Texas Department of Aging and Disability Services
Case Manager Community Care for Aged and Disabled Handbook
Effective: July 1, 2011
1100 Program Introduction
1110 Legal Base
Community Care for Aged and Disabled (CCAD) is a group of services purchased by the Department of Aging and Disability Services (DADS) in response to recommendations of the Texas Legislature. CCAD provides services in a person's own home or community for aged or disabled Texans who are not self-sufficient, and who might otherwise be subject to unnecessary institutionalization or to abuse, neglect or exploitation. CCAD includes the following direct services for eligible individuals (detailed descriptions of the services are in Section 4000, Specific CCAD Services):
- Adult Foster Care (AFC) — 24-hour care in a family home or small group home.
- Day Activity and Health Services (DAHS) — up to 10 hours of care per day in a licensed facility, with supervision by licensed nurses.
- Emergency Response Services (ERS) — an electronic signaling device for use in emergencies.
- Meals Services — Home-Delivered Meals (HDM).
- Personal Attendant Services (PAS) — assistance with personal care and housekeeping tasks:
- Community Attendant Services (CAS), which serves individuals who meet financial eligibility criteria for individuals living in an institutional setting;
- Family Care (FC), which serves individuals who meet Community Care financial eligibility criteria (see Section 3000, Eligibility for Services); and
- Primary Home Care (PHC), which serves individuals with full Medicaid benefits.
- Residential Care — 24-hour care in a group setting, including
- Emergency Care (EC) — care given to individuals who need immediate shelter or 24-hour care, or
- Residential Care (RC) — 24-hour care in licensed personal care homes.
- Special Services to Persons with Disabilities (SSPD) — a variety of in-home care and advocacy services for disabled individuals.
DADS also provides CCAD case management, information and referral (I&R) to other service resources. Case management is direct assistance to eligible individuals in managing the services that have been mutually planned and that use the individuals’ own resources as well as community resources. These services are planned to enable individuals to carry out activities of daily living and to continue living in the community. (For details see Section 2000, Case Management.)
See also Appendix XXIV, Legal Basis for Community Care Programs.
1120 Program Goals
CCAD goals are:
- to enable aged and disabled individuals to achieve or maintain personal self-sufficiency, to help them reduce or prevent dependency, and to help them accept and understand dependency when it occurs because of illness, accident, or normal aging;
- to prevent or reduce unnecessary institutional care by providing home-based and other less intensive care and to help individuals access institutional services when necessary and appropriate; and
- to prevent abuse and neglect, including adult self-neglect, and to refer to APS those adults who appear to be victims of abuse, neglect, or exploitation by others.
§48.1201 — The following words and terms, when used in these sections, shall have the following meanings unless the context clearly indicates otherwise:
- Abuse — "The willful infliction of injury, unreasonable confinement, intimidation, or cruel punishment with resulting physical harm, pain, or mental anguish; or the willful deprivation by a caretaker or one's self of goods or services which are necessary to avoid physical harm, mental anguish, or mental illness." (Chapter 48, Human Resources Code)
- Activities of daily living (ADL) — Activities that are essential to daily self-care; including bathing, dressing, grooming, toileting, housekeeping, shopping, meal preparation, and others.
- Adult — A person 18 or older, or an emancipated minor.
- Aged or elderly person — A person 65 or older.
- Applicant — A person initially requesting services.
- Attendant — A person who is employed by a provider agency to give personal care or housekeeping services or both to an eligible Family Care (FC) or Primary Home Care (PHC) client, according to a service plan.
- Caregiver — A relative, guardian, representative payee, or person who has contact with a client that is frequent enough or regularly scheduled enough that a personal relationship exists or the client perceives that person as having a role in helping the client to meet basic needs.
- Caregiver support — An interval of rest or relief from caregiving duties given to or arranged for the caregiver of a DHS client.
- Client — A person determined eligible for CCAD service.
- Community care — Services provided within the client's own home, neighborhood, or community, as alternatives to institutional care. Community care is sometimes called alternate care.
- Disabled/incapacitated person — A person who, because of physical, mental, or developmental impairment, is limited temporarily or permanently in his capacity to adequately perform one or more essential activities of daily living, which include, but are not limited to, personal and health care, moving around, communicating, and housekeeping.
- Earned income — Cash or liquid resources that a client receives for services he performs as an employee or as a result of self-employment. All other income is unearned income.
- Emancipated minor — A person under 18 who has the power and capacity of an adult. This includes a minor who has had the disabilities of minority removed by a court of law or a minor who, with or without parental consent, has been married. Marriage includes common-law marriage.
- Emotional or verbal abuse — Any use of verbal communication or other behavior to humiliate, intimidate, vilify, degrade, or threaten with harm.
- Expedited response — A face-to-face contact with an applicant by the caseworker within five calendar days of the date of the applicant's request for service.
- Exploitation — The illegal or improper act or process of a caregiver or others using an adult's income and resources for monetary or personal benefit, profit, or gain.
- Facility — A legal entity that contracts with the department to deliver to clients day services or 24-hour residential services.
- Fraud — A deliberate misrepresentation or intentional concealment of information in order to receive or to be reimbursed for the delivery of services to which the individual is not entitled.
- Functional need — An individual's requirement for assistance with activities of daily living, caused by a physical or mental limitation or disability.
- Immediate response — A face-to-face contact with an applicant by the caseworker within 24 hours of the applicant's request for services.
- Income eligible (I.E.) — An adult who, although neither a Medicaid recipient nor a Supplemental Nutrition Assistance Program (SNAP) head of household or spouse, nevertheless has income and resources equal to or less than eligibility levels established by the department.
- Institution — A nursing home, an intermediate care facility for the mentally retarded (ICF-MR), a state school, or a state hospital.
- Liquid resource — Cash or financial instruments that could be converted to cash within 20 workdays.
Examples: Cash, certain savings accounts, checking accounts, stocks, and bonds. Liquid resources do not include personal property such as automobiles, furniture, or clothing. Liquid resources also do not include real property such as land, houses, or other buildings.
- Medicaid eligible — An individual eligible for federal medical assistance as an SSI or TANF client, or eligible for medical assistance only (MAO) in a nursing home or while living in the community or through a federally approved waiver.
- Medicare eligible — An aged or disabled person who is a recipient of Social Security or Railroad Retirement benefit payments and meets eligibility criteria to have certain medical expenses paid by the federal Medicare program.
Call the local Social Security Administration office for further definition of and clarification about Medicare eligibility.
- Neglect — "The failure to provide for one's self the goods or services which are necessary to avoid physical harm, mental anguish, or mental illness; or the failure of a caretaker to provide such goods or services." (Chapter 48, Human Resources Code)
- Personal leave — Any leave from a Residential Care facility except for hospitalization or institutionalization. A day of personal leave is any period of 24 consecutive hours.
- Prior approval — A regional nurse's authorization that payment may be made to a provider agency, because a client meets the medical criteria for the requested Medicaid service.
- Provider agency — An agency that has contracted with DHS to provide the CCAD services that DHS has authorized for eligible clients.
- Resource — Any cash or other liquid assets or any real or personal property owned by an individual and spouse that could be converted to cash to use for support and maintenance.
- Responder — A person who responds to an ERS call activated by a client. Responders may include relatives, neighbors, volunteers, or staff of a sheriff's department, police department, emergency medical service, or fire department.
- Sexual abuse — Sexual contact or conduct which is without the voluntary, informed consent of the elderly or disabled adult.
- Supplemental Security Income (SSI) — Monthly payments made by the Social Security Administration (SSA) to an aged or disabled individual who meets the requirements for public aid. SSA determines eligibility for SSI.
- Support system — The network of family members, close friends, and neighbors who are usually available and willing to provide regular or occasional assistance to a person.
- Unearned income — Income received by a client from sources other than self-employment or employee work activities. (See earned income.)
- Unmet need — A requirement for assistance with activities of daily living that cannot be met adequately on an ongoing basis by friends, relatives, volunteers, or service agencies other than DHS.
- Verbal referral — A referral made by the caseworker to the provider agency in person or by telephone, no later than the first workday after the caseworker's determination that the applicant meets the criteria for an expedited or immediate response to a request for service, and needs immediate service initiation.
1140 Disclosure of Information
1141 Confidential Nature of the Case Record
Information that is collected in determining initial or continuing eligibility is confidential. The restriction on disclosing information is limited to information about individuals. The Department of Aging and Disability Services (DADS) may disclose general information about policies, procedures, or other methods of determining eligibility, and any other information that is not about or does not specifically identify an individual.
An individual may review all information in the case record and in DADS handbooks that contributed to the decision about his eligibility.
1141.1 Confidential Information on Notifications
The Department of Aging and Disability Services (DADS) is committed to protecting all confidential information supplied by the applicant or individual during the eligibility determination process. This covers inclusion of confidential information by DADS staff to third parties who receive a copy of a notification of eligibility form. Staff must ensure they do not include confidential information on the eligibility notice that should not be shared with the service provider or another third party. For example:
An individual is being denied Family Care due to an increase in income. It is a violation of confidentiality to record on Form 2065-A, Notification of Community Care Services, "Your income of $2,892 exceeds the eligibility limit of $2,022." The comment should simply state, "Your income exceeds the eligibility limit."
Another applicant is being denied Primary Home Care services because he does not meet the medical diagnosis criterion. It is a violation of confidentiality to record on Form 2065-A, "Your diagnosis of Schizophrenia does not meet the medical diagnosis criterion for eligibility for the Primary Home Care Program." The comment should simply state, "You do not have a medical diagnosis resulting in a functional limitation, as required for eligibility."
In the examples above, revealing the amount of the individual's income or his diagnosis is a violation of his right to confidentiality. In all cases, DADS staff must assess any information provided by the individual to determine if its release would be a confidentiality violation.
1142 Establishing Identity for Contact Outside the Interview Process
Keep all information DADS has about an individual or any individual on the individual's case confidential. Confidential information includes, but is not limited to, individually identifiable health information.
Before discussing or releasing information about an individual or any individual on the individual's case, take steps to be reasonably sure the individual receiving the confidential information is either the individual or a person the individual has authorized to receive confidential information (for example, an attorney or personal representative).
1142.1 Telephone Contact
Establish the identity of an individual who identifies himself as an individual using his knowledge of the individual's
- date of birth,
- other identifying information, or
- call back to the individual.
Establish the identity of a personal representative by using the individual's knowledge of the individual's
- date of birth,
- other identifying information,
- call back to the individual, or
- the knowledge of the same information about the individual's representative.
Establish the identity of attorneys or legal representatives by asking for the individual to provide Form 1826-D, Case Information Release, completed and signed by the individual.
Establish the identity of legislators or their staff by following regional procedures.
1142.2 In-Person Contact
Establish the identity of the individual who presents himself as an individual or individual's representative at a DADS office by using sources such as:
- driver's license,
- date of birth,
- SSN, or
- other identifying information.
Establish the identity of other DADS staff, federal agency staff, researchers, or contractors by using sources such as:
- employee badge, or
- government-issued identification card with a photograph.
Identify the need for other DADS staff, federal staff, research staff, or contractors to access confidential information through
- official correspondence or a telephone call from a state or regional office.
- contact with regional attorney.
Contact appropriate regional or state office staff when federal agency staff, contractors, researchers, or other DADS staff come to the office without prior notification or adequate identification and request permission to access DADS records.
1142.3 Verification and Documentation
If disclosing individually identifiable health information, document how the identity of the person was verified when contact is outside the interview.
Verify the identity of the person who requests disclosure of individually identifiable health information using sources such as:
- valid driver's license or Department of Public Safety ID card,
- birth certificate,
- hospital or birth record,
- adoption papers or records,
- work or school ID card,
- voter registration card,
- wage stubs, and
- U.S. passport.
1143 Custody of Records
Records must be safeguarded. Use reasonable diligence to protect and preserve records and to prevent disclosure of the information they contain, except as provided by DADS regulations.
"Reasonable diligence" for employees responsible for records includes:
- keeping records in a locked office when the building is closed;
- keeping records properly filed during office hours; and
- keeping records in the office at all times, except when authorized to remove or transfer them.
1144 Disposal of Records
To dispose of documents with individual-specific information, follow the Department of Aging and Disability Services procedures for destruction of confidential data in the Operational Handbook.
1145 When and What Information May Be Disclosed
Reasonable efforts must be made to limit the use, request, or disclosure of individually identifiable health information to the minimum necessary to determine eligibility and operate the program. The disclosure of individual medical information from DADS records must be limited to the minimum necessary to accomplish the requested disclosure. For example, if an individual authorizes release of income verification, including disability income, do not release related case medical information unless specifically authorized by the individual.
Give individual addresses or other case information only to a person who has written permission from the individual to obtain the information. The individual authorizes the release of information by completing and signing:
- Form 1826-D, Case Information Release; or
- a document containing all of the following information:
- the applicant/individual's full name (including middle initial) and case number, or full name (including middle initial) and either his date of birth or Social Security number;
- a description of the information to be released. If a general release is authorized, provide the information that can be disclosed to the individual. Withhold confidential information from the case record, such as names of persons who disclosed information about the household without the household's knowledge, and the nature of pending criminal prosecution;
- a statement specifically authorizing DADS to release the information;
- the name of the person or entity where the information will be released;
- the purpose of the release;
- an expiration event that is related to the individual, the purpose of the release, or an expiration date of the release;
- a statement about whether refusal to sign the release affects eligibility for delivery of services;
- a statement describing the applicant's or individual's right to revoke the authorization to release information;
- the date the document is signed; and
- the signature of the applicant or individual.
If the case information to be released includes individually identifiable health information, the document must also tell the applicant or individual that information released under the document may no longer be private, and may be released further by the person receiving the information.
Occasionally requests for information from the case records of deceased individuals are received. In these instances, protect the confidentiality of the former individuals and their survivors.
The Office of the General Counsel handles questions about the release of information under the Open Records Act. All questions and problems encountered by individuals concerning release of information should be referred to the Office of the General Counsel, State Office, W-615. Regional staff should direct questions and problems to the regional attorney.
Note: See Section 1146. Confidential Nature of Medical Information – HIPAA, for restrictions on the release of an individual's protected health information under Health Insurance Portability and Accountability Act regulations.
1145.1 Request for Release of Information Related to a Deceased Individual
This section provides guidance for handling requests for release of information related to a deceased applicant/individual. A request for such information is likely to occur in relation to the Medicaid Estate Recovery Program. The Department of Aging and Disability Services (DADS) does not provide a form to document when someone requests information. In lieu of a form, the following methods are acceptable for documenting the request for this type of release of information to the requestor:
- A release form or statement signed by the applicant/individual prior to death, and not revoked by the applicant/individual, authorizing release of information to the specific person requesting the information.
- A copy of an order from a probate court appointing the requestor as estate administrator or guardian.
- A copy of another type of order from a court authorizing the requestor to administer the affairs of the deceased.
- Documentation demonstrating the requestor has authority under Texas law to act for the deceased.
A person who has authority under Texas law to act on behalf of a deceased applicant/individual or the deceased's estate includes a surviving spouse, an adult child, a parent or an heir.Regional staff should first ask the requestor for any available document (noted above). If a document is not available, staff must determine and document if the requestor has authority under Texas law to act for the deceased applicant/individual. Regional staff may release information to the requestor if one of the documentation requirements above is met and filed/recorded in the case record.
1146 Confidential Nature of Medical Information – HIPAA
Health Insurance Portability and Accountability Act (HIPAA) is a federal law that sets additional standards to protect the confidentiality of individually identifiable health information. Individually identifiable health information is information that identifies or could be used to identify an individual and that relates to the:
- past, present, or future physical or mental health or condition of the individual;
- provision of health care to the individual; or
- past, present, or future payment for the provision of health care to the individual.
1147 Privacy Notice
DADS staff must send each individual Form 0401, HIPAA Privacy Notice, upon certification. This form tells the individual about
- his privacy rights;
- the duties of DADS to protect health information; and
- how DADS may use or disclose health information without his authorization. (Examples of use or disclosure include: health care operations (for example, Medicaid), public health purposes, reporting victims of abuse, law enforcement purposes, sharing with DADS contractors, and coordinating government programs that provide benefits.)
1148 Individual Authorization
The individual may authorize the release of his health information from DADS records by using a valid authorization form. Form 1826-D, Case Information Release, includes all the authorization elements required by HIPAA privacy regulations.
1149 Minimum Necessary
Reasonable efforts must be made to limit the use, request, or disclosure of individually identifiable health information to the minimum necessary to determine eligibility and operate the program. The disclosure of individual medical information from DADS records must be limited to the minimum necessary to accomplish the requested disclosure. Example: If an individual authorizes release of income verification, including disability income, do not release related case medical information unless specifically authorized by the individual.
1150 Personal Representatives
Only the individual or the individual's personal representative can exercise the individual's rights with respect to individually identifiable health information. Therefore, only the individual or individual's personal representative may authorize the use or disclosure of individually identifiable health information or obtain individually identifiable health information on behalf of an individual.
Exception: DADS is not required to disclose the information to the personal representative if the individual is subjected to domestic violence, abuse, or neglect by the personal representative. Consult the regional attorney if it is believed that health information should not be released to the personal representative.
Note: A responsible party is not automatically a personal representative.
1151 Adults and Emancipated Minors
If the individual is an adult or emancipated minor, including married minors, the individual's personal representative is a person who has the authority to make health care decisions about the individual and includes a:
- person the individual has appointed under a medical power of attorney, a durable power of attorney with the authority to make health care decisions, or a power of attorney with the authority to make health care decisions;
- court-appointed guardian for the individual; or
- person designated by law to make health care decisions when the individual is in a hospital or nursing home and is incapacitated or mentally or physically incapable of communication. Follow regional procedures to contact the regional attorney for approval.
1152 Unemancipated Minors
A parent is the personal representative for a minor child except when:
- the minor child can consent to medical treatment by him or herself. Under these circumstances, do not disclose to a parent information about the medical treatment to which the minor child can consent. A minor child can consent to medical treatment by him or herself when the:
- minor is on active duty with the U.S. military;
- minor is age 16 or older, lives separately from the parents, and manages his own financial affairs;
- consent involves diagnosis and treatment of disease that must be reported to local health officer or state health services;
- minor is unmarried and pregnant and the treatment (other than abortion) relates to the pregnancy;
- minor is age 16 years or older and the consent involves examination and treatment for drug or chemical addiction, dependency, or use at a treatment facility licensed by the Texas Council on Alcohol and Drug Abuse;
- consent involves examination and treatment for drug or chemical addiction, dependency, or use by a physician or counselor at a location other than a treatment facility licensed by the Texas Council on Alcohol and Drug Abuse;
- minor is unmarried, is the parent of a child, has actual custody of the child, and consents to treatment for the child; or
- consent involves suicide prevention or sexual, physical, or emotional abuse.
- a court is making health care decisions for the minor child or has given the authority to make health care decisions for the minor child to an adult other than a parent or to the minor child. Under these circumstances, do not disclose to a parent information about the health care decisions not made by the parent.
1153 Deceased Individuals
The personal representative for a deceased individual is an executor, administrator, or other person with authority to act on behalf of the individual or the individual's estate. These include:
- an executor, including an independent executor;
- an administrator, including a temporary administrator;
- a surviving spouse;
- a child;
- a parent; and
- an heir.
Consult the regional attorney if there are questions about whether a particular person is the personal representative of an applicant or individual.
1160 Correcting Information
An individual has a right to correct any information that DADS has about the individual and any other individual on the individual's case.
A request for correction must be in writing and:
- identify the individual asking for the correction;
- identify the disputed information about the individual;
- state why the information is wrong;
- include any proof that shows the information is wrong;
- state what correction is requested; and
- include a return address, telephone number, or email address at which DADS can contact the individual.
If DADS agrees to change individually identifiable health information, the corrected information is added to the case record, but the incorrect information remains in the file with a note that the information was amended per the individual's request.
Notify the individual in writing within 60 days (using current DADS letterhead) that the information is corrected, or will not be corrected, and the reason. Inform the individual if DADS needs to extend the 60-day period by an additional 30 days to complete the correction process or obtain additional information.
If DADS makes a correction to individually identifiable health information, ask the individual for permission before sharing with third parties. DADS will make a reasonable effort to share the correct information with persons who received the incorrect information from DADS if they may have relied or could rely on it to the disadvantage of the individual. Follow regional procedures to contact the DADS Privacy Officer for a record of disclosures.
Note: Do not follow above procedures when the accuracy of information provided by an individual is determined by another review process, such as a
- fair hearing,
- civil rights hearing, or
- other appeal process.
The decision in that review process is the decision on the request to correct information.
1170 Alternate Means of Communication
DADS must accommodate an individual's reasonable requests to receive communications by alternative means or at alternate locations.
The individual must specify in writing the alternate mailing address or means of contact, and include a statement that using the home mailing address or normal means of contact could endanger the individual.