed for diabetics
      6. walking belts, gait belts, transfer belts
      7. transfer boards
      8. bedside commodes, toilet frames, toilet seat extenders, toilet seat reducer rings, toilet elevator (unless the individual resides in an Assisted Living (AL) facility)
      9. hand-held shower sprays, transfer benches, non-customized shower chairs (unless the individual resides in an AL facility)
      10. service animals
      11. over-bed tray tables (unless the individual resides in an AL facility)
      12. bedpans, urinals
      13. portable shampoo basins for an individual who requires total care
    2. safety devices
      1. safety padding including wall and bed rail padding
      2. helmets for seizure precautions
      3. non customized medical alert bracelets
      4. noise activated baby monitors and batteries
      5. bed and wheelchair alarms and batteries for an individual with a diagnosis of Alzheimer's or dementia
      6. bath mats for tub

    Refer to Section 4142.3, Monitored Medication Unit Approvals, for additional procedures related to authorizing monitored medication units.
  13. Medically necessary heating and cooling equipment

CBA funds may be used to purchase medically necessary heating and cooling equipment (including wiring) for a principal living area for an individual with respiratory or cardiac problems, an individual who cannot regulate temperature or an individual who has conditions affected by temperature. The CBA program does not provide central air conditioning and heating or multiple heating and cooling units to cover an individual's residence. The CBA program does not provide installation of gas or propane lines.

Installation of approved heating and cooling equipment is included in the cost of the adaptive aid. Support platforms are frequently used to provide support for cooling equipment installed in home windows. The support platforms attach in a clamp-like manner without fasteners. The cost and installation of support platforms is considered an adaptive aid. The installation of heating and cooling equipment may require modification of the home (for example, additional wiring or widening of the windows). The modification of the home must be authorized as a Minor Home Modification.

List of Medical Supplies Approvable by the Case Manager

Medical supplies must be necessary for therapeutic or diagnostic benefit. Medical supplies that can be approved by the case manager include the following items.

  1. Gloves
  2. Gloves may be purchased through the CBA program for family use in the care of an individual with incontinence, if the individual has an active infectious disease that is transmitted through urine (if incontinent of urine) or stool (if incontinent of stool). Examples of active infectious diseases that qualify are Methicillin-Resistant Staphylococcus Aureus (MRSA) and hepatitis.

    Gloves may be purchased for family use to provide wound care to protect the individual. Documentation by the Home and Community Support Services Agency (HCSSA) must support the need of gloves to be left at the residence and for family use only.

    If the individual has other conditions requiring frequent use of gloves, the case manager must obtain regional nurse approval. The CBA program does not purchase gloves for universal precautions. Gloves for use by an Adult Foster Care (AFC) provider or any contracted provider staff should not be purchased with CBA funds. AFC rates take into account the higher level of care provided in the AFC home.

  3. Finger cots for an individual who requires a digital bowel program
  4. Enemas may be approved if not available through Medicaid or other third-party resources
  5. Tracheostomy care supplies, including tubes, cannulas, masks, sterile water, saline, gauze pads, cotton tipped applicators
  6. Decubitus care supplies, including wound cleansers, gauze pads, gauze bandages, gauze sponges, bandage wraps and rolls, tape, adhesive wound dressings, non-adhesive wound dressings, film dressings, foam dressings, gel dressings, hydro-cellular dressings, hydrocolloid dressings, calcium alginate dressings, sterile gloves for sterile wound dressings (refer to information on gloves above)
  7. Wound care supplies, including the items listed above under decubitus care
  8. Ostomy care supplies, including pouches, wafers, skin barriers, stoma paste, stoma cap, night drainage container with tubing
  9. Respiratory supplies, including filters, masks, tubing, sterile water, distilled water, saline suction catheters, oxygen cylinder refills
  10. Catheterization supplies, including straight, condom and Foley catheters, drainage bags, leg bags and straps, catheter tubing holders, irrigation trays, K-Y jelly and other water soluble lubricating jellies
  11. Incontinence supplies, including diapers, disposable bed pads (chux), briefs, protective liners, pull-ups, wipes, washable bed pads, moisture protective mattress covers, moisture barrier creams. (The case manager may approve moisture barriers if a medical need is documented and the product is verified as a skin barrier product.) Feminine protection products used as a cost-effective replacement for other incontinence supplies may be approved if adequately documented.
  12. Regular or antiseptic wipes may be approved if a medical need is documented.

    Medicaid pays for two boxes of diaper wipes per month for an individual who is also receiving diapers, briefs, pull-ons or liners. The case manager may approve up to three additional boxes of wipes per month for this individual if information supporting the need for additional wipes is submitted. Wipes greater than a total of five boxes per month are not covered.

    Wipes cannot be approved for an individual who is not receiving wipes through Medicaid.

    The case manager may approve moisture skin barriers if a medical need is documented and the product is verified as a skin barrier product. The case manager may consult with the regional nurse to ensure the product being approved is medically necessary for the medical condition.

  13. Enteral feeding formulas and supplies, including 60cc syringes for tube feedings, feeding pumps, IV poles, feeding bags, tubing, connectors
  14. Food-thickening agents
  15. Each individual service plan (ISP) year, a physician order is required for the authorization of food-thickening agents (such as Thick-It). A copy of the physician order must be included with the request from the HCSSA. Medicaid covers food-thickening agents for an individual with feeding tubes.

  16. Diabetic supplies including blood glucose monitors, strips, lancets
  17. Medicare pays for glucose monitors, test strips and lancets for an individual with diabetes at 80% of the cost. The CBA program can cover the 20% co-insurance if no other resources are available. In instances when the individual is not covered by QMB, 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, Adaptive Aids and Medical Supplies, for payment through the CBA program. Refer to Section 4149, Co-Insurance and Deductibles.

    Insulin syringes and needles are obtained by the individual through the Texas Medicaid Vendor Drug Program, not through the CBA program.

  18. Prescribed Transcutaneous Electrical Nerve Stimulation (TENS) units/supplies/repair
  19. Anti-embolism hose such as TED hose and Jobst stockings. The regional nurse must determine authorization for the initial request each ISP period. The case manager may approve subsequent requests in an ISP period when there has not been a change in the individual's condition and ability to apply and remove the hose.
  20. Stethoscopes, blood pressure monitors, including wrist monitors and thermometers for home use
  21. Mouth swabs, Toothettes

List of Adaptive Aids and Medical Supplies that Require Regional Nurse Review for Authorization Determination

  1. Diabetic slippers and socks
  2. Prescribed exercise equipment and therapy aids
  3. Nutritional supplements
  4. Air humidifiers
  5. Pulse oximeters
  6. Talking blood glucose monitors
  7. Specialized/customized wheelchairs
  8. Customized seating systems
  9. Specialty hospital bed mattresses (does not include mattresses for comfort only)
  10. Wedge pillows and support neck pillows
  11. Electronic/alarming medication dispensing boxes
  12. Bed rails
  13. Initial approval of anti-embolism hose such as TED hose and Jobst stockings each ISP period
  14. Auditory adaptations to mobility devices
  15. Monitored medication units

Notes:

  • Refer to Item 4142.2, Nutritional Supplement Approvals, for procedures related to requests for nutritional supplements.
  • One-time items, such as stethoscopes, blood pressure monitors, TED hose and allowable bed sheets can be authorized as an adaptive aid.

List of Items Excluded from Coverage by the CBA Program

The following items may not be purchased using CBA funds.

  1. Hot water heater
  2. Combination heater, light and exhaust fan
  3. Heating and cooling system filters
  4. Non-adapted appliances, such as refrigerators, stoves, dryers, washing machines and vacuum cleaners
  5. Water filtration systems
  6. Central air conditioning and heating
  7. Multiple air conditioning units to cover an individual's residence
  8. Non-adapted home furnishings to include (except as allowed through Transition Assistance Services (TAS)):
    1. Cooking utensils
    2. Non-hospital bed mattresses and springs, including Adjustamatic, Craftmatic, Tempur-Pedic®, Posturepedic and Sleep Number® beds
    3. Pillows (excluding neck pillows and support wedge pillows)
  9. Electrical heating elements (heating pads, electric blankets)
  10. Recreational Items, equipment and supplies including:
    1. bicycles and tricycles (2, 3 or 4 wheels)
    2. helmets for recreational purposes
    3. trampolines
    4. swing sets
    5. bowling and fishing gear
    6. karaoke machines
    7. entertainment systems
    8. off-road recreational vehicles
  11. Memberships in gyms, spas health clubs or other exercise facilities
  12. Communication items, including:
    1. telephones (standard, cordless or cellular)
    2. pagers
    3. pre-paid minute cards
    4. monthly service fees
  13. Computers for the following justifications:
    1. educational purposes
    2. self improvement/employment purposes
    3. improvement of general computer skills
    4. Internet and email access
    5. games and fun/craft activities
  14. Office equipment and supplies to include:
    1. fax machines
    2. printers/copiers
    3. scanners
    4. Internet and email services

    Note: An individual accessing the Consumer Directed Services (CDS) option may purchase office equipment and supplies through the CDS budget.

  15. Gloves for universal precautions, or gloves that are used by HCSSA staff, an AFC provider or any contracted provider staff
  16. Personal items of daily living activities such as hygiene products including soap, waterless soap, toothbrush, toothpaste, deodorant, powder, shampoo, lotions (except moisture barrier products), feminine products (except when documented for use as an incontinent supply), electric and manual razors, washcloths, towels, bibs and first-aid supplies
  17. Clothing items (including hospital gowns)
  18. Food
  19. Bottled water (for drinking and cooking)
  20. Nutritional drinks and products that do not meet the criteria in Section 4142.2, such as Carnation Instant Breakfast, V-8 Juice, Slim Fast, fruit juices, flavored water, vitamin enhanced water, nutrition and protein bars, breakfast cereals
  21. Vitamins, minerals and herbal supplements and over-the-counter drugs
  22. Title, license and registration for trailers or vehicles
  23. Wheelchairs and scooters for the purpose of facilitating participation in recreational activities and sports do not meet waiver requirements and are not covered by the CBA program
  24. Vehicle repairs, as part of normal maintenance
  25. Installation of gas or propane lines
  26. Restraints
  27. Experimental medical treatment and therapies, such as equestrian therapy

Physical restraints are defined as any mechanical device, material or equipment attached or adjacent to the individual's body that the individual cannot remove easily, which restricts freedom of movement or normal access to one's body. With one exception, an adaptive aid that meets this definition may not be purchased using CBA funds. An AL facility may use restraints in very limited situations in accordance with 40 Texas Administration Code (TAC) §92.41(p). The exception to the restraint exclusion is an adaptive aid that meets the definition of a restraint may be considered for authorization for an individual living in an AL facility if all the requirements under 40 TAC §92.41(p) are met.

Refer to Section 4424.1, Documentation of Necessity, in the Community Based Alternatives Provider Manual for HCSSA requirements for documentation of necessity and physician's order for adaptive aids and medical supplies.

Refer to Section 3670, Prescriptions, for information about obtaining medications and incurred medical expenses.

4142  Case Manager Approval of Adaptive Aids and Medical Supplies

Revision 12-2; Effective June 1, 2012

In the initial pre-enrollment assessment, the Home and Community Support Services Agency (HCSSA) nurse identifies the basic needs of the individual for adaptive aids and medical supplies along with the estimated costs on Form 3671-E, Adaptive Aids and Medical Supplies. The HCSSA nurse must provide documentation supporting the medical necessity for all adaptive aids and medical supplies. The documentation must be provided by the physician, physician assistant, nurse practitioner, registered nurse, physical therapist, occupational therapist or speech pathologist. The medical professional who completes and signs the documentation can be an employee of the HCSSA. Use of Form 3671-F, Rationale for Adaptive Aids, Medical Supplies, Dental Services and Minor Home Modifications, is optional as long as the required documentation as specified on Form 3671-F is provided.

Adaptive aids and medical supplies are approved for purchase as a waiver service by the case manager only if the documentation supports the requested item(s) as being necessary and related to the individual's disability or medical condition.

The case manager may consult with the Department of Aging and Disability Services (DADS) regional nurse regarding the adequacy of the documentation submitted or in making the decision as to whether an adaptive aid or medical supply is needed and related to the individual's condition based on the documentation submitted by the HCSSA. The regional nurse may contact the HCSSA medical professional to discuss the necessity or relationship of a requested item to the individual's condition. DADS makes the final decision if the purchase is necessary and will be authorized on the individual service plan (ISP).

If the individual's request for a particular adaptive aid or medical supply is denied as part of the initial approval of Community Based Alternatives (CBA) enrollment, at annual reassessment or during the ISP year (even though eligible for CBA services), the individual must be notified of the denial of the specific item in the comments section of Form 2065-B, Notification of Waiver Services.

If the individual requests an item that the 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, or alternate documentation. The case manager determines whether the justification is sufficient for denial.

For requests made by the individual during the ISP year, the medical professional completes Form 3671-F or alternate documentation, as previously stated. It is sent to the case manager with Form 2067, Case Information, to explain that the item(s) requested by the individual are not medically necessary or related to the individual's disability or medical condition.

For situations in which the individual requests an adaptive aid or medical supply, and the item(s) are documented by the HCSSA nurse or other medical professional to be medically necessary, but the case manager finds the item(s) are not on the approved list, the case manager has the option of denying the item(s) or submitting the request for the unlisted item(s) to the regional nurse. If an approval is not granted, the case manager sends the individual Form 2065-B identifying the specific item(s) not approved in the comments section.

The individual may appeal the denial by requesting a fair hearing. The individual does not receive the adaptive aid or medical supply unless the denial is reversed. If the denial is reversed, the item is added to the ISP after the hearing officer's decision. The cost of the item is reflected in the ISP in effect at the time of the hearing.

Service plans should be specific for the individual. All ISPs should not include electric toothbrushes or grab bars as the routine practice of the HCSSA. All items must be related to the individual's disability or medical condition.

To avoid delaying the provision of necessary supplies or adaptive aids to the individual, the case manager should authorize the HCSSA's estimate for approved items on the ISP registered on the Service Authorization System (SAS). If the 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 contract manager for investigation, along with appropriate documentation to explain his concerns. The contact manager should conduct a review of the purchase records to see if there is justification for the specific purchase, purchase history, or both. The amount of the authorization on the ISP is reduced if the HCSSA requests a reduction of the authorization after the contract manager's investigation or DADS administrative staff direct the case manager to reduce the dollar amount of the authorization.

The HCSSA is required to obtain medical supplies and adaptive aids in the most cost-effective manner. Other factors, such as delivery time or warranties, may justify the selection of a bid or vendor that is not the least expensive. The case manager should recognize that the purchase of supplies on sale that week at a local retail outlet may not be the most cost-effective in the long run or practical for the individual in terms of storage of bulk purchases in his home or his changing needs.

The 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 case manager. The case manager may change the ISP retroactively in emergencies where the HCSSA has followed the procedures described in Section 3610.4, Case Manager Response to Emergency Requests, or after Medicare, Medicaid home health, private insurance or other resource has denied the adaptive aid. Since in these instances the item has already been delivered before the case manager has authorized the item, the HCSSA is not required to obtain specifications or bids for the item. The HCSSA is required to document the medical necessity for the item and complete Form 3848, CBA Documentation of Completion of Purchase. The case manager must use a retroactive effective date in these situations if the item is approved.

The case manager may add additional adaptive aids or medical supplies to Form 3671-E, Adaptive Aids and Medical Supplies, if the case manager and the individual determine there is an unmet need for these items that was not included in the original pre-enrollment home health assessment. When the ISP attachments are sent to the HCSSA with the proposed ISP, the case manager documents on Form 2067, Case Information, any changes to the original assessment and requests that the HCSSA evaluate the necessity for the item and develop the documentation on Form 3671-F, Rationale for Adaptive Aids, Medical Supplies, Dental Services and Minor Home Modifications, or alternate documentation.

Medical supplies are expected to be delivered to the individual within five working days after the individual begins to receive CBA services. For ISP changes or annual reassessments, the HCSSA must deliver medical supplies within five working days of being authorized to purchase the supplies. The individual's current supply of these items should be considered. For example, if the individual has a supply of diapers that is expected to last for one month, the diapers authorized on the ISP do not need to be delivered immediately.

If the HCSSA cannot deliver the adaptive aids by the time frames in Section 4147, Time Frames for Adaptive Aids/Medical Supplies, the HCSSA must notify the case manager via Form 2067, and include the reasons that the adaptive aid will be late. The case manager reviews the information to determine if the reason given for the delay is adequate or if additional intervention is necessary. It may be necessary for the case manager to discuss the reasons for the delayed delivery with the individual, HCSSA staff and DADS contract management staff.

If the adaptive aid requested will not be delivered in the current 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 or medical supplies limit, authorization determination must be obtained from the regional nurse to exceed the service limit. If the authorization on the new ISP causes the service plan to exceed the ISP 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.

If the HCSSA does not agree with the initial Form 3671-E because, for example, the HCSSA has identified new needs, the HCSSA completes a new Form 3671-E and submits it to the case manager along with Form 3671-F or similar documentation in another format. The form should specify the item requested and describe why the item is necessary and how it relates to the individual's disability or medical condition. Following approval by the interdisciplinary team, 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 3312, Referral for Pre-Enrollment Home Health Assessment.

4142.1  Lift Chair Approvals

Revision 10-5; Effective December 1, 2010

Lift chairs may be authorized as an adaptive aid using the following policy.

Once the Home and Community Support Services Agency (HCSSA) determines a lift chair may be needed or is requested by the individual, the HCSSA assesses the individual to determine if the individual meets all of the following criteria required for Medicare to pay for the lift mechanism:

  • The individual must have severe arthritis of the hip or knee or have a severe neuromuscular disease.
  • The seat lift mechanism must be a part of the physician's course of treatment and be prescribed to effect improvement, or arrest or retard deterioration in the individual's condition.
  • The individual must be completely incapable of standing up from any chair in his/her home. Once standing, the individual must have the ability to ambulate.

Individual Meets All Criteria

If the HCSSA determines the individual meets all of the criteria for Medicare to pay for the lift mechanism, the HCSSA submits Form 3671-E, Adaptive Aids and Medical Supplies, and Form 3671-F, Rationale for Adaptive Aids, Medical Supplies, Dental Services and Minor Home Modifications, to the case manager requesting approval of the cost of the lift chair minus the mechanism. The HCSSA is not required to submit Form 3672, Medicare/Medicaid/Third-Party Resources Utilization Report, showing Medicare denial. The HCSSA requests the durable medical equipment provider to deliver the lift chair and bill Medicare for the mechanism. The HCSSA should state on Form 3671-E in the "Item/Type of Equipment" description, "Lift Chair: No Mechanism." If the HCSSA does not specifically document on Form 3671-E the request is for the lift chair without the mechanism, the case manager must document on the form, "Lift Chair: No Mechanism."

If a request for a lift chair is received without a prescription and the required medical statements, as described below in the procedures, Seat Lift Mechanism Cannot Be Obtained Through Medicare or Medicaid, the case manager assumes the request is for the cost of the chair minus the mechanism.

Individual Does Not Meet All Criteria

If the individual does not meet all of the criteria for Medicare, the HCSSA must initiate the process to obtain the seat lift mechanism through Medicaid.

Seat Lift Mechanism Cannot be Obtained Through Medicare or Medicaid

If the individual does not meet the criteria to obtain the seat mechanism through Medicare or Medicaid, the HCSSA submits Form 3671-E and Form 3671-F to the case manager requesting approval of the lift chair plus the mechanism. The HCSSA should state on Form 3671-E in the "Item/Type of Equipment" description, "Lift Chair: Plus Mechanism." The HCSSA is not required to submit Form 3672 showing Medicare or Medicaid denial. Along with Form 3671-E and Form 3671-F, the HCSSA must submit:

  • a signed prescription or statement signed by the physician certifying the need for the lift chair, specifically stating the individual has difficulty or is incapable of getting up from a chair; and
  • a statement by the physician or HCSSA specifically stating that once standing, the individual has the ability to ambulate or transfer with or without assistance.

Specific Case Manager Actions

The case manager approves the cost of the lift chair plus the mechanism if the request meets all Community Based Alternatives (CBA) criteria and the above documentation is received. If the HCSSA does not specifically document on Form 3671-E the request is for the lift chair and the mechanism, the case manager must document on the form, "Lift Chair: Plus Mechanism."

In instances where the HCSSA cannot obtain or provide the required documentation because the individual does not meet the requirements, the HCSSA must state in the Comments section of Form 3671-F that the lift chair is not medically necessary. The case manager denies the request for the lift chair.

If a request for a lift chair minus the mechanism is approved by the case manager, but the HCSSA later requests additional funds for the mechanism that is denied by Medicare or Medicaid, the case manager may approve the request if it meets all CBA criteria, and Form 3672 or other documentation is received stating that the lift mechanism was denied by Medicare or Medicaid. To avoid billing issues, the effective date of the change to add the funds for the lift mechanism must be the same as the effective date of the first change completed to approve the lift chair minus the mechanism.

4142.2  Nutritional Supplement Approvals

Revision 10-1; Effective March 11, 2010

The following procedures must be used when authorizing nutritional supplements in the Community Based Alternatives (CBA) program:

  • The case manager must send all requests for nutritional supplements to the Department of Aging and Disability Services (DADS) regional nurse.
  • Products such as Carnation Instant Breakfast, V-8 Juice, Slim Fast, fruit juices, flavored water, vitamin enhanced water, bottled water, nutrition bars, protein bars and breakfast cereals are not covered by CBA.

Liquid nutritional supplements are covered by CBA when they are medically necessary and have either a therapeutic or a diagnostic benefit specific to the individual's diagnosis that is necessary to carry out the individual service plan (ISP). Ensure, Boost, Resource, Jevity, Glucerna (which is used primarily by individuals with diabetes), Pulmocare (which is used primarily by individuals with pulmonary disease) and Arginaid (which is used primarily by individuals with burns or wound care) are examples of covered nutritional supplements. 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. Nutritional supplements, if approved, are authorized and billed as medical supplies.

Nutrition bars, protein bars and breakfast cereals, including those marketed to individuals with specific medical conditions such as Glucerna Cereal and Glucerna Snack Bars (marketed to individuals with diabetes), do not require medical supervision and are not covered by the CBA program. Products such as Carnation Instant Breakfast, V-8 Juice, Slim Fast, fruit juices, flavored water, vitamin enhanced water and bottled water are available to individuals for overall health benefits and convenience. These products do not require medical supervision and are not covered by CBA programs.

The CBA case manager must send all requests for nutritional supplements to the DADS regional nurse. This includes initial requests for nutritional supplements, requests to increase the quantity/amount of supplements that an individual is already receiving and ongoing requests for supplements when a new ISP is being developed. The DADS regional nurse will determine if the nutritional supplement will be approved on the ISP.

The case manager must submit to the DADS regional nurse:

  • Form 3671-1, Individual Service Plan;
  • Form 3671-E, Adaptive Aids and Medical Supplies;
  • Form 3671-F, Rationale for Adaptive Aids, Medical Supplies, Dental Services and Minor Home Modifications;
  • the most current Medical Necessity and Level of Care (MN and LOC) Assessment;
  • Form 3672, Medicare/Medicaid/Third-Party Resources Utilization Report, or a statement indicating the item(s) not covered by Medicare, Medicaid or other third-party resource; and
  • any additional documentation submitted by the Home and Community Support Services Agency (HCSSA), such as a physician's order.

The DADS regional nurse will review the information and determine if the nutritional supplement will be approved or denied. The regional nurse documents the determination and sends it to the CBA case manager. This process does not extend the 14-day time frame the case manager has to respond to service plan changes. Refer to Section 3610.2, Case Manager Response to Routine Change Requests.

Procedures found in Section 3610.8, Optional Change Procedures for Adaptive Aids/Medical Supplies, that allow the HCSSA to obtain certain adaptive aids and medical supplies costing $200 or less without prior approval cannot be used by the HCSSA for nutritional supplement requests.

Clinical Guidance for DADS Regional Nurse

Guidance is provided for the DADS regional nurse to determine when a nutritional supplement must be approved. Nutritional supplements are intended to be used under medical supervision.

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. Accordingly, the regional nurse must consider the individual's overall health condition when making a decision to approve or deny the request.

Maintenance of adequate nutrition and prevention of unintended weight loss is essential to good health; malnutrition in elderly populations is associated with poor clinical outcomes. In general, liquid nutritional supplements are composed of water, sugar, milk and soy proteins, oils, vitamins and minerals (some have added fiber). Whole foods are more complex and provide additional beneficial substances. It is preferable for an individual to meet nutritional needs by eating whole foods rather than nutritional supplements. Home-delivered meals and/or meal preparation can be included as a purchased task on the ISP for CBA consumers who are unable to prepare their own meals. Therefore, nutritional supplements should only be approved when there is a demonstrated medical need as supported by the required documentation.

Documentation

In order to support the medical need for the nutritional supplement, the documentation on Form 3671-F must address:

  • the individual's diagnoses and medical conditions;
  • the individual's specific medical need for the nutritional supplement; and
  • how the requested nutritional supplement will meet the identified medical need and benefit the individual's health status.

A diagnosis alone is not sufficient information to support the need for a nutritional supplement. 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, documentation containing these types of statements must also include information about the individual's health condition and how the requested nutritional supplement will specifically benefit the individual.

The 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.

Ideal body weight has not been definitively established for the frail elderly and those with chronic illnesses and disabilities. An individual could be overweight and a nutritional supplement may be medically appropriate. Conversely, an individual could be underweight and a nutritional supplement may not be medically appropriate.

Body Mass Index (BMI) is a tool used as an indicator of appropriate weight for height. It is the responsibility of the regional nurse to evaluate whether the documentation submitted supports the necessity for the requested nutritional supplement. Accordingly, if the BMI or information acquired via another tool is a factor in the medical necessity for the requested supplement, the documentation submitted by the HCSSA should supply that information.

Examples

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

  • Arthritis and uses a nebulizer — He receives home-delivered meals and states he eats breakfast and dinner. He requests Ensure three times per day to help maintain weight and nutritional status.
  • Diabetes — She requests Glucerna due to poor appetite. Her height is 5 feet and her weight is 170 pounds. Her daughter states Glucerna makes her feel better and keeps her from feeling weak.
  • 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.
  • Dementia and a loss of appetite — He requests Ensure to increase his oral intake.
  • History of a stroke and has left-side weakness — Her caregiver reports that she doesn't eat much. She is 5 feet 7 inches and weighs 149 pounds. She requests nutritional supplement to obtain daily requirements of vitamins and minerals.
  • Diabetes — He reports that he eats all meals. There are no documented chewing problems or weight loss. He requests a nutritional supplement to control or stabilize blood sugar.

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

  • Was recently hospitalized due to an exacerbation of Chronic Obstructive Pulmonary Disease (COPD) — The hospital discharge was two weeks ago. In the month prior to hospitalization, he had unplanned weight loss. Since discharge, the exertion of feeding himself causes shortness of breath making it difficult for him to consume adequate calories to meet his needs. He is 5 feet 8 inches and his weight is 144 pounds. He lives alone and will drink the requested supplement between meals to boost his caloric intake during the times he does not have a provider.
  • 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 between meals will provide needed nutrients and help to prevent skin breakdown.
  • Has Multiple Sclerosis and in recent months her functional abilities have declined due to the development of increased weakness — She had unplanned weight loss; her weight decreased from 160 pounds to 145 pounds in the past three months. Her height is 5 feet 6 inches. The requested supplement will provide a nutritious and balanced snack for her to use between meals. It will decrease the potential for further unplanned weight loss.
  • 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, authorization of a time-limited supply of the supplement should be considered.
  • Has dementia — He has lost interest in eating and is on anti-depressant medications. He spends the majority of his days and nights in his recliner chair. In addition, he is on medications to control high blood pressure and to treat arthritis pain. A recent visit to the dentist confirmed that his dentures fit properly but the individual refuses to wear them. He is 5 feet 7 inches and his weight has been stable over the past three months at 161 pounds. He is having difficulty maintaining sufficient nutritional intake with soft foods and liquids alone. He requests Ensure three times per day to prevent weight loss and maintain nutritional status.
  • Has diabetes and recently had a leg amputation — She has not regained her appetite since surgery and has lost eight pounds in the past month. She requests two cans of Glucerna per day to prevent further weight loss and aid in the healing process. Note: In this case, authorization of a time-limited supply of the supplement should be considered.

4142.3  Monitored Medication Unit Approvals

Revision 12-3; Effective September 4, 2012

A monitored medication (MM) unit is a medical alert used as a medication reminder to individuals. If the individual does not respond when the alert is sounded, the monitoring company calls the individual's point of contact to determine why the individual did not respond to the alert. MM units operate 24-hours, seven days a week, to help ensure the individual is reminded to take his medication.

Most MM units are offered through companies providing other monitoring services, such as Emergency Response Services (ERS) or medical alerts. The functions of an MM unit will vary depending on the unit model. The responsibilities of an MM company also vary. These companies may sub-contract with the Home and Community Support Services Agency (HCSSA) to deliver this service or the HCSSA may provide the service for individuals in CBA.

Requirements for Individuals

An individual may qualify for an MM unit if he:

  • lives alone, is alone for extended periods of time when medications are needed or lives with someone who is incapable of ensuring medications are taken as prescribed;
  • has ongoing needs that require monitoring to ensure medications are taken as ordered by a physician to maintain health and welfare;
  • does not have available informal supports or paid assistance (such as reminding to take medications by the personal assistance services or private paid attendant) during times when medications are needed; and
  • is able to understand and operate the system, including being able to hear and understand the alerts and be physically able to reach the machine when the alert sounds.

An individual must also have a telephone to connect the MM unit.

An MM unit must not be authorized for an individual who lives in an assisted living facility or adult foster care home.

Reviewing Requests for MM Units

HCSSAs or companies that provide MM units charge a monthly fee that includes rental of the MM unit and the monthly monitoring service. The monthly fee may also include medication cups, batteries, training (for the individual and his contact), repair and replacement of the MM unit. The Department of Aging and Disability Services (DADS) will not authorize itemized costs or fees documented on Form 3671-E, Adaptive Aids and Medical Supplies. DADS will only authorize reimbursement for the monthly fee. If items or services related to the MM unit are not included in the monthly fee, the individual is not responsible for payment to the HCSSA or MM unit company and should not be billed for the related items or services.

Neither DADS nor the individual receiving services is liable for payment for lost or damaged equipment.

The cost of the MM unit and monthly service is identified as an adaptive aid on Form 3671-E. The HCSSA should document the estimated annual cost of the MM unit on Form 3671-E. If the HCSSA submits a request for an MM unit as a monthly fee, the case manager must multiply the monthly fee amount by the number of months remaining in the Individual Service Plan (ISP) period. MM units do not require specifications; therefore, specification fees should not be authorized.

The case manager must send all requests for MM units to the DADS regional nurse for authorization determination. Supporting documentation must indicate why a basic medication dispenser will not meet the individual's need and identify any health and welfare issues related to the individual's ability to operate the MM unit. All third-party resources (TPR) and available informal supports to provide assistance with or administer medications must be explored.

Service Delivery

When an MM unit is authorized, the individual and the HCSSA or MM unit company will work together to identify:

  • medication schedules;
  • frequency of alerts;
  • duration of alerts after the initial alert; and
  • a contact who will be notified if the individual does not respond to the alert.

The individual will be required to identify a contact in the event the HCSSA or MM unit company needs to alert a person of a missed dose. The contact should be a person who has a close relationship with the individual and may have taken on the responsibility of filling the MM unit. The HCSSA nurse may also fill MM units if the units dispense medication. In addition to the identified contacts, some MM unit companies may also notify the HCSSA of missed doses.

For MM units that dispense medication, the HCSSA may include nursing hours to pre-fill the unit on Form 3671-C, Nursing Service Plan, or 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), as appropriate.

Termination of MM Unit Authorizations

An interdisciplinary team meeting may be needed:

  • if the individual is no longer able to operate the equipment;
  • to attempt to resolve an issue if a problem is identified but the individual wishes to continue using the equipment; and
  • to determine an alternate means to assist the individual with his medication regimen if the decision is made to terminate the MM unit authorization.

The MM unit authorization must be terminated upon the individual's death or if the individual acquires new informal supports and the unit is no longer required for maintaining the individual's medication regimen.

If the decision is made to terminate the MM unit authorization, the HCSSA or MM unit company will remove the equipment from the individual's home.

If the MM unit authorization is terminated, the case manager must complete and send Form 2065-B, Notification of Waiver Services, to the individual and HCSSA providing advance notice for the adverse action.

To terminate the MM unit authorization, the case manager must request the HCSSA submit Form 3671-E documenting the utilized cost of the MM unit up to the effective date of the change. The MM unit monthly fee is not prorated by the number of days in the month of termination. The case manager authorizes the cost of the MM unit monthly fee for the month of the authorization termination. Using the ISP change action in the Service Authorization System (SAS), the case manager adjusts the annual authorized amount in the Units field by subtracting the amount of the decrease from the previous amount entered in the Units field.

Example: The annual authorized amount in units for adaptive aids is $2,000. The original request for the MM unit was $1,200. The HCSSA notifies the case manager the utilized amount is $800. The case manager subtracts $800 from $1,200, which equals $400. The case manager subtracts $400 from $2,000, which equals $1,600. The case manager enters $1,600 in the Units field as the new annual authorized amount for adaptive aids.

This policy will be applied at the next annual reassessment for an individual who is currently authorized an MM unit and has an ISP that expires before May 2013.

Policy for MM unit requests does not apply to authorization determination procedures for:

  • medication devices, including manual medication reminder systems, pill organizers, medication boxes, pill planners, pill splitters, pill crushers and similar types of medication systems designed for diabetics on the List of Adaptive Aids Approvable by the Case Manager; or
  • electronic/alarming medication dispensing boxes on the List of Adaptive Aids and Medical Supplies that Require Regional Nurse Review for Authorization Determination.

Refer to Section 3811.2.3, Code 35 Procedures, for procedures related to reinstating monitored medication units when an individual is temporarily admitted into a nursing facility.

4142.4  Vehicle Modification Requirements

Revision 13-1; Effective March 1, 2013

The case manager may approve a vehicle modification to the primary transportation vehicle to be used by an individual receiving services as an adaptive aid if the Home and Community Support Services Agency (HCSSA) submits documentation showing the requested vehicle modification is: (a) necessary for the individual to optimal function, independence and well-being; and (b) related to the individual's disability or medical condition.

When requesting a vehicle modification, the HCSSA is required to submit information on the primary transportation vehicle to be modified, including:

  • Form 3671-E, Adaptive Aids and Medical Supplies;
  • Form 3671-F, Rationale for Adaptive Aids, Medical Supplies, Dental Services and Minor Home Modifications, or alternate documentation;
  • the year, make and model of the vehicle;
  • the mileage of the vehicle; and
  • Form 3672, Medicare/Medicaid/Third-Party Resources Utilization Report, or any other written documentation, to confirm that other third party resources are not available for the vehicle modification.

If the vehicle modification costs $1,000 or more and the vehicle has been driven more than 100,000 miles or is more than four years old, the HCSSA is required to obtain and submit a written evaluation of the requested vehicle modification to the case manager. The evaluation must be completed by a mechanic who is not the provider. The written documentation must include a statement indicating the sound mechanical condition of all major components of the vehicle, including a statement that the vehicle is mechanically and structurally sound to support the requested modification. The actual cost of the written evaluation as part of the invoice cost of the adaptive aid may not exceed $150. The written evaluation is a reimbursable expense whether or not the vehicle modification is approved as long as the evaluation submitted contains the required information. A written evaluation by a mechanic is not required for a vehicle modification repair that is under $1,000.

After approval of the vehicle modification by the case manager, the HCSSA will procure bids for the vehicle modification, if applicable. The HCSSA maintains the bid information in the HCSSA’s records and is not required to submit bid information to the case manager.

4142.5  Verification of Third-Party Resources for Adaptive Aids and Medical Supplies

Revision 13-1; Effective March 1, 2013

The Department of Aging and Disability Services (DADS) does not require a Community Based Alternatives (CBA) Home and Community Support Services Agency (HCSSA) to provide proof of denial for adaptive aids and medical supplies that acute care Medicaid would never approve. A list of items is found in Appendix XVIII, Acute Medicaid List of Adaptive Aids and Medical Supplies. The HCSSA may request items on the list that are marked "N" without having to provide a statement that Medicaid will not pay for the item. The HCSSA is required to provide a statement that acute care Medicaid will not pay for items designated on the list as "Y."

For all adaptive aids and medical supplies, the HCSSA is required to submit Form 3671-E, Adaptive Aids and Medical Supplies, to request approval. The HCSSA is also required to submit Form 3672, Medicare/Medicaid/Third-Party Resources Utilization Report, the Texas Medicaid & Healthcare Partnership (TMHP) denial letter, or other statement advising whether Medicare, Medicaid or other third-party resources will or will not pay for items requested on Form 3671-E. The HCSSA is required to submit one of the above documents with Form 3671-E to advise if:

  • Medicaid will or will not pay for items requested on Form 3671-E that are not on the attached list, or on the attached list marked as "Y"; and
  • Medicare or other third-party resources will or will not pay for items requested on Form 3671-E.

The HCSSA is required to use either Form 3671-F, Rationale for Adaptive Aids, Medical Supplies, Dental Services and Minor Home Modifications, or an alternate documentation source to verify why an item is needed and that it is related to the individual's condition.

DADS requires the HCSSA to attempt to purchase all items listed on the individual service plan (ISP) from Medicare, Medicaid or other third-party resources before requesting authorization for these items through CBA. The HCSSA is required to continue to work with the case manager to ensure that if the individual is eligible for Medicare (Title XVIII) or Medicaid (Title XIX) home health services or any other third-party resources, those resources are used to meet the individual's need for services. Federal regulations require the individual to access third-party resources before the state will provide CBA services. The HCSSA is responsible for knowing when to access Medicare and Medicaid Title XIX.

4143  Provider Responsibilities Pertaining to Adaptive Aids and Medical Supplies

Revision 12-2; Effective June 1, 2012

§48.6052 — Cost-Effective Purchases of Adaptive Aids.

(a)
Adaptive aid costing less than $500.
(1)
For any single adaptive aid expenditure costing less than $500, the HCSSA must:
(A)
determine and document the needs and preferences of the participant for the adaptive aid;
(B)
document the necessity for the adaptive aid;
(C)
consider renting the adaptive aid on a short-term basis if the participant's needs or desires cannot be accurately determined at the time of the assessment;
(D)
obtain comparative price quotes or use a price list to document prices of the adaptive aid from a minimum of three suppliers or annually select a supplier based on the lowest prices from the quotes or price list for the main types of adaptive aids purchased by the HCSSA;
(E)
document in the vendor records:
(i)
the names of the suppliers from whom all quotes or price lists were obtained;
(ii)
the amount of the quotes or price lists;
(iii)
the items for which the quotes or price lists were requested; and
(iv)
the dates the quotes or price lists were obtained;
(F)
document in the individual's record;
(i)
the reason each selection is made (examples are cost, delivery time of item, record of quality services, access to loaners during repairs, repair history, and warranty; the individual's personal preference alone is not sufficient justification for purchasing a more expensive item;) or
(ii)
the selection of an annual supplier; and
(G)
have an LVN, RN, occupational therapist, physical therapist, speech, hearing, and language therapist, or other appropriate HCSSA employee or contractor who has been involved in the procurement contact the individual within ten DADS workdays after delivery of the adaptive aid to the individual to:
(i)
verify that the adaptive aid meets the needs of the individual;
(ii)
verify that orientation was provided to the individual in the use of the adaptive aid; and
(iii)
document completion of the purchase and satisfaction of the individual on the CBA Documentation of Completion of Purchase form.
(2)
If the HCSSA becomes aware that additional orientation, training, or adjustments to the adaptive aid are needed, the HCSSA:
(A)
must ensure an LVN, RN, occupational therapist, physical therapist, speech, hearing, and language therapist, or durable medical equipment vendor conducts a home visit to provide the needed orientation, training or adjustments within 14 DADS workdays after the HCSSA becomes aware of the need; and
(B)
may request reimbursement for the home visit at the hourly rate for nursing or therapy services, depending on which professional provided the service.
(b)
Adaptive aid costing $500 or more.
(1)
For any single adaptive aid expenditure costing $500 or more, in addition to complying with the requirements listed in subsection (a) of this section, the HCSSA must:
(A)
obtain written specifications for the adaptive aid from:
(i)
a licensed physician;
(ii)
an RN;
(iii)
an occupational therapist;
(iv)
a physical therapist;
(v)
a speech, hearing, and language therapist; or
(vi)
for computer assistive technology, augmentative communication devices, or environmental controls, another appropriate professional, including a rehabilitation engineer;
(B)
record the following in a document maintained in the individual's record:
(i)
the individual's name and address;
(ii)
the adaptive aid that is the subject of the written specifications;
(iii)
the written specifications;
(iv)
the printed name and dated signature of the person who prepared the written specifications; and
(v)
the individual's dated signature;
(C)
maintain the following documentation in the individual's record:
(i)
a description of the relevant experience of the person who prepared the written specifications; and
(ii)
the invoice for the written specifications;
(D)
obtain comparative price quotes or use a price list to document prices of the adaptive aid from a minimum of three suppliers or annually select a supplier based on the lowest prices from the quotes or price list for the main types of adaptive aids purchased by the HCSSA; and
(E)
document in the vendor records;
(i)
the names of the suppliers from whom all quotes or price lists were obtained:
(ii)
the amount of the quotes or price lists;
(iii)
the items for which the quotes or price lists were requested; and
(iv)
the dates the quotes or price lists were obtained.
(2)
DADS approves reimbursement for written specifications authorized on an ISP if the written specifications:
(A)
were prepared by a person described in paragraph (1)(A)(i) or (vi) of this subsection and the claim does not exceed the amount of the invoice described in paragraph (1)(C)(ii) of this subsection subject to the limit described in §48.6078(6) of this subchapter (relating to Billable Units);
(B)
were prepared by a person described in paragraph (1)(A)(ii) of this subsection and the claim is submitted as a nursing service; or
(C)
were prepared by a person described in paragraph (1)(A)(iii) – (v) of this subsection and the claim is submitted as a therapy service.
(3)
A HCSSA may claim reimbursement for an assessment for an adaptive aid:
(A)
conducted by an RN as a nursing service; and
(B)
conducted by an occupational therapist, physical therapist, or speech, hearing, and language therapist as a therapy service.
(4)
If an appropriate professional described in paragraph (1)(A)(vi) of this subsection is required to provide an assessment for computer assistive technology, environmental controls, or augmentative communication devices, the actual cost of an assessment or a follow-up orientation or training visit is reimbursed, up to a maximum of $500. The HCSSA must maintain documentation to support the cost of providing an assessment and conducting a follow-up orientation or training visit.

The Home and Community Support Services Agency (HCSSA) nurse identifies the applicant's and individual's needs and preferences on Form 3671-E, Adaptive Aids and Medical Supplies, at the time of the pre-enrollment, annual reassessment 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.

If Medicare or Medicaid home health denies an adaptive aid, or if an adaptive aid is delivered following emergency procedures as outlined in Section 4145, Emergency Procurement of Adaptive Aids and Medical Supplies, the case manager changes the individual service plan (ISP) to include the adaptive aid and authorizes payment for the item. Since, in this case, an item has already been delivered before the case manager has authorized the item, the HCSSA is not required to get specifications or bids for the item. The HCSSA is required to document the medical necessity for the item and complete Form 3848, CBA Documentation of Completion of Purchase. For items delivered using emergency procedures or denied by Medicare or Medicaid home health, the case manager must use a retroactive date (date of service delivery) as the effective date.

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 or 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 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 a wheelchair. If the medical professional, the individual, or both, are 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 circumstances of the 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 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 case manager prior to replacement is required for Community Based Alternatives (CBA) to pay.

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

If the HCSSA chooses to annually select a supplier for all of the adaptive aids it will purchase during a calendar year, it must select a supplier based on the cost, delivery time, supplier record of quality service, or supplier's access to loaners, repair history and warranties. If the HCSSA annually selects a supplier, it is not required to get three bids, but is required to get written specifications for adaptive 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, CBA Documentation of Completion of Purchase, is used by the HCSSA to verify that the adaptive aid meets the individual's needs; that orientation was provided to the individual in the use of the adaptive aid; and to document completion of purchase and satisfaction of the individual. This form is not completed for the purchase of batteries. This form is completed based on a telephone contact or face-to-face visit, if applicable. The telephone contact or face-to-face visit to provide orientation, training, or both, must be made within 10 working days of delivering the adaptive aid. When making a telephone contact, HCSSA staff must document the date and name of the person (individual or his responsible party) 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 the Department of Aging and Disability Services (DADS) more than it charges the general public.

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

If determined via the telephone contact that additional orientation, training or adjustments to the adaptive aid are needed, or if the individual states the adaptive aid is not what was expected, or if the individual is dissatisfied with the adaptive aid, a therapist, nurse or durable medical equipment (DME) vendor must conduct a face-to-face visit within 14 working days of the telephone contact to provide additional orientation, training or adjustments to the adaptive aid. Form 3848 must be completed and submitted to the case manager within seven working days of the face-to-face visit. This face-to-face 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 in which CBA pays the entire cost of the item. For instances in which CBA only pays a portion of the cost, such as copay, CBA does not monitor for the completion of purchase, individual's satisfaction or need for any training or orientation.

If the HCSSA determines that hours for a face-to-face visit are needed for the nurse to develop specifications or orient or train the individual on the use of the adaptive aid, then this request must be documented on Form 3671-C, Nursing Service Plan, or 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). If therapy hours are needed to develop specifications or orient or train the individual 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 face-to-face visit are initially requested, the visit still can be conducted without prior approval of the case manager if a need for the visit is determined when the individual is contacted. If the HCSSA believes the existing estimated hours for the service category of the professional that will conduct the visit is insufficient to cover the visit, the HCSSA should inform the case manager on Form 3848, Section I, Item 9, Description of Job or Item, of the number of hours spent conducting the visit. The 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 HCSSA and the individual.

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

If any problem is identified during the orientation or training visit, the HCSSA must attempt to resolve the problem before submitting Form 3848 to the case manager. Examples of possible solutions include adjustments to improve 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 HCSSA can still submit a claim for the item. However, the HCSSA must assure notification to the case manager by documenting in Section IV of Form 3848 the individual's voiced dissatisfaction and reason. The case manager calls or visits the individual to investigate the reason for the dissatisfaction and determines the next steps that 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 face-to-face 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, Item 32, Specification Fee. The case manager will enter this fee amount on Form 3671-1, Individual Service Plan, under Service Code 040, Specifications. This fee amount will not impact the $10,000 adaptive aid and 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 include instances in which the HCSSA:

  • sent out reminder letters to the contractors who did not return a bid package (this can be documented by a certified mail receipt),
  • sent bid packages to more than three contractors (as evidenced by certified mail receipt), and
  • called contractors to follow up on 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. The individual's preference should not be the only factor in making purchasing decisions. The HCSSA 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 individual remain with the individual, if services are terminated or with the individual's estate upon death;
  • make vehicle modifications in accordance with the Department of Assistive and Rehabilitative Services' Standards for Automotive Adaptive Equipment and Vehicle Modifications; and
  • assure that the CBA waiver is the last payor for identified items.

For items over $500, the description in the DME catalog is acceptable for a specification. If the description contains multiple options for an item, the HCSSA must indicate or mark the options that will be provided to the individual. The HCSSA nurse may not claim service hours for specifications when a DME catalog description is used.

§48.6058 — Cost-Effective Purchases of Medical Supplies.

The Home and Community Support Services agency must:

(1)
prior to the selection of medical supplies, obtain comparative price quotes or use a price list to document prices of the medical supplies from a minimum of three suppliers, document the basis for selection and for those selected, document in the vendor records the names of the suppliers from whom all quotes/price lists were obtained, the amount of the quotes/price lists, the items for which the quotes/price lists were requested, and the dates the quotes/price lists were obtained; or
(2)
at least annually select supplies based on the lowest prices from the quotes/price list for the main types of supplies that the agency has been purchasing, and document the justification of the selection, including cost, delivery time of item, and record of quality services.

When making purchases based on the lowest prices quoted for the main types of supplies, the HCSSA 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, the HCSSA should keep the actual price list from the vendors to prove cost-effectiveness was considered in the selection process. When using a price list or obtaining comparative price quotes, the HCSSA must document the price quote, date of the quote, name of provider 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 case manager.

Medicaid home health can refer the individual 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 securing 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.

The HCSSA should not submit adaptive aid requests to the 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 DME are a one-time purchase and should not be authorized through CBA for an individual potentially eligible for Medicaid home health, unless Texas Medicaid & 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 DME may be rented through CBA in the interim or provided on an emergency basis to assure health and welfare.

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.)

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.

An individual who receives diapers or other medical supplies 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 pays for glucose monitors, test strips and lancets for all individuals with diabetes 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, Medicaid Qualified Medicare Beneficiary or a third-party resource for items covered through CBA and identified on the ISP, the co-insurance can be authorized on Form 3671-E for payment through CBA (under adaptive aids). See Section 4149, Co-Insurance and Deductibles.

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

4143.1  Agency Responsibilities Pertaining to Optional Change Procedures for Adaptive Aids/Medical Supplies

Revision 12-2; Effective June 1, 2012

A Home and Community Support Services Agency (HCSSA) registered nurse (RN) may provide certain adaptive aids and medical supplies without obtaining prior authorization from the case manager.

The HCSSA must check the most recent Form 3671-E, Adaptive Aids and Medical Supplies, for the addition of the $1,000 before delivery of an item under the optional procedures. If the HCSSA's records indicate that buffers have been expended, the HCSSA must request prior approval from the case manager, using the current procedures in Section 3610, Revising the Individual Service Plan (ISP), and Community Based Alternatives Provider Manual, Section 4452.2, Requests for Routine Service Plan Changes, for additional requests.

HCSSA Procedures for Change Requests Using the Optional Change Procedures

The HCSSA can deliver an adaptive aid or medical supply without prior authorization from the case manager if it meets the following three criteria:

  • The item costs less than $200.
  • The item is listed in the Community Based Alternatives Provider Manual on the approved list of adaptive aids and medical supplies.
  • There is a medical need for the item as determined and documented by an RN or other health professional.

The HCSSA RN must consider the following when determining delivery of an adaptive aid or medical supplies using the optional change procedures:

  • There is a change in the individual's medical condition, functional needs or environment.
  • There is a change in the caregiver's support or third-party resources (TPRs) that have been providing service to the individual.
  • A Community Based Alternatives (CBA) service or support (either a new or an expansion of existing service on a temporary or long-term basis) is needed to adequately support an individual to live in the most integrated setting in the community.

The HCSSA RN must make a determination on the basis of the necessity of the requested item, the individual's disability or medical condition, and the necessity of the service to adequately support the individual living in the most integrated setting possible in the community.

Within seven calendar days of identifying the individual's need for an item, the HCSSA sends the case manager:

  • Form 2067, Case Information;
  • Form 3671-E;
  • Form 3671-F, Rationale for Adaptive Aids, Medical Supplies, Dental Services and Minor Home Modifications, or alternate documentation; and
  • other appropriate forms.

The HCSSA must deliver to the individual an adaptive aid within 14 working days and a medical supply within five working days of the HCSSA RN's or health professional's signature on Form 3671-E and Form 3671-F, or alternate documentation. Form 2067, submitted to the case manager, must identify the item and clearly state that the item meets the adaptive aid or medical supply guidelines and has been delivered to the individual.

Semiannual Nursing Assessments

An HCSSA RN completes the semiannual nursing assessment and identifies additional changes in an individual's condition and initiates appropriate interventions. The HCSSA RN submits Form 2067 to the case manager within seven calendar days of completion of the semiannual nursing assessment, even if no service plan changes are required. Form 2067 must indicate:

  • the date of the semiannual nursing assessment;
  • new requests initiated at the semiannual assessment;
  • all items and requests delivered during the past six months; or
  • no changes requested.

Upon receipt, case managers review requests for adaptive aids and medical supplies to determine if the item delivered meets the criteria for delivery without prior authorization from a case manager. The case manager responds per procedures outlined in Section 3610.8, Optional Change Procedures for Adaptive Aids and Medical Supplies.

An HCSSA must continue to assure that Medicare, Medicaid and other TPRs are accessed before providing an adaptive aid or medical supply through the CBA program. If a request is submitted on Form 3671-E and subsequently approved for payment through Medicare, Medicaid or a TPR, the HCSSA advises the case manager by Form 2067 and the item is not included on the ISP update. When applicable, the HCSSA uses the emergency procurement procedures outlined in the Community Based Alternatives Provider Manual, Section 4424.4.2, Emergency Procurement of Adaptive Aids and Medical Supplies.

For requests costing more than $200, the HCSSA RN must follow normal procedures as outlined in the Community Based Alternatives Provider Manual, Section 4424.1, Documentation of Necessity.

For items requested that are not listed in the Community Based Alternatives Provider Manual, Section 4424.2, List of Adaptive Aids and Medical Supplies, the HCSSA RN follows the procedures as outlined in Section 4424.1 to document if the item meets medical criteria. The HCSSA RN submits Form 3671-E and appropriate attachments to the case manager.

4144  Requesting Adaptive Aids or Medical Supplies Not on the Approved List

Revision 11-1; Effective March 1, 2011

To request adaptive aids and medical supplies not on the approved list, the case manager must send a written request to the Department of Aging and Disability Services (DADS) regional nurse for approval to authorize the needed item(s). The case manager must send a written request on Form 1547, Regional Nurse/Dental Consultant Request Worksheet, along with appropriate documentation.

Although the Home and Community Support Services Agency (HCSSA) must certify the availability of resources, it is the case manager's responsibility to ensure that other resources are used before requesting items from the waiver.

If a request is made to the DADS regional nurse for 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 DADS regional nurse. The item(s) 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(s) is pertinent to the applicant's/consumer's disability or medical condition, authorization for the identified services will be delayed. More descriptive information may be requested by the case manager or regional nurse from the HCSSA to support the medical necessity and in some instances, to resubmit the request.

Adaptive aids and medical supplies that are not on the approved list may be requested more than once in the ISP year due to the consumer's recurring need for the item(s). Some adaptive aids and medical supplies may require closer review because of the consumer's medical condition. When initially approving an item not on the approved list, the DADS regional nurse must document on the approval form whether or not regional nurse approval is required at each subsequent request during the ISP period. If subsequent approvals are required, the DADS regional nurse must provide a brief comment explaining why the additional approvals are required.

For example, diabetic socks are not on the approved list and the request is submitted to the DADS regional nurse for approval. Based on medical documentation submitted with the request, the regional nurse:

  • approves the request;
  • determines that additional approval is not necessary for subsequent diabetic sock requests in the ISP year; and
  • documents on the approval form that regional nurse approval is not required for additional diabetic sock requests in the ISP year.

Regional nurse consultation and continued approval should always be considered when a request is received for a recurring item and the case manager has concerns about the consumer's condition and medical need, even if the DADS regional nurse has indicated the initial approval was for the entire ISP period.

If unsure about approving items, regional nurses may request state office to:

  • review the medical necessity and rationale for requests for an adaptive aid or medical supply not on the approved list;
  • advise if the item(s) is prohibited by waiver rules; and
  • provide a final determination of approval or disapproval of the item(s).

The DADS regional nurse will submit a written request to: State Office Nurse, Community Services Policy and Curriculum Development, Community Services and Program Operations, Mail Code W-351. The DADS regional nurse will send the state office nurse all supporting documentation provided by the case manager and any additional documentation obtained by the DADS regional nurse.

The state office nurse may request additional information if the documentation submitted is not sufficient to make a determination or does not support the regional recommendation. The state office nurse will approve or deny the request in writing to the DADS regional nurse.

4144.1  Requesting Regional Nurse Approval to Exceed Individual Service Cap

Revision 11-1; Effective March 1, 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 on Form 1547, Regional Nurse/Dental Consultant Request Worksheet, to the regional nurse along with appropriate documentation.

The DADS regional nurse reviews all materials submitted and consults with the case manager, Home and Community Support Services Agency (HCSSA), and other resources as appropriate, to make a professional judgement 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 items(s) on the list of adaptive aids and medical supplies. 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 case manager counsels the consumer of the possible risk of exceeding the annual $10,000 cost ceiling during the individual service plan (ISP) year. If additional funds are used during the ISP year to purchase adaptive aids that could be purchased later, without placing the consumer's health and safety at risk, funding may not be available during the current ISP year to meet the consumer's unforeseen needs.

4145  Emergency Procurement of Adaptive Aids and Medical Supplies

Revision 09-9; Effective December 1, 2009

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

If the case manager or the Home and Community Support Services (HCSS) agency identifies a need for the emergency purchase and delivery of a medical supply, the HCSS agency must deliver the item within two Texas Department of Human Services business days 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 consumer's health and/or safety at risk.

An emergency purchase is defined as a purchase precipitated by a change in the consumer's condition to meet his acute care needs brought about by the condition change. Examples of emergency purchases could be:

  • supplies and durable medical equipment (DME) needed to provide suctioning as ordered by the physician due to being notified of a consumer's respiratory distress;
  • incontinent supplies such as diapers needed due to a consumer's condition change and as an emergency for providing necessary hygiene; or
  • emergency dental treatments.

The lack of planning by a provider ordering 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 consumer 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 business day 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 consumer's or consumer'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 consumer's disability or medical condition; and
      3. a physician's statement that the adaptive aid or medical supply was for an emergency. This order can be obtained from the physician when receiving orders for interventions to meet the consumer'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.); and
    4. ensure delivery of the emergency item within two DADS business days of identifying the need.

A physician's statement is not needed for emergency repairs of adaptive aids or DMEs previously authorized through Community Based Alternatives for purchase.

4146  Effects of Changing Providers on Adaptive Aids Procurements

Revision 13-1; Effective March 1, 2013

If an individual wishes to change to another Home and Community Support Services Agency (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 HCSSA 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 HCSSA initiates service and the transferring HCSSA will bill for the adaptive aid upon delivery of the adaptive aid to the individual using the last day the transferring HCSSA is authorized to deliver services as the billing date.

4147  Time Frames for Adaptive Aids/Medical Supplies

Revision 02-0; Effective April 4, 2002

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

(a)
The Home and Community Support Services agency must purchase and ensure delivery of any adaptive aid within 14 Texas Department of Human Services (DHS) workdays of being authorized to purchase the adaptive aid, counting from either the effective date of the individual service plan form or the date the form is received, whichever is later.
(b)
A 90% compliance level is required. The provider must notify the participant and case manager in writing of any delay, with a new proposed date for delivery. The notification must be provided on or before the 14th DHS workday following authorization.

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

(a)
The Home and Community Support Services agency must purchase and ensure delivery of any adaptive aid within 30 Texas Department of Human Services (DHS) workdays of being authorized to purchase the adaptive aid, counting from either the effective date of the individual service plan form or the date the form is received, whichever is later.
(b)
A 90% compliance level is required. The provider must notify the participant and case manager of any delay, with a new proposed date for delivery. The notification must be provided on or before the 30th DHS workday following authorization.

Form 3671, 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 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 participant and the case manager on Form 2067 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, CBA Documentation of Completion of Purchase, Item 3, Date Completed/Delivered.

§48.6060 — Time Frames for Medical Supplies.

(a)
The Home and Community Support Services (HCSS) agency is responsible for assuring the purchase and delivery of any authorized medical supply within five Texas Department of Human Services (DHS) work days of the waiver service initiation date.
(b)
On existing cases, the HCSS agency must deliver medical supplies within five DHS workdays of being authorized to purchase the supplies, counting from the effective date of the individual service plan form or the date the form is received, whichever is later.
(c)
If the HCSS agency cannot ensure delivery of a medical supply due to unusual or special supply needs or availability within five DHS work days of receipt of DHS's authorization, the HCSS agency must submit the case information form to the case manager before the fifth day, containing an explanation why the medical supply cannot be delivered within the required time frame and including a new proposed date for the delivery.

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 participant and did not require delivery at this time. The waiver service initiation date will be documented on Form 3670, Documentation of Services Delivered. Form 3671 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 participant's home at a time.

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

4148  Reserved for Future Use

Revision 12-2; Effective June 1, 2012

4149  Co-Insurance and Deductibles

Revision 02-0; Effective April 4, 2002

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 participant 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 ISP, the deductible can be listed under adaptive aids on Form 3671-E for payment through CBA.

4149.1  Temporary Lease and Equipment Rental

Revision 02-0; Effective April 4, 2002

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 participant. If the medical professional and/or the participant 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/participant.

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 participant 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.

4149.2  Bulk Purchase of Medical Supplies

Revision 02-0; Effective April 4, 2002

The home and community support services agency 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.

4149.3  Reporting Medical Supplies on the Cost Report

Revision 02-0; Effective April 4, 2002

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. Home and community support services agencies are responsible for providing these items on a routine basis.

If a participant 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 participant's home to be used by his family, informal support, or attendant in providing care.

4149.4  Freight and Delivery Charges

Revision 12-2; Effective June 1, 2012

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

The Home and Community Support Services agency must assure that, if medical supplies or adaptive aids are delivered to the participant by means of any commercial carrier, such as United Parcel Services or United States Postal Service, the most cost effective carrier is used. Overnight delivery should not be used unless it is an emergency purchase that cannot be purchased locally and delivered by the next day after determining the need.

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.

4150  Minor Home Modifications

Revision 02-0; Effective April 4, 2002

Minor home modification services will be limited to those services identified and approved by DADS on the participant's ISP, Form 3671.

DEFINITION:

Minor home modifications are those services that assess the need for, arrange for, and provide modifications and/or improvements to a participant's home or an adult foster care home to enable participants 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 participant's needs. Ensure that minor home modifications directly aid the participant, avoid premature NF placement, and provide NF residents an opportunity to return to the community. Minor home modifications may be made to a participant's residence when he is receiving out-of-home respite services.

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

Minor home modifications can also be provided to participants 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.

4151  List of Minor Home Modifications

Revision 10-5; Effective December 1, 2010

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. worktable/worksurface 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 consumer, 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. There is no limit to the number of wheelchair ramps that can be authorized, provided the total cost does not exceed the cost ceiling, but documentation must support the justification for additional ramps as related to medical need or health and safety of the consumer.

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

Requests for items (or repair of items) or service calls that are considered routine home maintenance and upkeep cannot be approved.

Items that cannot be approved by the case manager or the regional nurse include:

  • carpeting (other than industrial grade);
  • newly constructed carports, porches, patios, garages, porticos or decks;
  • electric fences;
  • landscaping and yard work or supplies;
  • roof repair or replacement;
  • gutters;
  • leaky faucet repair;
  • elevators;
  • house painting;
  • electrical upgrades and/or electrical outlets unless needed to power adapted equipment, or a safety hazard exists;
  • air duct cleaning and maintenance; and
  • pest exterminations.

Heating and cooling equipment may be approved as an adaptive aid. Installation of approved heating and cooling equipment is included in the cost of the adaptive aid. Support platforms are frequently used to provide support for cooling equipment installed in home windows. The support platforms attach in a clamp-like manner without fasteners. The cost and installation of support platforms are considered as an adaptive aid. The installation of heating and cooling equipment may require modification of the home (for example, additional wiring or widening of the windows). The modification of the home must be authorized as a minor home modification.

Flooring applications, including vinyl and industrial carpet, may not be authorized for adaptations or improvements to the home that are of general utility and are not of direct medical or remedial benefit to the consumer.

4151.1  Home Modification Service Cost Lifetime Limit

Revision 09-9; Effective December 1, 2009

The minor home modification service category must not exceed a lifetime maximum cost of $7,500 per consumer without approval by the Department of Aging and Disability Services. The term "lifetime" is defined as the actual life or mortality of the Community Based Alternatives (CBA) individual and not the duration of the consumer's case.

The $7,500 service limit is linear and cumulative. The "lifetime" limit begins when a CBA consumer uses the minor home modification service and continues until the service limit is reached. A consumer who is suspended or discharged from the waiver and then becomes eligible at a later date, will have access to minor home modification services beginning from the remaining balance. Future minor home modifications will be added to the previous balance, thus accumulating all expenses until the service limit is reached. For example, a CBA consumer who uses $3,000 for minor home modification in March 2008, and then is suspended or discharged from the waiver, will still have access to the remaining balance ($4,500) for future use upon returning to eligible waiver status.

The CBA case manager must review the Service Authorization System and the closed case, if available, to determine the remaining balance amount of the $7,500 lifetime home modification service limit available to the consumer.

4152  Case Manager Responsibilities for Minor Home Modifications

Revision 12-2; Effective June 1, 2012

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 allowable under the Community Based Alternatives (CBA) program will be limited to those listed in Section 4150, Minor Home Modifications, or reviewed for authorization by the regional nurse based on documentation submitted. Minor home modifications allowable under CBA will be limited to those identified and approved by DADS on the individual service plan (ISP).

Specific minor home modifications needed are documented on the ISP Form 3671-D, Minor Home Modifications. This form is initially prepared by the Home and Community Support Services Agency (HCSSA) RN who completes the pre-enrollment home health assessment. If the applicant is in a hospital, nursing facility, or personal care facility at the time of the pre-enrollment assessment, the case manager completes Form 3671-D. The case manager totals the estimated costs for the minor home modifications in order to include the costs in the initial ISP and sends this form to the HCSSA as part of the coordination with the HCSSA on the development of the ISP. After approval by the case manager and inclusion of the estimated costs in the ISP, the HCSSA is authorized to provide the specific minor home modifications within the estimated amounts included on Form 3671-D. If additional minor home modifications are necessary or the identified costs are more than were estimated, the HCSSA must request an ISP change and obtain the case manager's approval of the additional minor home modification or increased costs prior to providing the service.

If the individual's request for a particular minor home modification is denied as part of the initial approval of his CBA enrollment, at the annual reassessment, or during the ISP year (even though he is eligible for CBA services), he must be notified of the denial of the specific minor home modification in the comments section of Form 2065-B, Notification of Waiver Services.

If the individual requests a minor home modification 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, Rationale for Adaptive Aids, Medical Supplies, Dental Services and Minor Home Modifications, or alternate documentation. The case manager determines whether the justification is sufficient for denial.

For requests made by the individual during the ISP year, the medical professional completes Form 3671-F, or alternate documentation, as previously stated. It is sent to the case manager, with Form 2067, Case Information, explaining that the medical professional has determined that the minor home modification requested by the individual is not medically necessary or related to the individual's disability or medical condition.

In situations where the individual requests a minor home modification, and it is documented by the HCSSA nurse or other medical professional to be medically necessary, but the case manager finds the minor home modification is not on the approved list, the case manager has the option of denying the request or submitting it to the regional nurse. If regional nurse determines the request should not be authorized, the case manager sends the individual Form 2065-B identifying the minor home modification not approved in the comments section.

The individual may appeal the denial by requesting a fair hearing. The individual does not receive the minor home modification unless the denial is reversed. If the denial is reversed, the item is added to the ISP after the hearing officer's decision and the cost is reflected in the ISP in effect at the time of the hearing.

The case manager is responsible for exploring the availability of third party resources, for example private insurance, community groups, or informal supports to modify the individual's home before authorizing the minor home modification on the ISP.

The case manager should include minor home modification on the ISP if he determines that the documentation supports the requested item as being necessary and related to the individual's disability or medical condition. Form 3671-F may be used to document necessity. Use of Form 3671-F is optional as long as the required documentation specified on Form 3671-F is provided with the request for minor home modifications on the ISP, Form 3671-D. If the case manager has a question about the need for a minor home modification or the adequacy of the documentation submitted, he should consult with the regional nurse.

The case manager may approve minor home modifications for individuals residing in their own homes, other independent settings or AFC homes. Minor home modifications must not be authorized for individuals living in Type B AL facilities or for individuals in temporary respite settings. General home repairs, maintenance, remodeling or major renovations are not covered through the CBA program. A minor home modification authorization requires an existing structure to be modified to improve the individual's accessibility.

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

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 HCSSA or individual.

4152.1  Interactions with Applicants/Participants Regarding Minor Home Modifications

Revision 02-0; Effective April 4, 2002

The case manager should discuss the date the modification is needed with the applicant and review with him the projected entered date of completion. If the projected date will not meet the needs of the participant, the case manager should intercede with the Home and Community Support Services Agency (HCSSA) to obtain a projected completion date which will better meet the individual's needs.

The case manager must advise all participants that it is their responsibility to understand what modifications are being planned, to convey their desires and needs to the HCSSA, and to sign off on the specifications or plan developed for the modification before the modification is started. The goal is to assure that all parties, including the participant, understand what is being purchased before the work starts to reduce the chance that the modification will not be satisfactory after it is completed. The case manager should make the participant aware of potential problems and advocate for the participant to make sure the modification planned is what is needed for the participant.

The HCSSA must notify the case manager if the minor home modification will not be completed by the date required in Section 4153, Agency Responsibilities Pertaining to Minor Home Modifications. The notification on Form 2067, Case Information, must include the reason(s) that the modification(s) will not be completed by the projected date. The case manager must evaluate the information to determine if the reason is adequate or requires additional intervention, such as notification of the contract manager or further discussions with the participant or provider agency staff.

If the minor home modification requested will not be completed in the current individual service plan (ISP), the item must be transferred to the new ISP. If the transfer of the minor home modification to the new ISP causes the ISP to exceed the minor home modification ceiling, approval must be obtained from the regional nurse to exceed the service category ceiling. If the authorization on the new ISP causes the service plan to exceed the annual cost ceiling, 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.

After the modification is completed, the participant and HCSSA must agree to accept the modification and be satisfied with the work completed. If the participant is not satisfied with the modification, the case manager must become involved to determine if the modification met the agreed upon plans. If the modification meets the plans and the modification meets ADA requirements, the HCSSA is entitled to bill for the completed job.

4152.1.1  Home Modifications Prior to Nursing Facility Discharge

Revision 09-9; Effective December 1, 2009

If a nursing facility resident is approved for Community Based Alternatives (CBA) services, the Home and Community Support Services Agency (HCSSA) can begin doing minor home modifications to the applicant's home before the individual is discharged from the nursing facility. In this case, the date of service is the date of completion of the modification and date of discharge from the nursing facility.

The case manager must determine the applicant eligible for CBA services before authorizing the HCSSA to begin the home modification. Form 2065-B, Notification of Waiver Services, must be sent to the consumer and HCSSA with a CBA eligibility date. Form 2065-B Comments section must include a statement that the applicant requested a home modification be started before discharge from the nursing facility, and that the HCSSA will contact the applicant to initiate the home modification.

The case manager authorizes the HCSSA to initiate the home modification by approving Form 3671-D, Minor Home Modifications. The case manager adds a statement in Form 3671-D Comments section to inform the HCSSA that the applicant is in the nursing facility and requires the home modification be started before discharge. The comment also informs the HCSSA that the effective date of the individual service plan (ISP) and date the HCSSA can bill will be determined by the date the consumer discharges from the nursing facility.

Once the applicant decides on a discharge date, Form 2065-B is sent to the consumer and HCSSA to notify of the CBA effective date. Other procedures related to authorizing CBA services are also completed.

Depending on the type of home modification being completed, the consumer may or may not be able to leave the nursing facility before the home modification is completed.

The case manager must include documentation in the case record to show the approval of the home modification before the nursing facility discharge.

4152.2  Requesting Minor Home Modifications Not on the Approved List

Revision 11-1; Effective March 1, 2011

To request a minor home modification not on the approved list, the case manager must send a written request to the Department of Aging and Disability Services (DADS) regional nurse for approval to authorize the identified modification. The case manager must send a written request on Form 1547, Regional Nurse/Dental Consultant Request Worksheet, along with appropriate documentation.

If a request is made to the DADS regional nurse for 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 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 Home and Community Support Services Agency (HCSSA) is incomplete or not descriptive of how the requested item(s) is pertinent to the applicant's/consumer's disability or medical condition, authorization for the identified services will be delayed. More descriptive information may be requested by the case manager or DADS regional nurse from the HCSSA to support the medical necessity and in some instances, to resubmit the request.

Regional nurses may request state office to:

  • review the medical necessity and rationale for requests for a minor home modification not on the approved list;
  • advise if the item(s) is prohibited by waiver rules; and
  • provide a final determination of approval or disapproval of the item(s).

The DADS regional nurse will submit a written request to: State Office Nurse, Community Services Policy and Curriculum Development, Community Services and Program Operations, Mail Code W-351. The DADS regional nurse will send the state office nurse all supporting documentation provided by the case manager and any additional documentation obtained by the DADS regional nurse.

The state office nurse may request additional information if the documentation submitted is not sufficient to make a determination or does not support the regional recommendation. The state office nurse will approve or deny the request in writing to the DADS regional nurse.

4152.3  Requesting Regional Nurse Approval to Exceed the Minor Home Modification Service Cap

Revision 11-1; Effective March 1, 2011

In the Community Based Alternatives (CBA) program, the maximum lifetime allowable expense for minor home modifications (MHM) is $7,500, unless a greater amount is approved one time by the Department of Aging and Disability Services (DADS) regional nurse. The case manager must send a written request on Form 1547, Regional Nurse/Dental Consultant Request Worksheet, to the DADS regional nurse along with appropriate documentation.

The DADS regional nurse reviews all materials submitted and consults with the case manager, Home and Community Support Services Agency (HCSSA), and other resources as appropriate, to make a professional judgement 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 item(s) on the list of minor home modifications. If the item meets all requirements, then it should be approved; do not deny the request because it is over the $7,500 limit.

The case manager counsels the consumer of the possible risk of exceeding the lifetime $7,500 service limit and not having additional funding for unforeseen needs.

Once the $7,500 maximum service cost limit or a higher amount approved by the DADS regional nurse is reached, only $300 per individual service plan (ISP) year per consumer, including the fees, will be allowed for repairs, replacement or additional modifications.

Since the consumer is limited to the $7,500 service cost limit, the CBA case manager should monitor the amount of MHM authorized that is actually utilized by a CBA consumer. Once the $7,500 maximum service cost limit or a higher amount approved by the DADS regional nurse is authorized, the case manager must submit additional requests to the DADS regional nurse for approval only if the year-to-date utilized unit is less than the $7,500 service cost limit. The case manager must submit with the MHM request documentation of previously authorized MHM amounts, actual utilized amounts and confirmation that all previously requested MHM are completed. The DADS regional nurse will review the MHM requests based on the actual utilized units. Provided all CBA criteria are met, the DADS regional nurse will give approval to authorize the MHM request if the year-to-date utilized units are under $7,500. Once the consumer has utilized the $7,500 service cost limit or once the DADS regional nurse approves an MHM request that causes the utilized units to exceed the $7,500 service cost limit, additional MHM requests must not be submitted to the regional nurse for approval. Only the $300 per ISP year maintenance amount is allowed.

Examples

  • An MHM costing $9,000 is requested with the initial ISP. The request is approved by the DADS regional nurse. The utilized units equal $9,000. Another MHM request for $1,000 is submitted later in the initial ISP period. The MHM for $1,000 must be denied by the CBA case manager because the CBA consumer has exceeded the maximum service cost limit of $7,500, including utilized units. A third MHM request for $250 is received near the end of the ISP. Provided all other program criteria are met, the case manager must approve the third request because the cost of the MHM and fee are within the allowed $300 per ISP year maintenance allowance.
  • For the same consumer in the example above, an MHM costing $8,000 is received with the reassessment ISP. The CBA consumer exceeded the maximum service cost limit of $7,500, including utilized units, during the initial ISP year. The case manager must deny the MHM costing $8,000 as the $7,500 service cost limit, including utilized units, was exceeded in the initial ISP.
  • The consumer was authorized a total of $8,000 for MHM. The HCSSA submits a new request for MHM with a total cost of $1,000. The year-to-date utilized unit amount is $5,000. The case manager must submit the request, along with required documentation, to the DADS regional nurse. The DADS regional nurse may approve the MHM request if it meets all CBA criteria because the utilized units have not reached the $7,500 amount.
  • For the same consumer in the example above, an MHM costing $2,000 is submitted by the HCSSA. The case manager determines the actual utilized unit amount is $6,000. The case manager must submit the request, along with required documentation, to the DADS regional nurse. Since the utilized unit amount is under $7,500, the DADS regional nurse may approve the MHM request if it meets all CBA criteria. If the CBA consumer utilizes the entire $7,500 service cost limit with this authorized MHM (the utilized $6,000 plus utilization of the entire $2,000 amount), then only the $300 per ISP year maintenance amount is allowed. The case manager cannot submit any more MHM requests to the DADS regional nurse.

In the Service Authorization System Service Approval screen, the case manager must indicate the approval method as:

  • Regional Nurse, when the DADS regional nurse approves the MHM that causes the maximum service cost limit of $7,500 to be exceeded. This could occur when the DADS regional nurse approves a single MHM with a cost over $7,500, when the cost of an additional MHM added to the current ISP MHM cost exceeds the $7,500 maximum service cost limit, or when the DADS regional nurse approves additional MHM requests based on utilized units; and
  • MHM Maintenance, when the case manager approves an additional MHM meeting the $300 maintenance allowance policy.

Form 2065-B, Notification of Waiver Services, sent to notify the consumer of denial of an MHM when the $7,500 maximum service cost limit or $300 maintenance allowance policy is not met, should include a reference to this item of the handbook and/or Rule 48.6003(b)(8)(B), Basic Eligibility Criteria.

4153  Agency Responsibilities Pertaining to Minor Home Modifications

Revision 12-2; Effective June 1, 2012

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

(a)
The HCSSA must:
(1)
determine and document the needs and preferences of the individual for the minor home modification;
(2)
document the necessity for the minor home modification;
(3)
for a minor home modification expected to cost $1,000 or more, obtain written specifications for use in procuring bids and inspecting the completed minor home modification;
(4)
after obtaining written specifications for a minor home modification expected to cost $1,000 or more, obtain a minimum of three written bids based on the written specifications;
(5)
select a bidder to provide the minor home modification and document the reason for selecting the bid including cost, completion time of modification, record of quality service, timely response to repair requests, and warranties; and
(6)
inspect the minor home modification for completion, compliance with the written specifications, if applicable, quality of workmanship, and compliance with Texas Accessibility Standards within seven DADS workdays after the work is completed.
(b)
The HCSSA must ensure that written specifications obtained in accordance with subsection (a)(3) of this section are obtained from a person with experience in minor home modifications.
(1)
If the minor home modification will involve more than one contractor, the HCSSA must obtain separate written specifications for the portion of the minor home modification to be completed by each contractor if that portion is expected to cost $1,000 or more. The HCSSA may request reimbursement for each set of written specifications.
(2)
The HCSSA must maintain documentation that supports the written specifications.
(3)
The HCSSA must record the following in a document maintained in the individual's record:
(A)
the individual's name and address;
(B)
a description of the minor home modification;
(C)
the specifications, including applicable local regulations, construction requirements, and Texas Accessibility Standards;
(D)
the printed name and dated signature of the person who prepared the specifications; and
(E)
the individual's dated signature.
(4)
The HCSSA must maintain the following documentation in the individual's record:
(A)
a description of the experience of the person who prepares the written specifications; and
(B)
the invoice for the written specifications.
(5)
The person who develops the written specifications may bid on the completion of the minor home modification.
(c)
The HCSSA must:
(1)
include the cost of the written specifications when submitting the ISP to DADS for authorization of the minor home modification;
(2)
submit a claim for a specification fee only if DADS authorizes the specification fee; and
(3)
ensure that amount of the specification fee submitted to DADS does not exceed the amount of the invoice described in subsection (b)(4)(B) of this section.
(d)
DADS authorizes reimbursement of the actual cost of the written specifications as documented in the invoice described in subsection (b)(4)(B) of this section subject to the limit described in §48.6078(5) of this subchapter (relating to Billable Units).
(e)
The inspection requirements are as follows:
(1)
The HCSSA must ensure that a qualified person conducts an inspection of the completed minor home modification in accordance with subsection (a)(6) of this section.
(2)
The HCSSA must ensure that the inspection is not performed by the contractor who completed the minor home modification, or the attendant.
(A)
The invoice cost of the inspection is reimbursable as a minor home modification up to a maximum of $150.
(B)
The HCSSA must maintain documentation to support the cost for performing the inspection.
(3)
Once the inspection is concluded and the minor home modification is completed, the HCSSA must send a copy of the CBA documentation of completion of purchase form to the DADS case manager within seven DADS workdays after the completion of the inspection.
(A)
The HCSSA may submit a claim to DADS for the cost of building materials before the minor home modification is completed.
(B)
The minor home modification must pass inspection before the HCSSA submits a claim to DADS for the costs of labor and completion

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

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

Specification and inspection fees for a minor home modification are authorized upon approval of the modifications; 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 minor home modification when part of the cost will be paid through a nonwaiver 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 minor home modification 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 a person with experience in home building for writing specifications. The HCSSA must document the person's experience and maintain this documentation. The HCSSA must obtain an invoice from the person writing the specifications, which is the amount the HCSSA can bill under service code 040, Specifications. 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 minor home modification cost when determining if the minor home modification is within the $7,500 service limit.

The HCSSA may obtain separate specifications when the minor home modification 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 person 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 the person qualified to perform the specifications indicates that the structure of the individual's home is unsafe.

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

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

Within seven days of completion of the minor home modification, an inspection must be completed to document completion in compliance with the written specifications, if applicable, and to document acceptance of the modification 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 his responsible party for every minor home modification. This inspection may be performed by the person who prepared 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. 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 minor home modification. 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 minor home 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 HCSSA 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 HCSSA 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 working days of completing the inspection.

If the minor home 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 HCSSA nurse's intervention on Form 3670, CBA Documentation of Services Delivered, in the comments section. The case manager must be informed by the HCSSA RN if the individual has a problem with the minor home modification. The case manager should contact the individual to discuss the situation.

The individual is allowed to pay for enhancements to the minor home modification approved by DADS. The Community Based Alternatives (CBA) program, for example, pays for wheelchair ramps made of treated lumber. This:

  • meets the individual's needs;
  • meets Americans with Disabilities Act requirements; and
  • is a cost-effective purchase.

If the individual wants a ramp made of another material, such as redwood to 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 case manager explains to the individual, with written documentation, the work authorized for CBA to pay. Written documentation is necessary to prevent any misunderstandings. The 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, minor home 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 the Texas Accessibility Standards. Having merged the federal and state standards, Texas Accessibility Standards are specifically concurrent with Americans with Disabilities Act (ADA) specifications;
  2. use A117.1-1986 as the basis of specifications for any other home adaptive or modification;
  3. make improvements or modifications in accordance with local and state housing codes;
  4. maintain documentation that any home modifications meet any applicable standards and/or codes;
  5. maintain documentation that repairs authorized for payment under the waiver fall outside the scope of any existing warranty for the item to be repaired;
  6. maintain documentation that homes to be repaired meet applicable health, safety, and fire codes or state inspection criteria;
  7. select a contractor who meets the applicable city and local ordinances and other requirements;
  8. 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;
  9. pay the sub-contractor directly for services rendered and agreed upon in the contract; and
  10. not hire the spouse of an individual to do a minor home modification.

Minor home 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 persons involved.

The HCSSA and the individual should be satisfied with the quality of the minor home modification before the contractor is paid. The modification should be completed as agreed in the written work agreement that the individual, contractor, and HCSSA 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.

4153.1  Minor Home Modification Procurement

Revision 02-0; Effective April 4, 2002

STANDARD.

  1. Home and Community Support Services Agency (HCSSA) employees may do minor home modifications for their own participants as long as the provider agency 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 ability and availability to provide routine maintenance and repair (see Appendix XVI, Community Based Alternatives Services Eligibility Process, 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 agency 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.

4153.2  Documentation of Necessity for Home Modifications

Revision 03-4; Effective Upon Receipt

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 4151, List of Minor Home Modifications, must be provided to the DADS case manager by the Home and Community Support Services Agency (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; and
    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 DADS regional nurse. (See Section 4152.2, 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.

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 a participant's condition. If this occurs, the DADS nurse will make the decision if the purchase is necessary.

4153.3  Accountability for Minor Home Modifications

Revision 02-0; Effective April 4, 2002

§48.6076 — Accountability for Minor Home Modifications.

If the minor home modifications require repair or replacement within one year of completion, the Home and Community Support Services agency must repair or replace the minor home modification without billing the Texas Department of Human Services or the participant, except when:

(1)
the finished modification met appropriate specifications and bid requirements agreed upon before the job was started; or
(2)
the repair or replacement is required due to circumstances beyond the control of the participant or participant's family members, or due to abuse caused by the participant or family members.

4153.4  Requests for Home Remodeling and Major Renovations

Revision 02-0; Effective April 4, 2002

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 participant's safety and accessibility.

If the case manager is not 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.

4153.5  Time Frames for Minor Home Modifications

Revision 02-0; Effective April 4, 2002

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

(a)
The Home and Community Support Services agency is responsible for assuring the completion of all minor home modifications within 60 Texas Department of Human Services (DHS) workdays of being authorized to do the minor home modification, counting from either the effective date of the individual service plan form or the date the form is received, whichever is later.
(b)
A 90% compliance level is required. The provider must notify the participant and case manager of any delay, with a new proposed date for delivery. The notification must be provided on or before the 60th DHS workday following authorization.

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

(a)
The Home and Community Support Services agency is responsible for assuring the completion of all minor home modifications within 30 Texas Department of Human Services (DHS) workdays of being authorized to do the minor home modification, counting from either the effective date of the individual service plan form or the date the form is received, whichever is later.
(b)
A 90% compliance level is required. The provider must notify the participant and case manager of any delay, with a new proposed date for delivery. The notification must be provided on or before the 30th DHS workday following authorization.

Form 3671 authorizing the purchase of the requested minor home modification must be date stamped upon receipt. The agency has 30 DADS work days counting from the effective date entered on Form 3671, 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 business days counting from the effective date entered on Form 3671, or the date the form is received, whichever is later.

If a client's individual service plan (ISP) 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 participant and the case manager on Form 2067 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 does not seem reasonable and will refer repeated extensions to the contract manager.

§48.6074 — Landlord Approval for Minor Home Modifications.

Prior to beginning the home modifications, the Home and Community Support Services (HCSS) agency must obtain written approval from the owner of the building for the proposed modifications if the rental agreement does not provide such approval. Additionally, all applicable building permits must be obtained prior to starting the home modifications.

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

4153.6  Changing Providers During a Home Modification

Revision 02-0; Effective April 4, 2002

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 participant 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.

4153.7  Minor Home Modifications in Adult Foster Care (AFC) Homes

Revision 02-0; Effective April 4, 2002

In providing minor home modifications in AFC homes, the agency must allow a minimum grace period of 30 days from the date the participant 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 participant placement and as based on recommendations of the interdisciplinary team.

4160  Reserved for Future Use

Revision 12-2; Effective June 1, 2012

4170  Dental Services

Revision 12-3; Effective September 4, 2012

Dental services are those services provided by a dentist to preserve teeth and meet the medical needs of the individual. Dental services must be provided by a dentist licensed by the State Board of Dental Examiners. The Home and Community Support Services Agency coordinates the needed dental services for individuals receiving Community Based Alternatives with licensed dentists.

In the Service Authorization System, dental services are authorized as Service Code 5A.

Case managers may use Appendix XXII, Helpful Information About Dental Services, as a resource for information regarding dental services.

4171  Allowable Dental Services and Service Limits

Revision 12-2; Effective June 1, 2012

Allowable Dental Services

Dental services are those services provided by a licensed dentist to preserve teeth and meet the medical needs of the individual. Allowable dental services include:

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

The case manager must ensure dental requests meet the criteria for allowable services before authorizing services except in an emergency situation. Dental services are provided by Community Based Alternatives (CBA) when no other financial resource for such services is available and when all other available resources have been used. Case managers must not authorize dental services for cosmetic treatments.

Service Limits

The new service limit for dental services in CBA is $4,675 per individual service plan (ISP) year and includes the cost for dental treatments and evaluations. The existing service limit for dental services in CBA is $5,000, See Section 3421.4, New Service Limits and Exception Criteria, for procedures to determine if dental services may be authorized over the new service limit but under the existing service limit. Services for general dentistry, including oral surgery procedures performed by a general dentist, or general dentistry performed by a licensed oral surgeon, cannot exceed $5,000 per ISP year. All requests that exceed the existing $5,000 service limit are limited up to an additional $5,000 for the services of an oral surgeon. The combined services for general dentistry and the services of an oral surgeon cannot exceed $10,000 per ISP year.

The initial existing $5,000 service limit may be used for general dentistry or for the services of an oral surgeon, or a combination of both. The requests for general dentistry or the services of an oral surgeon may be submitted in any order, based on the need of the individual. A request for general dentistry is not required before a request for dental services by an oral surgeon can be submitted. Up to an additional $5,000 may be approved by the dental contractor when the services of an oral surgeon are required. If the initial existing $5,000 service limit is used for the services of an oral surgeon, the dental contractor must determine authorization for dental evaluations and treatment plan requests that exceed the initial existing $5,000 service limit, including requests for general dentistry or the services of an oral surgeon.

Some individuals may require the dental treatment plan be performed in an outpatient facility. If the dental treatment plan requires the dental services to be performed in a hospital outpatient setting and/or requires the use of anesthesia services, the cost for the outpatient facility and the anesthesia must fall within the CBA service limit for dental services in order to be authorized.

Examples are given to provide guidelines regarding how to handle the service limit amounts. In the examples, it is assumed:

  • the cost of evaluations and buffers are included in the submitted cost;
  • no dental services have been authorized in the ISP year unless stated; and
  • the $400 buffer has been added to the ISP so the Home and Community Support Services Agency (HCSSA) can obtain the dental evaluation indicated in the example without case manager approval.

Example 1: An individual requires sedation for a dental evaluation and/or dental treatment to be performed. The HCSSA obtains a dental evaluation costing $200 performed by an oral surgeon without case manager approval. As a result of the evaluation, an initial request for $4,800 for dental treatment by an oral surgeon is submitted. All criteria are met and the case manager approves the dental treatment. Later in the ISP year, the individual requires additional dental care that must be provided by an oral surgeon. Since the initial existing $5,000 service limit has been used, the HCSSA must request case manager approval for a dental evaluation for the services of the oral surgeon. The case manager must submit the request for the evaluation to the dental contractor. The dental contractor determines authorization for the request and the case manager authorizes the dental evaluation. The amount of the dental evaluation is $200. As a result of the evaluation by the oral surgeon, a request for $4,500 for dental treatment by an oral surgeon is submitted. The request for the dental treatment must be sent to the dental contractor because the request involves approval of the additional $5,000 for the services of an oral surgeon. All criteria are met and the dental contractor determines authorization for the dental request because it is within the additional $5,000 limit, and the services of an oral surgeon are required beyond the initial existing $5,000 service limit allowed by CBA policy.

Example 2: An individual has an injury to the teeth that requires the service of an oral surgeon. The HCSSA obtains a dental evaluation without case manager approval. The evaluation is $200 and results in an initial request for dental treatment for $4,800. All criteria are met and the case manager approves the $4,800 dental treatment plan because it is within the initial existing $5,000 service limit. Later in the ISP year, the individual requires some general dentistry. Since the initial existing $5,000 service limit has been used for the services of an oral surgeon, the HCSSA must request case manager approval for a dental evaluation for the services of the general dentist. The case manager must submit the request for the evaluation to the dental contractor for authorization determination. The dental contractor determines the request may be authorized and the case manager authorizes the dental evaluation. The amount of the dental evaluation is $200. The evaluation by the general dentist results in a request for a $4,500 dental treatment plan. The request for the dental treatment by a general dentist must be sent to the dental contractor because the request involves approval of the additional $5,000 service limit. All criteria are met and the dental contractor determines the request may be authorized for general dentistry because it is within the additional $5,000 limit, and the previous treatment requiring the services of an oral surgeon are within the overall $10,000 hard cap allowed by CBA policy when the services of an oral surgeon are needed.

Example 3: An initial dental request, including dental evaluations, is submitted and includes $2,500 for general dentistry and $2,500 for oral surgery to be performed by the general dentist. All criteria are met and the case manager approves this request because it does not exceed the initial existing $5,000 service limit. No additional services by a general dentist may be approved in the ISP year; up to an additional $5,000 could be reviewed for authorization by the dental contractor for the services of an oral surgeon and approved by the case manager if all criteria are met.

Example 4: An initial dental request is submitted that includes $3,000 for general dentistry and $3,000 for oral surgery to be performed by the general dentist. The case manager denies this request because the service required of the general dentist exceeds the existing $5,000 service limit.

Example 5: An initial dental request is submitted that includes $4,000 for general dentistry and $5,000 for oral surgery to be performed by an oral surgeon. The entire dental request must be sent to the dental contractor for authorization determination. All criteria are met and the dental contractor determines the request may be authorized because the amount for general dentistry is under the existing $5,000 service limit, and the amount for the service of the oral surgeon may be approved using the rest of the initial $5,000 amount (existing service limit) and part of the additional $5,000 amount. An additional $1,000 may be authorized in the ISP year for general dentistry, the service of an oral surgeon, or both, if the dental contractor determines the request may be authorized.

Example 6: An initial dental request is submitted that includes $6,000 for general dentistry and $2,000 for oral surgery to be performed by an oral surgeon. The case manager denies this request because the service required of the general dentist exceeds the existing $5,000 service limit.

Example 7: An initial dental request is submitted that includes $5,000 for the service of an oral surgeon. All criteria are met and the case manager approves this request because it does not exceed the existing $5,000 service limit. Additional services up to $5,000 may be approved in the ISP year for the service of a general dentist, an oral surgeon, or both, if the dental contractor determines the request may be authorized.

Note: To ensure the existing $5,000 service limit for general dentistry is not exceeded, the dental contractor must review dental treatment plans to determine which procedures fall under the category of general dentistry and which procedures fall under the category of oral surgery.

4172  HCSSA Responsibilities for Dental Services

Revision 12-4; Effective December 3, 2012

The Home and Community Support Services Agency (HCSSA) nurse assesses the applicant or individual receiving Community Based Alternatives (CBA) and identifies his need for dental services during the pre-enrollment assessment, annual reassessment and during the semiannual nursing assessment, or when the individual requests dental services. Upon identification of the need for dental services, the HCSSA is responsible for initiating and coordinating with the licensed dentist to provide the needed dental services. The HCSSA schedules an evaluation for the individual with a general dentist, oral surgeon, or both. The dentist develops and submits the proposed treatment plan needed by the individual on Form 3671-J, Dental Services – Proposed Treatment Plan. The dentist obtains the individual's signature on Form 3671-J when sharing the treatment plan. The HCSSA reviews the treatment plan and submits Form 3671-J, Form 3671-H, Dental Services, Form 3671-F, Rationale for Adaptive Aids, Medical Supplies, Dental Services and Minor Home Modifications (or alternate documentation), or both, along with the estimated cost to request authorization for the dental evaluation(s), dental treatments, or both.

Dental Evaluations

The HCSSA nurse reviews the individual's need for dental services and coordinates the dental evaluations provided by dentist. The HCSSA may obtain a limited number of initial dental evaluations in the individual service plan (ISP) year without obtaining prior approval from the case manager. The HCSSA must obtain approval from the case manager for all other dental evaluations, including dental evaluations costing more than $200. The dental evaluations an HCSSA may obtain without prior approval include:

  • one initial non-emergency dental evaluation that costs $200 or less performed by a general dentist; and
  • one dental evaluation that costs $200 or less performed by a specialist.

The HCSSA is required to obtain approval for all evaluations after the first dental treatment plan is approved when the initial $5,000 limit has been used or once the allowable evaluations without case manager approval have been obtained during the ISP year, whichever comes first. This will ensure dental evaluations are not obtained when there are very little or no unused funds left in the dental services $5,000 service limit.

Case managers must include in the initial and reassessment ISP (unless the amounts would cause the ISP to exceed the ISP cost limit) a buffer of $400 in Service Code 5A to support billing of the dental evaluations that may be obtained by the HCSSA without case manager approval. The authorization of the buffer amount is included in the $5,000 ISP year dental service limit. Additional funds above the $5,000 service limit cannot be authorized for the buffer.

Before initiating and scheduling the individual's first dental evaluation in the ISP year, the HCSSA should review the ISP authorization to determine if the buffer was included in the dental services authorization by the case manager at the initial or annual reassessment. The HCSSA should request approval before obtaining the evaluation if the buffer was not added. If the buffer was not authorized in the dental services authorizations, the HCSSA can obtain the initial dental evaluation(s) without case manager approval without the buffer being added, or the HCSSA may obtain case manager approval before obtaining the evaluation.

Documentation of Dental Services by a Dentist

The HCSSA must ensure all requests for dental treatments include documentation by a professional dentist of the need for dental services. A dentist must determine the medical necessity for dental treatment and submit a detailed treatment plan on Page 2 of Form 3671-J to the HCSSA nurse to document the medical necessity and all specific dental procedures to be completed. The dentist may not bill the individual for the remainder of the cost over the approved amount.

Form 3671-F or an alternate form must be submitted to document the medical need for requested dental services. Medical necessity for dental services is completed by the dental professional on Form 3671-J. Form 3671-J may be accepted as an alternate form of medical documentation for dental services without submittal of Form 3671-F, or alternate documentation, if the information on Form 3671-J is sufficient to describe the medical need for the dental services. The dental professional obtains the signature of the individual on Form 3671-J during the review of the proposed dental plan with the individual.

The HCSSA coordinates the services to be provided by dentists once the dental evaluations are completed. The HCSSA reviews the proposed dental treatment plan on Form 3671-J, prepared by a dentist to ensure the request meets CBA allowable services. The HCSSA lists the total estimated cost of each treatment plan and evaluation on Form 3671-H. The HCSSA documents the actual cost of each dental evaluation not requiring prior approval and the estimated cost of dental evaluations and treatment plans requiring prior approval on Form 3671-H. The HCSSA submits to the case manager, as a separate document, Form 3671-H and the detailed proposed treatment plan that includes all specific dental procedures to be completed.

The HCSSA is not required to obtain estimates from three different dentists. The HCSSA documents on Form 3671-F (or an alternate form) the medical need as indicated by the dentist on the treatment plan. Form 3671-J may be submitted in lieu of Form 3671-F when only dental treatments are submitted on Form 3671-H. Form 3671-F or an alternate form must be submitted along with Form 3671-H when only a dental evaluation is being requested on Form 3671-H.

4173  Case Manager Responsibilities Pertaining to Dental Services

Revision 12-4; Effective December 3, 2012

Dental services are approved for purchase as a waiver service by the case manager only if the documentation supports the requested dental services as being necessary to preserve teeth and meet the medical needs of the individual and the dental services can be provided within the service limit and after other resources are used. The case manager must discuss with the individual any available resources to cover the expense of dental services for the individual and consider those resources before authorizing dental services through the Community Based Alternatives (CBA) program.

Dental Evaluations

The Home and Community Supports Services Agency (HCSSA) may obtain the following dental evaluations for an individual without case manager approval.

The evaluations include:

  • one initial non-emergency dental evaluation that costs $200 or less performed by a general dentist; and
  • one dental evaluation that costs $200 or less performed by a specialist.

Case managers must prior approve evaluations costing more than $200, and all evaluations after the first dental treatment is approved, when the initial existing $5,000 service limits has been used or once the allowable evaluations without case manager approval have been obtained during the individual service plan (ISP) year, whichever comes first. This will ensure dental evaluations are not obtained when there are very little or no unused funds left in the dental services $5,000 service limit.

Dental Buffer

Case managers must include in the initial and reassessment ISP (unless amounts would cause the ISP to exceed the ISP cost limit) a buffer of $400 in Service Code 5A to support billing of the dental evaluations obtained by the HCSSA without case manager prior approval. The authorization of the buffer amount is included in the $5,000 ISP year dental service limit. Additional funds above the $5,000 cannot be authorized for the buffer.

If the buffer is not added on the initial and reassessment ISP due to keeping the cost of the ISP within the cost limit, the case manager authorizes the actual cost of the evaluation(s) submitted when an initial request is received for a dental evaluation(s) that does not require prior approval during the ISP year. The actual cost of each evaluation must be $200 or less, and the total authorization for two evaluations cannot exceed $400. If only one evaluation is requested, the case manager enters the amount of the initial dental evaluation being requested, and could enter $200 as the buffer for one dental evaluation that still may be requested by the HCSSA without prior approval, if the initial $5,000 service limit has not been exceeded at the time of the request for the dental evaluation(s).

If the dental buffer was not added to the initial or reassessment ISP due to keeping the cost of the ISP within the cost limit and the HCSSA submits a request for a dental evaluation(s) that did not require prior approval, the case manager creates the dental service authorization record (5A) and enters the actual cost of the dental evaluation. The effective date of the service authorization records must be retroactive to the date the evaluation was completed, if the dental evaluation was completed prior to the submitted request. The case manager must check with the HCSSA to determine the exact date the evaluation was completed if the date of completion is not on the request submitted by the HCSSA. If the evaluation has not been completed when the request for the dental evaluation is received, the case manager makes the service authorization record effective the date the change is completed. Adding a dental services authorization record with a retroactive effective date is only applicable when the dental buffer was not added to the initial or reassessment ISP due to keeping the cost of the ISP within the cost limit.

Authorizing Dental Services

The case manager reviews Form 3671-H, Dental Services, Form 3671-F, Rationale for Adaptive Aids, Medical Supplies, Dental Services and Minor Home Modifications, or alternate documentation, and Form 3671-J, Dental Services – Proposed Treatment Plan, to ensure dental services requested are allowable per CBA dental policy. The case manager may consult the dental contractor if there is a question about the appropriateness of the dental service. The case manager documents the allowable amount of dental services from the dental treatment plan on Form 3671-H and approves the request if all criteria are met. Form 3671-1, Individual Service Plan, is updated to show the amount approved for dental services. See procedures in Section 4175, Referrals to Dental Contractor for Review, for required referrals to the dental contractor for authorization determination.

The individual is notified of the approval or denial of the requested dental services on Form 2065-B, Notification of Waiver Services. The individual may appeal the denial by requesting a fair hearing.

When the case manager approves dental treatments for the individual, Form H1746-A, MEPD Referral Cover Sheet, and copies of Form 3671-1 and Form 3671-H are sent to the Medicaid for the Elderly and People with Disabilities (MEPD) specialist to show the expense is being paid through CBA and is not an incurred medical expense.

Unless dental services are provided in an emergency, all dental treatments must be authorized by the case manager before the delivery of the service. In emergency situations, the HCSSA must meet the requirements in Section 4174, Emergency Procurement of Dental Services. If the HCSSA does not get prior approval or does not follow the procedures in Section 4174, DADS will not pay for the emergency dental treatments.

Before initiating and scheduling the individual's first dental evaluation in the ISP year, the HCSSA should review the ISP authorization to determine if a buffer amount was included in the dental services authorization by the case manager at the initial enrollment or annual reassessment. The HCSSA should request approval before obtaining the evaluation if the case manager did not add the dental buffer. If the HCSSA obtains the allowable dental evaluations without prior approval, the cost of the dental evaluation is authorized as noted above.

The case manager may refer issues related to inappropriate submission or cost effectiveness of dental requests by the HCSSA to the contract manager.

4174  Emergency Procurement of Dental Services

Revision 12-3; Effective September 4, 2012

All dental treatments must be prior authorized by the case manager before the delivery of the dental service except emergency dental services. Emergency dental services may be obtained by the Home and Community Support Services Agency (HCSSA) if precipitated by a change in the individual's condition to meet acute dental care needs brought about by the condition change. Emergency dental services can only be provided if there is sufficient money in the service limit for dental services available to cover the cost of the emergency treatment. The HCSSA must check the individual service plan authorization prior to obtaining the emergency treatment.

Emergency dental services include emergency:

  • dental treatment procedures that are necessary to control bleeding, relieve pain and eliminate acute infection; or
  • treatment due to an injury.

In procuring emergency dental services, the HCSSA must:

  • obtain a written agreement from the individual or caregiver that the emergency dental services are needed by obtaining the individual's signature on Form 3671-H, Dental Services, and Form 3671-2, Individual Service Plan;
  • verbally notify the case manager by the next Department of Aging and Disability Services (DADS) working day after the individual receives the emergency dental treatment;
  • submit the following documentation to the case manager within seven calendar days of the verbal notification of receipt of emergency dental treatment:
    • Form 3671-H and Form 3671-2, with the individual's or his caregiver's signature, showing agreement that the emergency dental treatment was needed;
    • Form 3671-J, Dental Services – Proposed Treatment Plan, signed by the individual and by the licensed dentist explaining the need for the emergency dental treatment;
    • Form 2067, Case Information, explaining why the emergency dental treatment was needed;
    • Form 3671-F, Rationale for Adaptive Aids, Medical Supplies, Dental Services and Minor Home Modifications, describing why the emergency dental treatment was necessary and how the treatment related to the individual's disability or medical condition; and
  • ensure delivery of the emergency dental treatment within two DADS working days of identifying the need.

DADS will not pay for the emergency dental treatments if the HCSSA does not obtain prior approval or fails to follow proper emergency dental treatment procedures.

If all of the above steps are followed, and there is sufficient money left in the service limit for dental services, the CBA case manager may authorize the emergency dental treatment using the date the individual received the emergency dental treatment.

4175  Referrals to Dental Contractor for Review

Revision 12-3; Effective September 4, 2012

The Department of Aging and Disability Services (DADS) established a contract with the University of Texas Health Science Center at San Antonio (UTHSCSA) for a Texas licensed dentist to provide the following related to the Community Based Alternatives (CBA) program's dental services:

  • Identify standards and tools for staff to use when assessing dental requests, resulting in more consistent decisions across the state.
  • Ensure dental determinations are appropriate and cost effective.
  • Develop clear dental policy based on the expertise and input of a licensed dentist.
  • Obtain recommendations for quality assurance and improvement.
  • Identify trends regarding requests for dental services, such as requests with excessive charges for dental services, and provide recommendations to DADS for addressing those trends.

The case manager must send to the dental contractor all dental requests:

  • for dental implants or fixed prosthodontics (also called a bridge). These include all requests for dental services with American Dental Association (ADA) code D6000-D6999;
  • for occlusal guards (also called night guard or athletic guard). These are ADA codes D9940 and D9941;
  • for root canal procedures. These include all requests for dental services with ADA code D3110-D3999;
  • that exceed the $5,000 service limit;
  • that require a decision regarding medical need;
  • that require consultation regarding cost effectiveness; or
  • that require consultation to determine if the dental treatment requested is allowable per CBA dental policy.

The case manager must review each dental request prior to sending it to the dental contractor to ensure that all required fields on individual service plan (ISP) attachments (listed below) are completed. If not complete, the case manager must send Form 2067, Case Information, to the Home and Community Support Services Agency (HCSSA) to request the required documentation. The case manager may be required to contact the HCSSA by phone to follow up on any requests for additional information.

The case manager must ensure the HCSSA includes contact information for the dentist who developed the treatment plan, including telephone number and email address, with the dental request. The case manager must ensure the dentist contact information is submitted to the dental contractor in case the dental contractor needs to contact the dentist to request additional information. The case manager must ensure the HCSSA email address is included in the request sent to the dental contact or so the dental contractor can copy the HCSSA when requesting and receiving additional information from the dentist.

The case manager must follow the procedures below when submitting dental requests to the dental contractor. Each individual's dental request must be sent in a separate email; therefore, do not include dental requests for multiple individuals in the same email.

  • The case manager must send all dental request documents in a secure email to the dental contractor. The case manager must ensure no confidential information is included in the email Subject line. The documents that must be scanned into the secure email as a PDF document include:
    • Form 3671-J, Dental Services – Proposed Treatment Plan;
    • Form 3671-H, Dental Services;
    • Form 3671-F, Rationale for Adaptive Aids, Medical Supplies, Dental Services and Minor Home Modifications, if provided;
    • Form 3672, Medicare/Medicaid/Third-Party Resources Utilization Report;
    • Form 3671-1, Individual Service Plan;
    • Form 2067, Case Information, as related to the dental request; and
    • any other documents received which relate to the dental request. This could include films/pictures or digital X-rays.
  • The first document scanned into the secure email must be Form 3671-J.
  • The secure email sent to the dental contractor must include a copy to the regional designee. In order to fully comply with Health Insurance Portability and Accountability Act (HIPAA) requirements, the case manager must use the following format for the subject line of the secure email sent to the dental contractor: Dental – Region number – Individual's initials (2 or 3 acceptable) – Individual's year of birth – Case manager's initials (2 or 3 acceptable). Example: Dental – 11 – RB – 1944 – LLC. In the text of the secure email (not in the scanned documents and not on Form 1547, Regional Nurse/Dental Consultant Request Worksheet), the case manager must include the same information as in the subject line of the secure email, but in its entirety. Example: Dental – 11 – Richard Brown – 12/8/1944 – Linda Lou, Case Manager.
  • Send the secure email to the dental contractor at hicksj@uthscsa.edu.

The case manager must also complete and send Form 1547 as a Word document, not as a PDF document, in the secure mail to the dental contractor. This enables the dental contractor to send an automated reply to the case manager. The dental contractor will enter the recommendation in field 27, Regional Nurse/Dental Consultant Comments, of Form 1547 and return the form to the case manager.

The case manager must ensure Form 1547 includes:

  • the document locator number (DLN) of the individual's most recent Medical Necessity and Level of Care (MN/LOC) Assessment;
  • the HCSSA's email address;
  • the name, telephone number, and email address of the dentist who completed the dental treatment plan.

The dental contractor has access to the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Portal and can view the individual's MN/LOC Assessment by using the DLN. For requests for services to exceed $5,000, the case manager must submit all Form 3671-Hs and Form 3671-Js for dental services that have been approved in the current ISP.

The dental contractor may request additional information from the dentist who developed the dental treatment plan. The dental contractor may contact the dentist by telephone if it is a simple matter of missing information or clarification, or may obtain the additional information by sending the dentist a secure email. The dental contractor will copy the HCSSA and the case manager if a secure email is sent to the dentist to request additional information. The dentist providing the additional information will provide the information in a secure email to the dental contractor with a copy to the HCSSA and case manager listed on the initial email request. The dental contractor will provide a suggested time frame for the dentist to provide the additional information.

It is very important for the case manager to keep a record of any additional information requested by the dental contractor from the dentist who developed the treatment plan, as well as the rationale provided by the dental contractor for denying or approving the request in case the individual appeals the decision.

The individual will continue to have the right to appeal decisions regarding dental services. The case manager will be required to represent the state on appeals and provide testimony justifying the denial.

The case manager must process dental requests utilizing the dental contractor within current policy time frames for initial enrollments, annual reassessments, and changes. Delays beyond current time frames must be documented in the case record.

Regional Tracking and Reporting

Each region must establish a regional process and designate a staff member to track all dental requests sent to the dental contractor. The regional designee will also complete any required reports and submit to state office by the fifth working day of each month. The report must include all dental requests sent to the dental contractor during the preceding month. If the regional designee has not sent any requests to the dental contractor that month, indicate that on the report. The report is sent to the designated Community Services and Program Operations staff.

4180  Complaint Procedures

Revision 11-2; Effective June 1, 2011

The consumer has the right to file complaints against individual providers or the Home and Community Support Services Agency (HCSSA). Refer to Section 3680, Reporting Service Delivery Issues to Consumer Rights and Services, for procedures related to complaints.

4200  Adult Foster Care

Revision 09-9; Effective December 1, 2009

4210  Introduction

Revision 08-10; Effective September 1, 2008

Adult Foster Care (AFC) provides a 24-hour living arrangement in a Department of Aging and Disability Services (DADS) contracted foster home for persons who, because of physical, mental or emotional limitations, are unable to continue independent functioning in their own homes. Services may include meal preparation, housekeeping, personal care, nursing tasks, supervision, companion services, daily living assistance and provision of, or arrangement for, transportation.

The Community Based Alternatives (CBA) AFC consumer must reside in the CBA AFC home. Providers of AFC must live in the household and share a common living area with the consumer. Detached living quarters do not constitute a common living area. The individual enrolled to provide AFC must be the primary caregiver. Providers may serve up to three adult consumers in a DADS-enrolled AFC home without licensure as a personal care home. Up to four residents may be served in a foster home, though there are limitations as to the number of consumers at each level that may reside in one home. The unit of service is one day.

The delegation of nursing tasks by a registered nurse to the AFC provider will be required based on the provider's abilities and the needs of the consumer. The three levels of participation for AFC are explained in Section 4234, Classification Levels of Adult Foster Care Consumers.

CBA consumers 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 AFC 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 Community Based Alternatives Provider Manual.

4211  Purpose

Revision 08-10; Effective September 1, 2008

The Adult Foster Care (AFC) provider must provide 24-hour care in a home enrolled by the Department of Aging and Disability Services. Services may include, but are not limited to:

Personal care — Help with activities related to the care of the consumer'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 delegated by a registered nurse in accordance with the rules promulgated by the Texas Board of Nurse Examiners.

Transportation — Arrangement of and/or direct transport of consumers to meet their basic needs for food, clothing, toiletries, medications, medical care and necessary therapy.

Supervision — Periodic checks or visits to the consumer throughout the 24-hour period to assure the consumer is well and safe. For some consumers 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 consumer.

Housekeeping — Activities related to housekeeping that are essential to the consumer'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 that is provided to all Community Based Alternatives (CBA) consumers in AFC, are provided on an "as needed" basis, with the flexibility to meet the consumer's needs in the least restrictive way possible. CBA consumers may not require assistance with medication, for example, or need help with transportation, but the services are available to all CBA consumers in AFC homes. Personal care tasks must be provided as identified on Form 2060, Needs Assessment Questionnaire and Task/Hour Guide. The AFC provider may provide more services for the consumer than are authorized, but not fewer.

CBA consumers, 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 consumers.

4211.1  Other Services Available to Adult Foster Care Consumers

Revision 09-9; Effective December 1, 2009

Adaptive Aids and Medical Supplies — The Community Based Alternatives (CBA) Adult Foster Care (AFC) consumer is eligible to receive needed adaptive aids and medical supplies under the CBA program. Adaptive aids and medical supplies are defined as medical equipment and supplies which include devices, controls or appliances specified in the plan of care that enable individuals to increase their abilities to perform activities of daily living or to perceive, control or communicate with the environment in which they live.

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

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 delegation of nursing tasks to the AFC provider is not possible, the case manager will discuss available options to the CBA consumer.

Minor Home Modifications — Services that assess the need, arrange for and provide modifications and/or improvements to an individual's residence to enable the individual to reside in the community and to ensure safety, security and accessibility. Minor home modifications will be limited to those modifications identified and approved by the Department of Aging and Disability Services on the individual service plan (ISP).

The CBA AFC provider must agree to have modifications made to the home if the consumer requires the minor home modifications be made so that the home will meet the consumer'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, Minor Home Modifications, in the Home and Community Support Services Agency (HCSSA) files.

When the provider and consumer 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 the consumer and the provider should sign the form agreeing to all included information and stipulations.

To save the consumer 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 health and/or safety of the consumer 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 interdisciplinary team (IDT) and approved by the case manager.

If more than one consumer 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 consumer's ISP, the cost of making the modification can be shared, with the consumer's share of the total being applied to his cap for the service.

Minor home modifications remain in a CBA AFC home even if the consumer for whom the modifications were made permanently leaves the home.

Dental Services — Services provided by a licensed dentist to preserve teeth and meet the medical need of the consumer.

Occupational Therapy — Interventions and procedures to promote or enhance safety and performance in the instrumental activities of daily living, education, work, play, leisure and social participation. 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 — Specialized techniques for the evaluation and treatment related to functions of the neuro-musculo-skeletal systems. 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 — The evaluation and treatment of impairments, disorders or deficiencies related to a consumer's speech and language. Services include the full range of activities provided by speech and language pathologists under the scope of the pathologist's state licensure.

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

A CBA AFC consumer may not receive CBA personal assistance services (PAS) while a resident in a CBA AFC home. Form 2060, Needs Assessment Questionnaire and Task/Hour Guide, is completed by the CBA case manager to determine the needed tasks for completion by the AFC provider. Non-waiver services may be considered in the development of the ISP.

4211.2  Adult Foster Care Provider Responsibilities

Revision 08-10; Effective September 1, 2008

Responsibilities of the Adult Foster Care (AFC) provider include:

  • Provide services according to the Community Based Alternatives (CBA) individual service plan (ISP) and Form 2327, Individual/Member and Provider Agreement.
  • Ensure that an approved substitute provider is present if at least one consumer 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 consumer who has a need for 24-hour supervision may not be left without the supervision of an approved substitute provider for any period of time.
  • Ensure that consumers are not abused, neglected or exploited while in AFC. Notify the CBA case manager and contract manager when the provider, substitute provider or a family member is the subject of an Adult Protective Services (APS) investigation.
  • Respond to, investigate and document consumer complaints.
  • Share clearly defined house rules, including smoking policies, with the consumer before moving to the AFC home.
  • For Level I and Level II, deliver any delegated nursing tasks according to the instructions of the supervising registered nurse (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.
  • Collect room and board payments according to Form 2327 and Form 2065-B, Notification of Waiver Services.
  • Take appropriate action if the provider finds that a consumer threatens the health and safety of others or himself.
  • Provide the consumer with a final accounting of the consumer's funds and refund any monies owed to the consumer within five days of discharge.
  • Maintain for each consumer a record that includes information regarding delegated nursing tasks and service plans, and names and telephone numbers of the interdisciplinary team (IDT) members including the physician, case manager and RN.
  • Report to the CBA case manager significant changes in the consumer's physical health, mental and/or behavior status, including planned and emergency hospitalizations, consumer requested termination of AFC services, physical injury or death, any offense against the person or family, or public indecency.
  • Seek or provide medical assistance/treatment as appropriate.
  • Notify the CBA case manager of serious occurrences involving the provider, the home or the consumers. These may include but are not limited to fire, accidents, altercations among consumers, break-ins, or illness of the provider or consumers.
  • Notify the CBA case manager before any consumer receives home and community support services not provided through CBA.
  • Provide the consumer with at least three meals daily that meet each consumer's dietary and nutritional needs.
  • Comply with rules regarding the storage and management of medications. Maintain prescription medication in the original container labeled with the consumer's name, date, instructions, the physician's name, and the name of the medication and dosage. Keep medications in a locked container, unless a waiver has been granted.
  • Provide or make arrangements to meet the transportation needs of consumers for medical appointments and care, shopping for personal needs and church activities.
  • Post a providers' bill of rights in a prominent place in the foster home.
  • Inform the consumer verbally and in writing, before or at the time of admission, of his rights and responsibilities. The rights and responsibilities include rules governing consumer conduct, complaints, bedhold policies for hospital and personal leave, and eviction procedures.
  • Treat the consumer with dignity and respect.

Refer to the Community Based Alternatives Provider Manual, Section 4236, Services Provided by CBA AFC Provider, for more detailed information related to the responsibilities of AFC providers.

4212  Four Bed Adult Foster Care Homes

Revision 08-10; Effective September 1, 2008

A Type C Assisted Living (AL) license is obtained if the Adult Foster Care (AFC) provider wants to serve four consumers. The home cannot be approved for the fourth consumer until the provider has applied for and received the Type C license. After AFC enrollment is complete, the provider may apply for a Type C license from the Department of Aging and Disability Services Regulatory Services division. The license must be renewed yearly and requires an annual fee. A single facility could be both licensed as an AL facility and enrolled as an AFC home.

Settings of one to three beds do not require licensure.

Refer to the Community Based Alternatives Provider Manual for specific information about contracting, qualifications and enrollment requirements.

4213  Small Group Homes

Revision 08-10; Effective September 1, 2008

Adult Foster Care (AFC) may also be provided in a small group home licensed by the Department of Aging and Disability Services (DADS) as Assisted Living (AL) Type A, Small, under the Minimum Licensing Standards for Assisted Living. The provider must submit a copy of the AL license to contract management staff before enrollment and upon renewal thereafter. The provider must report to contract management staff any problem(s) identified by Regulatory Services. DADS regional contract managers enroll small group homes. Providers must meet all applicable requirements in the Minimum Standards for AFC. Providers must serve no more than eight adult consumers in an enrolled small group home.

AFC provided in small group homes is subject to two sets of regulations: DADS minimum standards for AFC and Licensing Standards for Assisted Living Facilities. The stricter requirements apply when requirements conflict; therefore, an enrolled AFC provider home that is licensed as a small group home must comply with the requirement that an attendant be present at all times when residents are in the facility. This requirement applies regardless of the number of consumers currently residing in the facility.

4214  Contract Manager and Case Manager Responsibilities

Revision 08-10; Effective September 1, 2008

4214.1  Contract Manager Responsibilities

Revision 08-10; Effective September 1, 2008

Department of Aging and Disability Services regional contract managers are responsible for all requirements for Adult Foster Care (AFC) providers and homes. The contract manager's responsibilities include:

  • recruiting AFC homes;
  • processing AFC applications;
  • orientating and training the AFC provider;
  • conducting fire and health inspections;
  • disenrolling AFC homes;
  • approving private pay consumers;
  • conducting administrative reviews;
  • reassessing the AFC provider and home; and
  • processing payments.

4214.2  Case Manager Responsibilities

Revision 08-10; Effective September 1, 2008

Department of Aging and Disability Services case managers are responsible for all requirements for Adult Foster Care (AFC) applicants and consumers. The case manager's responsibilities include:

  • completing the AFC applicant intake and assessment process;
  • determining eligibility for AFC;
  • assessing the applicant and provider to determine whether an appropriate environment can be provided;
  • providing information to interested applicants about potential AFC homes and arranging visits to the homes;
  • developing a service plan and completing the consumer and provider agreement;
  • acting as coordinator of the interdisciplinary team;
  • authorizing AFC services;
  • monitoring the consumer;
  • notifying the applicant/consumer of room and board and copayment amounts; and
  • processing changes and conducting annual reassessments of the consumer.

4220  Adult Foster Care Eligibility

Revision 08-10; Effective September 1, 2008

To be eligible for Adult Foster Care (AFC), applicants and consumers must meet basic eligibility requirements for Community Based Alternatives (CBA) services as well as specific requirements related to AFC. Basic eligibility requirements for CBA can be found in Section 1700, Eligibility for Enrollment. In addition, applicants/consumers will be classified for level of service based on their assessed needs for care. Refer to Section 4234, Classification Levels of Adult Foster Care Consumers.

4230  Adult Foster Care Intake and Assessment

Revision 08-10; Effective September 1, 2008

Adult Foster Care (AFC) is appropriate for individuals who, because of physical, mental or emotional limitations, are unable to continue independent functioning in their own homes and who need and desire the support and security of family living. AFC is also appropriate for individuals who do not need institutional care, but are unable to resume independent living or have no relatives who are able to provide a home.

All existing Community Care for Aged and Disabled AFC consumers should be offered the opportunity to have their names placed on the Community Based Alternatives interest list.

4231  Response to Request for Services

Revision 08-10; Effective September 1, 2008

Upon receipt of an intake for Community Based Alternatives Adult Foster Care, the case manager follows the procedures in Section 3311, CBA Enrollment Process — Initial Assessment.

4232  Consumer's Rights and Responsibilities

Revision 08-10; Effective September 1, 2008

The case manager must explain the room and board requirements in Adult Foster Care (AFC) and ensure that the applicant understands that he must pay a portion of his monthly income for room and board. Explain that some AFC consumers are required to contribute to the cost of their care by paying a copayment.

Review Form 2307, Rights and Responsibilities, and Form 2307-F, AFC Rights and Responsibilities, with the applicant/consumer. Make sure that the applicant/consumer understands his responsibilities as a resident in an AFC home.

4233  Assessing Potential Adult Foster Care Homes

Revision 08-10; Effective September 1, 2008

If the applicant appears to meet eligibility criteria, the case manager provides information about potential Adult Foster Care (AFC) homes. The case manager can arrange visits to appropriate AFC homes or, if the applicant is capable or has family/supports available, the applicant/family may make the arrangements to visit potential AFC homes. In some situations, the case manager may need to assist the applicant in making the visit(s).

The purpose of the visits to potential AFC homes is to let the applicant assess the home and let the AFC provider assess if the applicant will be appropriate in the AFC home. The case manager may contact the provider and share information about the applicant, including the applicant's particular needs and problems, to ensure that the potential provider is fully aware of the responsibilities involved in caring for the applicant and to prevent a potential mismatch of the applicant and the provider. The case manager also shares information on nursing care, home modifications or adaptive aids that may be necessary. In choosing a home, consideration should be given to the provider's willingness and capability in performing nursing tasks. The case manager must also inform the AFC provider if the applicant can be left alone for up to three hours, based on the Home and Community Support Services provider nurse's assessment, documented on Form 3671-C, Nursing Service Plan. If the applicant cannot be left alone, the AFC provider will be responsible for providing or arranging for 24-hour supervision.

To guide the applicant in the selection of the AFC home, the case manager relies on the recommendation of the registered nurse completing the pre-enrollment assessment regarding the appropriate level (I, II or III) of AFC. Refer to Section 4234, Classification Levels of Adult Foster Care Consumers.

If a Community Based Alternatives (CBA) AFC home is filled, the provider must maintain an interest list. If the AFC home is also enrolled for Community Care for Aged and Disabled (CCAD), the provider must maintain two separate interest lists. Those on the CBA interest list will take priority over those on the CCAD interest list.

4234  Classification Levels of Adult Foster Care Consumers

Revision 08-10; Effective September 1, 2008

STANDARD. Classification of Adult Foster Care (AFC) consumers is based on their assessed needs for care as follows.

  1. Level I AFC Consumer. Certain tasks provided in Level I AFC homes may require the delegation and supervision of a registered nurse (RN) under applicable rules of the Board of Nurse Examiners in 22 TAC Chapter 225. The consumers need less complex assistance with tasks or supervision than those of Level II or Level III. Level I nursing facility consumers 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; or
      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 AFC Consumer. Certain skilled tasks in Level II AFC homes may require the delegation and supervision of a RN under applicable rules by the Board of Nurse Examiners in 22 TAC Chapter 225. These consumers 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 that 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. consumers who are determined by the RN to exhibit confusion, disorientation and behavior problems, as validated on the Medical Necessity and Level of Care (MN/LOC) Assessment.
  3. Level III AFC Consumers. Skilled tasks in Level III AFC must be provided by a licensed RN, licensed vocational nurse (LVN), or substitute RN or substitute LVN. These consumers 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 consumers require timely assessment, planning, and intervention by a licensed nurse on a 24-hour basis.

The level of each Community Based Alternatives (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 enrolled, the AFC provider will be notified by letter of any change in the level of consumers the provider may accept. A copy of the letter will become part of the contract file kept by CBA contract staff.

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

The licensed nurse of the AFC home determines if the level of the consumer is Level III. If the case manager has a concern about whether a consumer is classified as Level III, the Department of Aging and Disability Services (DADS) regional nurse must be consulted to assess participation. The determination by the DADS regional nurse is final.

4235  Placement on the Interest List

Revision 08-10; Effective September 1, 2008

If an intake is received for Adult Foster Care (AFC) but no foster homes are available to provide care or the individual's choice of homes is at capacity, the individual's name may be placed on the interest list maintained by the AFC home. The case manager should discuss other alternatives and living arrangements where Community Based Alternatives (CBA) services may be provided.

If other arrangements are not available or suitable, the applicant may choose to withdraw the application and have his name added back to the CBA interest list. Refer to Section 3212, Placement on the Community Services Interest List (CSIL), for procedures.

4236  Adult Protective Services and Adult Foster Care

Revision 08-10; Effective September 1, 2008

4236.1  Placement of Adult Protective Services Consumers in Adult Foster Care

Revision 08-10; Effective September 1, 2008

In some areas, Adult Protective Services (APS) may use Adult Foster Care (AFC) as a resource for placement of APS consumers. Approval by the contract manager is required before an APS consumer moves into a Department of Aging and Disability Services enrolled AFC household. The purpose of the approval is to determine the:

  • appropriateness of the consumer's characteristics;
  • capacity of the foster home to meet the consumer's needs; and
  • compatibility of service delivery to the APS consumer and the delivery of services to the certified AFC consumers.

If it is determined by the contract manager that placement in foster care is inappropriate, the APS worker and the provider will help the consumer make other living arrangements.

4236.2  Adult Protective Services Investigations of Adult Foster Care Providers

Revision 13-1; Effective March 1, 2013

Any time Department of Aging and Disability Services (DADS) staff suspect abuse, neglect or exploitation of an individual in an Adult Foster Care (AFC), a report must be made immediately to Adult Protective Services (APS).

If reports are made to APS from outside sources, DADS staff may not be notified of the individual's allegations against a service provider until after the allegations have been validated. However, APS staff may ask DADS staff to assist with the delivery of services during the course of the investigation if the alleged mistreatment poses an immediate threat to the safety of the individual in an AFC home.

The contract manager assigned to the facility handles disenrollment and corrective actions against the AFC provider, as appropriate. If the case manager is unable to find a suitable residence for the individual, the individual is referred to APS for assistance in moving from the AFC home.

An individual who has the capacity to consent may decide not to move from the AFC home, even though the allegation has been validated and the situation is likely to recur. In such an instance, the individual's AFC services must be terminated and payments to the home will terminate. However, the individual may continue to reside in the home by making private pay arrangements with the AFC provider.

If an individual who does not appear to have the capacity to consent refuses to move from the AFC home operated by a person identified as the perpetrator in a case of validated abuse, neglect or exploitation, make a referral to APS.

4237  Private Pay in Adult Foster Care

Revision 13-1; Effective March 1, 2013

Some Adult Foster Care (AFC) providers may wish to accept persons for private payment. Approval by the contract manager is required before the AFC provider accepts persons for private payment. The AFC provider must contact the contract manager when considering admitting a private pay person. The contract manager will furnish Form 2330, Assessment and Service Plan Approval for Adult Foster Care, to the AFC provider. The AFC provider must complete Form 2330 and return it to the contract manager to approve or disapprove the arrangement. The purpose of the approval is to determine the:

  • appropriateness of the private pay person based on his condition and behavior;
  • capacity of the AFC home to meet the private pay person's needs; and
  • compatibility of service delivery to the private pay person and the delivery of services to the individual receiving AFC services through the Community Based Alternatives program.

If the contract manager determines that placement of the private pay person in foster care is inappropriate, the AFC provider cannot accept the person.

Refer any issues regarding placements that need to be resolved to the contract manager.

4240  Adult Foster Care Case Manager Procedures

Revision 08-10; Effective September 1, 2008

4241  Eligibility Determination

Revision 08-10; Effective September 1, 2008

To determine eligibility for Adult Foster Care (AFC), the case manager must:

  • certify that the applicant meets all criteria for the Community Based Alternatives program (see Section 1700, Eligibility for Enrollment); and
  • determine that the applicant has an agreement with an enrolled AFC home to potentially move into the home.

The case manager must ensure that the AFC consumer is placed in the appropriate level (I, II or III) of AFC as determined by the consumer's classification. Refer to Section 4234, Classification Levels of Adult Foster Care Consumers.

4242  Service Planning

Revision 08-10; Effective September 1, 2008

The final care and monitoring plan for the consumer should address functional, medical, social and emotional needs and how the needs might be met in the selected Adult Foster Care (AFC) home. Assess whether other resources in the community should be used to meet specialized needs of the consumer. Use of those resources should be documented in the care plan.

Form 2060, Needs Assessment Questionnaire and Task/Hour Guide, Part A, Functional Needs Assessment, is completed by the Community Based Alternatives case manager to document the specific personal care tasks the AFC provider must assist the consumer with. The AFC provider may provide more tasks but not less than those listed on Form 2060.

Upon approval for AFC, the case manager determines if the consumer has any special needs that require additional monitoring in the foster home setting beyond the scheduled monitoring. If needed, a monitoring schedule is developed and documented in the case record on Form 2327, Individual/Member and Provider Agreement. Use the "Other Special Arrangements" space under the "Miscellaneous Arrangements" section.

The case manager contacts the consumer and the AFC provider to arrange for the initial visit and a negotiated move-in date for the consumer. If there are health concerns regarding the consumer, the regional nurse may be consulted and a recommendation may be made for the consumer to have a physical/medical exam before moving into the AFC home.

The case manager coordinates with the interdisciplinary team regarding the AFC consumer's care.

4250  Finalizing the Care Plan

Revision 08-10; Effective September 1, 2008

On or before the date the consumer moves into the Adult Foster Care (AFC) home, a face-to-face meeting with the consumer and the AFC provider is required to discuss the consumer's care plan and to complete Form 2327, Individual/Member and Provider Agreement.

The interdisciplinary team, including the consumer's family members or responsible person, may be included in the meeting and the meeting should preferably take place in the AFC home.

Discuss the consumer's care plan with the consumer and family members/responsible party and reach understanding with them about how the foster care provider will meet his needs. This discussion should ensure that the consumer, his family/responsible party and the foster care provider are adequately prepared for a new consumer in the home and that adjustments occur smoothly. Document the care plan and any special needs of the consumer or special agreements between the consumer and provider on Form 2327.

If the consumer is already residing in the AFC home, Form 2327 must be completed face-to-face with the consumer and AFC provider before certification or recertification of AFC services.

4251  Consumer and Provider Agreement

Revision 08-4; Effective December 18, 2008

During the initial home visit, the case manager documents the service arrangements and the agreement of the room and board payment on Form 2327, Individual/Member and Provider Agreement.

The case manager reviews all of the information on the agreement with the consumer, family and/or responsible person and the provider. All conditions of the agreement and the following topics must be covered in the discussion:

  • A full description of the care needs of the consumer and services needed, including the schedule of care.
  • The need for 24-hour supervision or care delegated to the Adult Foster Care (AFC) provider by a licensed registered nurse.
  • The beginning and ending date of the agreement.
  • A detailed description of the rights and responsibilities of the consumer and the provider.
  • An explanation of the consumer's and provider's right to privacy and confidentiality.
  • The monthly dollar amount the consumer agrees to pay the provider for room and board as documented on Form 2327 and Form 2065-B, Notification of Waiver Services.
  • The arrangements for a trust fund if the Community Based Alternatives consumer requests such service from the AFC provider.
  • An inventory of personal belongings.
  • The names, addresses and telephone numbers of the persons to be notified in an emergency, including the consumer's physician, family members and/or responsible person.
  • Any special habits and needs of the consumer and any special arrangements or agreements between the consumer and the provider.
  • Any additional training needs of the provider and methods to obtain that training.
  • The rights and responsibilities of both the consumer and the provider for notifying the case manager and contract manager of problems, such as illnesses, medication reactions, hospitalizations, acts of violence, accidents, complaints about abuse, neglect or exploitation.
  • Other conditions that reflect changes in the consumer's condition that might affect the appropriateness of the foster home placement.

Fully discuss with the AFC provider the likelihood of problems arising after the consumer moves into the home, notification procedures and suitable actions that should be taken to resolve problems. Also, discuss with the provider the impact of a new consumer on members of the foster care family and other consumers in the home. Anticipate problems that might arise and how they should be handled. Outline the schedule of monitoring visits that have been planned for the consumer.

Item 1, under Miscellaneous Arrangements on Form 2327, is used to document special monitoring schedules and other resources used in the plan of care.

The consumer and the provider must sign Form 2327 after all of the above issues are discussed and both parties are in agreement. Both Form 2327 and Form 2307-F, AFC Rights and Responsibilities, must be completed and signed before authorizing and reauthorizing AFC. Any changes or incidents must be reported to the case manager within 24 hours of the occurrence.

4252  Copayment and Room and Board Requirements

Revision 08-10; Effective September 1, 2008

Copayment and room and board are applicable to Adult Foster Care (AFC) consumers as described in Section 3550, Copayment and Room and Board, and Appendix VI, Calculation of Copayment and Room and Board.

If copayment is applicable, the AFC consumer's copayment amount is listed on both Form 3671-1, Individual Service Plan, and Form 2065-B, Notification of Waiver Services. Form 2065-B is used to report to the consumer the amount of his copayment for the first month of authorized service and subsequent months. The Community Based Alternatives (CBA) AFC provider also receives a copy of Form 2065-B.

The room and board amount is entered on Form 2065-B and Form 2327, Individual/Member and Provider Agreement. Ensure that the consumer and AFC provider understand that the room and board arrangement with the provider is separate from the Department of Aging and Disability Services (DADS) payment for services. The consumer pays the provider the room and board amount listed on Form 2327 and Form 2065-B. If the consumer is moving into the AFC home mid-month, prorate the amount of room and board for the month and advise the consumer and provider of the prorated amount.

When the copayment and/or room and board amounts change, the case manager must notify the provider and the consumer of the new amount before the change.

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

STANDARD. The CBA AFC provider must collect the copayment from the consumer. 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 DADS.

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

If the consumer 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 consumer or the consumer's responsible party explaining the consequences of continued refusal to pay. If the consumer does not pay his required fees within 30 days of the due date, the case manager can terminate AFC services to the consumer. The consumer can then be evicted from the home, according to local eviction ordinances and procedures.

4253  Trust Funds

Revision 08-10; Effective September 1, 2008

The Community Based Alternatives (CBA) case manager must offer money management assistance by the Adult Foster Care (AFC) provider to the applicant/consumer and document that the applicant/consumer either accepted or refused the assistance. If the applicant/consumer expresses an interest in money management, the case manager documents the expressed interest on Form 2067, Case Information, and sends the form to the AFC provider. The requirement for money management services may also be documented on Form 2327, Individual/Member and Provider Agreement.

The CBA AFC provider must maintain trust fund records. The AFC provider must:

  • have written permission from the consumer to handle his personal financial affairs;
  • keep consumer trust accounts separate from the provider's operating accounts. The separate account must be identified "Trustee, (name of the CBA AFC provider), Consumer's Trust Fund Account." If the AFC provider maintains a trust fund, the provider must:
    • deposit the consumer'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 consumer's monthly income into the operating account and then deposit the personal needs and room and board allowance into the trust fund account;
  • make the consumer trust fund records available for review by Department of Aging and Disability Services staff during work hours without prior notice;
  • not charge the consumer for services that the provider is expected to provide for the consumer;
  • not charge the consumer for banking service costs if the consumer trust fund is in a pooled account;
  • obtain and maintain current written individual records of all financial transactions involving the consumer's personal funds that the provider is handling. The provider must include at least the following in the records:
    • consumer's name;
    • identification of consumer's representative payee or responsible party;
    • admission date;
    • consumer's earned interest; and
    • transactions. The provider may choose one of the following options:
      • 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 consumer. If the consumer is unable to sign when funds are being withdrawn from his trust funds, the transactions or receipt must be signed by a witness;
      • 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 consumer. If the consumer is unable to sign his name, a witness must sign the transaction or receipt; and
  • distribute the interest earned on any pooled interest banking account in one of the following options:
    • prorated to each consumer on an actual interest earned basis; or
    • prorated to each consumer on the basis of his end-of-quarter balance.

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

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

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

4254  Hospital Leave

Revision 08-10; Effective September 1, 2008

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

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

During the initial home visit, the case manager reviews the information regarding the consumer's responsibility to pay a bedhold charge when away from the home.

4255  Authorization of Adult Foster Care

Revision 09-9; Effective December 1, 2009

After all Community Based Alternatives eligibility is established and all additional Adult Foster Care (AFC) procedures are completed, the case manager sends the consumer Form 2065-B, Notification of Waiver Services. The case manager authorizes AFC on Form 3671-1, Individual Service Plan, and in the Service Authorization System.

The case manager sends to the AFC provider:

  • a copy of Form 3671-1;
  • applicable individual service plan 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-H, Dental Services, and Form 3671-J, Dental Services – Proposed Treatment Plan);
  • Form 2060, Needs Assessment Questionnaire and Task/Hour Guide; and
  • Form 2327, Individual/Member and Provider Agreement.

4256  Adult Foster Care and Day Activity and Health Services

Revision 09-9; Effective December 1, 2009

Title XIX, Day Activities and Health Services (DAHS), may be authorized for Community Based Alternatives (CBA) Adult Foster Care (AFC) consumers residing in Level I and Level II homes. DAHS must not be authorized for CBA consumers residing in AFC Level III homes.

CBA consumers residing in AFC Level I and Level II homes may receive up to 10 units of DAHS per week.

4260  Monitoring Quality of Care

Revision 08-14; Effective December 18, 2008

The quality of care provided to waiver consumers residing in Adult Foster Care (AFC) homes will be monitored by the Community Based Alternatives (CBA) case manager, the regional contract manager and the Home and Community Support Services Agency (HCSSA) registered nurse (RN) responsible for delegation and supervision of nursing tasks. The regional contract manager completes on-site monitoring to determine the AFC provider's compliance with contract terms and program rules. The RN monitors the performance of nursing tasks in the nurse's delegation/treatment plan in accordance with applicable rules by the Board of Nurse Examiners in Texas Administration Code 22, Chapter 225.

Regular monitoring visits by the case manager must assess the consumer's needs and whether the provider is addressing and meeting those needs. The case manager must contact the contract manager if the AFC provider is not addressing or meeting the needs of the consumer. The consumer's physical and medical condition should be carefully monitored to determine whether initial problems are resolved and/or whether new problems are arising due to decreased functional capacity or illness. The HCSSA nurse or Department of Aging and Disability Services regional nurse may be used in the assessment/monitoring process as needed.

Item 1, under Miscellaneous Arrangements on Form 2327, Individual/Member and Provider Agreement, is used to document special monitoring schedules and other resources used in the plan of care.

Refer to Section 3710, Monitoring Contacts, and Section 3714, Monitoring of Adult Foster Care (AFC), for monitoring requirements for CBA AFC consumers.

4270  Significant Changes

Revision 08-10; Effective September 1, 2008

It is the responsibility of the case manager and the Adult Foster Care (AFC) provider to ensure that the AFC consumer is in an appropriate setting to meet his needs. When the AFC consumer has a change in functional need, health problems or changes in behavior, it is the responsibility of the AFC provider to notify the case manager.

The case manager must follow up with the consumer and provider to determine if changes to the care arrangement are needed.

The case manager must give particular attention to consumers who reflect dramatic changes in functional need, medical problems or behaviors that are inappropriate for foster care. Family members and/or the responsible party or guardian should be alerted to the situation. Discuss with them and the consumer the potential for the consumer to remain in the AFC home. A guardian appointed by the court acts on the consumer's behalf. If the consumer has had a decline in his medical condition or functional ability, consult the Home and Community Support Services nurse to determine if a visit should be made to assess the consumer's medical status. The CBA case manager may also consult the Department of Aging and Disability Services regional nurse for issues related to the consumer's medical decline.

Long-range care plans should be discussed frankly with the consumer, family members and the AFC provider to ensure that all are aware of the capabilities and limitations of AFC services for consumers with deteriorating medical or functional conditions. Consumers who become inappropriate for foster care must be advised of other available options. Assistance should be provided to consumers and their family members in this decision process and with transfer activities when necessary. If the provider decides that the consumer is not appropriate for care in his home, the provider contacts the case manager to request that the consumer be transferred to another placement. The case manager is responsible for preparing the consumer for transition when the consumer becomes inappropriate for a particular AFC home or AFC services.

4271  Termination of Adult Foster Care Services

Revision 13-1; Effective March 1, 2013

During the course of an individual's stay in an Adult Foster Care (AFC) home, the individual may experience changes in his condition or the care required. If the individual begins to need services that cannot be provided by the AFC provider, it will be necessary for the case manager, in consultation with the Home and Community Support Services Agency (HCSSA) registered nurse supervising the AFC provider's delivery of delegated nursing tasks to the individual, if any, to assure that the necessary care is obtained. An HCSSA may provide skilled care in the AFC home for stabilization or rehabilitation.

If the short term services provided in the home by HCSSA staff are not sufficient and other services are not available to support the individual in that AFC arrangement, the case manager, in conjunction with other members of the interdisciplinary team (IDT), should explore alternatives. More long term chronic changes in service needs will likely require that the individual move to another setting that provides more skilled intervention, such as a Level II or Level III AFC home or nursing facility.

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 individual'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 individual's condition has deteriorated 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 4272, Discharge and Termination Due to Health and Safety.

Community Based Alternatives (CBA) AFC providers cannot terminate AFC services to an individual without the prior approval of the case manager, and must follow procedures for providing a 30-day written notice with an exception for an individual whose behavior or condition threatens the health or safety of himself or others. During the 30 days after written notice is served to the individual to vacate the AFC home, the case manager is responsible for working with the individual to assure alternative services will be available.

Once an individual is identified as inappropriate for AFC services, the case manager must negotiate a time frame with the individual, his responsible party and the AFC provider for the individual to move. The time frame is determined on a case-by-case basis depending on the urgency and severity of the situation and how quickly an appropriate placement can be arranged. If the individual has been a threat to the health and safety of other individuals in the AFC home or has exhibited inappropriate behaviors so that the AFC provider is asking the individual to move immediately, then the case manager must make every effort to locate another living arrangement as soon as possible. If other living arrangements are not readily available for the individual, submit a referral to Adult Protective Services (APS) to assist in locating appropriate placement for the individual.

If there is resistance to the move from the individual, his responsible party or the AFC provider, an additional staffing with the individual, his responsible party and the AFC provider may be required to resolve the problem. Request that the supervisor and contract manager attend the staffing, if necessary. The case manager advises the individual and AFC provider that AFC services will terminate on the date specified on Form 2065-B, Notification of Waiver Services, or Form 2065-C, Notification of Ineligibility or Suspension of Waiver Services. If the individual transfers to another AFC home or CBA living arrangement, send the individual Form 2065-B. If the individual does not transfer to another AFC or CBA living arrangement, send the individual Form 2065-C to terminate CBA program eligibility. The AFC provider has the right to begin eviction proceedings as specified in the provider's resident rights and responsibilities. Ensure that the individual and his responsible party understand the consequences of eviction. If the AFC provider must use eviction procedures and the individual has refused to make other living arrangements, submit a referral to APS.

If the individual and AFC provider decide that the individual will remain in the AFC home as a private pay person, the contract manager must give approval. Make sure the individual and AFC provider understand that there are no case management services or payment arrangements from the Department of Aging and Disability Services for a person who private pays the AFC provider.

Refer to Section 4272 for more details on how to handle situations when the individual threatens the health or safety of himself or others in the AFC home.

4272  Discharge and Termination Due to Health and Safety

Revision 13-1; Effective March 1, 2013

Any individual whose medical condition or behavior threatens the health and safety of himself or others is subject to discharge without notice from a Community Based Alternatives (CBA) Adult Foster Care (AFC) home.

The AFC provider must take appropriate action if the individual's medical condition has deteriorated and he requires more skilled intervention to ensure his health and safety. Depending on the individual's condition, appropriate action could be calling emergency medical services, the individual's physician or the Home and Community Support Services Agency (HCSSA) registered nurse (RN) working with the individual. If some action is taken by the AFC provider, the provider must inform the Department of Aging and Disability Services (DADS) contract manager and case manager on the same day the provider becomes aware of the individual's condition.

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

The AFC provider must take appropriate action if the individual's behavior has deteriorated and he threatens the health and safety of himself or others. Depending on the individual's behavior, appropriate action could be calling the police or sheriff's department, the individual's physician, the HCSSA RN working with the individual or the case manager. The individual must be removed from the AFC home as soon as possible if he becomes a threat to the health or safety of himself or others. In some instances, the case manager may call Adult Protective Services (APS) if hospitalization for psychiatric observation seems warranted.

The case manager must mail or give a completed Form 2065-B, Notification of Waiver Services, to the individual 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 or given to the individual, even if the decision is appealed. Though the individual may not be terminated from CBA, the individual has a right to appeal the decision of removal from the AFC home.

The individual may not remain in the AFC home during the appeal process. The case manager must work with APS or providers of other CBA services to arrange alternate placement for the individual. Refer to Section 3814, Crisis Intervention Requiring Immediate Suspension or Reduction of Services Without Advance Notice.

4280  Annual Reassessment

Revision 08-10; Effective September 1, 2008

Complete the annual reassessment of the Community Based Alternatives Adult Foster Care (AFC) consumer per policy in Section 3640, Reassessments. Additional tasks include the completion of:

  • Form 2327, Individual/Member and Provider Agreement; and
  • Form 2307-F, AFC Rights and Responsibilities.

Form 2060, Needs Assessment Questionnaire and Task/Hour Guide, Part A, must be completed annually to specify personal assistance tasks to be provided by the AFC provider to the consumer.

4300  Residential Care Services

Revision 10-3; Effective June 1, 2010

4310  Introduction

Revision 10-3; Effective June 1, 2010

Assisted Living/Residential Care services provide a 24-hour living arrangement for persons who, because of physical or mental limitation, are unable to continue independent functioning in their own homes. Services are provided in personal care facilities licensed by the Department of Aging and Disability Services (DADS). Community Based Alternatives (CBA) consumers are responsible for their room and board costs and, if applicable, copayment for Assisted Living/Residential Care services.

The purpose of Assisted Living/Residential Care services is to promote the availability of appropriate services for elderly and disabled persons in a home-like environment to enhance the dignity, independence, individuality, privacy, choice and decision-making ability of the consumer.

4311  Housing Options in Licensed Personal Care Facilities

Revision 10-3; Effective June 1, 2010

A personal care facility must specify in its contract the type(s) of setting(s) it uses to provide Assisted Living/Residential Care (AL/RC) services according to the following guidelines:

  • 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.
  • 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.
  • 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.

For more detailed information about housing options, refer to the Contracting to Provide Assisted Living and Residential Care Services Handbook located at: www.dads.state.tx.us/handbooks/cpalrcs/index.htm.

Personal Care 3 settings are also available in Community Based Alternatives (CBA) AL/RC. Refer to Section 4324, Personal Care 3, for facility qualifications and case manager procedures.

The facility must provide each consumer with a private (singe occupancy) or semi-private (double occupancy) living unit. CBA AL/RC contracts specify whether the facility has contracted to provide services under the housing options of AL/RC or RC Non-Apartment. The AL/RC provider may not deliver CBA services in a housing option for which the provider has not contracted to deliver services. The facility may adjust the number of beds for Department of Aging and Disability Services (DADS) consumers by contract amendment. If a provider wishes to maintain both AL (single occupancy) and RC apartments (double occupancy) in one facility, the contract must specify that information.

If the AL/RC provider wishes to limit the types of apartments in the facility available to CBA consumers, the provider must specify these limitations in the contract, either at the time of signature or by amendment. The apartments in question must meet all qualifications for the type setting. If there are no such specifications in the contract, all types of apartments in the facility must be available to CBA consumers.

If the facility limits the type of apartment available for CBA consumers and there is no apartment of that size available, the facility can refuse to accept any CBA consumer, based on not having space available. This would apply both for a consumer wanting to move into the facility from the outside, or to a private pay consumer currently in the facility who is becoming a CBA consumer. The consumer would then have the option of reviewing other available AL/RC facilities in the area or adult foster care homes.

"Freestanding" is defined as not physically connected to a licensed nursing facility, hospital or another licensed personal care facility, unless the total licensed capacity of both personal care facilities does not exceed 16 beds. At minimum, a covered walkway between buildings is required for physical connection.

At the consumer's request, portable kitchen units may be removed from the living area.

4320  Description of Services

Revision 10-3; Effective June 1, 2010

§46.41 Required Services

(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, except in the Community Care for Aged and Disabled (CCAD) Residential Care (RC) Program;
(H)
transferring/ambulating, except in a Type A assisted living facility;
(I)
twenty-four-hour supervision, which means the facility must:
(i)
conduct checks or visits to each client as identified in the client's service plan, to ensure that each client is safe and well; and
(ii)
document the checks and visits in the client's file;
(J)
meal services, which means 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, including 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 in the client's assessment by a home and community support services agency's licensed nurse. A facility is not required to designate someone to participate in a client's assessment in 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.

Personal care tasks must be provided as identified on the service plan completed for the consumer by the AL/RC facility. A registered nurse (RN) must perform the medication administration assessment of the consumer. The Assisted Living/Residential Care (AL/RC) provider is responsible through its contract with the Department of Aging and Disability Services (DADS) for providing administration of medications, which is the direct administration of all medications or the assistance with or supervision of medication. This includes injections if needed. Only a licensed nurse can give injections.

The personal care facility may provide more services for the consumer than are identified on the service plan developed, but not fewer.

The health assessment/service plan is developed and documented using Form 3050, DAHS Individual Service Plan, or other health assessment/service plan document chosen by the AL/RC provider.

Licensure as a personal care facility requires the facility to provide soap and toilet tissue at all times for consumer use. Other personal items must be purchased by the consumer.

CBA consumers receiving AL/RC are entitled to receive medical transportation services through Medicaid for Medicaid-covered medical appointments. The AL/RC facility personnel are responsible for scheduling the transportation according to medical transportation procedure. If the CBA consumer wishes to attend an activity outside the facility that is not a group activity sponsored by the facility, the consumer is responsible for paying for his own transportation.

The AL/RC facility may charge the consumer or the consumer's representative for additional items or services that DADS does not require the AL/RC facility to provide. The consumer or the consumer's representative must request and approve the additional items or services in writing. Items not required to be provided by the AL/RC provider through the AL/RC facility licensing standards or contacting rules (for example, returned check fees, service deposits) may be charged to the consumer if listed in the admission agreement. Contract management staff or regulatory staff can provide information about allowable charges for additional items. Additional items the AL/RC facility may charge the consumer are found in the Texas Administrative Code, §46.15, Additional Services and Fees.

4321  Case Management Duties Related to Assisted Living/Residential Care

Revision 02-0; Effective April 4, 2002

Additional information on case management duties related to assisted living/residential care services is included in Section 3311.2.2.

4322  Initial Responsibilities for Individuals Residing in an Assisted Living Facility

Revision 12-2; Effective June 1, 2012

The case manager is responsible for helping the applicant or individual select an Assisted Living (AL) facility that can meet his needs. After the individual service plan (ISP) is developed and signed by the applicant or individual, the case manager sends the ISP to the selected provider, as described in Section 3433, Coordination of ISP with HCSSA, AFC and AL/RC Providers. If the provider accepts the referral, the case manager completes the eligibility determination process, authorization of services and registration of the ISP. A written notification is sent as described in Section 3435.3, Written Authorization to ERS, AFC and AL/RC providers.

The AL provider must assess the individual within 72 hours of admission and complete Form 3050, DAHS Individual Service Plan, or other health assessment/service plan document chosen by the provider. The health assessment/service plan completed by the provider identifies the specific needs of the individual and how those needs will be met by the facility. The health assessment/service plan describes how the individual's condition prevents him from performing activities of daily living. The plan should be agreed upon and signed by the individual or his family and the provider. A copy of the health assessment/service plan is given to the individual.

The case manager is not given a copy of the initial or reassessment Form 3050 or other health assessment/service plan document. The AL facility is responsible for providing the personal care tasks as identified on Form 3050 or other health assessment/service plan document. For individuals residing in an AL facility, it is not necessary for the case manager to complete Form 2060, Needs Assessment Questionnaire and Task/Hour Guide, and Form 2060-A, Addendum to Form 2060 for Personal Assistance Services, as the facility identifies the tasks needed by the individual.

The case manager must offer money management to the individual and document that the individual either accepted or refused the service. If the individual expresses an interest in money management, the case manager must document that the individual expressed an interest in money management on Form 2067, Case Information, which is sent to the AL provider.

The case manager must explain the copayment requirement and room and board charges, as described in Section 4341, Room and Board and Copayment Requirements, and Appendix VI, Calculation of Copayment and Room and Board, to the individual. Room and board must be paid by every individual residing in an AL facility. Copayment is not required of individuals who receive Supplemental Security Income (SSI). Copayment is required for AL services from individuals whose financial eligibility was determined under the special institutional criteria. The case manager must:

  • calculate the room and board payment amount;
  • determine the copayment for the initial month of service and ongoing copayment amount for subsequent months;
  • register the amounts on Form 3671-1, Individual Service Plan, and in the Service Authorization System (SAS);
  • verbally notify the individual and the provider of the amounts to be collected and include this information on Form 2065-B, Notification of Waiver Services, as described in Section 3821, Notifications; and
  • assist the individual and provider in resolving problems related to collection of the individual's copayment and room and board contributions.

The case manager may have to estimate the initial and ongoing copayment amounts for the initial ISP development. If the amount available for copayment is not documented in the Texas Integrated Eligibility Redesign System (TIERS) prior to the Medicaid eligibility determination, the case manager estimates the copayment based on the individual's self-reported income from Form H1200, Application for Assistance – Your Texas Benefits,/Form H1010, Texas Works Application for Assistance – Your Texas Benefits. The estimated copayment amount is necessary in order to compute an ISP for individuals residing in an AL facility. The ISP with the estimated copayment amounts is not to be registered in SAS. When the accurate amount available for copayment is available in TIERS, the case manager recalculates the copayment amounts. The correct copayment amounts, not the estimated amounts, are included in Form 2065-B and registered in SAS.

The case manager must explain to the individual that failure to pay his room and board charges or copayment will result in termination of Community Based Alternatives (CBA) services.

4323  Admission to Facility

Revision 10-3; Effective June 1, 2010

Before admission, the case manager will fax or mail Form 3671-1, Individual Service Plan, Form 3671-2, Individual Service Plan, Form 8598, Non-Waiver Services, all attachments and the Medical Necessity and Level of Care (MN/LOC) Assessment to the Assisted Living/Residential Care (AL/RC) facility for signature on Form 3671-2 to signify the administration's agreement to serve the new applicant or current consumer at reassessment. The AL/RC facility must return Form 3671-2 by mail within two calendar days of receipt of the form.

Within 72 hours of the consumer's admission to the AL/RC facility, the AL/RC facility must assess the new consumer during a face-to-face interview, and complete Form 3050, DAHS Individual Service Plan, or other health assessment/service plan document chosen by the provider.

Form 3050 or other health assessment/service plan document must identify the specific needs of the consumer and how those needs will be met by the AL/RC facility. The health assessment/service plan should describe the condition that prevents the consumer from performing activities of daily living. The plan should be agreed upon and signed by the consumer, his family and the provider. A copy of Form 3050 or other health assessment/service plan document is given to the consumer.

The health assessment/service plan may be conducted by the manager of the AL/RC facility or the registered nurse (RN), if one is available. An RN must complete the medication administration section of the form.

For current consumers, the AL/RC facility must develop a health assessment/service plan for the consumer at the next annual reassessment.

The Community Based Alternatives (CBA) AL/RC facility is expected to provide a new consumer with a tour of the AL/RC facility, including staff and resident introductions.

Consumers are encouraged to bring basic furnishings for bedroom areas with them. Their choice to rent furniture must not be jeopardized through the use of coercion or harassment by or through an agreement or request. In the event the consumer does not provide personal furnishings, the AL/RC facility must provide for each consumer a bed with mattress, chair, table or dresser, and enclosed closet space for clothing and personal belongings. Drawer space shall be provided. Furnishings provided by the AL/RC facility must be maintained in good repair.

4324  Personal Care 3

Revision 09-8; Effective September 1, 2009

Community Based Alternatives (CBA) applicants/consumers with heavy personal care needs who choose to reside in Assisted Living/Residential Care (AL/RC) non-apartment settings may be approved for Personal Care 3 level services.

Classification of a CBA applicant/consumer at the Personal Care 3 level will be based on the applicant's/consumer's assessed needs as evidenced by a value of two or greater in one or more of the activities of daily living of transferring, eating or toileting, as assessed on the Medical Necessity and Level of Care (MN/LOC) Assessment, Section G, Physical Functioning and Structural Problems, Column A, Self Performance.

During the initial pre-enrollment assessment and annual reassessment, the Home and Community Support Services Agency (HCSSA) nurse will complete the MN/LOC Assessment and use the information recorded for transferring, eating or toileting to make a recommendation regarding the applicant's/consumer's need for the Personal Care 3 level. The recommendation will be recorded on Form 3671-C, Nursing Service Plan, in Item V., Recommendations.

At initial certification and each annual reassessment, case managers must check Form 3671-C to determine if the applicant/consumer who chooses to reside in an AL/RC non-apartment setting is identified as meeting the Personal Care 3 level. If the HCSSA nurse does not provide a recommendation for Personal Care 3 level, the case manager must contact the HCSSA nurse to obtain a Personal Care 3 level. The case manager documents the HCSSA nurse's recommendation in the case record. The case manager must inform the applicant/consumer that he meets the Personal Care 3 level, and ensure the applicant/consumer is aware of all facilities contracted to provide care at the Personal Care 3 level by presenting a choice list of AL/RC facilities that specifically identifies the Personal Care 3 facilities.

The case manager authorizes the Personal Care 3 reimbursement rate in the Service Authorization System (SAS) if the applicant/consumer meets the Personal Care 3 level and chooses to reside in a contracted Personal Care 3 facility.

Changes may occur in a CBA consumer's health during the individual service plan (ISP) year that may cause the consumer to require a greater level of care in an AL/RC facility, or move to an AL/RC setting from a community setting. The case manager should review the most current MN/LOC Assessment to determine the HCSSA nurse's recommendation regarding the consumer's Personal Care 3 level and ensure the consumer is presented with a choice of AL/RC facilities that are contracted at the Personal Care 3 level to provide a higher level of care.

Designation of an AL/RC facility as a Personal Care 3 facility will be determined in the contracting process. To qualify as a Personal Care 3 facility, the AL/RC facility must meet the following requirements:

  • The facility must be a personal care facility licensed for four to 16 beds in a non-apartment setting.
  • The facility must provide 60 percent or more of its CBA consumers with a single occupancy bedroom.
  • The facility must maintain a minimum staffing ratio of one direct care staff member for every four consumers during the day and evening shifts, and a minimum of one direct care staff member for every eight consumers during the night shift.
  • At least 60 percent of the total consumers served each month must require a minimum of one-to-one staff assistance as evidenced by a value of three or greater in one or more of the activities of daily living of transferring, eating or toileting, as assessed on the MN/LOC Assessment.

See the Community Based Alternatives Provider Manual for additional information regarding requirements for Personal Care 3.

4325  Nursing Services for AL/RC Consumers

Revision 10-3; Effective June 1, 2010

If a consumer is residing in an Assisted Living/Residential Care (AL/RC) setting, all administration of medications, including injections, are provided by the AL/RC facility; the Home and Community Support Services Agency (HCSSA) cannot be authorized to deliver the nursing task of administration of medications.

It is possible that a consumer residing in an AL/RC setting does not need any nursing tasks that are to be delivered by the Community Based Alternatives (CBA) program. For example, this may occur when the consumer's only nursing need is for medication administration provided by the AL/RC staff or when the consumer is receiving nursing services through Medicare.

4326  Response to AL/RC Consumer Condition Change

Revision 10-3; Effective June 1, 2010

If the consumer experiences a change in health or conditions related to the amount and type of care he requires, the case manager, in conjunction with the other members of the interdisciplinary team (IDT), the Assisted Living/Residential Care (AL/RC) provider and the consumer/legal representative, may explore other means to serve the consumer adequately in his current setting. The use of Day Activity and Health Services (DAHS) for daily nursing tasks or the direct provision of nursing by Home and Community Support Services Agency (HCSSA) nurses may be explored as alternatives that would avoid disrupting the consumer's living arrangement. Nursing tasks cannot be delegated in AL/RC settings.

If a consumer exhibits behavior that threatens the health or safety of himself or others, or his needs exceed the licensed capacity of the AL/RC facility, the AL/RC provider must take appropriate action and notify the case manager verbally by the next Department of Aging and Disability Services (DADS) working day after services are suspended. The AL/RC provider should confirm this verbal report in writing within five working days of the initial notification. The case manager must take appropriate actions based on the verbal notification to assess the consumer's continued eligibility for the Community Based Alternatives (CBA) program. Also see Section 4351, Facility Reporting and Notification Requirements.

If a CBA consumer living in one of the apartment settings (assisted living or residential care apartment) becomes a safety hazard to himself or others due to his operation of the stove or cooking unit in the apartment, the AL/RC provider can disconnect the unit and must notify the case manager by the next DADS working day. The case manager is to investigate the situation and document any recent or previous incident that indicates a threat to the health or safety of the consumer or others. The case manager, in cooperation with the IDT, which in this kind of situation must include the consumer, AL/RC provider and the consumer's family or responsible party, if any, makes a decision regarding reconnection or continued disconnection of the cooking unit. The decision is documented on Form 2067, Case Information, which is sent to the AL/RC provider within three business days of the IDT meeting.

4327  RUG Resets

Revision 11-1; Effective March 1, 2011

Assisted Living/Residential Care (AL/RC) providers that participate in the attendant compensation rate enhancement program receive payment based on the consumer's Resource Utilization Group (RUG). If the AL/RC provider believes the consumer's functional needs have changed and it will impact his level of care, the AL/RC provider may request a RUG reset by sending Form 2067, Case Information, to the case manager.

The AL/RC provider may request only two RUG resets during each calendar year for each CBA consumer for the following time periods:

  1. January through June; and
  2. July through December.

The case manager sends Form 2067 to authorize the Home and Community Support Services Agency (HCSSA) to complete the RUG reset.

The HCSSA can bill for the RUG reset as a nursing service, but cannot bill more than two hours per RUG reset. The AL/RC provider must provide the HCSSA nurse any documentation the AL/RC provider has that reflects what the needs of the consumer are and the services the AL/RC provider is delivering.

If the RUG reset results in a new RUG that changes the AL/RC provider's payment, the AL/RC provider may bill DADS at the new payment rate effective the date of the new assessment.

An AL/RC provider cannot refuse to accept an applicant based on the RUG level.

4330  Other Services Available to Consumers

Revision 09-9; Effective December 1, 2009

Each of the following services will be provided according to the needs of the consumer, as authorized on the individual service plan (ISP), as a waiver or non-waiver service. The case manager will make referrals for the services and coordinate delivery.

Adaptive Aids and Medical Supplies — The Community Based Alternatives (CBA) Assisted Living/Residential Care (AL/RC) consumer is eligible to receive needed adaptive aids and medical supplies under the CBA program. Adaptive aids and medical supplies are defined as medical equipment and supplies that include devices, controls or appliances specified in the plan of care that enable individuals to increase their abilities to perform activities of daily living or to perceive, control or communicate with the environment in which they live. See Section 4141, List of Adaptive Aids and Medical Supplies, for a list of adaptive aids and supplies that can be purchased through the CBA program.

Minor Home Modifications — Services that assess the need, arrange for and provide modifications and/or improvements to an individual's residence to enable the individual to reside in the community and ensure safety, security and accessibility. Minor home modifications will be limited to those modifications identified and approved by the Department of Aging and Disability Services on the ISP and made in Type A facilities only.

Occupational Therapy — Interventions and procedures to promote or enhance safety and performance in the instrumental activities of daily living, education, work, play, leisure and social participation. Occupational therapy services consist of the full range of activities provided by a licensed occupational therapist, or a licensed occupational therapy assistant, if under the direction of a licensed occupational therapist, within the scope of state licensure.

Physical Therapy — Specialized techniques for the evaluation and treatment related to functions of the neuro-musculo-skeletal systems. Physical therapy services consist of the full range of activities provided by a licensed physical therapist or a licensed physical therapy assistant, under the direction of a licensed physical therapist and within the scope of state licensure.

Hearing and Language Therapy — The evaluation and treatment of impairments, disorders or deficiencies related to a consumer's speech and language. Services include the full range of activities provided by licensed speech and language pathologists under the scope of the pathologist's state licensure.

Nursing Service — Services provided by a licensed registered nurse or licensed vocational nurse within the scope of state licensure. Nursing services can be brought into the personal care facility for the consumer. If the projected cost of the consumer's services will exceed the annual cost limit, the case manager will meet with the consumer to discuss the options for care. Such options as other living arrangements in Adult Foster Care or Day Activity and Health Services Title XIX services will be explored. The consumer's choice for service delivery will be given first priority as long as the cost for the service does not exceed the annual cost limit. Non-waiver resources will also be explored by the case manager for the delivery of all waiver services.

The use of self-administered oxygen is allowed in a CBA AL/RC facility. Since oxygen is a flammable substance, precautions must be taken to ensure that smoking is prohibited in or around the area where the oxygen is being self-administered.

4340  Copayment/Room and Board/Leave

Revision 10-3; Effective June 1, 2010

4341  Room and Board and Copayment Requirements

Revision 13-1; Effective March 1, 2013

The individual must pay the required fees to be eligible for Assisted Living (AL) services. Refusal to pay the required fees can result in termination of AL services or eligibility for the Community Based Alternatives (CBA) program.

The AL 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. The AL 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 AL facility must collect the entire copayment and room and board on or before the first working day thereafter. If the individual or his responsible party fails to pay the entire copayment and room and board by the due date, the AL facility must notify the individual or his responsible party and the case manager in writing no later than the first working day after the due date.

The AL facility must refund the individual'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 10 working days of awareness that the individual will be discharged or is deceased. The AL facility must document the date of awareness of the individual's discharge from the AL facility.

A credit balance is an amount due to the individual or his responsible party when there is an overpayment by the individual or his responsible party. The AL facility must provide written notice of a credit balance to the individual or his responsible party within 35 calendar days of receipt of the payment resulting in a credit balance.

The AL facility must offer the individual or his responsible party the following options in the credit balance notice:

  • the individual or his responsible party may choose to provide the corrected payment, and the AL facility will return the original amount paid;
  • the AL facility will provide the individual or his responsible party with a refund of the credit balance; or
  • the individual or his responsible party may choose to have the credit balance applied to the following month's payment. The individual may choose to spread the credit balance over several months.

If the individual or his responsible party fails to contact the AL facility within 35 days of the date of the credit balance notice, the AL facility must, on the 35th day:

  • provide the individual or his responsible party with a refund of the credit balance or apply the credit balance to the following month's payment; and
  • provide written notice of the AL facility's choice of action to the individual or his responsible party. The written notice of the AL facility's choice of action may be a monthly statement if the monthly statement specifies the AL facility's choice of action.

4341.1  Room and Board Requirements

Revision 10-3; Effective June 1, 2010

All consumers must pay the room and board charges to be eligible for Assisted Living/Residential Care (AL/RC). Room and board cannot be waived, but an AL/RC facility may choose to accept an individual for a lower amount. The Department of Aging and Disability Services (DADS) Community Based Alternatives (CBA) policy does not direct the AL/RC facility to accept or reject the individual. The room and board charge is based on the Supplemental Security Income (SSI) federal benefit rate (FBR), minus a personal needs allowance (PNA) of $85. This is a set rate unless there is a change in the FBR. Generally, the FBR only changes annually on Jan. 1. The room and board charge is adjusted accordingly based on that change.

For the initial month of entry, the monthly rate is divided by the number of days in that month, and then multiplied by the number of days the consumer is in the AL/RC facility. See Appendix VI, Calculation of Copayment and Room and Board, for calculations. The consumer must be notified of the initial amount of room and board to pay and the ongoing amount of room and board to pay.

4341.2  Copayment Requirements

Revision 12-2; Effective June 1, 2012

The ongoing copayment amount the individual is required to pay is calculated by the Texas Integrated Eligibility Redesign System (TIERS) and documented in the copayment record. The case manager then determines the amount of copayment each individual is to pay for the initial month of entry in an Assisted Living (AL) facility, and for ongoing months. The case manager notifies the Medicaid for the Elderly and People with Disabilities specialist by means of Form 2067, Case Information.

The case manager sends Form 2065-B, Notification of Waiver Services, to the individual. The case manager also sends a copy of Form 2065-B to the AL facility detailing the first month's copayment and the amount of subsequent months. The copayment amount is registered on Form 3671-1, Individual Service Plan, and in the Service Authorization System (SAS).

4342  Personal Leave

Revision 10-3; Effective June 1, 2010

STANDARD. The consumer is entitled to 14 days of personal leave from the Assisted Living/Residential Care (AL/RC) facility each calendar year. The consumer is responsible for the room and board charge and copayment for all personal leave days. The consumer is responsible for all charges for services if he exceeds the allowable limit of personal leave days.

A day of personal leave is defined as a continuous 24-hour period, measured from midnight to midnight, when the consumer is absent from the AL/RC facility for personal reasons. Community Based Alternatives (CBA) AL/RC consumers must sign out when leaving the AL/RC facility and sign in upon returning. The sign-in log must have at minimum the following information:

  • name of the person;
  • time and date of departure;
  • destination;
  • emergency contact; and
  • type of leave (for example, personal leave or hospital leave).

The AL/RC facility must not bill the Department of Aging and Disability Services (DADS) for more than 14 days of personal leave taken by the consumer each calendar year. The AL/RC facility must notify the DADS case manager when the consumer has used 10 personal leave days in the current calendar year.

4343  Institutional Leave

Revision 11-2; Effective June 1, 2011

Institutional leave is when a consumer is absent from the Assisted Living/Residential Care (AL/RC) facility because the consumer temporarily enters an institution. An institution is defined as a hospital, nursing facility, state supported living center, state hospital or intermediate care facility serving persons with intellectual and developmental disability. A hospital includes a rehabilitation hospital or a rehabilitation floor or wing of a medical hospital.

The AL/RC facility must hold the Community Based Alternatives (CBA) AL/RC consumer's bed for 60 calendar days if the consumer is in any type of institution. The AL/RC facility must charge the consumer or the consumer's representative for bedhold charges during institutional leave. Bedhold charges for a CBA AL/RC consumer is the room and board charge. The AL/RC facility must not charge the consumer or the consumer's representative more than the maximum amount allowed by the Department of Aging and Disability Services (DADS) for bedhold. The AL/RC facility must refund the CBA consumer's entire copayment for the days the consumer uses institutional leave. The AL/RC facility does not bill DADS for days the consumer is in an institution.

The AL/RC facility must notify the case manager via Form 2067, Case Information, when the consumer has been in the hospital for 30 days. The case manager monitors the consumer's situation up to 120 calendar days to determine if the stay will become permanent. If the consumer stays in the institution longer than 120 calendar days, the case manager terminates the case.

4344  Termination Due to Failure to Pay the Required Contribution to the Cost of Care

Revision 13-1; Effective March 1, 2013

If the individual or his responsible party fails to pay the entire copayment and room and board by the Assisted Living (AL) facility's due date, the AL facility must notify the individual or his responsible party and the Department of Aging and Disability Services (DADS) case manager in writing that payment was not received. The AL facility is required to notify DADS no later than the first working day after the due date.

The AL facility notifies the case manager orally by the next working day, and follows up in writing within five calendar days of when the individual or his responsible party fails to pay the required payments.

Upon receipt of the notice, the case manager:

  • coordinates with the AL facility to convene a meeting of the interdisciplinary team (IDT) within five working days of receipt of the notification. The IDT must include the individual, an AL facility representative, the case manager and the individual's responsible party, if applicable;
  • explores with the individual and IDT if there are new circumstances preventing the individual from making the required payment. Circumstances to consider are:
    • the individual has a situation involving a mandatory recoupment or other changes in income requiring an adjustment in countable income;
    • circumstances indicate that the individual is being exploited by another person; and
    • other situations exist in which the individual and AL facility can work out an agreement for the individual to pay the required payments;
  • makes every effort to resolve the problem with the individual and the AL facility;
  • advises the individual of the consequences that will result from refusal to make the required payments to the AL facility, including:
    • termination of AL services or possibly program eligibility if the individual does not continue to reside in an approved waiver setting;
    • eviction from the AL facility; and
    • being placed at the end of the interest list if Community Based Alternatives (CBA) program eligibility is terminated and he reapplies for services in the future; and
  • asks the individual to read and sign Form 2119, Residential Care or Assisted Living Contribution Acknowledgement, if the situation cannot be resolved and the individual continues to refuse to pay the required payments. The form states the individual refuses to pay the required payments and understands the consequences of not meeting the requirement. If the individual refuses to sign, the case manager documents the refusal on the form and requests a witness to sign the form. The case manager leaves the individual a copy of the form and retains the original copy with the signature in the individual's case record. The case manager advises the individual that a notice of AL service termination will be sent, and he will not be allowed to move to another AL facility while he has an outstanding balance at the current AL facility. The current facility may evict the individual for refusal to pay. The case manager coordinates the notice of AL service termination with the AL facility.

Even if there is a legitimate reason (such as the individual's income check has not been received by the 10th day of the month) for the non-payment of the required fees, the individual is still under obligation to pay the fees.

After the IDT meeting, the case manager makes any appropriate referrals to adjust countable income, or refers to Adult Protective Services (APS), if exploitation is suspected.

If the situation cannot be resolved and the individual refuses to pay for any reason, the case manager sends the individual Form 2065-B, Notification of Waiver Services, giving the individual a 30-calendar-day notice that AL services will be terminated unless the individual pays the required payments. In the comments section of the form, the case manager advises the individual that AL services will end and the AL facility may evict the individual if payment is not made by the 30th day. Send the AL facility a copy of Form 2065-B.

The AL facility initiates the eviction proceedings by giving the individual an eviction notice in writing.

The case manager must discuss with the individual that CBA services cannot continue if the individual does not pay the required payments and is evicted, and once evicted, does not relocate to another approved waiver setting. The case manager must begin working with the individual to locate another approved waiver setting.

If the individual does not appeal, the case manager terminates AL services 30 calendar days from the Form 2065-B notice. The AL facility receives payment from DADS during the 30-calendar-day period. If the individual has not made other living arrangements at the end of the 30 days, the case manager must make a referral to APS. Provided the AL facility is in compliance with the provisions of its license and contract regarding the eviction of the individual, the AL facility evicts the individual on the date provided on the written eviction notice. The individual cannot receive other CBA services in the AL setting once the individual is no longer eligible for AL services. The case manager must suspend all other CBA services and assist the individual in locating to another approved waiver setting.

The individual may continue to receive other CBA services as long as the individual resides in an approved waiver setting, but may not receive AL services in any AL facility until all outstanding payments are made.

If the individual does not relocate to another approved waiver setting, the case manager must send Form 2065-C, Notification of Ineligibility or Suspension of Waiver Services, to terminate CBA eligibility. The individual no longer meets the CBA eligibility requirements. Refer to Section 3211.1, Basic Eligibility Criteria, for approved waiver settings.

4350  Standards for Operation

Revision 10-3; Effective June 1, 2010

The Assisted Living/Residential Care (AL/RC) facility must accept all Department of Aging and Disability Services (DADS) referrals unless it would cause the facility to exceed its licensed capacity or the number of beds specified in the contract with DADS. The AL/RC facility may also refuse to accept a referral from DADS if the consumer's condition makes him inappropriate for the AL/RC facility according to the facility's personal care licensure. The AL/RC facility must convene an interdisciplinary team meeting (IDT) before refusing to accept the referral.

The AL/RC facility must negotiate a move-in date with the DADS case manager and the consumer or the consumer's representative. The AL/RC facility must reserve a living unit for three calendar days from the agreed upon move-in date for each referred consumer. The AL/RC facility may request another referral after three days if the move-in date is not re-negotiated.

Having a communicable disease does not necessarily make a consumer inappropriate for placement in an AL/RC setting. Transmission of communicable diseases and conditions can be prevented through the implementation of infection control procedures, including universal precautions. Licensure standards for personal care facilities require facilities to have infection control policy and procedures, including universal precautions, in operation to safeguard employees and residents from these and other diseases and contagious conditions. If transmission of the condition or disease cannot be controlled, the applicant/participant cannot be placed in a Community Based Alternatives (CBA) AL/RC setting.

If space is not available, the AL/RC facility must keep a waiting list. If the AL/RC facility has both AL/RC and RC contracts and maintains waiting lists for both, the CBA consumer has priority. RC consumers on the waiting list should be assessed for CBA services. If they are not eligible for the CBA, their names remain on the RC waiting list.

To receive AL/RC services under the CBA program, the consumer must first be determined eligible financially and found to have a medical necessity (MN) for the service. MN is established through use of the Medical Necessity and Level of Care (MN/LOC) Assessment, completed by the Home and Community Support Services Agency (HCSSA) provider nurse. The case manager will coordinate with the Medicaid for the Elderly and People with Disabilities (MEPD) specialist, as applicable, to complete the Medicaid eligibility determination.

The case manager will discuss residential options with the consumer, allowing him to choose his preference. If AL/RC is chosen, a verbal referral is made to the AL/RC facility to alert it that space is needed. The starting date for services is negotiated with the AL/RC facility and the initial copayment amount is computed based on the starting date. Form 3671-1, Individual Service Plan, and applicable attachments are sent as follow up, along with a copy of Form 2065-B, Notification of Waiver Services, which authorizes the provider to deliver CBA services, and Form 2067, Case Information, confirming the negotiated service initiation date.

The AL/RC facility must complete a health assessment and individual service plan within 72 hours of the consumer's admission to the AL/RC facility. The AL/RC facility manager or a nurse must complete the health assessment and individual service plan. A nurse must complete the medication administration portion of the health assessment for CBA consumers. 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.

The AL/RC facility must complete a new service plan any time there is a need for a change in the consumer's service plan. The facility must implement service plan changes within seven calendar days from the assessment date.

The AL/RC facility must provide each consumer with training in the emergency/disaster procedures and evacuation plan within three days from the date of service initiation. The training must be documented in the consumer's record. The facility must also document all training and orientation provided to consumers and facility staff.

The AL/RC facility must provide services according to the consumer's health assessment/individual service plan, and document the consumer's daily activity and service delivery on the daily census record. The AL/RC facility must obtain written approval from DADS before discharging a consumer, except when DADS staff cannot be reached and the consumer threatens the health or safety of others or himself.

Appropriate action must be taken if the AL/RC facility finds that a consumer threatens the health and safety of others or himself. If a stove or cooking unit needs to be disconnected, the case manager, in cooperation with the IDT, makes this decision. The IDT must also include the AL/RC facility and the consumer's family or responsible party, if any, in this instance.

The AL/RC facility can disconnect the stove or cooking unit if the consumer exhibits a behavior that threatens the health and safety of others or himself. The AL/RC facility must inform the case manager of the disconnection by the next DADS business day after it occurs. The case manager investigates the situation and documents any recent or previous incidents that indicate a threat to the health or safety of the consumer or others. If the decision is made to approve a disconnection, the case manager documents it on Form 2067 that is sent to the AL/RC facility within three calendar days. The AL/RC provider must help the consumer to prepare for transfer or discharge.

The AL/RC facility must allow the consumer to manage his finances and/or trust funds. The facility must provide assistance to the consumer in managing his finances only if the consumer requests assistance in writing.

The AL/RC facility must inform the consumer verbally and in writing, before or at the time of admission, of bedhold policies for hospital/nursing facility stays, personal leave, eviction procedures and all available services in the AL/RC facility. The AL/RC facility must inform the consumer of charges for services not paid by DADS and/or not included in the facility's basic daily rate. Examples of charges not paid by DADS could be destruction of facility property or any additional charge, such as pet deposits.

4351  Facility Reporting and Notification Requirements

Revision 10-3; Effective June 1, 2010

The Assisted Living/Residential Care (AL/RC) facility must notify the Department of Aging and Disability Services (DADS) case manager orally or by facsimile about a change no later than one DADS working day 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.

The facility must notify DADS case manager when one of the following happens:

  • significant changes in the consumer's health and/or condition;
  • the consumer temporarily enters an institution;
  • serious occurrences or emergencies involving the consumer or facility staff;
  • the consumer or the consumer's representative requests that services end;
  • the consumer refuses to comply with the service plan;
  • the consumer engages in discrimination in violation of applicable law;
  • the consumer or the consumer's representative fails to pay copayment;
  • the consumer uses 10 personal leave days in the current calendar year;
  • the consumer or the consumer's representative requests to move to another facility; or
  • the facility believes that a consumer's functional needs have changed such that it will impact the consumer's level of care, if the facility provides assisted living services under the Community Based Alternatives (CBA) AL/RC Program and participates in the attendant compensation rate option.

If a consumer exhibits behavior that threatens the health or safety of others or himself, or his needs exceed the licensed capability of the personal care facility, the provider's written notice must explain the situation and the reasons the consumer is no longer appropriate for the services. With the concurrence of the case manager, discharge can be as soon as practical when:

  • the health or safety of individuals in the facility would be endangered if the consumer would remain in the facility; or
  • the consumer's medical needs escalate beyond the capability of the personal care facility to meet his needs. For example, the consumer's mental condition may deteriorate to the point that involuntary commitment to a mental institution is necessary.

If the case manager is not available, notification may be made to and concurrence for actions needed may be given by his supervisor. Written notification must be made on Form 2067, Case Information.

4351.1  Assisted Living Provider Transfers or Termination Due to Refusal to Comply Issues

Revision 13-1; Effective March 1, 2013

§46.35

(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.

An Assisted Living (AL) facility is required to convene an interdisciplinary team (IDT) meeting, including the individual or his responsible party, facility representative and case manager, within three working days of becoming aware of a service delivery issue. The IDT must evaluate the issue, identify any solutions to resolve the issue and make recommendations to the facility. Within two working days after the IDT meeting, the AL facility must implement the recommendations of the IDT, which may or may not include discharge of the individual from the facility. If the individual is discharged, the case manager works with the individual to select another AL facility. The AL facility could possibly convene several IDT meetings related to service delivery issues prior to a decision to discharge the individual from the facility.

The case manager must also be aware of actions by the individual that result in refusal to comply with program or service delivery requirements. If an IDT meeting has not already been scheduled by the AL facility, the case manager must contact the AL facility within three working days of awareness of the non-compliance with program or service delivery requirements to request an IDT meeting be scheduled. After each IDT meeting, the case manager must ensure the individual and AL facility receive a written notice explaining the reason for the IDT meeting, the effort made to resolve the issue and recommendations of the IDT. The individual must be informed of actions to be taken by the AL facility and actions required by the individual. The case manager must inform the individual that AL services or Community Based Alternatives (CBA) eligibility may be terminated if the individual refuses to comply with program or service delivery requirements. The case manager must document in the case record whether the individual is aware of and able to understand the consequences of his actions.

If the IDT agrees that placement in another setting is appropriate, the case manager obtains the individual's choice of another available AL facility and completes the provider transfer. The case manager completes and sends Form 2065-B, Notification of Waiver Services, to document the transfer from the current AL facility to the new one chosen by the individual.

If the AL facility requires the individual to be discharged from the facility, but the individual refuses to leave, the AL facility can discharge the individual within 30 calendar days of the date the facility provides written notification, or sooner if the individual threatens the health or welfare of himself or others. If the individual refuses to leave the facility by the time frame provided, the AL facility may start eviction procedures.

  • The individual has the right to appeal the discharge from the AL facility if the right to appeal is addressed in the specific AL facility's bill of rights and responsibilities. The individual does not have the right to appeal discharge from an AL facility through the fair hearings process. The individual does have the right to appeal actions initiated by Department of Aging and Disability Services, such as termination of AL services or CBA eligibility, through the fair hearings process. The individual remains eligible for AL services in the AL facility through the discharge date.
  • The case manager must discuss IDT recommendations with the individual and offer him the opportunity to transfer to another AL facility or another CBA setting, such as Adult Foster Care or a home in the community.
    • If the individual chooses another AL facility, the case manager completes the transfer from the current facility to the new AL facility chosen by the individual and sends Form 2065-B documenting the provider transfer.
    • If the individual chooses another CBA setting, the case manager negotiates the date of the move to the new setting and terminates AL services and sends Form 2065-B documenting the termination. The case manager documents in the case record that the individual requested and chose another CBA setting, and ensures any additional CBA services needed in the new CBA setting are reviewed and authorized as appropriate.
    • If the individual still refuses to leave the AL facility or choose another CBA setting after the IDT meetings and discussions, the case manager terminates the individual from CBA and sends Form 2065-C, Notification of Ineligibility or Suspension of Waiver Services, to notify the individual of the CBA program termination and the right to appeal through the fair hearings process. The case managers uses "40 TAC §48.6003(b)(10)" and Section 3211.1, Basic Eligibility Criteria, on Form 2065-C. The case manager must make a referral to the Department of Family and Protective Services Adult Protective Services, if appropriate.

4352  Assisted Living Facility Documentation

Revision 13-1; Effective March 1, 2013

The Assisted Living (AL) facility must maintain records for each individual receiving Community Based Alternatives (CBA) services that include at least the following information:

  • Form 3671 (pages 1 and 2), CBA Individual Service Plan;
  • Form 3050, DAHS Individual Service Plan, or other health assessment/service plan document chosen by the AL facility;
  • serious occurrences or emergencies involving an individual or AL facility staff;
  • incidents when an individual threatens the health or safety of himself or other residents in the AL facility;
  • when the individual has used 10 personal leave days during the current individual service plan (ISP) effective period;
  • when the individual's needs exceed the licensed capability of the AL facility;
  • termination of AL services to an individual;
  • hospitalization of an individual;
  • death of an individual; and
  • when an individual requests to move to another AL facility.

4360  Reserved for Future Use

 

4370  Trust Funds

Revision 10-3; Effective June 1, 2010

The case manager should document in the case record that the consumer was offered money management and either accepted or refused the service. If the applicant expresses an interest in money management, the case manager must inform the Assisted Living/Residential Care (AL/RC) facility via Form 2067, Case Information. Before the AL/RC facility can assist the consumer with any financial activity, such as check writing or balancing checkbooks, a trust fund must be set up and written permission obtained from the consumer.

The AL/RC facility must maintain a ledger to reflect all payments received from or on behalf of consumers at the time the payment is received, even if the payment is made from a trust fund. The facility must provide receipts for all copayment and room and board payments.

4371  Trust Fund Management

Revision 10-3; Effective June 1, 2010

Community Based Alternatives (CBA) consumers living in an Assisted Living/Residential Care (AL/RC) facility have the right to perform their own money management, request that the AL/RC facility provide or assist with money management, or designate another person to provide or assist with money management.

The case manager will inform the AL/RC facility if a consumer wishes the AL/RC facility to provide or assist with money management. The AL/RC facility must not require consumers to request the AL/RC facility to provide or assist with money management. The AL/RC facility must have the consumer's or the consumer's representative's written authorization to provide or assist with money management. The AL/RC facility must provide a written statement of the trust fund rights and responsibilities regarding the consumer's financial affairs.

The contracted ALRC facility must keep funds received from or on behalf of a consumer for a trust fund in a separate bank account from the AL/RC facility's operating funds. The account must be identified as "Trustee, (Name of Facility), Consumer's Trust Fund Account." The funds for a CBA consumer may be commingled with the funds of a private pay consumer.

The AL/RC facility must keep written records of all financial transactions involving the consumer's personal funds for which it is holding, safeguarding and providing accounting services.

The AL/RC facility must return the full balance of the consumer's personal funds held in the AL/RC facility to the consumer or the consumer's representative immediately upon request if the request is made during normal business hours. The AL/RC facility must return the full balance of the consumer's personal funds that the AL/RC facility has deposited in any bank account to the consumer or the consumer's representative within 10 working days of request. This refund must include any interest reported as of the date of the request.

Refer to Title 40, Texas Administrative Code, Chapter 46, for additional information regarding AL/RC facility management of consumer trust funds.

4372  Trust Fund Transactions

Revision 10-3; Effective June 1, 2010

The Assisted Living/Residential Care (AL/RC ) facility must keep records of all trust fund transactions. AL/RC facility staff must record on the consumer's trust-fund ledger or deposit/withdrawal document at least the following:

  • the date and amount of each deposit;
  • the source of each deposit;
  • the date and amount of each withdrawal;
  • the reason for each withdrawal;
  • the name of the person or entity who accepted the withdrawn funds; and
  • the balance after each transaction.

The consumer or the consumer's representative must sign for each withdrawal transaction at the time of the transaction.

4373  Payment of Copayment and Room and Board from Trust Fund

Revision 10-3; Effective June 1, 2010

It is an acceptable and recommended practice to deposit the consumer income into the trust fund account and then pay the copayment and room and board from the trust fund account. In this way, the consumer's monthly payments can be traced to the trust fund. When the copayment and room and board is paid from the trust fund account, the corresponding consumer's accounts receivable ledger must show proper credit to the consumer's account.

4374  Trust Fund Refunds

Revision 10-3; Effective June 1, 2010

The Assisted Living/Residential Care (AL/RC) facility must return the full balance of the consumer's personal funds held in the AL/RC facility to the consumer or the consumer's representative immediately upon request if the request is made during normal business hours. 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.

The AL/RC facility must return the full balance of the consumer's personal funds that the facility has deposited in any bank account to the consumer or the consumer's representative within 10 working days of request. This refund must include any interest reported as of the date of the request.

4375  Trust Fund Refunds for Consumer Discharge or Death

Revision 10-3; Effective June 1, 2010

The Assisted Living/Residential Care (AL/RC) facility must refund the discharged consumer's personal funds and provide a final accounting of those funds to the consumer or the consumer's representative. The AL/RC facility must complete the refund and provide a final accounting within 10 working days of the date of discharge, or the date of the AL/RC facility's awareness of the consumer's discharge, whichever is later.

The AL/RC facility must refund the deceased consumer's personal funds and provide a final accounting of those funds to the beneficiary, heir or executor of the deceased consumer's estate. The AL/RC facility must complete the refund and provide a final accounting within 30 days of awareness of the consumer's death, if the beneficiary, heir or executor is known, located or identified. The AL/RC facility must make a bona fide effort to locate the beneficiary, heir or executor of a deceased consumer's estate within 30 days.

The AL/RC facility must provide notification either:

  • in person; or
  • by mail via certified return receipt.

4376  Participant Authorization

Revision 02-0; Effective April 4, 2002

If the participant is unable to sign or initial the transaction or if he signs his name with a mark (X), the transaction must be signed by a witness. A witness is anyone other than

  • the facility employee who is responsible for managing the trust fund accounts,
  • the supervisor of the employee who manages the trust fund account, or
  • the person who is receiving payment for services to the participant.

4377  Refunds to Discharged or Deceased Participants

Revision 02-0; Effective April 4, 2002

The facility must refund the full balance of the participant's monies deposited in his trust fund account within five days after the participant is discharged.

If the participant dies, there should be no payment from his trust fund account other than the refund to the responsible party or DADS' escheat account. No funds may be dispensed to reimburse the facility for damages caused by the client to an assisted living/residential care (AL/RC) apartment. If there is a responsible party, the facility may request voluntary reimbursement prior to the refund, but the responsible party is not obligated to agree. Maintenance to the facility is included in the cost report as an allowance expense. See Appendix XVII, Cost Determination Process, in the CBA Provider Manual.

The two types of refunds are listed below.

Cash — If the refund was made in cash, the cancelled check or a copy of the receipt must be signed by the participant or responsible party.

Check — If the refund was made by check, the receipt must be signed by the participant or responsible party.

4400  Respite

Revision 13-2; Effective June 3, 2013

Respite is authorized to provide for the planned or emergency short-term relief of the unpaid caregiver normally providing care of an individual when the caregiver is temporarily unavailable to provide supports due to non-routine circumstances. Non-routine circumstances are events that may occur more than on a weekly basis.

4410  Case Management Duties Related to Respite

Revision 13-2; Effective June 3, 2013

Respite is available on an emergency or short-term basis to relieve a caregiver who normally provides unpaid care for an individual who is unable to care for himself.

To receive respite, the individual must live in his own home or with relatives or other persons. The individual may not live in an Adult Foster Care (AFC) home or Assisted Living (AL) facility.

The respite provider must not be the individual’s caregiver, whether or not he is related to the individual, and must not live with the individual for whom respite is needed. If the individual’s caregiver is the paid attendant who also provides uncompensated care, in-home respite may be provided only during the time the caregiver would be providing uncompensated care to the individual. If the caregiver is the paid attendant and will be absent during time for which he is normally paid, the Home and Community Support Services Agency (HCSSA) is obligated to provide a substitute attendant during this period. The caregiver who is a paid attendant can never be paid as the respite provider. However, an individual whose caregiver is providing uncompensated care and is also the paid attendant may receive out-of-home respite.

The respite rate in out-of-home settings includes payment for room and board. The individual does not pay a copayment or room and board charges for respite in an out-of-home setting.

The case manager is responsible for documenting in the case record the need for respite and informs the respite provider of the individual’s need for respite on Form 2067, Case Information.

The case manager can can obtain information on respite contractors from regional contract management staff. The individual must be given the opportunity to choose from the contracted providers that are appropriate considering his needs and the licensed capabilities of the respite provider. In-home respite is provided by a licensed HCSSA with a contract to provide HCSSA services. Out-of-home respite is provided by a licensed nursing facility, a licensed AL facility, or an AFC home with a contract to provide out-of-home respite for the Community Based Alternatives program.

The HCSSA that delivers in-home respite is responsible for providing Personal Assistance Services (PAS) authorized on the individual service plan (ISP). When an individual is receiving in-home respite and the HCSSA attendant providing respite is not the PAS attendant to whom the nursing tasks were delegated, the HCSSA nurse may directly provide the nursing tasks. It will be necessary for the case manager to modify the ISP to include the increased nursing units based on information provided by the HCSSA. Other HCSSA services, for example, physical therapy or minor home modifications, may continue to be delivered at the same time in-home respite is delivered.

Example 1: If 11 hours of respite are to be used per month, the ISP authorization is for six units. The calculation is 11 hours per month times 12 months = 132 hours divided by 24 hours = 5.5 units, rounded to next higher unit, or six.

Example 2: The individual’s caregiver has three, four-day trips planned during the ISP year. In this situation, the case manager may authorize 12 days (units) of respite. The 12 units of respite may be authorized for delivery as in-home respite, out-of-home respite, or both.

Example 3: The individual’s caregiver visits her sister in a neighboring town once a month and is away from the individual for four hours. In this situation, the case manager may authorize two units of respite for the ISP year.

4 hours per month × 12 months = 48 hours per year

48 hours per year ÷ 24 hours per unit = 2 units per year

Example 4: On Monday, the HCSSA representative informs the case manager the individual’s caregiver was hospitalized for 48 hours over the weekend. The HCSSA follows up with Form 2067 and Form 3671-2, Individual Service Plan, signed by the individual, to the case manager within seven calendar days after the verbal notification indicating the HCSSA delivered 48 hours (two units) of respite due to the caregiver’s hospitalization. The case manager authorizes two units of respite following emergency service plan change procedures.

When there is an emergency need for respite and respite is not authorized on the ISP, the HCSSA must follow the procedures in the Community Based Alternatives Provider Manual, Section 4452.1, Requests for Service Plan Change in Emergencies. The case manager follows procedures in Section 4410, Case Management Duties Related to Respite Care, Section 3610.3, Emergency Service Plan Changes to the Individual Service Plan, and Section 3610.4, Case Manager Response to Emergency Requests.

Respite may be authorized as often as needed for caregiver relief or emergency absences of the caregiver, up to a 30-day maximum per ISP year, within the limit of the ISP cost limit. Both in-home and out-of-home respite may be used in hourly increments and billed by the provider in hourly increments. Respite must be authorized on Form 3671-1, Individual Service Plan, in daily units.

The annual respite service limit is 30 days, equivalent to 720 hours (30 days times 24 hours per day), unless approval to exceed the 30-day service limit is given by the DADS regional nurse. See Section 4410.1, Requesting Regional Nurse Approval to Exceed the Respite Service Limit, for procedures for submitting a request to exceed the respite service limit. The case manager who has overall responsibility for the coordination of the CBA services must keep track of the respite units used and must not authorize more than 30 days of respite during the ISP period, which is identified in Item 6 on Form 3671-1, unless approved by the DADS regional nurse. The HCSSA may use Form 2067 to notify the case manager of the dates and duration of respite delivered so the case manager can track the number of respite days used.

When respite is authorized, the case manager must:

  • document in the case record that the individual lives in his own home, with relatives or other persons (the individual does not live in an AFC home or AL facility); and
  • identify the caregiver on Form 8598, Non-Waiver Services, in Item 5, Family and Community Supports.

4410.1  Requesting Regional Nurse Approval to Exceed the Respite Service Limit

Revision 13-2; Effective June 3, 2013

To request approval to exceed the annual individual service plan (ISP) 30-day limit on respite, the case manager must send a written request on Form 1547, Regional Nurse/Dental Consultant Request Worksheet, to the Department of Aging and Disability Services (DADS) regional nurse documenting the:

  • need for additional respite units;
  • number of additional units needed;
  • cost estimate considering the location(s) in which the respite will be delivered;
  • overall service plan is within the ISP cost limit; and
  • service plan is adequate and meets the individual's needs in the community.

The DADS regional nurse provides written authorization determination of the request to the case manager.

In reviewing requests to exceed the respite service limit, the DADS regional nurse should consider the intent of respite services to relieve the caregiver during emergency or planned short-term periods. Approval to exceed the 30-day maximum should be related to situations such as:

  • an individual whose caretaker becomes ill, hospitalized or has a family emergency;
  • extenuating circumstances that cause care to be required beyond routine or periodic respite relief; or
  • a breakdown in care to the individual, causing an increased risk of institutionalization because of the physical and emotional stress of providing continuous support and care to the individual.

4420  In-Home Respite

Revision 13-2; Effective June 3, 2013

In-home respite is provided by the Home and Community Support Services Agency (HCSSA), on a short-term basis, to an individual who is unable to care for himself because of the absence or need of relief for his caregiver.

STANDARD.

  • In-home respite is provided in the individual’s own home, as authorized on Form 3671-1, Individual Service Plan, when the unpaid caregiver needs relief.
  • The HCSSA is responsible for providing to the individual the tasks authorized on the individual service plan (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.
  • The HCSSA is required to document:
    • the fact that the in-home respite service provider was given a briefing on the individual’s status, needs and preferences prior to delivering respite, and
    • the dates and duration when respite was delivered.

In-home respite helps prevent the individual’s or caregiver’s breakdown and the consequent institutionalization which may result from the physical and emotional stress of providing continuous support and care to the individual.

The in-home respite service provider must deliver the personal assistance services. The HCSSA registered nurse 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, for example, to go to the pharmacy or grocery store to pick up medications or grocery items. The caregiver should be encouraged to be out of the house for brief respite when the attendant is providing the personal assistance services.

4430  Out-of-Home Respite Services

Revision 02-0; Effective April 4, 2002

4431  Introduction

Revision 08-10; Effective September 1, 2008

Out-of-home respite services provide a 24-hour living arrangement in a Department of Aging and Disability Services-enrolled Adult Foster Care 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 Home and Community Support Services provider registered nurse unless facility licensure prohibits delegation.

4432  Consumer Eligibility

Revision 08-10; Effective September 1, 2008

STANDARD. In order to receive out-of-home Community Based Alternatives (CBA) respite services, the applicant or consumer 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 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 applicant for CBA respite services must complete the same eligibility determination process as other CBA applicants. A consumer, whose caregiver is providing uncompensated care and is also the Home and Community Support Services paid attendant, may receive out-of-home respite.

4433  Provider Qualifications

Revision 13-2; Effective June 3, 2013

STANDARD. An out-of-home Community Based Alternatives (CBA) respite provider 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.

In order to deliver CBA out-of-home respite services, the provider must have an approved contract with DADS to deliver out-of-home respite for CBA.

4434  Description of Services

Revision 08-10; Effective September 1, 2008

The Community Based Alternatives (CBA) consumer may receive out-of-home respite services in a nursing facility, a personal care facility or a Department of Aging and Disability Services enrolled Adult Foster Care 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 consumer may take any adaptive aids he is using to the out-of-home respite setting.

The case manager will provide the out-of-home respite provider with the ISP attachments pertinent to the services the consumer will receive while in the facility/home. The provider must deliver services as identified on the consumer's ISP attachments.

4435  Respite Service in a Personal Care Facility or Adult Foster Care Home

Revision 08-10; Effective September 1, 2008

The Community Based Alternatives (CBA) consumer receiving respite services in a personal care facility or Adult Foster Care (AFC) home may receive nursing services or therapy services from outside providers while residing in the respite setting. The consumer's need for any service must be authorized on his individual service plan (ISP) before he receives the service.

The waiver services the consumer receives from outside providers while receiving respite services in a personal care facility or AFC home are considered separate services and are billed separately.

The CBA consumer receiving respite services in an AFC home must qualify for placement in the particular level of AFC home by meeting the specific criteria for that level of home.

Nursing services provided in an AFC home, Levels I or II, may be delegated, according to the professional judgment of the Home and Community Support Services provider registered nurse.

Personal care facility licensure prohibits delegation of nursing tasks. In Assisted Living/Residential Care out-of-home respite settings, nursing services must be provided directly by licensed nurses.

4436  Respite Service in a Nursing Facility

Revision 08-10; Effective September 1, 2008

The Community Based Alternatives (CBA) consumer receiving respite services in a nursing facility may receive therapy services from outside providers. The consumer's need for any service must be authorized on his individual service plan (ISP) before receiving the service. The nursing facility will be responsible for providing the needed nursing services to the consumer.

Costs for all services are included in the assessed rate of payment to the nursing facility and are not to be billed separately. Unless there has been a significant change in the consumer's condition, a new assessment for the ISP cost limit will not be requested.

4440  Room and Board

Revision 08-10; Effective September 1, 2008

STANDARD. Room and board charges are not allowable charges to the Community Based Alternatives consumer receiving out-of-home respite services.

Room and board charges are included in the rates for the services.

4450  Billing Documentation

Revision 08-10; Effective September 1, 2008

The nursing facility provider completes Form 1290, Long Term Care Claim, for all consumers 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, Residential Care Services.

The facility/provider must document on these records:

  • that services were delivered consistently with program requirements described in Section 4430, Out-of-Home Respite Services;
  • the amount of service provided to consumers; 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 consumer in the respite facility. Respite is billed on a daily basis.

If a consumer is at home in the morning and receives two hours of attendant services, then enters a respite setting in the afternoon, the Home and Community Support Services provider 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.

4451  Billing Units of Respite Services

Revision 02-0; Effective April 4, 2002

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.

4500  Emergency Response Services

Revision 08-7; Effective June 6, 2008

4510  Introduction

Revision 08-5; Effective March 28, 2008

Emergency Response Services (ERS) are provided through an electronic monitoring system and used by functionally impaired adults who live alone or who are functionally isolated in the community. In an emergency, the consumer 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 provider responds to an alarm call from a consumer.

4511  Program Purpose

Revision 02-0; Effective April 4, 2002

The purposes of Emergency Response Services (ERS) 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.

4511.1  Program Definitions

Revision 06-7; Effective July 14, 2006

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

Alarm call — A signal transmitted from the equipment to the provider's response center indicating that an individual needs immediate assistance.

Call button — An electronic device that, when pressed, triggers an alarm call to the provider's response center to alert the provider that an individual needs immediate assistance. The device may be held in the hand, worn around the neck, hung on a garment or kept within the client's reach.

Installer — A volunteer, a subcontractor or an employee of a provider who connects, maintains or repairs the equipment .

Monitor — A volunteer, subcontractor or an employee of a provider who monitors Emergency Response Services (ERS) and ensures that an alarm call is responded to immediately.

Responder — A person designated by an individual to respond to an emergency call activated by the individual. A responder may be a relative, neighbor or a volunteer.

Response center — The site where a provider's ERS monitoring system is located.

Subcontractor — An organization or individual who delivers a component of ERS for the provider for a fee and is not an employee or volunteer of the provider.

4512  Eligibility and Referral Procedures

Revision 08-5; Effective March 28, 2008

4512.1  Eligibility

Revision 12-2; Effective June 1, 2012

STANDARD. In order to be eligible for Emergency Response Services through the Community Based Alternatives (CBA) program, an individual must:

  1. Have been determined eligible for the CBA by the Department of Aging and Disability Services (DADS) as specified in 40 Texas Administrative Code §48.6003 of this title (relating to Eligibility Criteria).
  2. Be mentally alert enough to operate the equipment properly, in the judgment of the case manager.
  3. Have a telephone with a private line, if the system requires a private line to function properly.
  4. Be willing to sign a release statement that allows the responder to make a forced entry into the individual's home if he is asked to respond to an activated alarm call and has no other means of entering the home to respond.
  5. Live in a place other than an Assisted Living or Adult Foster Care setting, institution, or any other setting where 24-hour supervision is available.

4512.2  Referral Process

Revision 08-5; Effective March 28, 2008

§52.401 — Referrals.

(a)
A provider must accept all DADS referrals for ERS.
(b)
DADS refers an individual to a provider either with a negotiated referral or a routine referral.
(1)
A case manager makes a negotiated referral:
(A)
by phone; and
(B)
on DADS' Notification of Community Based Alternatives (CBA) Services, Authorization of Community Care Services, or Notification of Consolidated Waiver Program (CWP) Services form.
(2)
A case manager makes a routine referral on DADS' Notification of CBA Services, Authorization of Community Care Services, or Notification of CWP Services form.

The case manager gives eligible applicants an explanation of the service. He explains that applicants/consumers are required to:

  • participate in the service delivery requirements; and
  • sign Form 2307-B, ERS Eligibility Criteria and Responsibilities, which includes a statement allowing the responder to enter the consumer's home, by force if necessary, to assist the consumer.

The case manager follows procedures as outlined in Section 3000, Case Management Responsibilities.

4513  Case Management Duties Related to Emergency Response Services (ERS)

Revision 08-7; Effective June 6, 2008

If the applicant/consumer appears to be in need of ERS and wants to receive ERS, the case manager determines if the applicant/consumer meets the general criteria for participating in ERS, as described in Section 4512.1, Consumer Eligibility. The case manager may involve other members of the interdisciplinary team (IDT) in the decision regarding the consumer's physical and mental ability to participate in the ERS program. ERS may be authorized through CBA when it appears the consumer may need the capability to notify a respondent of an emergency. ERS services are limited to those individuals who:

  • live alone;
  • are alone for significant parts of the day;
  • have no regular caregiver for extended periods of time and who would otherwise require extensive supervision; or
  • live with someone who is too incapacitated to call for help should the need arise.

If the consumer is considered eligible for ERS, the case manager shares the regional list of all ERS providers. The applicant/consumer selects a provider from the list of providers. If the applicant/consumer has no preference, the case manager refers the applicant to the provider agency with the lowest rate. If more than one provider has the same lowest rate, the case manager makes the referral by rotation of providers. If a special service initiation date is necessary, the case manager follows the procedures in Section 3435.1, Verbal Negotiation with CBA Providers Regarding Service Initiation Date for Applicants, and then completes a written authorization as described in Section 3435.3, Written Authorization to ERS, AFC and AL/RC Providers. If negotiation of a special service initiation date is not necessary, the case manager follows the procedures in Section 3435.2, Written Authorization to HCSSA, to refer a consumer for services.

For an initial individual service plan (ISP) with an effective period beginning on the first of a month, and for reassessments that include ERS, the case manager must authorize 12 units of ERS on the ISP. For an initial ISP with an effective period beginning on any day other than the first of a month, the case manager must authorize 13 units of ERS because the ISP will be extended until the end of the same month of the next year.

The case manager may assist the consumer or the provider in identifying potential responders, and in periodically updating the information the provider maintains in its files on responders and other emergency numbers. The case manager must not be an emergency responder for the consumer.

DADS rules require the ERS provider to notify the case manager no later than the next DADS business day of alarms, other consumer emergencies or changes in the consumer's behavior or condition that would prevent the consumer from using ERS.

At least annually, the case manager must review the list of responders given to the provider to ensure the list is current. During the course of the services, the case manager and the provider have the joint responsibility of keeping each other informed of changes or problems.

4520  Service Delivery Requirements

Revision 08-5; Effective March 28, 2008

4521  Service Initiation

Revision 08-5; Effective March 28, 2008

§52.403 — Service Initiation.

(a)
Service initiation requirements. To initiate services, a provider must:
(1)
secure responders, as described in §52.303 (relating to Responders);
(2)
install the equipment as described in §52.405 relating to equipment installation;
(3)
train an individual on the use of the equipment, including:
(A)
demonstrating how the equipment works; and
(B)
having the individual activate an alarm call;
(4)
explain to the individual:
(A)
that the individual must participate in a system check each month;
(B)
that the individual must contact the provider if:
(i)
his telephone number or address changes; or
(ii)
one or more of his responders change; and
(C)
that the individual must not willfully abuse or damage the equipment;
(5)
inform the individual that a responder can forcibly enter an individual's home if necessary;
(6)
obtain a signed release for forcible entry; and
(7)
inform an individual of the procedures for filing a complaint against a provider.
(b)
Service initiation due dates.
(1)
If DADS refers an individual to a provider with a routine referral, the provider must initiate services within 14 days after the service effective date given on the appropriate form listed in §52.401(b)(2) of this chapter (relating to Referrals), or within 14 days after the date the provider receives the form, whichever is later.
(2)
If DADS refers an individual to a provider with a negotiated referral, the provider must initiate services on the date orally negotiated with the case manager.
(3)
If an individual is not available during the time frames described in paragraph (1) or (2) of this subsection, a provider must initiate services within 72 hours after becoming aware that an individual is available, or within 72 hours after the date the individual is available, whichever is later.
(c)
Delay in service initiation. A provider must document any failure to initiate services by the applicable date in subsection (b) of this section.
(1)
DADS does not hold the provider accountable if a service delay is:
(A)
beyond the control of the provider; and
(B)
not directly caused by the provider.
(2)
Documentation must include:
(A)
the reason for the delay;
(B)
either the date the provider anticipates it will initiate services or specific reasons the provider cannot anticipate a service initiation date; and
(C)
a description of the provider's ongoing efforts to initiate services.
(d)
Documentation of service initiation. A provider must maintain documentation of service initiation in an individual's file.

When the provider receives a copy of Form 3671-1, Individual Service Plan (3671 pg.1), Form 3671-2, Individual Service Plan (3671 pg.2), and Form 8598, Non-Waiver Services, and Form 2065-B, Notification of Waiver Services, he:

  • contacts the consumer to make an appointment to install the emergency response home unit equipment.
  • prepares a consumer file, which includes applicable provider forms. Example: individual information, home entry release statement, ownership of equipment statement and complaint procedure form.

If there is a negotiated service initiation date, the provider will receive Form 2067, Case Information, from the case manager that confirms the negotiated service initiation date by which services must begin.

The case manager evaluates whether an alternative service or other resources are available to meet the consumer's needs. The case manager instructs the provider to retain the authorization and initiate services as soon as possible, or requests the return of the written referral packet.

4522  Securing Responders

Revision 06-7; Effective July 14, 2006

§52.303 — Responders

(a)
Responder responsibilities. A responder must:
(1)
go to the individual's home if an alarm call is made to a provider, and
(2)
take appropriate action, including contacting public service personnel, based on the situation.
(b)
Securing responders. A provider must attempt to secure the names of at least two responders from an individual on or before the date the provider initiates services.
(1)
If the provider is able to secure the name of only one responder from an individual, the provider must:
(A)
designate public service personnel in place of the individual's second responder; and
(B)
document the reason the provider could secure the name of only one responder.
(2)
If a provider is unable to secure the names of any responders from an individual, the provider must:
(A)
designate public service personnel in place of the individual's responders; and
(B)
send written notification to the case manager of the inability to secure the names of any responders within 14 days after initiating services.
(c)
Responder orientation. A provider must:
(1)
orient a responder in person, by telephone, or in writing on the responder's responsibilities on or before the date the responder is first contacted by the provider and asked to respond to an alarm call;
(2)
document the following information concerning the orientation:
(A)
the name and telephone number of the responder;
(B)
the name of the individual;
(C)
the date the responder was secured;
(D)
the date of orientation;
(E)
the method of orientation; and
(F)
the topics covered; and
(3)
ensure that a responder receives written procedures on how to respond to an alarm call and document the date the procedures were provided to the responder. The provider may mail the written procedures to the responder.
(d)
Replacing a responder.
(1)
A provider must secure a replacement responder when an individual's responder is no longer able to participate.
(A)
If an individual has two responders, a provider must secure a second responder within seven days after becoming aware that the individual will no longer have two responders.
(B)
If an individual has one responder, a provider must secure a replacement responder within four days after becoming aware that the individual's sole responder is no longer able to participate.
(C)
If a provider is unable to secure any replacement responders, the provider must:
(i)
designate public service personnel in place of the replacement responders; and
(ii)
provide the case manager with written notification within 14 days after the provider determines it cannot secure a replacement responder.
(2)
A provider must document:
(A)
the date the provider became aware that a responder was no longer able to participate; and
(B)
the date the provider secured a replacement responder.
(e)
Current responders. A provider must maintain a record of the names of current responders for each individual.

4523  Home Visit

Revision 08-5; Effective March 28, 2008

§52.405 — Equipment Installation.

(a)
During an initial home visit, an installer must:
(1)
install and make an initial test of the equipment;
(2)
ensure that the equipment has an alternate power source in the event of a power failure;
(3)
install within limits set forth in manufacturers' installation instructions; and
(4)
if necessary:
(A)
purchase a telephone extension cord;
(B)
connect and run a telephone extension cord not to exceed 50 feet between the wall jack and the equipment; and
(C)
safely tack the telephone extension cord against the wall or floorboard to prevent a hazard to an individual.
(b)
An installer is not required to:
(1)
adapt the physical environment in an individual's home to make it compatible with the equipment;
(2)
arrange or pay for relocation of the telephone; or
(3)
purchase or install electrical extension cords. An installer must not use an electrical extension cord when installing equipment.
(c)
A provider must document a failure to install the equipment, including:
(1)
the reason for the delay;
(2)
the date the provider anticipates it will install the equipment or the specific reason the provider cannot anticipate a date; and
(3)
a description of the provider's ongoing efforts to install the equipment, if applicable.

During the home visit, the installer connects the equipment and obtains the information needed to complete the applicable provider forms.

If the installer is unable to complete installation, the provider will document the reason for the delay, the date he anticipates he will install the equipment and a description of ongoing efforts to install the equipment, if applicable.

After installing the equipment, the installer demonstrates the equipment and allows the consumer to activate an alarm call to become familiarized with the equipment. The installer explains that the consumer is responsible for the following service delivery requirements:

  • participating in the monthly systems checks,
  • contacting the provider if he moves or has his telephone number changed, and
  • contacting the provider agency if he becomes aware of changes related to his responder(s).

The installer provides the consumer with a written copy and an explanation of the complaint procedures. See Section 4521, Service Initiation, for detailed information.

4524  Provider Follow-Up Procedures

Revision 06-7; Effective July 14, 2006

The provider notifies the case manager of service initiation as outlined in Section 4521, Service Initiation.

The provider maintains ongoing communication with the case managers and the regional contract manager. He discusses individual-specific issues with the case manager, and contract management issues (overall service delivery, policies and procedures) with the regional contract manager.

4525  Selection of Providers and Provider Changes

Revision 08-5; Effective March 28, 2008

The Department of Aging and Disability Services (DADS) will encourage the consumer to choose the most economical alternative for service provision.

The consumer must contact his case manager to request a provider change. The case manager determines:

  • the consumer's reason for dissatisfaction,
  • whether the consumer's satisfaction can be met without changing providers,
  • if the provider will agree to the transfer, and
  • if the request was received within six months of service authorization.

The case manager attempts to resolve any problems the consumer may be having with the current provider before processing a transfer. If the case manager determines the consumer's dissatisfaction is based on the consumer's failure to comply with the service plan, the case manager may convene an interdisciplinary team to discuss the issues. The case manager may authorize the transfer if it is determined that the consumer's satisfaction cannot be met without the consumer changing providers, or if the consumer insists on changing providers, if services do not have to be terminated due to failure to comply with the service plan.

The case manager asks the consumer to select another provider and processes the transfer by coordinating the following with both providers:

  • the date the current provider will end services, and
  • the date the new provider will begin services.

4530  Service Delivery

Revision 08-5; Effective March 28, 2008

4531  Alarm Calls

Revision 08-5; Effective March 28, 2008

§52.409 — Alarm Calls.

(a)
Response time. A provider must respond to an alarm call within 60 seconds of the alarm, 24 hours a day, seven days a week.
(b)
Response to alarm calls. A provider must, in response to an alarm call:
(1)
record the response time in seconds;
(2)
attempt to contact the individual to verify that an emergency exists before contacting a responder; and
(3)
immediately contact a responder if:
(A)
the individual verifies there is an emergency; or
(B)
the provider is unable to reach the individual.
(c)
Documentation of alarm calls.
(1)
A provider must document an alarm call at the time the alarm call is received and after it is resolved. The documentation must include:
(A)
the name of the individual;
(B)
the date and time the provider receives the alarm call, recorded in hours, minutes, and seconds;
(C)
the time the monitor called the individual in response to the alarm call, recorded in hours, minutes, and seconds;
(D)
the name of the contacted responder, if applicable;
(E)
a brief description of the incident; and
(F)
a statement of how the incident was resolved.
(2)
A provider must provide written notification to the case manager by the next working day after an alarm call that results in a responder being dispatched to an individual's home.

Activated alarms received at the response center are responded to immediately. The monitor keeps track of an incident from the time the alarm is activated to the time the consumer receives assistance. Each activated alarm call must be considered an emergency, not an accident.

The monitor immediately contacts the responder(s) and/or proper authorities if the consumer activates an alarm. If the monitor contacts the consumer before a responder, he must talk to the consumer to verify that an emergency exists.

Monitors contact a responder whenever an alarm call is activated and the monitor is unable to reach the consumer.

4532  Systems Checks

Revision 08-5; Effective March 28, 2008

§52.407 — System Checks.

(a)
Purpose. The purpose of a system check is to ensure:
(1)
that an individual can successfully make an alarm call; and
(2)
that the equipment is working properly.
(b)
Conducting a system check.
(1)
A provider must conduct a system check at least once during each calendar month.
(2)
The system check must be conducted during normal working hours or as negotiated with the individual.
(3)
A provider must document a completed system check. The documentation must include the date and time of the completed system check and confirm that the individual was contacted.

The test involves contacting the consumer and instructing him to press the call button to activate the alarm call. If two consumers live in the same residence, the monitor conducts a monthly systems check for each consumer.

The following procedures apply when the monitor is unable to reach the consumer to conduct a monthly systems check.

Calendar Procedures
For three consecutive months
  1. Try to reach the individual at least three times on three different days during the month.
  2. After three attempts, contact a responder and try to find out why the individual is unable to participate in the test.
  3. If a provider is unable to complete a system check during a calendar month, the provider must notify the case manager in writing as outlined in Chapter 52, Contracting to Provide Emergency Response Services.
    Note: If within three consecutive months a monthly systems check is not successful, the provider may continue to receive payments if the provider continues to attempt to conduct system checks and convene an interdisciplinary team (IDT) meeting.

Note: In each of the three months, the provider is eligible for payment if all requirements are met. The provider is not eligible for partial payment for partial completion of procedures.

The provider documents the reasons why the consumer is unable to participate in the monthly systems check. The provider will contact the responder if he does not have a documented reason why the system checks have not been completed. The provider must ask the responder to find out why the consumer is unable to complete the system check. The information may be documented in the consumer's case folder or the monthly log of systems checks. Written notification is provided to the case manager as outlined in Chapter 52, Emergency Response Services.

An IDT is convened and the case manager evaluates the situation and determines if the consumer continues to be appropriate for the service. The case manager completes and returns Form 2067, Case Information, if continuing services for the consumer; if terminating services, he completes Form 2065-B, Notification of Waiver Services.

The case manager may allow the consumer's authorization to remain effective if the consumer continues to be eligible for the services but is unable to participate in the monthly systems check.

The case manager ensures that the consumer's authorization does not exceed three consecutive billing months during which the consumer is unable to participate in the monthly system checks.

4533  Equipment Malfunction

Revision 08-5; Effective March 28, 2008

§52.411 — Equipment Maintenance.

(a)
Equipment failure. A provider must:
(1)
contact an individual by the end of the next working day after learning of an equipment failure; and
(2)
replace the equipment:
(A)
by the end of the next working day after learning of an equipment failure if the individual is available; or
(B)
by the end of the third working day after learning of an equipment failure if the individual is not available within one working day.
(b)
Low battery. A provider must visit an individual's home to check the equipment within five working days after the equipment has registered five or more "low battery" signals in a 72-hour period. The provider must replace a defective battery during the visit.
(c)
Documentation. A provider must document and maintain a record of each equipment failure and low battery signal. The documentation must include:
(1)
the date the provider became aware of the equipment failure or low battery signal;
(2)
the equipment or subscriber number;
(3)
a description of the problem; and
(4)
the date the equipment is repaired or replaced.

The provider must ensure the equipment is functioning properly and that each consumer receives services during the entire authorization period.

The following persons may report equipment malfunctions to the provider:

  • consumer
  • consumer's family members
  • consumer's responders
  • case managers
  • monitors

As equipment malfunctions are reported, the provider sends the installer to the consumer's home to repair or replace the equipment.

The provider keeps a record of each equipment malfunction in the provider's files.

The provider must respond to "low battery" signals received from consumer's equipment. Provider staff should contact the consumer by telephone after receiving a "low battery" signal to determine if the "low battery" could be caused by an accident, such as the unit having been unplugged. If the "low battery" signals continue, the provider must send a staff member to check and repair or replace the consumer's emergency response services equipment within five days after the receipt of the fifth "low battery" signal.

4540  Suspension and Termination of Emergency Response Services

Revision 13-1; Effective March 1, 2013

§52.417 — Required Notification.

(a)
Required notification. A provider must provide written notification to the case manager if:
(1)
an individual complains of pain;
(2)
an individual requests that services end;
(3)
an individual is temporarily admitted to an institution;
(4)
an individual abuses the service by activating:
(A)
four false alarms within a six-month period that result in a response by the fire department, police, sheriff, or ambulance; or
(B)
20 false alarms of any kind within a six-month period;
(5)
a provider makes three unsuccessful attempts for three consecutive months to contact an individual for a monthly system check;
(6)
an individual or someone in an individual's home engages in illegal discrimination against a provider staff or DADS employee; or
(7)
an individual or someone in an individual's home exhibits reckless behavior, which may result in imminent danger to the health and safety of the individual, provider staff, or another person. If this occurs, the provider must immediately notify:
(A)
the Department of Family and Protective Services or other appropriate protective services agency;
(B)
local law enforcement, if appropriate; and
(C)
the case manager.
(b)
Method and due date. A provider must notify the case manager orally or by fax no later than one working day after becoming aware of a circumstance detailed in subsection (a) of this section. If the provider's first notification is oral, the provider must send written notification to the case manager within five working days of the oral notification. Written notification must include:
(1)
the date the provider became aware of a circumstance detailed in subsection (a) of this section; and
(2)
the reason for the written notification.
(c)
Allowed payment. A provider may continue to receive payment when the provider is unable to conduct a monthly system check for the reasons outlined in subsection (a) of this section for three consecutive months. In order to receive payment, the provider must:
  1. comply with the requirements of §52.407(b) of this chapter (relating to System Checks); and
  2. convene an IDT meeting, as described in §52.413 of this chapter (relating to Interdisciplinary Team) to address subsection (a)(5) and (6) of this section.

§52.419 — Suspension.

(a)
Required suspensions. A provider must suspend services to an individual if the individual:
(1)
permanently leaves the state or moves to a county where the provider does not contract with DADS to provide ERS;
(2)
permanently moves to a location where ERS cannot be provided, such as an assisted living facility;
(3)
dies;
(4)
is admitted to an institution for more than 120 consecutive days; or
(5)
is no longer mentally alert enough to operate the equipment properly.
(b)
Notification. A provider must notify the case manager orally or by fax no later than one working day after suspending services. If a provider's notification is oral, the provider must send written notification to the case manager within five working days after the oral notification. Written notification must include:
(1)
the date services were suspended; and
(2)
the reason services were suspended.
(c)
Payment. DADS does not pay a provider after the month in which services were suspended.

§52.421 — Termination.

(a)
If DADS terminates ERS, a provider may be paid for the last month of service, regardless of how many days of service were provided that month, if:
(1)
the provider has already conducted a system check that month before the termination of services;
(2)
the provider conducted a system check on the day it picked up the equipment; or
(3)
the provider could not complete a system check because:
(A)
the individual's telephone was disconnected;
(B)
the individual damaged the equipment;
(C)
the equipment was picked up at a location other than the individual's home; or
(D)
the individual changed his telephone number or address without allowing the provider to remove the equipment from the individual's home.
(b)
The provider must:
(1)
document the results of the final system check; or
(2)
document the reason the provider was unable to complete a system check.

An interdisciplinary team may need to be called if monthly system checks are unsuccessful or an individual or someone in his home engages in illegal discrimination against a provider staff or a Department of Aging and Disability Services (DADS) employee. The case manager uses Form 2067, Case Information, to notify the emergency response services (ERS) provider that services should continue and Form 2065-B, Notification of Waiver Services, to terminate ERS.

The case manager reports to the ERS provider any changes involving the individual. (Examples: hospitalization, change of residence or visits with relatives.)

An ERS provider may leave ERS equipment in an individual's home and continue service delivery when the individual has temporarily entered an institution. The ERS provider must suspend services once the individual has been in the institution for more than 120 consecutive days. The ERS provider is eligible for payment if the system checks are conducted during the 120-day period.

The ERS provider requests termination of ERS when the individual is no longer mentally alert enough to operate the equipment properly. Situations include, but are not limited to, when the individual:

  • damages the equipment,
  • disconnects the equipment and has received two warnings that are documented in the case record, or
  • refuses to participate in the monthly systems checks.

The ERS provider documents staff's inability to test the home unit in the ERS provider's case record for the individual.

The ERS provider requests the installer to remove the equipment from the individual's home after the case manager authorizes that ERS be terminated.

An ERS provider may leave ERS equipment in an individual's home and continue services until the end of the month the ERS service authorization expires. The ERS provider receives payment for the month the ERS service authorization ends, as long as:

  • monitoring continues until the equipment is picked up, and
  • the equipment is tested during the same calendar month or at the time of pickup.

If DADS terminates ERS, the ERS provider may be paid for the last month of service regardless of how many days of service were provided in that month if the ERS provider has complied with ERS requirements.

The individual is not liable for payment of lost or damaged equipment.

4541  Interdisciplinary Team (IDT) Meetings

Revision 08-5; Effective March 28, 2008

§52.413 — Interdisciplinary Team.

(a)
IDT. An IDT is a designated group of people who meet when the need arises to discuss service delivery issues. An IDT meeting must include:
(1)
the individual or the individual's representative or both;
(2)
a provider representative; and
(3)
a DADS representative, who is:
  • a case manager (or designee);
  • a contract manager (or designee); or
  • a regional nurse (or designee).
(b)
Convening an IDT meeting. A provider must convene an IDT meeting within three working days after the date the provider:
(1)
suspends services to an individual for reasons explained in §52.419 of this chapter (relating to Suspension); or
(2)
identifies an issue that prevents the provider from carrying out a requirement of this chapter.
(c)
IDT meeting.
(1)
A provider may conduct an IDT meeting by telephone conference call or in person.
(2)
The IDT must:
(A)
evaluate the service delivery issue;
(B)
identify solutions to resolve the service delivery issue; and
(C)
make recommendations to the provider.
(d)
IDT meeting outcome. A provider must implement the recommendations of an IDT within two working days after the IDT meeting.
(e)
Documentation of an IDT meeting. A provider must document an IDT meeting in the individual's file, including:
(1)
the specific reason for calling the IDT meeting;
(2)
the names of the participants in the IDT meeting;
(3)
the provider's attempts to convene an IDT meeting with all the members if all members described in subsection (a) of this section are unable to participate in the meeting;
(4)
the IDT's recommendations;
(5)
the provider's action as a result of the IDT recommendations; and
(6)
the reasons for a provider's actions.
(f)
Failure to convene an IDT meeting with a DADS representative present. If a provider convenes an IDT meeting without a DADS representative present, the provider must send the documentation described in subsection (e) of this section to the designated DADS staff for the region in which the individual resides.
(1)
The documentation must be sent within five working days after the date of the IDT meeting.
(2)
After reviewing the IDT meeting documentation, the designated DADS staff may require the provider to take further action.

The provider will convene an IDT meeting when the need arises. A meeting must be called in those situations where the provider is unable to resolve issues with the consumer. A DADS representative, who should be the case manager, must participate in the IDT to assist in resolving issues. The IDT could result in continuation or discontinuation of services. Policy relating to failure to comply with the service plan should be considered, if applicable.

4550  Rates and Contracts

Revision 08-5; Effective March 28, 2008

The Health and Human Services Commission (HHSC) determines a unit rate ceiling for emergency response services. Rates can be accessed at: www.hhsc.state.tx.us/medicaid/programs/rad/ER/Ers.html

The provider must maintain financial records and documentation of claims as outlined in §52.501, Record Keeping, in addition to the records required to be maintained for the consumers.

4551  Advertising and Solicitation

Revision 06-7; Effective July 14, 2006

DADS may investigate complaints of solicitation of coerced individuals. Validated complaints may lead to adverse actions or termination of contracts. The ERS provider is in violation of the ERS contract if the provider employs a person:

  • who is paid money each time he recruits a new Medicaid recipient; or
  • whose sole responsibility is recruitment, regardless of how he is compensated.

The ERS provider may have an employee who is responsible for recruitment in addition to other assignments, as long as he is paid a regular salary and does not receive bonuses or anything that could be construed as a bonus for recruitment of Medicaid recipients.

4552  Disclosure of Previous Employment and Certification

Revision 06-7; Effective July 14, 2006

If a former or current DADS employee, or former or current council member or their relatives are an officer, director, owner or employee, the commissioner of DADS or designee must approve the contract or contract renewal.

4553  Consumer Records

Revision 08-5; Effective March 28, 2008

§52.501 — Record Keeping.

(b)
Individual's file. A provider must maintain the following information for each individual:
(1)
the individual's name, telephone number, address, and medical condition;
(2)
the name and telephone number of each responder;
(3)
a record of all completed and attempted system checks;
(4)
a record of each alarm call;
(5)
a copy of all required notices sent to the case manager;
(6)
a signed release for forcible entry;
(7)
acknowledgement that the equipment belongs to the provider;
(8)
if applicable, documentation showing approval for the continuation of service delivery; and
(9)
if applicable, documentation showing that service delivery is suspended.

4600  Home-Delivered Meals

Revision 09-3; Effective February 27, 2009

4610  Description

Revision 02-0; Effective April 4, 2002

Meals services provide hot, nutritious meals that are served in the client's home. Meals provided by contracted agencies are approved by a dietitian consultant who is either a registered dietitian licensed by the Texas State Board of Examiners of Dietitians or has a baccalaureate degree with major studies in food and nutrition, dietetics, or food service management.

4620  Provider Responsibilities

Revision 09-3; Effective February 27, 2009

Refer to the Contracting to Provide Home-Delivered Meals Handbook for the minimum standards for home-delivered meal providers.

The provider must notify the case manager on the day that meals services are suspended. The provider must suspend services in any of the following situations:

  • The consumer moves out of the geographic area served by the provider.
  • The consumer enters an institution.
  • The consumer requests that services be suspended or terminated.
  • The consumer dies.
  • The case manager directs the provider to suspend services.

Unless the interruption is the result of one of the above situations, the provider must obtain the case manager's approval for service interruptions of more than two consecutive days.

When the consumer requests that services be suspended and specifies a date for services to resume, the provider is not required to notify the case manager.

Home-delivered meals are delivered to the consumer's home as authorized. The individual delivering the meal reports any consumer illnesses, potential threats to his safety, or observable changes in the consumer's condition to the provider. The provider must notify the case manager about the report within 24 hours.

The provider also informs the case manager whenever the home-delivered meal is found uneaten or untouched and the consumer cannot be found. This report must also reach the case manager within 24 hours of the event.

4620.1  Frozen or Shelf-Stable Meals

Revision 09-3; Effective February 27, 2009

A provider that contracts with the Department of Aging and Disability Services (DADS) to provide home-delivered meals (HDM) must agree to provide services:

  • for a specific number of service days, with a minimum of five meals per week;
  • within specific geographic service areas established in the contract; and
  • to all eligible consumers in a service area unless services are suspended or unless the provider is unable to provide a certain therapeutic medical diet.

HDM providers must submit a waiver request to the DADS contract manager if the provider determines that delivery of frozen or shelf-stable meals is required for certain individuals within the provider's contracted service area. Any waiver granted is effective for a period not to exceed one fiscal year. The provider must not implement the waiver for delivery of a hot meal five days a week before DADS approval of the waiver request.

Case managers must work closely with DADS contract managers to be aware of delivery provisions of each HDM provider.

4700  Transition Assistance Services

Revision 10-4; Effective September 1, 2010

4710  Introduction

Revision 06-2; Effective February 2, 2006

Transition assistance services (TAS) assist Medicaid recipients who are nursing facility residents discharged from the facility to a waiver program to set up a household. A nursing facility resident discharged from the facility into a waiver program is eligible to receive up to $2,500 in TAS. TAS is available on a one-time only basis and is not available to residents moving from a nursing facility who are approved for any of the following waiver services:

  • assisted living services;
  • adult foster care services;
  • support family services;
  • 24-hour residential habilitation; or
  • family surrogate services.

Waiver individuals who are temporarily residing in a nursing facility with a Code 35 in the service authorization system (SAS) may also be eligible for TAS. TAS may be used if the waiver client's living conditions are inadequate. Inadequate living conditions may include situations where the individual has lost his residence because of moving into the nursing facility or conditions in the previous residence are so inadequate that the individual cannot return.

4711  Service Description

Revision 10-4; Effective September 1, 2010

Transition Assistance Services (TAS) pays for non-recurring, set-up expenses for individuals transitioning from nursing facilities to a home in the community. Allowable expenses are those necessary to enable the individual to establish a basic household and may include:

  • payment of security deposits required to lease an apartment or home;
  • set-up fees or deposits to establish utility services for the home, including telephone, electricity, gas and water;
  • purchase of essential furnishings for the apartment or home, including table, chairs, window blinds, eating utensils, food preparation items and bath linens;
  • payment of moving expenses required to move into or occupy the home or apartment; and
  • payment for services to ensure the health and safety of the individual in the apartment or home, such as pest eradication, allergen control or a one-time cleaning before occupancy.

TAS does not include relocation services and is not available to assist the applicant in locating a residence.

TAS does not pay for transportation of the individual from the nursing facility to the community.

4720  Case Manager Procedures at the Initial Interview

Revision 06-2; Effective February 2, 2006

All Community Based Alternative (CBA) applicants who are in a nursing facility (NF) must be advised of the availability of transition assistance services (TAS) and screened for the potential need for services.

At the initial interview with the applicant, the case manager discusses the applicant's available living arrangements in the community and asks the applicant where he intends to live upon discharge from the nursing facility.

TAS may be considered in any of the following situations the applicant:

  • plans to rent an unfurnished apartment;
  • plans to rent an unfurnished house;
  • has a home, but all the utilities have been off while in the NF;
  • has a home, but it may need cleaning, pest eradication or allergen control before it can be occupied again; or
  • needs his belongings moved to the new residence.

If these or any other situations exist in which the applicant could benefit from TAS services, continue with the screening for TAS.

4730  Assistance from Relocation Specialists

Revision 09-4; Effective March 27, 2009

All applicants for Community Based Alternatives using the Money Follows the Person option must be referred to a relocation specialist. Relocation assistance consists of, but is not limited to:

  • assessment for relocation;
  • information about Medicaid waiver and non-waiver services and supports;
  • information about and assistance with applying for affordable, accessible housing;
  • coordination with the various state agency services for which the person is eligible;
  • coordination of community services/resources that can assist in transitioning to the community;
  • development of persons/family-directed transition plans and arrangements;
  • support and assistance to individuals and families making the transition; and
  • follow-up assessment after transition.

In addition to providing relocation assistance, some relocation specialists may also contract to provide Transition Assistance Services (TAS).

Form 1579, Referral for Relocation Services, is also used to refer an ongoing CBA consumer who has entered a nursing facility (NF) for a Code 35, Temporary Nursing Facility Stay. Form 1579 must be sent to the Relocation Specialist within two business days of completing the Code 35 action in the Service Authorization System.

Although relocation services may be available when the consumer is discharged back to the community after a temporary NF stay, TAS may not be available if the consumer had previously utilized TAS services with a prior move from the NF to the community. TAS is available on a one-time only basis.

See Section 3314.2, Referral to Relocation Specialists, for more information for making referrals.

4740  Identification of Needed Items and Services

Revision 06-2; Effective February 2, 2006

The case manager will conduct the interview with the applicant and/or authorized representative to identify the applicant's needs and determine if other resources are available to meet the needs. The case manager completes Form 8604, Transition Assistance Services (TAS) Assessment and Authorization, by marking each identified need and writing a description of the exact need.

Example: If the applicant needs a deposit made for electricity, the case manager will enter the name and address of the utility company and enter the amount required.

4741  Items and Services Included Under TAS

Revision 06-2; Effective February 2, 2006

Form 8604, Transition Assistance Services (TAS) Assessment and Authorization, is divided into three main categories: deposits, household needs and site preparation needs.

4741.1  Deposits

Revision 06-2; Effective February 2, 2006

Deposits include security deposits for rental and utilities, including basic telephone service. Security deposits or utility deposits must be in the applicant's name.

Security deposits may be paid as long as the payment is specifically called a security deposit and not rent, the payment is for a one-time expense, and the amount of the payment is no more than the equivalent of two months rent. Transition assistance services (TAS) cannot pay for rent.

TAS can be used to pay for arrears on previous utilities if the account is in the client's name and the client will not be able to get the utilities unless the previous balance is paid. TAS cannot pay the first month's payment on utilities.

TAS can be used to pay for a telephone since it is a basic need, but minutes or services on the telephone cannot be paid for.

TAS cannot pay for any charges for upgraded services beyond the basic service.

TAS funds can be used to pay for initial setup or reconnection fees to propane or butane service, including the minimal supply of fuel if the utility company has a policy that requires a minimal supply of fuel to be delivered during the initial or reconnection service call. TAS funds cannot be used to top off a tank with fuel when the individual's home is connected and has a supply of butane or propane.

TAS can pay for pet deposits only if the pet is a service animal essential to the client.

4741.2  Household Needs

Revision 06-2; Effective February 2, 2006

Household needs include basic furniture/appliances. This includes bedroom furniture, living room furniture, kitchen furniture, refrigerator, stove, washer, dryer, etc.

An applicant may request a specific brand or type of appliance, furniture or other TAS item as long as the applicant's needs are met within the cost limit.

TAS items may be placed in someone's home other than the applicant only when furnishings are not available and are necessary for the applicant to transition to the community. TAS cannot pay for items that would only be used by the other person.

If existing items are not usable and the lack of a usable basic/essential item creates a barrier keeping the individual from returning to the community, the item is considered a need.

4741.3  Housewares

Revision 06-2; Effective February 2, 2006

Housewares can include pots, pans, dishes, silverware, cooking utensils, linens, towels, clock and other small items required for the household.

4741.4  Small Appliances

Revision 06-2; Effective February 2, 2006

Small appliances include a microwave oven, electric can opener, coffee pot, toaster, etc.

4741.5  Cleaning Supplies

Revision 06-2; Effective February 2, 2006

Cleaning supplies include a mop, broom, vacuum, brushes, soaps and cleaning agents.

4741.6  Other Items Not Listed

Revision 06-2; Effective February 2, 2006

Any special requests from the applicant not covered in the general list, which meet the criteria as a basic essential item to move to the community, may be considered.

4742  Services and Items Not Included in Transition Assistance Services (TAS)

Revision 10-4; Effective September 1, 2010

TAS does not include any items or services that will be included under Community Based Alternatives (CBA) services such as adaptive aids, minor home modifications, medical supplies or medications.

TAS does not include any recreational items/appliances, including televisions, VCR or DVD players, games, computers, cable TV, satellite TV, exercise equipment, vehicles or other modes of transportation.

TAS will not cover the cost of repairs on the individual's dwelling. TAS may not be used for remodeling or renovation, upgrading of existing items or purchase of non-essential items.

TAS funds cannot be used for food. The case manager may refer the individual to emergency Supplemental Nutrition Assistance Program (SNAP) or local food pantry resources. Some funds are still available through the Transition to Living in the Community (TLC) Program. While funds are primarily designated for nonwaiver individuals, if a waiver individual has no other resources, TLC could be used to pay for food.

Room and board are not allowable TAS expenses.

TAS does not pay for monthly rental or mortgage agreements or ongoing utility charges.

TAS does not pay for transportation of the individual from the nursing facility to the community.

4743  Site Preparation

Revision 06-2; Effective February 2, 2006

Site preparation can include the following services:

  • moving expenses, which include the cost of moving the applicant's items from another location, or delivery charges on large purchased items;
  • pest eradication, if the applicant's place of residence has been unattended and some type of extermination is needed;
  • allergen control, if the applicant's place of residence has been unattended or the applicant is moving into a place that poses a respiratory health problem; or
  • one-time cleaning, if the applicant's place of residence has been unattended or the applicant is moving into a private home or apartment where pre-move-in cleaning should not be expected, e.g., a family friend has an empty house available, but cannot provide the cleaning.

TAS cannot pay for septic systems.

4750  Estimated Cost of Items and Services

Revision 09-8; Effective September 1, 2009

Case managers provide a description and estimated cost of each item identified as needed under each service category on Form 8604, Transition Assistance Services (TAS) Assessment and Authorization. The actual cost of an item may be used, if known. The amounts, either actual or estimated, must be less than or equal to $2,500.

The case manager must be as specific as possible when describing what items are needed and the estimated cost. The description should include size, color, specific types or any other identifying information, as specified by the individual, that will assist the TAS agency in meeting the individual's needs.

4751  Totaling the Estimated Cost and Authorization of Transition Assistance Services (TAS)

Revision 09-8; Effective September 1, 2009

The case manager totals each section of Form 8604, Transition Assistance Services (TAS) Assessment and Authorization, and enters the amounts in the totals section to arrive at the final amount to be authorized under the TAS program. The $2,500 total amount is not entered as a flat rate.

The applicant must sign the form stating that the items listed are the basic, essential needs required to move into the community, and he agrees that the TAS agency selected is authorized to make the purchases for him.

The applicant selects a TAS agency from the list of contracted agencies.

The case manager must explain to the applicant that the service will not be authorized until the applicant is determined eligible for Community Based Alternatives (CBA) services, and notified in writing that he is eligible. The case manager must contact the applicant or applicant's representative before certification to verify that the applicant has made arrangements for relocating to the community and has finalized a projected discharge date.

The case manager sends the applicant the notification of eligibility and sends the TAS agency Form 8604 and the authorization. The completion date on the authorization is two days before the projected nursing facility discharge date. Allow at least five days between the authorization date and the completion date. The TAS agency is expected to have all services and items completed by that date. In situations where a shorter completion date is needed, the case manager may contact the TAS agency and negotiate an earlier date.

Additional applicant information to the TAS agency may be included on Form 8604 or Form 2067, Case Information.

The case manager enters the TAS authorization into the Service Authorization System (SAS). The Begin date in SAS is the Form 8604 authorization date, the date the form is signed and mailed to the TAS provider. Form 8604 is mailed after the applicant is determined eligible for waiver services.

The TAS agency may only obtain items/services for which the agency has received authorization on Form 8604. If the TAS agency identifies other items/services that the individual may need, the TAS agency must obtain prior approval from the case manager. Refer to Section 4752, Changes to the Authorization.

4752  Changes to the Authorization

Revision 09-8; Effective September 1, 2009

If the Transition Assistance Services (TAS) agency or the consumer identify additional items required by the consumer after the TAS authorization has been sent, the TAS agency must obtain approval from the case manager on Form 8604, Transition Assistance Services (TAS) Assessment and Authorization, prior to obtaining the item/service.

The TAS agency must stay within the total dollar amount authorized on Form 8604. If the total amount of the items/services needed is more than the total amount authorized, the TAS agency must obtain prior approval and an updated Form 8604 from the case manager.

The case manager must send an amended Form 8604 updating the authorization to the TAS agency within two business days with the additional items and amounts authorized.

If a change request is received and the original authorization has been entered into the Service Authorization System (SAS), the case manager modifies the units in SAS, but all other information remains the same.

Supervisory approval is required to authorize delivery of TAS services after the nursing facility discharge date.

4753  Authorization of Transition Assistance Services (TAS) in Service Authorization System (SAS)

Revision 07-2; Effective February 1, 2007

Service Authorization System (SAS) Wizards are used to authorize Transition Assistance Services (TAS) and the associated fee. To prevent inaccurate authorizations and billing problems, TAS screens must reflect the appropriate service units and rates. Completing the following steps in SAS Wizards creates TAS authorizations.

  • Select Service Request Folder: Service Request Window: Select "CBA." Select "Transition Assistance Services."
  • Select CBA/CLASS Wizard:
    • To Create a TAS Authorization for a New Applicant: Service Action Window: Select "Create TAS." Enter the Application Date (date applied for CBA services), Assignment Date (date application assigned to case manager), and the Effective Date (date the TAS agency is authorized to provide services). Click NEXT.
    • To Create a TAS Authorization for a Code 35 Participant:
      • Service Action Window: Select "ISP Change." Do not select "Create TAS." Enter the Effective Date (date the TAS agency is authorized to provide services). This date must be within the dates the participant has an active SAS nursing facility record. Click NEXT.
      • ISP Change Window: TAS Services and TAS Requisition fees display as "Add." All other services display "No Change."
    • Continue the following steps in SAS for both new applicants and Code 35 participants.
      • Service Arrangement Window: Confirm client's county of residence for provider selection. Click NEXT.
      • Provider Selection Window: Double click on the selected provider name. Provider name will appear in upper corner of window. Click NEXT.
      • Service Unit/Rate Entry Window: The screen will automatically default to the following information for the selected provider.
        • Code 53 Transition Assistance Services Units: 0.00 Unit Rate: 1.00 — In the Units field, enter the amount of TAS services authorized up to $2,500.
        • Code 53A Transition Assistance Services Fee Units: 1.00 Unit Rate: $156 — Leave the Units and Unit Rate fields at the default. Click NEXT.
      • Worker's BJN Window: Confirm or change information. Click NEXT.
      • Service Summary Window: Confirm information. Click Generate and Submit.

This process creates an open-ended TAS service authorization record for the new CBA participant and a service authorization that will end the same date as the individual service plan (ISP) for a Code 35 participant.

Upon confirming that all TAS items and services are delivered, the case manager simultaneously terminates the TAS service authorization (Code 53) and fee (Code 53A) records by completing an ISP change action using the CBA/CLASS Wizard. The case manager processes the ISP change action to terminate TAS only after the initial ISP has processed.

If TAS service authorizations are created manually, the case manager enters in the Code 53 TAS Unit field the authorized dollar amount not to exceed $ 2,500. For Code 53A TAS fee, enter a "1" in the Unit field.

4760  Transition Assistance Services (TAS) Agency Responsibilities

Revision 06-2; Effective February 2, 2006

The TAS agency accepts all TAS clients referred by the case manager. Upon receipt of the authorization, the TAS agency must review the forms carefully and contacts the case manager if there are any questions regarding what has been authorized. This contact must occur by the next business day of receipt of the forms, and before any TAS purchase is made. The case manager contacts the client, if necessary, to discuss the item in question. The case manager provides a revised TAS authorization form within two business days, if he clarifies an item that is authorized or approves a change to the authorization.

The TAS agency purchases the authorized items/services and arranges and pays for the delivery of the purchased items, if applicable. The TAS agency only purchases services or items within the dollar amount authorized by the case manager. The TAS agency contacts the client or client's authorized representative, if necessary, to coordinate service delivery.

The TAS agency delivers the authorized services by the completion date recorded on the TAS authorization form. The agency provides a copy of the purchase receipts and any original product warranty information to the client. The TAS agency maintains the original purchase receipts, including sales tax, delivery or installation charges.

The TAS agency orally notifies the case manager of a delivery delay before the completion due date and document the delay. The agency also contacts the client or the client's representative, by the completion date to confirm that all authorized TAS services were delivered.

4770  Three-Day Monitor Required

Revision 10-3; Effective June 1, 2010

The case manager monitors the consumer within three business days of the nursing facility discharge date to assure that all services and items authorized through the Transition Assistance Services (TAS) agency have been received. If the consumer reports that any items have not been delivered or services not performed, the case manager contacts the TAS agency by telephone and follows up with Form 8604, TAS Assessment and Authorization, to identify items that have not been delivered.

Once the case manager confirms that all items/services have been delivered, the case manager closes the TAS authorization in the Service Authorization System (SAS). If the case manager does not close the authorization, the system automatically closes the authorization 120 days from the effective date.

The case manager documents the three-day monitor in the comments section of Form 2314, Satisfaction and Service Monitoring. The three-day monitoring is entered into the SAS Monitoring Wizard.

4780  Failure to Leave the Facility

Revision 06-2; Effective February 2, 2006

While the case manager makes every effort to confirm that the client has definite plans to leave the facility, there may be situations in which the client changes his mind or has a change in his health making it impossible for him to relocate to the community as planned. In this situation, the case manager notifies the transition assistance services (TAS) agency that the client is no longer moving and no further items are to be purchased.

The TAS agency must attempt to return any item(s) purchased on behalf of the individual and collect a refund for the amount of the purchase. The TAS agency also must attempt to recoup security, utility and other deposits paid on behalf of the individual.

  • If the TAS agency is unsuccessful in returning the item(s) for the amount of monies paid or the deposits paid on behalf of the individual cannot be recouped, the TAS agency is entitled to cost of the item(s) and/or reimbursement for deposits paid, not to exceed the authorized amount. The TAS agency sends the case manager written notice stating the item(s) could not be returned or the deposits could not be recouped. The case manager contacts a local charity to donate the items and makes arrangements for pick-up. The charity must serve individuals whose needs are similar to those of the individual for whom the items were purchased or must be dedicated to assisting individuals establish a home.
  • If the TAS agency is able to return the item(s) or receives the deposits back, the TAS agency is not entitled to reimbursement. If the TAS agency recoups part of the monies paid, the TAS agency is entitled to the costs of the item(s) or deposits less any monies recouped. Any claims that had been filed and paid for the item(s) or deposits would need to be adjusted by the TAS agency to pay the monies back to DADS.
  • If a service has already been provided, i.e. pest eradication, then the TAS agency is entitled to the costs of the service, not to exceed the authorized amount.

If the individual is only in the community for a few days and returns to the nursing facility, the individual keeps the item(s) purchased through TAS.

The agency can bill for the TAS fee in all the above situations.

The TAS agency will be paid for any purchases that have been made. However, the case manager must request a force change in the funding code from "1915C" to "100% State " in the Service Authorization System Online (SASO).

4790  Client Notifications and Appeals

Revision 11-1; Effective March 1, 2011

The purpose and limitations of Transition Assistance Services (TAS) should be explained to the applicant when determining the applicant's needs. The applicant may appeal a decision regarding a needed item or service, but transition services should not be delayed due to the appeal.

Form 2065-B, Notification of Waiver Services, must be sent advising the client of the date of eligibility for the waiver program before the authorization of any services. If the client has finalized his discharge plans, Form 8604, Transition Assistance Services (TAS) Assessment and Authorization, may be sent to the TAS provider on the same day Form 2065-B is sent to the client. If discharge plans are not finalized at the time of eligibility, Form 8604 may be sent at a later date. The case manager uses Form 2065-B Comments section to notify the applicant of TAS information, including eligibility or changes in TAS services or items.

The TAS provider is given provider authorization to deliver TAS services on Form 8604, not from the Provider Authorization section of Form 2065-B.