PURPOSE

This form is completed by the HCSS agency nurse to:

• provide a worksheet for the initial development of the individual service plan (ISP);
• identify nursing tasks to be delegated, directly provided or provided through Medicare, other third party resources, family, and other informal support;
• project hours per month required to perform nursing tasks, including delegated nursing tasks;
• request delegation and training hours; and
• provide the Consolidated Waiver Program (CWP) case manager a recommendation on:
  • whether the participant can be left unsupervised for up to three hours at a time, and
  • the level of Adult Foster Home placement.

This form is used by the case manager to:

• determine the level of the AFC home appropriate for the applicant based on the nurse's recommendation; and
• approve the nursing service plan prepared by the home and community support services (HCSS) agency.

PROCEDURE

When to Prepare

The HCSS agency RN completes the items on the form based on the instructions below but may not complete any of the items marked "For DADS Use Only."

The HCSS nurse completes:

• Items 1, 2, 4, and 5 in the identifying data at the top of page 1;
• Section II: C, D, E, F, G for items 1-12 and items 15, 16, 17, and 18;
• Section III: column B, items 1-4;
• Section V: items 1 and 2; and
• Section VI: Optional Weekly Schedules on page 2.

The HCSS nurse is also reponsible for acquiring the signatures and dates in the Certification by Interdisciplinary Team Members section on page 2 when:

• completing the pre-enrollment home health assessment,
• requesting service plan changes during the ISP year or at the time of the coordination of the initial ISP, or
• performing the assessment for the annual service plan revision.

The case manager completes:

• item 3, Effective Date, in the identifying information section;
• Section I: A, B, C;
• Section II: 13, 14, and 19;
• Section IV: column B, items 1-5;
• signature and date on page 2 when approving:
  • the services identified on Form 2221 completed as part of the pre-enrollment home health assessment;
  • service plan changes from the HCSS agency; and
  • the services identified on the form following the annual re-assessment.

Number of Copies

An original form for the case manager and a copy for:

• the authorized HCSS, AFC, and AL/RC provider agency(ies); and
• each member of the interdisciplinary team (IDT).

Transmittal

The original 2221 is submitted to the case manager by the HCSS nurse:

• after completion of the pre-enrollment home health assessment, within the time frame indicated on Form 2229;
• within two DADS workdays after negotiating for a change in initial service plan at the time of the coordination of the initial ISP;
• within seven days when requesting emergency and routine service plan changes;
• after completion of the annual reassessment.

With each form revision, the case manager maintains the original in the participant's case folder and mails or gives copies to the authorized HCSS agency, AL/RC facility, AFC home, 24 Hour Residential Habilitation Services home, Family Surrogate Services home, and IDT members within 14 days of receipt of the notification of the need for a service plan change that is approved.

The case manager sends a copy of this form to the receiving HCSS agency when there is an HCSS agency provider change to inform the receiving agency of the ISP and to obtain a signature from a representative of the HCSS agency to acknowledge his agreement with the services identified on this form.

Form Retention

Each provider must keep copies of Form 2221 in the participant's case record according to the retention requirements found in the Consolidated Waiver Program Provider Manual. The case manager will keep all originals of this form in the participant's folder for five years after services are terminated.

Supply Source

This form is available online only from the Department of Aging and Disability Services (DADS) website.

DETAILED INSTRUCTIONS

Identifying Data

1. Applicant/Participant Name —  Self-explanatory.

2. Medicaid No. —  Enter the applicant's/participant's nine-digit Medicaid number.

3. Effective Date —  Enter the effective date from Form 2217, ISP, from the initial ISP, reassessment ISP, or ISP change that includes the authorization for the nursing services contained on this Form 2221.

4. Case Manager —  Enter the name of the CWP case manager for the applicant/participant.

5. Provider Vendor No. —  Enter the CWP vendor number for the HCSS agency.

I. GRAND TOTALS

A. PAS Hours – (Delegated Nursing Hours) —  Enter total hours identified in Section II, item 12, column D to be done by the PAS attendant. This must be included on Form 2060-A when calculating PAS hours also.

B. Direct Nursing Hours —  Enter total hours needed for direct delivery, delegation, training, and program required hours for licensed nurses as identified in:

C. Number of Program Required Direct Nursing Hours —  Enter the total of program required direct nursing hours as identified in Section IV, item 5, total of column B.

The total of B should include any nursing hours already authorized and delivered in the current ISP period and is the number of units of nursing authorized in the estimated annual units column on Form 2217, Nursing Services.

II. NURSING TASKS

Check any of the tasks the applicant/participant requires as identified in 1-11.

Identify the need for the tasks based on the data as assessed on Form 3652-A, CARE, from what the applicant/participant says, documentation in the clinical record, any physician's orders, and nursing judgement. Identify the needed task(s) as a task that is needed even if it is currently being provided by other resources (i.e., attendants, AFC providers, family, friends (informal support), Medicare, and other third party resources).

Tasks 1-10 —  Specific nursing tasks. These nursing tasks may be delegated according to the rules from the Board of Nurse Examiners for the State of Texas, 22 TAC §218.

Task 11  —  This task will be identified if there is a task, other than the tasks listed above in 1-10, that would be nondelegable to an unlicensed person. This task, such as I.M. injections or insulin injections, must be provided directly by a licensed nurse or trained family members or informal support. Note: The exception is when using to document the need for extension of therapy.

12. Totals —  Enter the totals for columns C-G.

13. Number of months remaining in current ISP year —  Enter the number of months remaining in the ISP. Use 12 for initial and reassessment ISPs; round fractions to the next higher month.

14. Subtotal —  Multiply the total in 12G by the number of months remaining in the ISP effective period entered in item 13 and enter the number as the subtotal for nursing tasks.

15. Number of nursing hours already authorized —  For ISP changes, enter the number of direct nursing hours for nursing tasks in Section II. authorized and scheduled to have been provided already in the current ISP. Enter the estimated units, or the units actually delivered, if known, up to the effective date of the ISP change.

16. Number of nursing hours needed to develop specifications —  Enter hours as documented on Form 2233. The case manager should convert the hours recorded in this item to a dollar amount and transfer to Form 2217, item 41-C, column 20.

17. Number of nursing hours needed to provide orientation —  Enter hours as documented on Form 2233.

18. Number of RN hours needed to complete the annual reassessment —  Self-explanatory.

19. Direct nursing hours by HCSS nurse needed this ISP year —  Enter the sum of items 14, 15, 17, and 18.

Explanation of Columns in Section II., Nursing Tasks

B. AFC Level —  With each identified task, there is an associated level of AFC home in which the task may be provided. The nurse must be knowledgeable of the task(s) which can be provided in different levels of AFC homes to make a recommendation for AFC level placement. Based on the identified tasks and associated AFC level (as printed beside the tasks), the nurse makes a recommendation for AFC placement in Section V., item 2, of this form.

C. Hours per month needed —  Enter the hours needed per month to perform the identified task as performed by one or more providers.

D. Hours Delegated to PAS, FSS, or AFC Provider —  If delegation is to the personal care attendant, the case manager converts the monthly number of hours to weekly by dividing by 4.33 and enters this weekly total in item II. 3. A. of Form 2060-A. The nurse will identify the unlicensed person receiving delegation by circling the PAS, FSS, or the AFC provider.

E. Hours Performed by Informal Support —  Enter the number of nursing hours for each identified task that will be provided monthly by nonpaid informal support to include family and friends. (This number will be a portion or all of the total hours needed per month as identified in column C.)

F. Hours Performed by Medicare/Other —  Enter the monthly hours that Medicare and other third party resources, excluding family and informal supports, are providing of an identified task.

G. Direct Nursing by HCSS Provider —  Enter the number of monthly hours the licensed nurse will need to provide the identified task on a monthly basis.

III. NURSING SERVICES RELATED TO DELEGATION/TRAINING

A. Delegation/Training Activities —  This section relates to the licensed nurse hours needed to delegate and supervise personal care attendants and AFC providers, as well as the hours needed to train the family or other informal support in performing nursing tasks. This will only be completed if hours have been identified in Section II, columns D and E. There is no delegation in AL/RC facilities, AFC homes, Level III, or in AFC homes run by licensed vocational nurses.

1. B. – Initial Delegation Activities —  Enter the hours required to set up initial delegation activities involving the attendant or the AFC provider and provider substitute for the identified tasks listed in Section II, tasks 1-10, or when there is a change in the attendant or AFC provider/provider substitute. (Example: In an AFC home, there may be six hours the first month of waiver service setting up a delegation plan and supervising closely in follow up to ensure compliance with the task and that quality care is being provided. On an ongoing basis, the nurse may only need two hours monthly to supervise the delegated tasks (see below.) Hours will be entered here only if hours are entered in column D, line 12, in Section II.

2. B. – Ongoing Delegation Activities —  Enter the annual hours required to supervise and monitor the delegated nursing tasks as being performed by the attendant, AFC provider, and provider substitute. (The nurse must know what the monthly hours are and multiply by 12 for the annual hours.) Hours will be entered here only if hours are entered in column D, line 12, in Section II. This is also to be used for ISP changes when a new attendant is hired and additional nursing hours are required for training and delegation to the new attendant.

3. Training of Family Members/Informal Support Providers —  Enter the hours required to train the family/informal support to perform the identified nursing tasks, Section II, tasks 1-10 or 11, if applicable or any personal assistance service task. (Refer to the CWP Provider Manual, Item 1220, Nursing Services.) Hours will be entered here only if hours are entered in column E, line 12, in Section II. This may also be used for ISP changes to increase nursing hours when informal supports change and more time for training or delegation is required.

4. Total Annual Hours Requested for Delegation/Training Activities —  Enter the total of all the hours entered in column B, lines 1-3. Include any previously authorized hours.

IV. MANDATORY DIRECT NURSING SERVICES TO BE AUTHORIZED

A. Hours to be Authorized by Program Requirements —  Authorize in column B the allowed program hours, lines 1-4, according to program requirements and as appropriate according to the participant's living arrangement.

5. Total number of hours authorized for program requirements —  Enter the total of lines 1-4. Carry over the total of column B to Section I, GRAND TOTALS (Direct Nursing Hours).

V. RECOMMENDATIONS

1. Can applicant/participant be left unsupervised for up to three hours at a time? —  (This question is answered on all participants at the time of the assessment but is applicable only to participants classified as AFC Levels I or II). Yes or No

2. RN's Recommendation for AFC Level? —  In making this recommendation, the nurse must have identified the nursing tasks needed by the participant (in Section II, tasks 1-11) and have the knowledge of what tasks are performed in Level I and II of AFC (as identified next to the task). Skilled tasks in Level III homes must be provided by a licensed registered nurse, licensed vocational nurse, or substitute registered or vocational nurse. The AFC Level III nurse provider makes the determination if the participant is a Level III participant. These participants have a medical disorder, disease, or both with a related impairment being so complex or of such sufficient seriousness that their needs exceed the care that may be delegated to an unlicensed person. These participants require timely assessment, planning, and interventions by a licensed nurse on a 24-hour basis.

Certification by Interdisciplinary Team Members

Signatures

The HCSS agency RN signs and dates the form on the line labeled "Signature – HCSS Nurse Assessor" after completing the pre-enrollment assessment or annual reassessment, and when requesting a change in the ISP related to nursing services.

The case manager signs and dates the form to authorize the HCSS agency to provide the identified nursing services.

The HCSS agency representative signs and dates the form on the line labeled "Signature – HCSS Representative" at the time of a provider change to acknowledge his agreement with this portion of the ISP. He does not have to sign this form for initial or reassessment ISPs because he signs Form 2218. No signature is required for other ISP changes.

The applicant/participant/responsible party does not have to sign the signature line on this page for initial or reassessment ISPs because he must sign Form 2218. For ISP changes, the case manager writes "verbally approved" on the Applicant/Participant/Responsible Party signature line when he obtains the applicant/participant or responsible party's agreement with the ISP change by telephone. If verbal approval for the change is not appropriate, such as if the participant has no telephone or has a cognitive or communication impairment precluding understanding the change over the telephone, the case manager makes a home visit to obtain the participant's approval and sends notification on Form 2200 to the participant and provider, along with a copy of the ISP attachment that includes the change.

The informal support individual or family member who has agreed to perform the identified tasks will sign in the signature line at the time of the initial ISP, reassessment, or when there is a change in the tasks the informal support will provide.

If more than one informal support individual or family member is providing care, each will sign in agreement to provide the task(s). The HCSS nurse is responsible for obtaining these signatures when obtaining the informal support or family member's commitment to be involved in the applicant's/participant's plan of care.