Texas Department of Aging and Disability Services
Nursing Facility Requirements for Licensure and Medicaid Certification Handbook
Revision: 15-3

Subchapter I

§19.801 Resident Assessment

A facility must conduct, initially and periodically, a comprehensive, accurate, standardized, reproducible assessment of a resident's functional capacity. The facility must electronically transmit to CMS resident-entry-and-death-in-facility tracking records required by the RAI; and OBRA assessments, including admission, annual, quarterly, significant change, significant correction, and discharge assessments.

(1)
Admission orders. At the time a resident is admitted, the facility must have physician orders for the resident's immediate care.
(2)
Comprehensive assessments.
(A)

A facility must make a comprehensive assessment of a resident's needs, using the current RAI process, including the MDS, Care Area Assessment process, and the Utilization Guidelines specified by DADS and approved by CMS. The current RAI process is found in the MDS 3.0 manual posted by CMS on http://www.cms.gov.

(B)
A facility must conduct an additional assessment and document the summary information if the MDS indicates an additional assessment on a care area is required.
(C)
A facility must conduct a comprehensive assessment of a resident as follows:
(i)
within 14 calendar days after admission, excluding readmissions in which there is no significant change in the resident's physical or mental condition. For purposes of this section, "readmission" means a return to the facility following a temporary absence for hospitalization or for therapeutic leave.
(ii)
within 14 calendar days after the facility determines, or should have determined, that there has been a significant change in the resident's physical or mental condition. For purposes of this section, a "significant change" means a major decline or improvement in the resident's status that will not normally resolve itself without further intervention by staff or by implementing standard disease-related clinical interventions, that has an impact on more than one area of the resident's health status, and requires interdisciplinary review or revision of the care plan, or both.
(iii)
not less often than once every 12 months.
(3)
Quarterly review assessment. A facility must assess a resident using the quarterly review instrument specified by DADS and approved by CMS not less frequently than once every three months.
(4)
Use. A facility must maintain all resident assessments completed within the previous 15 months in the resident's active record and use the results of the assessments to develop, review, and revise the resident's comprehensive plan of care as specified in §19.802 of this subchapter (relating to Comprehensive Care Plans).
(5)
PASRR. A Medicaid-certified facility must coordinate assessments with the PASSR process in 42 CFR, Part 483, Subpart C to the maximum extent practicable to avoid duplicative testing and effort.
(6)
Automated data processing requirement.
(A)
A facility must complete an MDS for a resident. The facility must enter MDS data into the facility's assessment software within 7 days after completing the MDS and electronically transmit the MDS data to CMS within 14 days after completing the MDS.
(B)
A facility must complete the Long Term Care Medicaid Information form on an OBRA assessment that is submitted to the state Medicaid claims system for a Medicaid recipient or Medicaid applicant according to DADS instructions located on the Texas Medicaid Healthcare Partnership Long Term Care Portal at http://www.tmhp.com.
(C)
Data format. The facility must transmit MDS data to CMS in the format specified by CMS and DADS.
(D)
Information concerning a resident is confidential and a facility must not release information concerning a resident except as allowed by this chapter, including §19.407 of this chapter (relating to Privacy and Confidentiality) and §19.1910(d) of this chapter (relating to Clinical Records).
(7)
Accuracy of assessments. The assessment must accurately reflect the resident's status.
(8)
Coordination. A registered nurse must conduct or coordinate each assessment with the appropriate participation of health professionals.
(9)
Certification.
(A)
A registered nurse must sign and certify that the assessment is completed.
(B)
Each individual who completes a portion of the assessment must sign and certify the accuracy of that portion of the assessment.
(10)
Penalty for falsification under Medicare and Medicaid.
(A)
An individual who willfully and knowingly:
(i)
certifies a material and false statement in a resident assessment is subject to a civil money penalty of not more than $1,000 for each assessment; or
(ii)
causes another individual to certify a material and false statement in a resident assessment is subject to a civil money penalty of not more than $5,000 for each assessment.
(B)
Clinical disagreement does not constitute a material and false statement.
(11)
Use of independent assessors in Medicaid-certified facilities and dually certified facilities. If DADS determines, under a certification survey or otherwise, that there has been a knowing and willful certification of false statements under paragraph (10) of this section, DADS may require (for a period specified by DADS) individuals who are independent of the facility and who are approved by DADS to conduct and certify the resident assessments under this section.
(12)
Pediatric resident assessment.
(A)
A facility must ensure that a pediatric assessment:
(i)
is performed by a licensed health professional experienced in the care and assessment of children;
(ii)
includes parents or guardians in the assessment process; and
(iii)
includes a discussion with a parent or guardian about the potential for community transition.
(B)
The clinical record of a child must include a record of immunizations, blood screening for lead, and developmental assessment. The local school district's developmental assessment may be used if available. See §19.1934 of this chapter (relating to Educational Requirements for Persons Under Age 22).
(C)
A licensed health professional must assess a child's functional status in relation to pediatric developmental levels, rather than adult developmental levels.
(D)
A facility must ensure pediatric residents receive services in accordance with the guidelines established by the Department of State Health Services' Texas Health Steps (THSteps). For Medicaid-eligible pediatric residents between the ages of six months and six years, blood screening for lead must be done in accordance with THSteps guidelines.

§19.802 Comprehensive Care Plans

(a)
A facility must develop a comprehensive care plan for each resident that includes measurable short-term and long-term objectives and timetables to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment. If a child is admitted to the facility, the comprehensive care plan must be based on the child's individual needs. The comprehensive care plan must describe the following:
(1)
the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being as required under §19.901 of this title (relating to Quality of Care); and
(2)
any services that would otherwise be required under §19.901 of this title but are not provided due to the resident's exercise of rights, including the right to refuse treatment under §19.402(g) of this title (relating to Exercise of Rights).
(b)
The comprehensive care plan must be:
(1)
developed within seven days after completion of the comprehensive assessment;
(2)
prepared by an interdisciplinary team that includes the attending physician, a registered nurse with responsibility for the resident and other appropriate staff in disciplines as determined by the resident's needs, and, to the extent practicable, with the participation of the resident, the resident's family or legal representative;
(3)
periodically reviewed and revised by a team of qualified persons after each assessment; and
(4)
for a resident under 22 years of age, annually reviewed at a comprehensive care plan meeting between the facility and the resident's LAR as defined in §19.805(a)(5) of this title (relating to Permanency Planning for a Resident Under 22 Years of Age), which includes a review of:
(A)
the LAR's contact information as required by §19.805(b)(5)(F) of this title;
(B)
the resident's comprehensive assessment;
(C)
the resident's educational status; and
(D)
the resident's permanency plan.
(c)
A comprehensive care plan must include:
(1)
for a resident under 18 years of age, the activities, supports and services that, when provided or facilitated by the facility, will enable the resident to live with a family; or
(2)
for a resident 18-22 years of age, the activities, supports and services that, when provided or facilitated by the facility, will result in the resident having a consistent and nurturing environment in the least restrictive setting, as defined by the resident and LAR as defined in §19.805(a)(5) of this title.
(d)
A comprehensive care plan may include a palliative plan of care. This plan may be developed only at the request of the resident, surrogate decision maker or legal representative for residents with terminal conditions, end stage diseases or other conditions for which curative medical interventions are not appropriate. The plan of care must have goals that focus on maintaining a safe, comfortable and supportive environment in providing care to a resident at the end of life.
(e)
For a resident under 22 years of age, the facility must provide written notice to the LAR, as defined in §19.805(a)(5) of this title, of a meeting to conduct an annual review of the resident's comprehensive care plan no later than 21 days before the meeting date and request a response from the LAR.
(f)
The services provided or arranged by the facility must:
(1)
meet professional standards of quality; and
(2)
be provided by qualified persons in accordance with each resident's written plan of care.
(g)
The comprehensive care plan must be made available to all direct care staff.

§19.803 Discharge Summary (Discharge Plan of Care)

(a)
Before or at the time of a resident's discharge, the facility must give the resident a discharge summary that includes:
(1)
a recapitulation of the overall course of the resident's stay;
(2)
a statement notifying a resident granted permanent medical necessity (PMN) under the Medicaid program that:
(A)
PMN status continues after discharge, unless the resident is discharged to home;
(B)
PMN status expires 30 consecutive days after the resident is discharged to home; and
(C)
a new medical necessity determination is required if the resident applies to be admitted to a nursing facility under the Medicaid program more than 30 consecutive days after the resident moves home from a nursing facility; and
(3)
a post-discharge plan of care, developed with the participation of the resident, and a family representative, responsible party or legal guardian, that will, after discharge, assist the resident to adjust to his new living environment.
(b)
The facility discharge summary must be available as required by subsection (a) of this section when a resident is being discharged home; to another nursing facility; a Medicare skilled nursing facility; or another residential facility, such as a board and care home, an intermediate care facility for individuals with an intellectual disability or related conditions, or an assisted living facility.

§19.804 Capacity Assessment for Self Care and Financial Management

(a)
A facility will perform a Capacity Assessment for Self Care and Financial Management for persons who will be referred to a court for guardianship if the person:
(1)
is elderly, which is defined as a person 60 years of age or older; or
(2)
has mental retardation or a developmental disability; or
(3)
is suspected of being a person with mental retardation or a developmental disability.
(b)
The assessment will be completed when:
(1)
a facility determines that a guardian of the estate, or the person, or both, may be appropriate and a referral to a court for guardianship is anticipated; or
(2)
requested to do so by a court.
(c)
The facility will use the Capacity Assessment for Self Care and Financial Management instrument developed by the Texas Department of Mental Health and Mental Retardation.
(d)
The Capacity Assessment for Self Care and Financial Management will be performed by the facility social worker, with assistance from other professionals as requested by the social worker.

§19.805 Permanency Planning for a Resident Under 22 Years of Age

(a)
Definitions. The following words and terms, when used in this subchapter, have the following meanings, unless the context clearly indicates otherwise.
(1)
Permanency planning – A philosophy and planning process that focuses on the outcome of family support by facilitating a permanent living arrangement, with the primary feature of an enduring and nurturing parental relationship. Family-directed planning empowers the family of a child under the age of 18 to direct the development of supports and services that meet the child's and family's personal outcomes as related to that child. Person-directed planning empowers the child who is between 18 and 22 years of age to direct the development of a plan of supports and services that meets the needs for self-determination.
(2)
Child – A person with a developmental disability who is under 22 years of age.
(3)
CRCG (Community resource coordination group) – A local interagency group composed of public and private agencies that develops service plans for individuals whose needs can be met only through interagency coordination and cooperation. The group's role and responsibilities are described in the Memorandum of Understanding on Coordinated Services to Persons Needing Services from More Than One Agency, available on the Health and Human Services Commission website at www.hhsc.state.tx.us/crcg/crcg.htm.
(4)
Emergency situation – An unexpected situation involving a child's health, safety or welfare, of which a person of ordinary prudence would determine that the LAR should be informed, such as:
(A)
a child needing emergency medical care;
(B)
a child being removed from his residence by law enforcement;
(C)
a child leaving his residence without notifying staff and not being located; and
(D)
a child being moved from his residence to protect the child (for example, because of a hurricane, fire or flood).
(5)
LAR (legally authorized representative) – A person authorized by law to act on behalf of a resident with regard to a matter described in this subchapter, which may include a parent, guardian, managing conservator of a minor individual, a guardian of an adult individual or legal representative of a deceased individual.
(6)
Permanency planner – A person assigned by DADS to conduct permanency planning activities for a child who resides in a facility.
(b)
Facility responsibilities regarding permanency planning.
(1)
A facility must request a Preadmission Screening and Resident Review (PASARR) on every child who is a potential admission to a facility, as well as on all children currently residing in a facility who have not had a previous PASARR completed. Documentation regarding the request for or completion of a PASARR must be kept in the chart.
(2)
A facility must notify the following entities of the child’s admission not later than the third day after a child is initially placed in the facility:
(A)
DADS via fax, using DADS Form 2437, Notification of Nursing Facility Admission of Individual Under Age 22;
(B)
the CRCG in the county where the LAR resides (see www.hhsc.state.tx.us/crcg/crcg.htm for a listing of CRCG chairpersons by county);
(C)
the local office of the Early Childhood Intervention (ECI) Program of the Texas Department of Assistive and Rehabilitative Services, if a child is less than three years of age (see www.dars.state.tx.us/ecis/index.shtml or call 1-800-628-5115 for a listing of ECI programs by county); and
(D)
the local school district, if a child is 3 to 22 years of age, with which the facility must coordinate educational opportunities (See §19.1934 of this title (relating to Educational Requirements for Persons under Age 22)).
(3)
A facility must keep in a separate section at the front of each child's records:
(A)
documentation regarding the notifications required in paragraph (2);
(B)
a copy of all PASARR documents; and
(C)
a copy of the current permanency plan.
(4)
A facility must:
(A)
cooperate with the permanency planner by:
(i)
allowing access to a child's records or providing other information in a timely manner as requested by the permanency planner or the Health and Human Services Commission;
(ii)
participating in meetings to review the child's permanency plan; and
(iii)
identifying, in coordination with the permanency planner, activities, supports and services that can be provided by the family, LAR, facility, or the permanency planner to prepare the child for an alternative living arrangement;
(B)
encourage regular contact between the child and LAR and, if desired by the child and LAR, between the child and advocates and friends in the community to continue supportive and nurturing relationships;
(C)
encourage participation in the comprehensive care plan meetings by the LAR, and, if desired by the child or LAR, by family members, advocates and friends in the community;
(D)
make reasonable accommodations to promote the participation of the LAR in all planning and decision-making regarding the child's care, including participating in:
(i)
the initial development and annual review of the child's comprehensive care plan;
(ii)
decision-making regarding the child's medical care;
(iii)
routine interdisciplinary team meetings; and
(iv)
decision-making and other activities involving the child's health and safety;
(E)
ensure that reasonable accommodations include:
(i)
conducting a meeting in person or by telephone, as mutually agreed upon by the facility and the LAR;
(ii)
conducting a meeting at a time and, if the meeting is in person, at a location that is mutually agreed upon by the facility and the LAR;
(iii)
if the LAR has a disability, providing reasonable accommodations in accordance with the Americans with Disabilities Act, including providing an accessible meeting location or a sign language interpreter, if appropriate; and
(iv)
providing a language interpreter, if appropriate;
(F)
upon admission and annually thereafter:
(i)
request from and encourage an LAR to provide the following information for a child during the annual comprehensive care plan meeting and, for an applicant, upon admission:
(I)
the LAR's:
(-a-)
name;
(-b-)
address;
(-c-)
telephone number;
(-d-)
driver license number and state of issuance or personal identification card number issued by the Department of Public Safety; and
(-e-)
place of employment and the employer's address and telephone number;
(II)
the name, address, and telephone number of a relative of the child or other person whom DADS or the facility may contact in an emergency situation, a statement indicating the relation between that person and the child, and at the LAR's option:
(-a-)
that person's driver license number and state of issuance or personal identification card number issued by the Department of Public Safety; and
(-b-)
the name, address, and telephone number of that person's employer; and
(III)
a signed acknowledgement of responsibility stating that the LAR agrees to:
(-a-)
notify the facility of any changes to the contact information submitted; and
(-b-)
make reasonable efforts to participate in the child's life and in planning activities for the child; and
(ii)
inform the LAR that if the information described in clause (i) of this subparagraph is not provided or is not accurate and the facility and DADS are unable to locate the LAR as described in subparagraph (J) of this paragraph, DADS refers the case to the Department of Family and Protective Services, in accordance with subsection (c) of this section;
(G)
refrain from providing the LAR with inaccurate or misleading information regarding the risks of moving the child to another facility or community setting;
(H)
if an emergency situation occurs, attempt to notify the LAR as soon as the emergency situation allows and request a response from the LAR;
(I)
if an LAR does not respond to a notice of the child's annual comprehensive care plan meeting, a request for the LAR's consent, or an emergency situation, attempt to locate the LAR by contacting a person identified by the LAR in the contact information described in subparagraph (F) if this paragraph;
(J)
no later than 30 days after the date the facility determines that it is unable to locate the LAR, notify DADS at 1-800-458-9858 of that determination and request that DADS initiate a search for the LAR;
(K)
before a child who is under 18 years of age, or who is 18-22 years of age and for whom an LAR has been appointed, is transferred to another facility operated by the transferring facility, attempt to obtain consent for the transfer from the LAR, unless the transfer is made because of a serious risk to the health and safety of the child or another person; and
(L)
document compliance with the requirements of this paragraph in the child's records.
(5)
The facility administrator must ensure that the social worker or other appropriate staff, as needed, will contribute to the development of the permanency plan.
(6)
Paragraphs (3)-(5) of this subsection do not apply to short-stay care of less than 14 days; however, the facility must notify DADS, the CRCG, ECI, and the local school district as required in paragraph (2)(A)-(D) of this subsection.
(c)
If, within one year of the date DADS receives the notification described in subsection (b)(4)(J) of this section, DADS is unable to locate the LAR, DADS refers the case to:
(1)
the Child Protective Services Division of the Department of Family and Protective Services if the child is under 18 years of age; or
(2)
the Adult Protective Services Division of the Department of Family and Protective Services if the child is 18-22 years of age.