Reducing administrative requirements: ICF/IID

The Texas Department of Aging and Disability Services convened a stakeholder meeting on Nov. 17, 2011, to receive input on potential areas in the Intermediate Care Facilities for Individuals with an Intellectual Disability or Related Conditions (ICF/IID) program where administrative requirements could be reduced or streamlined.

View the Status Chart for Implementation of Suggestions for Reducing Administrative Requirements for ICF/IID in PDF format.

Intermediate Care Facilities — Status Chart of Suggestions for Reducing Administrative Requirements as of May 9, 2013
No. Requirement Description/Suggestion Benefits DADS Response Status As of 05/09/2013
1 Trust Fund Expenditures Eliminate need to submit receipts to DADS for trust fund expenditures under $50.00. Reduce a provider's workload for accounting expenditures under $50.00. Removing the requirement to obtain sales receipts for purchases less than $50.00 would weaken internal controls related to trust fund management and limit DADS ability to provide oversight and assurance that trust fund purchases comport with TAC. Should DADS not require program providers to maintain receipts for purchases less than $50.00, trust funds will be more vulnerable to exploitation and fraud. Not Implemented
2 Critical Incident Data Entered Into Client Assignment and Registration System (CARE) Monthly Change frequency of critical incident data entry to semi-annual or quarter. Other rules already require immediate notification to DADS of certain issues like deaths. Save provider staff hours entering data into CARE - number of hours depends on size of provider. For Special Texas Homes, currently around 1.25 hrs/month. To ensure accurate reporting, the monthly frequency will continue. Not Implemented
3 Entry of Living Options Form (LOF) Change entry of LOF into the CARE System to annual; LOF is only discussed during an individual's admission, annual staffing, or upon request of the individual.  In addition, extend the timeframe for entering LOF in order to prevent a provider being placed on vendor hold. This would save a provider staff hours for entry of LOF data into CARE and prevent risk of placement on vendor hold. Community ICFs/IID providers are currently required to conduct the Review of Living Options discussion at least annually, and upon the request of the individual or legally authorized representative (LAR).  The vendor hold process, outlined in IL# 10-127, was updated to allow a longer time frame to correct any identified delinquencies.  ICF/IID Contracting department reports since this new process has been in use there have been no vendor holds. Completed
4 Information Entry Into CARE System Currently a provider must enter all therapeutic passes and other movement of an individual into CARE system. Recommend only entering discharges, admissions, and extended passes into CARE. This would save CARE entry time for provider staff. To discontinue entry of therapeutic leave and other movement into CARE will prevent DADS from verifying DADS was not billed for unpayable leave increasing the potential for Medicaid fraud. Medicaid payments are based on individuals' leave history in CARE.  Not Implemented
5 Method for Recording Review of Living Options (RLO) Allow providers to record the results of the RLO process in an individual's annual staffing only rather than also entering the data in the CARE System.  DADS survey staff could confirm recording of RLO during annual staffing. This would save staff time and reduce risk of vendor hold. The Review of Living Options process was reviewed as a result of the July 2008 State Auditor's Office report that stated in Chapter 1-B, "DADS should strengthen its monitoring of Community Living Options discussions and living arrangement decisions, and it should improve the accuracy of automated data regarding consumer's preferences."  In response, DADS developed additional questions to be asked during the Living Options discussion and developed a monitoring report and a self-assessment tool for ICF/IID providers to monitor their Living Options discussions nearing delinquency. Not Implemented
6 Investigation Responsiveness Improve investigation responsiveness by DFPS. Overly lengthy investigation process results in loss of labor while staff is suspended with pay. Reduce cost to agency. To change these timeframes would be a significant workload issue for DFPS and would require considerable legislative funding to implement.  Costs are too significant. Not Implemented
7 Intellectual and Developmental Disability with Related Conditions (IDRC) Update Annual, Inventory for Client and Agency Planning (ICAP) Done Every 3rd Year Complete IDRC every 3rd year along with Inventory for Client and Agency Planning (ICAP). Intellectual and Developmental Disability (IDD) population is stable. Level of Needs (LON) do not change often. Save provider staff hours completing form, getting MD signature, and CARE entry - 3 hr/IDRC. There is a federal requirement for the physician to recertify the need for inpatient care annually.  DADS uses the ID/RC for this purpose so the requirement to update the ID/RC annually will remain.  Not Implemented
8 Level of Need (LON) Revisit use of LON. Increases are relatively impossible to obtain for clients needing one-to-one treatment. LON on admission often done by someone not having full responsibility for care.  This would save staff time. Providers must  complete a 30- day assessment after admission allowing them to become familiar with the individual and his/her needs. If an LON increase is denied providers may request a reconsideration.  The DADS ICF/IID webpage  includes information  on the process and a 1-800 number for technical assistance in  completing a LON increase.  This process is not exclusive to ICF and is utilized by waiver programs as well.   Not Implemented
9 Transportation Costs Evaluate if the mile rule for the proximity between a provider's ICFs can be changed in favor of a density rule. This would reduce transportation costs between a provider's ICFs. This would require a statutory change. However, DADS does not refer to this statute in any of the agency's rules. Not Implemented
10 Interest List Require Local Authority to Inform Individuals on Interest List about ICF Option. During the biannual contact, require a Local Authority (LA) to inform individuals on the Home and Community-based Services (HCS) interest list of the ICF option. During this period of limited funds and increasing demand for services, DADS should make efforts to assure individuals are fully aware of all available community-based options for which they are eligible. Individuals would have access to more information regarding the community-based options for which they are eligible. DADS has finalized questions to be added to the data entry screens in the Community Services Interest Lists. Upon completion, the performance contract with the LAs will be amended to reflect the new requirement. In Progress
11 Life Safety Code (LSC) Combine Life Safety Code Inspections and Programmatic Surveys. Other than initial LSC review, combine subsequent visits with the programmatic surveys. Develop a checklist for program surveyors to use to check pertinent LSC issues during the annual certification process.  Create a Report of Structural Changes which is submitted to Survey and Certification to trigger a LSC review should changes occur to the building after the initial visit. The report will be the responsibility of the provider. There will be less intrusion in the lives of the people who live in the homes.  The State will benefit from needing less staff in the Life Safety Code division.  There will be more uniformity in the implementation of LSC code requirements across the state. The CMS State Operations Manual does not permit cluster review of multiple small ICF/IID. Each vendor must be reviewed individually. Not Implemented
12 TAC 40, Part 1, Chapter 9, Subchapter E, Division 7, §9.266 Follow-up Survey Eliminate follow-up survey or confine survey to items that were out of compliance. Reduce staff time set aside to be available to the survey team for the follow-up review. Often times, these follow-up surveys mirror annual recertification surveys. Recent change in policy was made to allow a desk review instead of a follow-up survey depending on what was cited and the program manager's discretion. Not Implemented
13 Evaluate Survey Process

Evaluate the purpose and schedule of all surveys performed to determine if any could be performed less than annually without violating any federal standards and jeopardizing health and safety.

Develop an inter-rater reliability process to assure uniform enforcement of regulations across surveyors.

Surveyors should provide a copy of the applicable rule or policy information letter allowing a provider to verify all citations of non-compliant.

Create cost savings for provider and DADS plus improvements to survey the process. Federally the time limited agreement has changed, which allows surveys to be done between 9 and 15-months so long as a 12-month average is maintained. In Progress
14 Transfer into the ICF Program Remove contract and other requirements for medical professionals serving individuals transferring into ICF program. When transferring into the ICF program, providers must obtain signed contracts, evidence of licensure//credentialing and other paperwork for individuals' doctors and other medical professionals, who sometimes do not want to supply information. Not requiring signed contracts and other information would save time for doctors and other medical professionals and would allow individuals to continue receiving care from doctors and other medical professionals with whom they have established relationships. Contracts and certification fall under federal requirement and DADS cannot remove contract and other requirements for medical professionals serving individuals transferring into the ICF/IID program. Not Implemented
15 Medication Requirements Multiple medication clients too costly to serve. Multiple medication clients can cost more to serve than reimbursement covers because of 3 med policy and are not accepted thus going to much more costly psychiatric facilities. This will reduce a costly practice. DADS staff recommends expanding the three drug policy for the ICF/IDD program. This was  included as an exceptional item for the 2014-15 Legislative Appropriations Request. In Progress
16 Extremely Detailed Annual Cost Reports (Yearly Cost Reports) Use less frequent and detailed cost report

Replace cost report (other than ACRE) with audited financials; and

Cost report every two years (timed to be ready for legislative session)

Reduce cost to providers of about $6000.

Reduce department time of review and auditing.

At least 80 man hours per provider for non-Automated Cost Reporting and Evaluation (ACRE) cost report could be eliminated. Depending on complexity of corporation/report may eliminate as many as 240 man hours
HHSC already is addressing this suggestion with implementation of State of Texas Automated Information Reporting System (STAIRS). Providers cannot use the same cost report for 2 years due to the age of the data (must use current data for both rates and budget estimates). Completed
17 Billing of Applied Income Eliminate Applied Income being billed by provider. Review Trust Fund rules as they have become very complicated over time. Have Social Security pay DADS directly for consumer's portion of Applied Income. Commented that whatever is decided will need to be flexible to accommodate individuals moving between providers over time. Eliminates DADS from having to assess Applied Income (AI) for each consumer through Medicaid Eligibility Service Authorization Verification (MESAV) and eliminates multiple calls to the Help desk for each consumer that is new to the Provider. It would only impact DADS for new consumers to the ICF program, not for transfers from one provider to the next, since AI would remain the same, regardless of the provider. DADS does not have the resources to have the agency act as payee for Social Security payments to individuals in the ICF/IID  program. Not Implemented
18 Quality Assurance Fee (QAF) Reporting Eliminate both monthly and annual QAF reporting. This would save staff time and reduce staff workload. QAF is statutorily required by the Texas Health and Safety, Chapter 252, Intermediate Care Facilities, §252.202, and the Texas Administrative Code, Title 40, Social Services and Assistance, Part 1 DADS, Chapter 11, QAF. In addition, the QAF cost is used to set the rate providers receive. Not Implemented
19 Comprehensive Functional Assessment (CFA) Timeframe Change CFA timeframe from annual to every third year. This would reduce staff time and workload. The CFA is a federal requirement as cited in W259, 42 Code of Federal Regulations, §483.440(f)(2). Not Implemented
20 List of Excluded Individuals/Entities (LEIEs) Change the frequency for completing the List of Excluded Individuals/Entities (LEIEs) by the status of employee. Complete LEIEs for newly hired employees and contracted/subcontracted employees upon hiring and then annually after that. This would save administrative staff time by not having to complete monthly LEIEs. DADS requires monthly checks in accordance with CMS letter #09-001 to State Medicaid Directors, dated January 16, 2009 which states: "States should require providers to search the HHS-OIG website monthly to capture exclusions and reinstatements that have occurred since the last search." Not Implemented
21 Use of Existing Facilities Make use of large specialty facilities. Utilization of large or specialty facilities for clients isolated in HCS or requiring support services in excessive amounts or having to go into psychiatric facilities costing multiples of ICF-ID rates. This would result in cost savings for DADS. The SSLCs cannot further extend use of their services to HCS providers at this time. Not Implemented
22 Day Activities The requirement for determining day activities is overly stringent. This precludes inclusion of voluntary or training activities as part of day activities. As a result, opportunities for employment are reduced. This would reduce expenses for day activities and increase employment opportunities for individuals residing at ICFs. Requirement for day activities are established by two federal standards. Federal standards W 119 §483.410(d)(2)(ii) identifies the facility responsible assuring that outside services meet the standards for quality services. Federal standards Q120 §438.410(d)(3) specifies the facility must assure the outside services meet the needs of individuals receiving services at the facility. Not Implemented
23 Duplication of Utilization Reviews. One utilization review is sufficient. Why do everything twice?

Reduce Department time and money

Reduce provider employee time to assist DADS staff when they review

Use of utilization reviews is a statutory requirement. Not Implemented
24 Interpretation of LSC Across DADS Enforcement Staff Establish a process for ensuring standardization in the implementation and interpretation of LSC regulations by DADS enforcement staff in regional state offices. This should include developing a means of checking for interrater reliability in the process. This would minimize confusion and improve consistency in application of LSC regulations. DADS always provides Life Safety Code (LSC) information to providers via CMS Federal Survey and Certification Letters, Federal Regional Survey and Certification Letters, DADS Alerts, Provider Letters, and State Survey and Certification Clarification Memos and recommends providers contact DADS with LSC questions. Not Implemented
25 Annual Recertification Visits of Multiple Small ICFs Survey multiple small facilities during annual recertification visits. Require providers to recommend a plan for certification visits that considers location and program oversight. The number of facilities in the group can be no more than 4.  The homes must be within an hour drive time of each other. The homes must be in the same component code and DADS Region. The sample will include at least one person from each home. There will be less intrusion in the lives of the people who live in the homes.  The process will require less resources from DADS resulting in cost savings.  Providers will spend less time with regulatory staff, resulting in various efficiencies. The CMS State Operations Manual does not permit cluster review of multiple small ICF/IID. Each vendor must be reviewed individually. Not Implemented
26 Plan of Correction Improve the use of Plan of Corrections (PoC) by making it easier to understand and write, less repetitive and an option for addressing five or fewer deficiencies received during an annual review. Reduce frustration with completing PoC and time necessary for completing it. This will also make better use of surveyor time by removing the need for follow-up survey. DADS offers both joint training and computer-based training for writing an acceptable PoC.  The CBT can be accessed here. The joint training schedule can be accessed here. In addition, DADS has the PL 01-50 - Required Core Elements for Acceptable Plans of Correction on CMS Form 2567. Not Implemented
27 Annual Surveys Streamline all surveys into one survey. Eliminate separate surveys (audits) such as billing audit /program audit / utilization review / residential review into one survey every other year

Time is money. Reduce administrative employee time to concentrate on consumer needs.

Reduce need for DADS staff – travel and staff positions.

CMS requires an annual survey an average of every 12 months and at least every 15 months. Not Implemented
28 Daily Rate Reduce the ICF daily rate fee by the QAF amount. This reduction should be based on an individual's LON. This reduction would save staff time by removing the need to complete the monthly QAF. QAF is statutorily required by the Texas Health and Safety, Chapter 252, ICF, and the Texas Admin Code, Title 40, Social Services and Assistance, Part I DADS, Chapter 11, QAF. In addition, the QAF cost is used to set the rate providers receive. QAF is included as a cost to providers on their annual cost report. Not Implemented
29 Annual Surveys Reduce number of surveys. Currently, a 6 bed facility gets an annual program survey and an annual life safety code survey. Most homes have been open for years and have very minor if any Life Safety issues. Program surveyors already walk through and inspect the home as part of their survey. Train program surveyors to do the life safety inspections on any home in operation for 5 years or more. For any re-located or new homes (Due to selling and moving the license) could be inspected by Life Safety staff for 5 years and then it reverts back to program surveyors to do. (Previous:  Program surveyors already walk through and inspect the home as part of their survey.  Train program surveyors to do the life safety inspections on any home in operation for 5 years or more.  For any relocated or new homes (due to selling and moving the license) could be inspected by Life Safety staff for 5 years and then it reverts back to program surveyors to do.) Reduce the number of staff, reduction in travel expenses, eliminates some duplicity. CMS requires annual survey. In addition, federal and state requirements specify 12-month time limited provider agreement. Not Implemented
30 Reportable Incidents Reduce length and detail of information on reportable incidents. Current practice is excessively lengthy and detailed for patently unsustainable cases. System prone to manipulation by clients and employees. This would create a paperwork convenience. Information reported for a reportable incident is statutorily required. Not Implemented


top of page

Updated: June 30, 2014