Part 1.
TEXAS DEPARTMENT OF HUMAN SERVICES
Chapter 47.
CONTRACTING TO PROVIDE PRIMARY HOME CARE
The Texas Department of Human Services (DHS) proposes new Subchapter
A, concerning introduction, §§47.1, 47.3, and 47.5; Subchapter B,
concerning provider agency contracts, §47.11; Subchapter C, concerning
staff requirements, §§47.21, 47.23, and 47.25; Subchapter D, concerning
service plan development, §§47.41, 47.43, 47.45, 47.47, and 47.49;
Subchapter E, concerning service requirements, §§47.61, 47.63, 47.65,
47.67, 47.69, 47.71, and 47.73; and Subchapter F, concerning claims payment
and documentation, §§47.81, 47.83, 47.85, 47.87, 47.89, and 47.5902,
in its renamed Contracting to Provide Primary Home Care chapter. DHS proposes
to repeal Subchapter A, concerning general provisions and services, §§47.1901-47.1904;
Subchapter B, concerning service requirements, §§47.2901-47.2905
and §§47.2908-47.2914; Subchapter C, concerning claims payment; §§47.3906-47.3908;
Subchapter D, concerning provider contracts, §§47.4902-47.4905;
Subchapter E, concerning support documents, §47.5902; and Subchapter
F, concerning sanctions, §47.6902, in its Primary Home Care chapter.
The purpose of the new sections and the repeals is to rewrite the chapter
in plain English so that the sections are easier to read and understand. Subchapters
have been reorganized to improve the clarity of the chapter. The new sections
also incorporate existing policy into rule language, as well as provide clearer
definitions and explanations of policies. The proposed rules make program
changes that reduce provider liability and allow more flexibility in service
delivery. These improved policies include: greater flexibility for Primary
Home Care Program provider agencies in use of required forms, provision for
the resolution of service delivery issues including the addition of an interdisciplinary
team, minimizing requirements beyond licensure standards for certain program
areas, and clearer direction for service delivery. The proposed sections address
the standards for provider agencies contracting to provide services to eligible
clients through DHS's Primary Home Care Program. The requirements in this
chapter apply to three types of services in the Primary Home Care Program:
primary home care (PHC) services, family care (FC) services, and community
attendant (CA) services.
Gordon Taylor, Chief Financial Officer, has determined that, for the first
five-year period the proposed sections are in effect, there are no fiscal
implications for state or local government as a result of enforcing or administering
the sections.
Bettye M. Mitchell, Deputy Commissioner for Long Term Care, has determined
that, for each year of the first five years the sections are in effect, the
public benefit anticipated as a result of enforcing the sections is to have
rules that provider agencies and the public can more easily navigate and understand.
Rule clarity and consistency will help provider agencies and agency staff
ensure quality services for clients. Incorporating existing policy into rule
language ensures that all applicable rules, policies, and procedures are easy
to find and in one location. Allowing provider agencies flexibility in the
use of forms will help reduce provider agency overhead. The addition of the
requirements for the interdisciplinary team will ensure better services for
clients and allow provider agencies a method of review for service delivery
problems. The interdisciplinary team ensures that options are explored for
quality service delivery. Minimizing program requirements beyond licensure
requirements, where appropriate, will relieve provider agencies from keeping
up with different requirements for multiple authorities. Clearer service delivery
requirements should enable provider agencies to follow the service delivery
requirements more easily, which should result in better quality service to
clients. There is no adverse economic effect on small or micro businesses
as a result of enforcing or administering the sections, because the proposed
rules streamline the Primary Home Care Program's process. There is no anticipated
economic cost to persons who are required to comply with the proposed sections.
There is no anticipated effect on local employment in geographic areas affected
by these sections.
Questions about the content of this proposal may be directed to Cathryn
Horton at (512) 438-4259 in DHS's Long Term Care section. Written comments
on the proposal may be submitted to Supervisor, Rules and Handbooks Unit-043,
Texas Department of Human Services E-205, P.O. Box 149030, Austin, Texas 78714-9030,
within 30 days of publication in the
Texas Register
.
Under §2007.003(b) of the Government Code, DHS has determined that
Chapter 2007 of the Government Code does not apply to these rules. The changes
these rules make do not implicate a recognized interest in private real property.
Accordingly, DHS is not required to complete a takings impact assessment regarding
these rules.
These rules are promulgated by DHS. This state agency is currently scheduled
to be merged some time in 2004 into two successor agencies, the Texas Health
and Human Services Commission (HHSC) and the Texas Department of Aging and
Disability Services. This change is mandated by legislation passed by the
78th Legislature.
At the time of that transition, HHSC will have complete authority for these
and all related rules. This may result in these rules being changed from one
chapter of the Texas Administrative Code to another or other changes.
Subchapter A. INTRODUCTION
40 TAC §§47.1, 47.3, 47.5
The new sections are proposed under the Human Resources Code,
Chapters 22 and 32, which authorizes DHS to administer public and medical
assistance programs, and under Government Code, §531.021, which provides
the Texas Health and Human Services Commission with the authority to administer
federal medical assistance funds.
The new sections affect the Human Resources Code, §§22.0001-22.040
and §§32.001-32.067.
§47.1.Purpose.
This chapter establishes the requirements for provider agencies contracting
to provide in-home attendant services to eligible clients through the Texas
Department of Human Services (DHS) Primary Home Care Program. The requirements
in this chapter apply to primary home care services, family care services,
and community attendant services, unless otherwise specified in the text.
§47.3.Definitions.
The following words, terms, and phrases have the following meanings
when used in this chapter, unless the context clearly indicates otherwise:
(1)
Attendant--An employee of a provider agency who provides
the authorized tasks to the client.
(2)
Case manager--A Texas Department of Human Services (DHS)
employee who is responsible for case management activities. Activities include
eligibility determination, client registration, assessment and reassessment
of client's need, service plan development, and intercession on the client's
behalf.
(3)
Client--A Community Care for Aged and Disabled (CCAD) client,
as defined in Chapter 48 of this title (relating to Community Care for Aged
and Disabled), who is eligible to receive services under this chapter. References
in this chapter to "client" include the client's representative, unless the
context indicates otherwise.
(4)
Community attendant (CA) services--A service under the
Primary Home Care Program providing in-home attendant services to clients.
Clients receiving CA services must have a medical need for specific tasks.
CA services (formerly known as §1929(b) or frail elderly) are provided
under Title XIX of the federal Social Security Act (relating to Grants to
States for Medical Assistance Programs) at 42 U.S.C. §1396t (relating
to Home and community care for functionally disabled elderly individuals).
(5)
Contract--The formal, written agreement between DHS and
a provider agency to provide services to DHS clients eligible under this chapter
in exchange for reimbursement.
(6)
Contract manager--A DHS employee who is responsible for
the overall management of the contract with the provider agency.
(7)
Days--Any reference to days means calendar days, unless
otherwise specified in the text. Calendar days include weekends and holidays.
(8)
Family care (FC) services--A service under the Primary
Home Care Program providing in-home attendant services to eligible adults.
FC services are provided under Title XX of the federal Social Security Act
(relating to Block Grants to States for Social Services) at 42 U.S.C. §1397
et seq.
(9)
Imminent danger--An immediate, real threat to a person's
safety.
(10)
Medical need--A medical diagnosis that results in a need
for assistance with activities of daily living. For purposes of this chapter,
activities of daily living do not include services that must be provided or
supervised by licensed personnel.
(11)
Negotiated referral--A request from the case manager to
a provider agency to evaluate a person for service delivery, in which the
case manager determines that the person's needs require that services begin
on a particular date.
(12)
Non-priority--One of two types of eligibility status for
service delivery determined by the case manager. The other type of eligibility
status for service delivery is priority. A non-priority client does not meet
the criteria described in §48.2918(f) of this title (relating to Eligibility
for Primary Home Care). Services delivered to such a client may be referred
to as non-priority services, and an attendant who serves such a client may
be referred to as a non-priority attendant.
(13)
Practitioner--A physician currently licensed in Texas,
Louisiana, Arkansas, Oklahoma or New Mexico, a physician assistant currently
licensed in Texas, or a registered nurse approved by the Texas State Board
of Nurse Examiners to practice as an advanced practice nurse.
(14)
Practitioner's statement--A document such as the DHS Practitioner's
Statement of Medical Need form that includes:
(A)
a statement signed by a practitioner that the client has
a current medical need for assistance with personal care tasks and other activities
of daily living; and
(B)
certification that the provider agency verified with the
United States' Centers for Medicare and Medicaid Services that the practitioner
is not excluded from participation in Medicare or Medicaid.
(15)
Practitioner's statement date--The practitioner's statement
date is:
(A)
the later of the following:
(i)
the practitioner's signature date on the practitioner's
statement; or
(ii)
the date the provider agency receives the practitioner's
statement. If the provider agency fails to stamp the receipt date on the form,
the date of the practitioner's signature will be used to determine the practitioner's
statement date; or
(B)
the date of the practitioner's oral statement obtained
for a negotiated referral. The provider agency must document the practitioner's
oral statement date on the practitioner's written statement required in §47.47(c)(2)
of this chapter (relating to Medical Need Determination).
(16)
Primary Home Care Program--A DHS attendant care services
program. Community attendant (CA), primary home care (PHC), and family care
(FC) are the three types of services available under the Primary Home Care
Program.
(17)
Primary home care (PHC) services--A service under the
Primary Home Care Program providing in-home attendant services to clients.
Clients receiving PHC services must have a medical need for specific tasks.
PHC services are provided under Title XIX of the federal Social Security Act,
at 42 U.S.C. §1396a (relating to State plans for medical assistance).
(18)
Priority--One of two types of eligibility status for service
delivery determined by the case manager. The other type of eligibility status
for service delivery is non-priority. A priority client meets the criteria
described in §48.2918(f) of this title. Services delivered to such a
client may be referred to as priority services, and an attendant who serves
such a client may be referred to as a priority attendant.
(19)
Provider agency--A home and community support services
agency that contracts with DHS to provide services to clients in exchange
for reimbursement.
(20)
Reckless behavior--Acting with conscious indifference
to the consequences.
(21)
Regional nurse--A DHS employee who is responsible for
authorizing a client to receive CA services.
(22)
Representative--The client's spouse, other responsible
party, or legal representative.
(23)
Routine referral--A request from the case manager to a
provider agency to evaluate a person for service delivery, in which the case
manager determines that the person's needs do not require a negotiated referral.
(24)
Service schedule--A schedule for delivering attendant
services that is agreed upon and signed by the client. A fixed service schedule
specifies certain days, times of day, or time periods for delivery of the
services. A variable service schedule states the number of authorized hours
of services to be delivered per day, per week, or per month, and does not
otherwise specify any certain days, times of day, or time periods for delivery
of the services.
(25)
Signature--A person's name written in longhand or a mark
representing his or her name on a document to certify it is correct. Initials
are not an acceptable substitute for a signature.
(26)
Supervisor--A provider agency employee who:
(A)
coordinates the delivery of services in the client's service
plan;
(B)
supervises attendants; and
(C)
meets the requirements found in §97.404 of this title
(relating to Standards Specific to Agencies Licensed to Provide Personal Assistance
Services).
(27)
Unit of service--One hour of service delivered to a client.
(28)
Working days--Days DHS is open for business.
(29)
Written--Information recorded on paper or other legible
document. Written information may be sent by mail or fax, or hand-delivered.
§47.5.Overview of Process.
The provider agency must:
(1)
provide the tasks described in §47.41 of this chapter
(relating to Allowable Tasks);
(2)
accept all referrals as described in §47.43 of this
chapter (relating to Referrals);
(3)
conduct pre-initiation activities as described in §47.45
of this chapter (relating to Pre-Initiation Activities);
(4)
resolve any service delivery issues as described in §47.49
of this chapter (relating to Interdisciplinary Team);
(5)
ensure attendants are qualified and oriented to the client
and service plan as described in §47.23 of this chapter (relating to
Attendant Qualifications) and §47.25 of this chapter (relating to Attendant
Orientation);
(6)
start services for the client as described in §47.61
of this chapter (relating to Service Initiation);
(7)
provide services to the client as described in §47.63
of this chapter (relating to Service Delivery);
(8)
process any need for service plan changes as described
in §47.67 of this chapter (relating to Service Plan Changes);
(9)
coordinate client transfers to or from another provider
agency as described in §47.69 of this chapter (relating to Transfers);
(10)
suspend services only as described in §47.71 of this
chapter (relating to Suspensions); and
(11)
process special requirements for annual reauthorizations
for community attendant services as described in §47.73 of this chapter
(relating to Annual Reauthorization for Community Attendant Services).
This agency hereby certifies that the proposal has been
reviewed by legal counsel and found to be within the agency's legal authority
to adopt.
Filed with the Office of
the Secretary of State on January 22, 2004.
TRD-200400451
Paul Leche
General Counsel, Legal Services
Texas Department of Human Services
Earliest possible date of adoption: March 7, 2004
For further information, please call: (512) 438-3734
40 TAC §47.11
The new section is proposed under the Human Resources Code,
Chapters 22 and 32, which authorizes DHS to administer public and medical
assistance programs, and under Government Code, §531.021, which provides
the Texas Health and Human Services Commission with the authority to administer
federal medical assistance funds.
The new section affects the Human Resources Code, §§22.0001-22.040
and §§32.001-32.067.
§47.11.Contracting Requirements.
(a)
General contracting requirements. The provider agency must
meet all provisions described in this chapter and Chapter 49 of this title
(relating to Contracting for Community Care Services).
(b)
Licensure. The provider agency in the Primary Home Care
Program must deliver only personal assistance services, as defined in §97.2
of this title (relating to Definitions), only under the Personal Assistance
Services (PAS) category of Home and Community Support Services Agency licensure.
This agency hereby certifies that the proposal has been reviewed
by legal counsel and found to be within the agency's legal authority to adopt.
Filed
with the Office of the Secretary of State on January 22, 2004.
TRD-200400452
Paul Leche
General Counsel, Legal Services
Texas Department of Human Services
Earliest possible date of adoption: March 7, 2004
For further information, please call: (512) 438-3734
40 TAC §§47.21, 47.23, 47.25
The new sections are proposed under the Human Resources Code,
Chapters 22 and 32, which authorizes DHS to administer public and medical
assistance programs, and under Government Code, §531.021, which provides
the Texas Health and Human Services Commission with the authority to administer
federal medical assistance funds.
The new sections affect the Human Resources Code, §§22.0001-22.040
and §§32.001-32.067.
§47.21.Supervisor Training Requirements.
(a)
General training. The provider agency must train all supervisors
as described in §97.245 of this title (relating to Staffing Policies).
(b)
Program-specific training. The provider agency must ensure
the supervisor understands the applicable rules and procedures of the Primary
Home Care Program.
§47.23.Attendant Qualifications.
In addition to the requirements described in §97.404 of this title
(relating to Standards Specific to Agencies Licensed to Provide Personal Assistance
Services), attendants must:
(1)
be an employee of the provider agency;
(2)
be 18 years of age or older;
(3)
not be a legal or foster parent of a minor who receives
the service; and
(4)
not be the spouse of a client who receives the service.
This paragraph is not applicable to family care services.
§47.25.Attendant Orientation.
(a)
Orientation. In addition to the requirements described
in this section, the provider agency must ensure each attendant is oriented
as described in Chapter 97, Subchapter C, of this title (relating to Minimum
Standards for All Home and Community Support Services Agencies) and §97.404
of this title (relating to Standards Specific to Agencies Licensed to Provide
Personal Assistance Services). Orientation is not required for supervisors
acting as attendants.
(b)
Method of orientation.
(1)
An attendant must receive orientation in person in the
client's home or other location where services are delivered.
(2)
The client must be present when the attendant receives
orientation in person.
(3)
An attendant may receive orientation by telephone or in
the provider agency office, at the discretion of the supervisor, if the attendant:
(A)
meets the requirements described in §97.701 of this
title (relating to Home Health Aides); or
(B)
has six continuous months of experience in delivering attendant
care.
(4)
An attendant may receive orientation by telephone, at the
discretion of the supervisor, when:
(A)
the service plan changes; or
(B)
the attendant previously worked for the client.
(5)
The provider agency supervisor may use discretion to determine
if the attendant needs to be oriented if:
(A)
the attendant previously worked for the client; and
(B)
the service plan has not changed since the attendant worked
for the client.
(c)
Due dates. The supervisor must orient each attendant on
or before the time the attendant begins to provide attendant services.
(d)
Documentation of attendant orientation.
(1)
The attendant orientation must be recorded on a single
document that includes:
(A)
the client name and DHS client number;
(B)
the attendant name;
(C)
the date of the attendant orientation;
(D)
whether the orientation was conducted in person with the
client or by telephone;
(E)
information about how the client's condition affects the
performance of tasks;
(F)
the tasks to be performed;
(G)
the service schedule;
(H)
the number of hours the attendant is to provide;
(I)
the total number of hours the client is authorized to receive;
(J)
safety and emergency procedures, including universal precautions;
(K)
specific situations about which the attendant should notify
the provider agency, including:
(i)
changes in the client's needs;
(ii)
incidents that affect the client's condition;
(iii)
hospitalization of the client;
(iv)
the client's absence or relocation from home; and
(v)
the attendant's inability to work; and
(L)
the signature of the:
(i)
supervisor who conducts the orientation;
(ii)
the attendant who is oriented, if present; and
(iii)
the client, if present.
(2)
The provider agency must maintain documentation of the
attendant orientation in the client file.
This agency hereby certifies that the proposal has been
reviewed by legal counsel and found to be within the agency's legal authority
to adopt.
Filed
with the Office of the Secretary of State on January 22, 2004.
TRD-200400453
Paul Leche
General Counsel, Legal Services
Texas Department of Human Services
Earliest possible date of adoption: March 7, 2004
For further information, please call: (512) 438-3734
40 TAC §§47.41, 47.43, 47.45, 47.47, 47.49
The new sections are proposed under the Human Resources Code,
Chapters 22 and 32, which authorizes DHS to administer public and medical
assistance programs, and under Government Code, §531.021, which provides
the Texas Health and Human Services Commission with the authority to administer
federal medical assistance funds.
The new sections affect the Human Resources Code, §§22.0001-22.040
and §§32.001-32.067.
§47.41.Allowable Tasks.
The Primary Home Care Program includes the following tasks:
(1)
Personal care tasks related to the care of the client's
physical health. These tasks include:
(A)
bathing, which is:
(i)
drawing water in sink, basin, or tub;
(ii)
hauling or heating water;
(iii)
laying out supplies;
(iv)
assisting in or out of tub or shower;
(v)
sponge bathing and drying;
(vi)
bed bathing and drying;
(vii)
tub bathing and drying; and
(viii)
providing standby assistance for safety;
(B)
dressing, which is:
(i)
dressing the client;
(ii)
undressing the client; and
(iii)
laying out clothes;
(C)
meal preparation, which is:
(i)
cooking a full meal;
(ii)
warming up prepared food;
(ii)
planning meals;
(iii)
helping prepare meals; and
(iv)
cutting client's food for eating;
(D)
feeding/eating, which is:
(i)
spoon-feeding;
(ii)
bottle-feeding;
(iii)
assisting with using eating and drinking utensils and
adaptive devices. This does not include tube feeding; and
(iv)
providing standby assistance or encouragement;
(E)
exercise, which is walking with the client;
(F)
grooming/shaving/oral care, which is:
(i)
shaving;
(ii)
brushing teeth;
(iii)
shaving underarms and legs, when requested;
(iv)
caring for nails; and
(v)
laying out supplies;
(G)
routine hair/skin care, which is:
(i)
washing hair;
(ii)
drying hair;
(iii)
assisting with setting, rolling, or braiding hair. This
does not include styling, cutting, or chemical processing of hair;
(iv)
combing or brushing hair;
(v)
applying nonprescription lotion to skin;
(vi)
washing hands and face;
(vii)
applying makeup; and
(viii)
laying out supplies;
(H)
assistance with self-administered medications. This means
assistance with medication as defined in §97.2(10) of this title (relating
to Definitions);
(I)
toileting, which is:
(i)
changing diapers;
(ii)
changing colostomy bag or emptying catheter bag;
(iii)
assisting on or off bedpan;
(iv)
assisting with the use of a urinal;
(v)
assisting with feminine hygiene needs;
(vi)
assisting with clothing during toileting;
(vii)
assisting with toilet hygiene, including the use of toilet
paper and washing hands;
(viii)
changing external catheter;
(ix)
preparing toileting supplies and equipment. This does
not include preparing catheter equipment; and
(x)
providing standby assistance; and
(J)
transfer/ambulation, which is:
(i)
non-ambulatory movement from one stationary position to
another (transfer). This does not include carrying;
(ii)
adjusting or changing the client's position in a bed or
chair (positioning);
(iii)
assisting in rising from a sitting to a standing position;
(iv)
assisting in positioning for use of a walking apparatus;
(v)
assisting with putting on and removing leg braces and prostheses
for ambulation;
(vi)
assisting with ambulation or using steps;
(vii)
assisting with wheelchair ambulation; and
(viii)
providing standby assistance.
(2)
Home management tasks that support the client's health
and safety. These tasks include:
(A)
cleaning, which is:
(i)
cleaning up after the client's personal care tasks;
(ii)
emptying and cleaning the client's bedside commode;
(iii)
cleaning the client's bathroom;
(iv)
changing the client's bed linens and making the client's
bed;
(v)
cleaning floor of living areas used by client;
(vi)
dusting areas used by client;
(vii)
carrying out the trash and setting out garbage for pick
up;
(viii)
cleaning stovetop and counters;
(ix)
washing the client's dishes; and
(x)
cleaning refrigerator and stove;
(B)
laundry, which is:
(i)
doing hand wash;
(ii)
gathering and sorting;
(iii)
loading and unloading machines in residence;
(iv)
using Laundromat machines;
(v)
hanging clothes to dry;
(vi)
folding and putting away clothes; and
(C)
shopping, which is:
(i)
preparing a shopping list;
(ii)
going to the store and purchasing or picking up items;
(iii)
picking up medication; and
(iv)
storing the client's purchased items.
(3)
Escort. Escort includes the following:
(A)
accompanying the client outside the home to support the
client in living in the community;
(B)
arranging for transportation. The provider agency may also
choose to directly provide transportation; however, direct client transportation
is not reimbursed under the Primary Home Care Program;
(C)
accompanying the client to a clinic, doctor's office, or
location for medical diagnosis or treatment; and
(D)
waiting in the doctor's office or clinic with a client
when necessary due to client's condition or distance from home.
§47.43.Referrals.
(a)
The provider agency must:
(1)
accept all Texas Department of Human Services (DHS) referrals
for services under the Primary Home Care Program; and
(2)
conduct the pre-initiation activities as described in §47.45
of this chapter (relating to Pre-Initiation Activities).
(b)
There are two methods of referral:
(1)
For negotiated referrals, the case manager makes the referral
by phone and on DHS's Authorization for Community Care Services form.
(2)
For routine referrals, the case manager makes the referral
on DHS's Authorization for Community Care Services form.
§47.45.Pre-Initiation Activities.
(a)
Pre-initiation activities. The supervisor must complete
the following activities for each referral:
(1)
Conduct an evaluation.
(A)
The evaluation must be a single document that includes
the person's self-report of:
(i)
the dates and reasons for any hospitalization within the
last three months; and
(ii)
the assistance needed for the person to achieve activities
of daily living, including any assistive devices or medical equipment used
by the person.
(B)
If the provider agency determines during the evaluation
that the client exhibits reckless behavior that results in imminent danger
to the health and safety of the client, the provider agency must convene an
Interdisciplinary Team meeting as described in §47.49 of this chapter
(relating to Interdisciplinary Team) to discuss the barriers to service delivery.
(2)
Develop a service plan. The service plan must be a single
document that:
(A)
is agreed upon and signed by the client and the provider
agency;
(B)
indicates the location of service delivery. The provider
agency must:
(i)
make a reasonable effort to deliver services at a location
outside the client's home, if requested by the client; and
(ii)
maintain written justification if the client's request
was not granted; and
(C)
includes the following:
(i)
the tasks the client will receive.
(I)
The provider agency must ensure that at least one personal
care task is authorized by the Texas Department of Human Services (DHS), scheduled,
and provided.
(II)
Recipients of family care services are not required to
receive any personal care tasks.
(III)
The provider agency must ensure the tasks the client
will receive do not duplicate any services received from any other source;
(ii)
the total weekly hours of service DHS authorizes the client
to receive;
(iii)
the service schedule;
(iv)
frequency of supervisory visits; and
(v)
a statement that:
(I)
the Primary Home Care Program only provides the tasks allowable
in the program as described in §47.41 of this chapter (relating to Allowable
Tasks) and agreed to on the service plan; and
(II)
the provider agency is not responsible for meeting the
applicant's needs other than tasks allowed under the Primary Home Care Program.
(3)
Obtain a practitioner's statement as described in §47.47
of this chapter (relating to Medical Need Determination). This paragraph does
not apply to family care services.
(b)
Service plan differences.
(1)
The provider agency must orally notify the case manager
when the initial service plan developed by the provider agency:
(A)
has more hours than authorized on DHS's Authorization for
Community Care Services form; or
(B)
has no personal care tasks. This subparagraph does not
apply to family care services.
(2)
The provider agency must discuss the difference in the
service plan with the case manager.
(3)
The provider agency must provide services according to
the existing service plan, until the provider agency receives a new DHS Authorization
for Community Care Services form.
(4)
The provider agency must maintain the following documentation
regarding the service plan difference in the client file:
(A)
the specific difference in the service plan; and
(B)
the decision regarding the difference.
(c)
Pre-initiation activities due date. The provider agency
must complete the pre-initiation activities as follows:
(1)
for routine referrals, within 14 days after one of the
following dates, whichever is later:
(A)
the referral date (Item 1) on DHS's Authorization for Community
Care Services form; or
(B)
the date the provider agency receives DHS's Authorization
for Community Care Services form. If the provider agency fails to stamp the
receipt date on the form, the referral date (Item 1) will be used to determine
timeliness; and
(2)
for negotiated referrals, by the service initiation date
negotiated with the case manager.
(d)
Delay in pre-initiation activities.
(1)
The provider agency must document any failure to complete
the pre-initiation activities for routine referrals by the due date, including:
(A)
the reason for the delay, which must be beyond the control
of the provider agency;
(B)
either the date the provider agency anticipates it will
complete the pre-initiation activities or specific reasons why the provider
agency cannot anticipate a completion date; and (C) a description of the provider
agency's ongoing efforts to complete pre-initiation activities.
(2)
The provider agency must orally notify the case manager
of any failure to complete the pre-initiation activities for negotiated referrals
before the negotiated service initiation date. Oral notice means directly
speaking with the case manager and does not include a message left by voice
mail. The case manager may refer the client to another provider agency.
(e)
Documentation of pre-initiation activities.
(1)
The provider agency may combine the evaluation and service
plan into a single document, but each item must be clearly identifiable.
(2)
The provider agency must maintain documentation of the
pre-initiation activities in the client file.
§47.47.Medical Need Determination.
(a)
Applicability. This section does not apply to family care
services.
(b)
Determining medical need. The provider agency must ensure
medical need determination by obtaining and submitting a practitioner's statement
by the applicable due date, as described in §47.45 of this chapter, (relating
to Pre-Initiation Activities) for:
(1)
persons whom the Texas Department of Human Services (DHS)
refers to the provider agency (unless the person requests and is to receive
family care services);
(2)
clients who are receiving family care services and whom
DHS refers to the provider agency for primary home care or community attendant
services; and
(3)
clients whom DHS refers to the provider agency to have
medical need reassessed, as requested by the case manager, such as when the
initial medical need was established for a limited time.
(c)
Negotiated referrals. In the case of negotiated referrals,
the provider agency must:
(1)
obtain a practitioner's oral statement if the provider
agency is unable to obtain a practitioner's written statement so that the
provider agency can begin services on the date negotiated; and
(2)
follow up with a practitioner's written statement as described
in §47.45 of this chapter within 14 days from the date the case manager
contacts the provider agency to make the negotiated referral.
(d)
Mental illness and mental retardation. Persons diagnosed
with mental illness, mental retardation, or both are not considered to have
established medical need based solely on such diagnoses, but may establish
medical need through a related diagnosis.
(e)
Documentation of medical need determination. The provider
agency must maintain the practitioner's statement in the client file.
§47.49.Interdisciplinary Team.
(a)
Interdisciplinary Team (IDT). The IDT is a designated group
that includes the following individuals who meet when the provider agency
identifies the need to discuss service delivery issues or barriers to service
delivery:
(1)
the client or the client's representative, or both;
(2)
a provider agency 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 provider agency must convene an IDT meeting within
three working days of the date the provider agency:
(A)
suspends services to a client under §47.71(a)(7) or
(b) of this chapter (relating to Suspensions); or
(B)
identifies an issue that prevents the provider agency from
carrying out a requirement of the Primary Home Care Program.
(2)
If the provider agency is unable to convene an IDT meeting
with all the members described in subsection (a) of this section, the provider
agency must convene the IDT meeting with the available members and 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 by the provider agency may be required,
based on a DHS 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 provider agency.
(d)
IDT meeting outcome. The provider agency 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 provider agency and refer
the case back to the case manager for referral to another provider agency.
(e)
Documentation of the IDT meeting. The provider agency must
document the IDT meeting in the client file, including the:
(1)
specific reasons for calling the IDT meeting. If the specific
reasons include staffing issues, the provider agency must document good faith
efforts to find staffing for the client. Examples of good faith efforts may
include:
(A)
placement of newspaper, television, or radio ads;
(B)
outreach through churches and other nonprofits;
(C)
use of employment agencies;
(D)
use of state agency administered programs; and
(E)
efforts to encourage clients to locate and refer to the
provider agency potential attendants in the community;
(2)
participants in the IDT meeting. If all members described
in subsection (a) of this section are unable to participate, the provider
agency must document all efforts made to convene an IDT meeting with all the
members;
(3)
recommendations of the IDT;
(4)
provider agency's action as a result of the IDT recommendations;
and
(5)
reasons for the provider agency's actions.
This agency hereby certifies that the proposal has been
reviewed by legal counsel and found to be within the agency's legal authority
to adopt.
Filed
with the Office of the Secretary of State on January 22, 2004.
TRD-200400454
Paul Leche
General Counsel, Legal Services
Texas Department of Human Services
Earliest possible date of adoption: March 7, 2004
For further information, please call: (512) 438-3734
40 TAC §§47.61, 47.63, 47.65, 47.67, 47.69, 47.71, 47.73
The new sections are proposed under the Human Resources Code,
Chapters 22 and 32, which authorizes DHS to administer public and medical
assistance programs, and under Government Code, §531.021, which provides
the Texas Health and Human Services Commission with the authority to administer
federal medical assistance funds.
The new sections affect the Human Resources Code, §§22.0001-22.040
and §§32.001-32.067.
§47.61.Service Initiation.
(a)
Medical need requirement. The provider agency must not
initiate services to a person identified in §47.47(b) of this chapter
(relating to Medical Need Determination) until the practitioner has established
medical need for that person. This section does not apply to family care services.
(b)
Service initiation. The provider agency must initiate services:
(1)
for routine referrals described in §47.43 of this
chapter (relating to Referrals):
(A)
for family care services, within 14 days after the following,
whichever is later:
(i)
the referral date (Item 1) on DHS's Authorization for Community
Care Services form; or
(ii)
the date the provider agency receives DHS's Authorization
for Community Care Services form. If the provider agency fails to stamp the
receipt date on the form, the referral date (Item 1) is used to determine
timeliness; or
(B)
for primary home care and community attendant services,
by the initiation date determined by the provider agency. The service initiation
date must be within seven days of the practitioner's statement date; and
(2)
for negotiated referrals described in §47.43 of this
chapter, on the date negotiated.
(c)
Notification of service initiation and practitioner's statement
date.
(1)
The provider agency must send written notice of:
(A)
service initiation to the case manager for family care,
primary home care, and community attendant services; and
(B)
the practitioner's statement date:
(i)
to the case manager, for primary home care; or
(ii)
to the regional nurse, for community attendant services.
(2)
The provider agency must send the written notice within
14 days after initiating services.
(d)
Delay in service initiation. The provider agency must document
any failure to initiate services by the applicable due date in subsection
(b) of this section, including:
(1)
the reason for the delay, which must be:
(A)
beyond the control of the provider agency; and
(B)
not caused directly by the provider agency;
(2)
either the date the provider agency anticipates it will
initiate services, or specific reasons why the provider agency cannot anticipate
a service initiation date; and
(3)
a description of the provider agency's ongoing efforts
to initiate services.
(e)
Documentation of service initiation. The provider agency
must maintain documentation of service initiation in the client file.
§47.63.Service Delivery.
(a)
Service interruptions. A service interruption occurs when,
on a particular day or time when services are scheduled:
(1)
the client requests that:
(A)
no hours of service be provided; or
(B)
fewer hours of service than reflected in the service schedule
be provided; or
(C)
a specific attendant not provide services to the client;
(2)
the client is not at home when services are scheduled;
(3)
services are suspended as described in §47.71 of this
chapter (relating to Suspensions); or
(4)
services are not delivered for other reasons beyond the
control of the provider agency, such as acts of nature and other disasters.
(b)
Delivery of services.
(1)
The provider agency must ensure:
(A)
services are delivered according to the service plan described
in §47.45 of this chapter (relating to Pre-Initiation Activities);
(B)
all authorized and scheduled services are provided to a
client, except in the case of a service interruption, as defined in subsection
(a) of this section; and
(C)
a client does not receive, during a calendar month, more
than five times the weekly authorized hours on the Texas Department of Human
Services' (DHS's) Authorization for Community Care Services form.
(2)
The provider agency must not exceed the weekly authorized
hours except in the case of a temporary increase:
(A)
due to unusual circumstances and client need; and
(B)
requested by the client.
(C)
This paragraph does not apply to the circumstances described
in subsection (d) of this section.
(c)
Service interruption documentation.
(1)
In the case of a priority client, the provider agency must
document all service interruptions by the 30th day after the beginning of
the service interruption.
(2)
In the case of a non-priority client, the provider agency
must document all service interruptions that exceed 14 consecutive days by
the 30th day after the day service interruption exceeds 14 consecutive days.
(A)
For a fixed service schedule, the service interruption
begins on the first day services are scheduled but not delivered.
(B)
For a variable service schedule, the service interruption
begins the Sunday following the week the client did not receive all the weekly
hours on a service plan approved by the client.
(3)
The reason documented must be a reason listed in subsection
(a) of this section.
(4)
If the provider agency learns of a service interruption
after the deadlines listed in paragraphs (1) and (2) of this subsection, the
provider agency must document the following as soon as the provider agency
learns of the service interruption:
(A)
the reason for the service interruption. The reason documented
must be a reason listed in subsection (a) of this section;
(B)
the reason for the delay in documenting the service interruption;
and
(C)
the date the provider agency learned of the service interruption.
(d)
Service delivery outside the client's home.
(1)
The provider agency may develop a service plan that includes
services regularly delivered at a location other than the client's home. The
service plan must not exceed the weekly hours authorized on DHS's Authorization
for Community Care Services form.
(2)
The provider agency may deliver services outside the client's
home when the service plan does not include the regular delivery of such services.
(3)
The provider agency:
(A)
may deliver services outside the client's home only if
the client requests such services.
(B)
is not required to pay for expenses incurred by attendants
delivering services outside the client's home.
(C)
must:
(i)
make a reasonable effort to deliver services at a location
other than the client's home when requested by the client;
(ii)
maintain written justification if the client's request
was not granted; and
(iii)
document in the client's file:
(I)
each instance when a client requested services at a location
other than the home;
(II)
whether the client's request was granted;
(III)
what services were provided; and
(IV)
where the services were delivered.
(e)
Service delivery documentation.
(1)
The provider agency must document the delivery of services,
including:
(A)
the provider agency name;
(B)
the provider agency vendor number;
(C)
the attendant name;
(D)
the client name;
(E)
the DHS client number;
(F)
the specific service delivery period, including month,
day, and year, as applicable;
(G)
the tasks assigned;
(H)
the units of service delivered;
(I)
the dates services were delivered;
(J)
certification that the attendant delivered the documented
tasks.
(i)
For electronic service delivery documentation systems,
each person delivering services inputs a unique identifier to certify the
services delivered.
(ii)
For paper service delivery documentation systems, each
person delivering services signs the timesheet to certify the services delivered.
(I)
The attendant must sign his or her name or a mark representing
his or her name on the timesheet to certify that it is correct. Initials are
not an acceptable substitute for a signature.
(II)
An attendant who is unable to sign the timesheet may designate
another person to sign the timesheet. The provider agency must maintain written
documentation of the:
(-a-)
reason the attendant is unable to sign the timesheet;
and
(-b-)
identity of the person authorized to sign the timesheet
on behalf of the attendant.
(2)
Paper service delivery documentation must be a single document
with a specific service delivery period not exceeding one calendar month.
(f)
Documentation of service delivery. The provider agency
must maintain documentation of service delivery in the client file. The provider
agency must be able to identify all attendants delivering tasks to the client.
§47.65.Supervisory Visits.
(a)
Supervisory visits. A supervisor must conduct supervisory
visits to assess and document on a single form whether the:
(1)
service plan is adequate;
(2)
client continues to need the services;
(3)
client needs a service plan change;
(4)
attendant continues to be competent to provide the authorized
tasks; and
(5)
attendant is delivering the authorized tasks.
(b)
Frequency. The supervisor must establish the frequency
of supervisory visits, based on the specific needs of the client, the attendant,
or both. The frequency of supervisory visits must be at least annually.
(c)
Documentation of supervisory visits. The provider agency
must maintain documentation of each supervisory visit in the client file.
§47.67.Service Plan Changes.
(a)
Increase in hours or terminations.
(1)
The provider agency must notify the case manager in writing
within seven days of learning of any change that may:
(A)
require an increase in hours in the client's service plan;
or
(B)
result in the client receiving no personal care tasks.
This subparagraph does not apply to family care services.
(2)
The notification must include the:
(A)
date the provider agency learned of the need for the change;
(B)
reason for the change;
(C)
type of change (including the number of service hours);
and
(D)
signature and date of the provider agency representative.
(b)
Decrease in hours. The provider agency must develop a new
service plan, as described in §47.45(a)(2) of this chapter (relating
to Pre-Initiation Activities), within 21 days of the provider agency identifying
the need for an ongoing decrease in hours from the service plan currently
approved by the client.
(c)
Immediate increase in hours.
(1)
The provider agency must discuss with the case manager
the reason(s) a client requires an immediate increase in service hours, and
must obtain approval from the case manager of both the number of additional
service hours to be provided the client and the effective date of the change.
(2)
The provider agency must implement the immediate increase
in hours on the date negotiated with the case manager.
(3)
The provider agency must document the immediate increase
in hours. Documentation must include:
(A)
the date the provider agency received approval for the
change;
(B)
the name of the case manager who approved the change;
(C)
the effective date of the change; and
(D)
the number of hours authorized.
(4)
The provider agency must maintain documentation of service
plan changes:
(A)
in the client file; and
(B)
according to the terms of the contract.
(d)
Implementation of service plan changes. The provider agency
must implement the service plan change on the following date, whichever is
later:
(1)
the authorization date (Item 4) on the Texas Department
of Human Services' (DHS's) Authorization for Community Care Services form;
or
(2)
five days after the date the provider agency receives DHS's
Authorization for Community Care Services form. If the provider agency fails
to stamp the receipt date on the form, the authorization date (Item 4) will
be used to determine timeliness.
(e)
Delay in service implementation. The provider agency must
document by the next working day any failure to implement a service plan change
on the effective date of the change. The documentation must include:
(1)
the reason for the failure to timely implement the service
plan change; and
(2)
the new implementation date.
§47.69.Transfers.
(a)
Negotiation of client transfer from one provider agency
to another. The provider agencies involved in a client transfer must coordinate
with the case manager to negotiate the transfer date.
(b)
Initiation of services. The receiving provider agency must
initiate services on the negotiated date. The negotiated date is the begin
date (Item 4) on the Texas Department of Human Services' (DHS's) Authorization
for Community Care Services form.
(c)
Evaluation and service plan. On or before the begin date
(Item 4), the receiving provider agency must:
(1)
conduct an assessment, as described in §47.45 of this
chapter (relating to Pre-Initiation Activities); and
(2)
develop a service plan, as described in §47.45 of
this chapter.
§47.71.Suspensions.
(a)
Required suspensions. The provider agency must suspend
services if:
(1)
the client permanently leaves the state or moves to a county
where the provider agency does not contract with the Texas Department of Human
Services (DHS) to provide services under the Primary Home Care Program;
(2)
the client moves to a location where services cannot be
provided under the Primary Home Care Program;
(3)
the client dies;
(4)
the client is admitted to an institution. An institution
is defined as a:
(A)
hospital;
(B)
nursing facility;
(C)
state school;
(D)
state hospital; or
(E)
intermediate care facility serving persons with mental
retardation or a related condition;
(5)
the client requests that services or specific tasks end;
(6)
DHS denies the client's Medicaid eligibility (not applicable
to family care services); or
(7)
the client or someone in the client's home exhibits reckless
behavior, which may result in imminent danger to the health and safety of
the client, the attendant, or another person. If this occurs, the provider
agency must make an immediate referral to:
(A)
the Texas Department of Protective and Regulatory Services
or other appropriate protective services agency;
(B)
local law enforcement, if appropriate; and
(C)
the client's case manager.
(b)
Optional suspensions. The provider agency may suspend services
if:
(1)
the client or someone in the client's home engages in discrimination
against a provider agency or DHS employee in violation of applicable law;
or
(2)
the client refuses services for more than 30 consecutive
days.
(c)
Notification of service suspension. The provider agency
must notify the case manager by fax of any suspension by the next working
day. The faxed notice of a suspension must include:
(1)
the date of service suspension;
(2)
the reason(s) for the suspension;
(3)
the duration of the suspension, if known; and
(4)
an explanation of the provider agency's attempts to resolve
the problem that caused the suspension, including the reasons why the problem
was not resolved. This paragraph only applies to suspensions under subsection
(a)(7) and (b) of this section.
(d)
Interdisciplinary Team (IDT) meeting. The provider agency
must convene an IDT meeting, as described in §47.49 of this chapter (relating
to Interdisciplinary Team), if services are suspended under subsection (a)(7)
or (b) of this section.
(e)
Resuming services after suspension.
(1)
The provider agency must resume services after suspension:
(A)
upon the client's return home, or the date the provider
agency becomes aware of the client's return home, if applicable;
(B)
on the date specified in writing by the case manager;
(C)
as a result of a recommendation by the IDT; or
(D)
upon the provider agency's receipt of notification from
the case manager that the provider agency must resume services pending the
outcome of the appeal.
(2)
The provider agency must notify the case manager in writing
of the date services resume and must send the notice within seven days of
that date.
§47.73.Annual Reauthorization for Community Attendant Services.
(a)
Reauthorization request.
(1)
The provider agency must request annual reauthorization
for all community attendant services clients.
(2)
The provider agency must send the following to the regional
nurse to obtain annual reauthorization:
(A)
the Texas Department of Human Services' (DHS's) Authorization
for Community Care Services form received from the case manager; and
(B)
a signed statement indicating whether the supervisor agrees
or disagrees with the tasks and hours indicated on DHS's Authorization for
Community Care Services form. If the supervisor disagrees, the statement must
provide the specific reasons for disagreeing with the hours and tasks on this
form.
(b)
Reauthorization request due date. The provider agency must
submit the information described in subsection (a)(2) of this section to the
regional nurse within 14 days after one of the following dates, whichever
is later:
(1)
the referral date (Item 1) on DHS's Authorization for Community
Care Services form; or
(2)
the date the provider agency receives DHS's Authorization
for Community Care Services form. If the provider agency fails to stamp the
receipt date on the form, the referral date (Item 1) will be used to determine
timeliness.
(c)
Documentation of annual reauthorization. The provider agency
must maintain documentation of the written request for reauthorization for
community attendant services in the client file.
This agency hereby certifies that the proposal has been reviewed
by legal counsel and found to be within the agency's legal authority to adopt.
Filed
with the Office of the Secretary of State on January 22, 2004.
TRD-200400455
Paul Leche
General Counsel, Legal Services
Texas Department of Human Services
Earliest possible date of adoption: March 7, 2004
For further information, please call: (512) 438-3734
40 TAC §§47.81, 47.83, 47.85, 47.87, 47.89, 47.5902
The new sections are proposed under the Human Resources Code,
Chapters 22 and 32, which authorizes DHS to administer public and medical
assistance programs, and under Government Code, §531.021, which provides
the Texas Health and Human Services Commission with the authority to administer
federal medical assistance funds.
The new sections affect the Human Resources Code, §§22.0001-22.040
and §§32.001-32.067.
§47.81.Monitoring Medicaid Eligibility.
(a)
Applicability. This section does not apply to clients who
are receiving family care services.
(b)
Verification of Medicaid eligibility. The provider agency
must verify each month that a client remains Medicaid eligible. The provider
agency may verify the client's current Medicaid eligibility by:
(1)
viewing the client's Texas Department of Human Services
(DHS) Medicaid Identification form; or
(2)
using the current systems available to verify client registration.
(c)
Reimbursement. The provider agency is not entitled to payment
from DHS for services delivered if the provider agency fails to verify the
client has current Medicaid eligibility.
§47.83.Monitoring Reviews.
(a)
Monitoring reviews. The Texas Department of Human Services
(DHS) conducts monitoring reviews in the Primary Home Care Program as described
in Chapter 49 of this title (relating to Contracting for Community Care Services)
and in this chapter.
(b)
Fiscal monitoring. Fiscal monitoring in the Primary Home
Care Program includes monitoring financial errors, which are applied to the
entire unit of service. Financial errors include the following instances:
(1)
DHS reimburses the provider agency for services, but the
service delivery documentation is missing for the period for which services
are reimbursed. DHS applies the error to the total number of units reimbursed
for the pay period.
(2)
DHS reimburses the provider agency for services, but the
attendant fails to complete the units of service delivered portion of the
service delivery documentation. DHS applies the error to the total number
of units reimbursed for the pay period.
(3)
DHS reimburses the provider agency for hours that exceed
the total number of hours recorded on the service delivery documentation.
DHS applies the error to the total number of units reimbursed in excess of
the units recorded on the service delivery documentation. The lesser of the
two totals is used to calculate the total number of hours recorded on the
service delivery documentation if the following occurs:
(A)
the time in and time out are recorded on the service delivery
documentation, and the sum of the time in and time out does not equal the
total time recorded for the pay period; or
(B)
the sum of the daily totals of time does not equal the
total time recorded for the pay period.
(4)
DHS reimburses the provider agency for units of service
for days on which the client did not receive services. DHS applies the error
to the total number of units reimbursed for the day on which the client did
not receive services.
(5)
DHS reimburses the provider agency for units of service
for days on which the client was Medicaid ineligible. DHS applies the error
to the total number of units reimbursed for the days on which the client was
Medicaid ineligible. This paragraph does not apply to family care services.
(6)
The provider agency makes a claim for services, but a valid
practitioner's statement is missing. DHS applies the error to the total number
of units claimed and not covered by a valid practitioner's statement. This
paragraph does not apply to family care services.
(7)
The provider agency makes a claim for services, but the
practitioner's statement date is after the first day services were delivered.
DHS applies the error to the total number of units claimed before the practitioner's
statement date. This paragraph does not apply to family care services.
§47.85.Retroactive Payment Procedures.
(a)
Applicability.
(1)
This section does not apply to family care services.
(2)
A provider agency that chooses to request retroactive payment
must comply with the requirements of this section.
(b)
Definition of retroactive payment. A retroactive payment
is payment by the Texas Department of Human Services (DHS) to a provider agency
for services under the Primary Home Care Program that are provided before
the date the case manager determines the person's eligibility for the services.
(c)
Reimbursement.
(1)
The provider agency may be reimbursed for services provided
before the date a completed, signed, and dated copy of DHS's Application for
Assistance--Aged and Disabled form is received:
(A)
for up to three months for a person who does not have Medicaid
eligibility at the time of the request for retroactive payment; and
(B)
for an indefinite period for a person who is Medicaid eligible
at the time of the request for retroactive payment.
(2)
DHS only reimburses the provider agency for the:
(A)
services described in §47.41 of this chapter (relating
to Allowable Tasks);
(B)
number of hours of services allowed to be provided the
person, calculated as described in §48.2918(c) of this title (relating
to Eligibility for Primary Home Care); and
(C)
allowable costs of the Primary Home Care Program, as described
in 1 TAC, Chapter 355 (relating to Medicaid Reimbursement Rates).
(3)
DHS will not reimburse the provider agency for the retroactive
period if:
(A)
the provider agency fails to submit the required documentation
within the required time frames; or
(B)
the person provided services does not meet the requirements
described in subsection (d) of this section.
(d)
Requirements before requesting retroactive payment. The
provider agency may not request retroactive payment unless:
(1)
the person appears to be Medicaid eligible as defined in §48.1201
of this title (relating to Definition of Program Terms);
(2)
the provider agency obtains a practitioner's written statement
as described in §47.47 of this chapter (relating to Medical Need Determination);
(3)
the person requires at least one personal care task as
described in §47.41 of this chapter; and
(4)
the provider agency has verified and documented that the
person is not already receiving services under the Primary Home Care Program
from another provider agency.
(e)
Pre-initiation activities. The provider agency must complete
the pre-initiation activities described in §47.45(a) of this chapter
(relating to Pre-Initiation Activities).
(f)
Intake referral. On the day that the provider agency completes
the pre-initiation activities, the provider agency must contact the local
DHS office by telephone and make an intake referral by providing DHS information
on the person to start the eligibility process.
(g)
Service initiation. The provider agency must not begin
to provide services to the person before the date the provider agency completes
the pre-initiation activities and processes the intake referral as described
in subsections (e) and (f) of this section.
(h)
Requesting retroactive payment.
(1)
A provider agency's written request for retroactive payment
must include:
(A)
a copy of the service plan required by subsection (e) of
this section;
(B)
a copy of DHS's Practitioner's Statement of Medical Need
form; and
(C)
the retroactive payment information, including the:
(i)
name of the provider agency;
(ii)
contact information for the person;
(iii)
date services were started;
(iv)
tasks provided to the person. This includes both tasks
allowed and not allowed by the Primary Home Care Program;
(v)
weekly hours of service provided to the person. This includes
hours allotted to tasks allowed and not allowed by the Primary Home Care Program;
and
(vi)
cost per hour of service charged to the person.
(2)
The provider agency must submit the written request for
retroactive payment:
(A)
to the case manager or, if no case manager has been assigned,
to DHS intake staff; and
(B)
within seven days after the date the provider agency processes
the intake referral.
(i)
Charges to persons who receive services.
(1)
The provider agency may charge a person for services for
which the provider agency intends to request retroactive payment, unless the
person is Medicaid eligible.
(2)
The provider agency must reimburse the entire amount of
all payments made by the person to the provider agency for eligible services,
even if those payments exceed the amount DHS will reimburse for the services,
if DHS determines that the person is eligible for the Primary Home Care Program.
(j)
Documentation of retroactive payment requests. The provider
agency must maintain documentation of retroactive payment requests in the
person's file.
§47.87.Record Keeping.
(a)
General record keeping requirements. The provider agency
must maintain records according to:
(1)
Chapter 49 of this title (relating to Contracting for Community
Care Services);
(2)
Chapter 69 of this title (relating to Contracted Services);
and
(3)
the terms of the contract.
(b)
Program specific records. The provider agency must maintain
records of compliance with the requirements of this chapter.
(c)
Financial records. The provider agency must maintain financial
records:
(1)
to support its billings to the Texas Department of Human
Services (DHS) for payment under §47.89 of this chapter (relating to
Reimbursement);
(2)
to document reimbursements made by DHS. The documentation
must include:
(A)
amount of reimbursement;
(B)
voucher number;
(C)
warrant number;
(D)
date of receipt; and
(E)
any other information necessary to trace deposits of reimbursements
and payments made from the reimbursements in the provider agency's accounting
system; and
(3)
in accordance with generally accepted accounting principles
(GAAP) and DHS procedures. A provider agency's financial records must include
the following:
(A)
deposit slips, bank statements, cancelled checks, and receipts;
(B)
purchase orders;
(C)
invoices;
(D)
journals and ledgers;
(E)
payroll and tax records;
(F)
service delivery documentation;
(G)
Internal Revenue Service, Department of Labor, and other
government records and forms;
(H)
records of insurance coverage, claims, and payments (for
example, medical, liability, fire and casualty, and workers' compensation);
(I)
equipment inventory records;
(J)
records of the provider agency's internal accounting procedures;
(K)
chart of accounts, as defined by GAAP; and
(L)
records of the provider agency's company policies.
(d)
Subcontractor records. If a provider agency utilizes a
subcontractor, the provider agency must maintain records of the subcontractor's
activities. Maintaining all records to support subcontractor claims is the
responsibility of the provider agency.
(e)
Failure to maintain records. Failure to maintain records
as specified in this section may result in:
(1)
corrective action plans;
(2)
monetary exceptions; or
(3)
other actions deemed necessary or appropriate by DHS.
§47.89.Reimbursement.
(a)
Billing requirements.
(1)
The provider agency must bill for services provided as
described in §49.41 of this title (relating to Billings and Claims Payment).
(2)
The provider agency must not bill Texas Department of Human
Services (DHS) for:
(A)
more hours than the client's weekly authorization, except
when services are delivered as described in §47.63(b) of this chapter
(relating to Service Delivery);
(B)
services delivered in a licensed facility, if the facility
is required by the license to provide those services; and
(C)
services or tasks that duplicate any services or tasks
provided to the client by another source.
(b)
Unit rate. The provider agency must agree to accept the
unit rate authorized by DHS.
(c)
Documentation. The provider must maintain the documentation
described in this chapter to be eligible for reimbursement.
(d)
Rounding. The provider agency must bill DHS for services
in quarter-hour increments, rounding up to the next quarter-hour if the actual
time worked is eight minutes or more, and rounding down to the previous quarter
hour if the actual time worked is seven minutes or less.
(e)
Allowable Tasks. The provider agency must bill DHS only
for the tasks described in §47.41 of this chapter (relating to Allowable
Tasks).
§47.5902.Reimbursement Methodology for Primary Home Care.
(a)
General requirements. The Texas Department of Human Services
(DHS) or its designee applies the general principles of cost determination
as specified in §20.101 of this title (relating to Introduction).
(b)
Cost reporting. Provider agencies must follow the cost-reporting
guidelines as specified in §20.105 of this title (relating to General
Reporting and Documentation Requirements, Methods, and Procedures).
(1)
All provider agencies must submit a cost report unless
the number of days between the date the first DHS client received services
and the provider agency's fiscal year end is 30 days or fewer. The provider
agency may be excused from submitting a cost report if circumstances beyond
the control of the provider agency make cost report completion impossible,
such as the loss of records due to natural disasters or removal of records
from the provider agency's custody by any governmental entity. Requests to
be excused from submitting a cost report must be received at the address specified
in the letter mailed with the cost report before the due date of the cost
report.
(2)
Provider agencies are responsible for reporting only allowable
costs on the cost report, except where cost report instructions indicate that
other costs are to be reported in specific lines or sections. Only allowable
cost information is used to determine recommended reimbursement. DHS or its
designee excludes from reimbursement determination unallowable expenses included
in the cost report and makes the appropriate adjustments to expenses and other
information reported by provider agencies. The purpose is to ensure that the
database reflects costs and other information which are necessary for the
provision of services and are consistent with federal and state regulations.
(A)
Individual cost reports may not be included in the database
used for reimbursement determination if:
(i)
there is reasonable doubt as to the accuracy or allowability
of a significant part of the information reported; or
(ii)
an auditor determines that reported costs are not verifiable.
(B)
When material pertinent to proposed reimbursements is made
available to the public, the material will include the number of cost reports
eliminated from reimbursement determination for the reason stated in subparagraph
(A)(i) of this paragraph.
(c)
Reimbursement determination. Reimbursement is determined
in the following manner.
(1)
Cost determination by cost area. Allowable costs are combined
into three cost areas, after allocating payroll taxes to each salary line
item on the cost report on a pro rata basis based on the portion of that salary
line item to the amount of total salary expense and after applying employee
benefits directly to the corresponding salary line item.
(A)
Service support cost area. This includes field supervisors'
salaries and wages, benefits, and mileage reimbursement expenses. This also
includes building, building equipment, and operation and maintenance costs;
administration costs; and other service costs. Administration expenses equal
to $0.18 per priority unit of service are allocated to priority. The administration
costs remaining after this allocation are summed with the other service support
costs.
(B)
Non-priority attendants cost area. This includes non-priority
attendants' salaries and wages, benefits, and mileage reimbursement expenses.
This cost area is calculated as specified in §20.112 of this title (relating
to Attendant Compensation Rate Enhancement).
(C)
Priority attendants cost area. This includes priority attendants'
salaries and wages, benefits, mileage reimbursement, expenses. This cost area
is calculated as specified in §20.112 of this title.
(2)
Recommended reimbursement by cost area. For the service
support cost area described in paragraph (1)(A) of this subsection, the following
is calculated:
(A)
Projected costs. Each contract's total allowable costs,
excluding depreciation and mortgage interest, per unit of service are projected
from each contract's reporting period to the next ensuing reimbursement period,
as described in §20.108 of this title (relating to Determination of Inflation
Indices) to calculate the projected expenses. Reimbursement may be adjusted
where new legislation, regulations, or economic factors affect costs as specified
in §20.109 of this title (relating to Adjusting Reimbursement When New
Legislation, Regulations, or Economic Factors Affect Costs).
(B)
Projected cost per unit of service. To determine the projected
cost per unit of service for each contract, the total projected allowable
costs for the service support cost area are divided by total units of service,
including non-priority services, priority services, and STAR+PLUS services,
in order to calculate the projected cost per unit of service.
(C)
Projected cost arrays. Each contract's projected allowable
costs per unit of service are rank ordered from low to high, along with each
contract's corresponding units of service for each cost area.
(D)
Recommended reimbursement for the service support cost
area. The total units of service for each contract are summed until the median
hour of service is reached. The corresponding projected expense is the weighted
median cost component. The weighted median cost component is multiplied by
1.044 to calculate the recommended reimbursement for the service support cost
area. The service support cost area recommended reimbursement is limited,
if necessary, to available appropriations.
(3)
Total recommended reimbursement.
(A)
For non-priority clients. The recommended reimbursement
is determined by summing the recommended reimbursement described in paragraph
(2) of this subsection and the cost area component from paragraph (1)(B) of
this subsection.
(B)
For priority clients. The recommended reimbursement is
determined by summing the recommended reimbursement described in paragraph
(2) of this subsection and the cost area component from paragraph (1)(C) of
this subsection.
(d)
Reimbursement determination authority. The reimbursement
determination authority is specified in §20.101 of this title.
(e)
Desk reviews and field audits of cost reports. Desk reviews
or field audits are performed on cost reports for all provider agencies. The
frequency and nature of the field audits are determined by DHS or its designee
to ensure the fiscal integrity of the program. Desk reviews and field audits
will be conducted in accordance with §20.106 of this title (relating
to Basic Objectives and Criteria for Audit and Desk Review of Cost Reports),
and provider agencies will be notified of the results of a desk review or
an audit in accordance with §20.107 of this title (relating to Notification
of Exclusions and Adjustments). Provider agencies may request an informal
review and, if necessary, an administrative hearing to dispute an action taken
under §20.110 of this title (relating to Informal Reviews and Formal
Appeals).
(f)
Factors affecting allowable costs. Provider agencies must
follow the guidelines in determining whether a cost is allowable or unallowable
as specified in §20.102 of this title (relating to General Principles
of Allowable and Unallowable Costs) and §20.103 of this title (relating
to Specifications for Allowable and Unallowable Costs).
(g)
Reporting revenues. Revenues must be reported on the cost
report in accordance with §20.104 of this title (relating to Revenues).
This agency hereby certifies that the proposal has been reviewed
by legal counsel and found to be within the agency's legal authority to adopt.
Filed
with the Office of the Secretary of State on January 22, 2004.
TRD-200400456
Paul Leche
General Counsel, Legal Services
Texas Department of Human Services
Earliest possible date of adoption: March 7, 2004
For further information, please call: (512) 438-3734
Subchapter A. GENERAL PROVISIONS AND SERVICES
40 TAC §§47.1901 - 47.1904
(Editor's note: The text of the following sections proposed for
repeal will not be published. The sections may be examined in the offices
of the Texas Department of Human Services or in the Texas Register office,
Room 245, James Earl Rudder Building, 1019 Brazos Street, Austin.)
The repeals are proposed under the Human Resources
Code, Chapters 22 and 32, which authorizes DHS to administer public and medical
assistance programs, and under Government Code, §531.021, which provides
the Texas Health and Human Services Commission with the authority to administer
federal medical assistance funds.
The repeals affect the Human Resources Code, §§22.0001-22.040
and §§32.001-32.067.
§47.1901.Definitions.
§47.1902.Required Services.
§47.1903.Staffing Requirements.
§47.1904.Training Requirements.
This agency hereby certifies that the proposal has been
reviewed by legal counsel and found to be within the agency's legal authority
to adopt.
Filed
with the Office of the Secretary of State on January 22, 2004.
TRD-200400457
Paul Leche
General Counsel, Legal Services
Texas Department of Human Services
Earliest possible date of adoption: March 7, 2004
For further information, please call: (512) 438-3734
40 TAC §§47.2901 - 47.2905, 47.2908 - 47.2914
(Editor's note: The text of the following sections proposed for
repeal will not be published. The sections may be examined in the offices
of the Texas Department of Human Services or in the Texas Register office,
Room 245, James Earl Rudder Building, 1019 Brazos Street, Austin.)
The repeals are proposed under the Human Resources
Code, Chapters 22 and 32, which authorizes DHS to administer public and medical
assistance programs, and under Government Code, §531.021, which provides
the Texas Health and Human Services Commission with the authority to administer
federal medical assistance funds.
The repeals affect the Human Resources Code, §§22.0001-22.040
and §§32.001-32.067.
§47.2901.Referrals to Provider Agencies.
§47.2902.Assessment, Service Plan, and Requesting Prior Approval.
§47.2903.Provider Agency Requirements after Verbal Referral for Primary Home Care or Community Attendant Services.
§47.2904.Critical Omissions/Errors for Primary Home Care or Community Attendant Services.
§47.2905.Initiation of Service.
§47.2908.Monitoring Medicaid Eligibility for Primary Home Care.
§47.2909.Medical Need Determination.
§47.2910.Service Breaks.
§47.2911.Orientation of Attendants.
§47.2912.Service Plan Changes.
§47.2913.Prior Approval Renewal for Community Attendant Services.
§47.2914.Suspension of Services.
This agency hereby certifies that the proposal has been
reviewed by legal counsel and found to be within the agency's legal authority
to adopt.
Filed
with the Office of the Secretary of State on January 22, 2004.
TRD-200400458
Paul Leche
General Counsel, Legal Services
Texas Department of Human Services
Earliest possible date of adoption: March 7, 2004
For further information, please call: (512) 438-3734
40 TAC §§47.3906 - 47.3908
(Editor's note: The text of the following sections proposed for
repeal will not be published. The sections may be examined in the offices
of the Texas Department of Human Services or in the Texas Register office,
Room 245, James Earl Rudder Building, 1019 Brazos Street, Austin.)
The repeals are proposed under the Human Resources
Code, Chapters 22 and 32, which authorizes DHS to administer public and medical
assistance programs, and under Government Code, §531.021, which provides
the Texas Health and Human Services Commission with the authority to administer
federal medical assistance funds.
The repeals affect the Human Resources Code, §§22.0001-22.040
and §§32.001-32.067.
§47.3906.Claims Payment Reviews and Audits.
§47.3907.Missing Records.
§47.3908.Retroactive Payment Procedures.
This agency hereby certifies that the proposal has been
reviewed by legal counsel and found to be within the agency's legal authority
to adopt.
Filed
with the Office of the Secretary of State on January 22, 2004.
TRD-200400459
Paul Leche
General Counsel, Legal Services
Texas Department of Human Services
Earliest possible date of adoption: March 7, 2004
For further information, please call: (512) 438-3734
40 TAC §§47.4902 - 47.4905
(Editor's note: The text of the following sections proposed for
repeal will not be published. The sections may be examined in the offices
of the Texas Department of Human Services or in the Texas Register office,
Room 245, James Earl Rudder Building, 1019 Brazos Street, Austin.)
The repeals are proposed under the Human Resources
Code, Chapters 22 and 32, which authorizes DHS to administer public and medical
assistance programs, and under Government Code, §531.021, which provides
the Texas Health and Human Services Commission with the authority to administer
federal medical assistance funds.
The repeals affect the Human Resources Code, §§22.0001-22.040
and §§32.001-32.067.
§47.4902.Primary Home Care Provider Qualifications.
§47.4903.Provisional Contracts.
§47.4904.Current Contractors.
§47.4905.Option To Contract for Family Care Services.
This agency hereby certifies that the proposal has been
reviewed by legal counsel and found to be within the agency's legal authority
to adopt.
Filed
with the Office of the Secretary of State on January 22, 2004.
TRD-200400460
Paul Leche
General Counsel, Legal Services
Texas Department of Human Services
Earliest possible date of adoption: March 7, 2004
For further information, please call: (512) 438-3734
Subchapter B. PROVIDER AGENCY CONTRACTS
Subchapter C. STAFF REQUIREMENTS
Subchapter D. SERVICE PLAN DEVELOPMENT
Subchapter E. SERVICE REQUIREMENTS
Subchapter F. CLAIMS PAYMENT AND DOCUMENTATION
Chapter 47.
PRIMARY HOME CARE
Subchapter B. SERVICE REQUIREMENTS
Subchapter C. CLAIMS PAYMENT
Subchapter D. PROVIDER CONTRACTS
Subchapter E. SUPPORT DOCUMENTS