Intellectual and Developmental Disability Preadmission Screening and Resident Review (IDD-PASRR) Handbook

1000, Introduction to PASRR

Revision Notice 22-1; Effective Nov. 28, 2022

Preadmission screening and resident review (PASRR) is a federal requirement documented in the Code of Federal Regulations, Title 42, Part 483, Subpart C. PASRR is a process to identify people with a mental illness (MI), intellectual disability (ID), or developmental disability (DD), which is also known as a related condition (RC), who apply to, or reside in, a Medicaid-certified nursing facility (NF) to ensure that NF admission is appropriate. PASRR is also intended to ensure that people with MI, ID or DD are receiving all the necessary specialized services.

In Texas, local intellectual and developmental disability authorities (LIDDAs), local mental health authorities (LMHAs) and local behavioral health authorities (LBHAs) play key roles in the PASRR process.

Texas Health and Human Services Commission (HHSC) rules governing PASRR are in:

  • 26 Texas Administrative Code (TAC) Chapter 303, for LIDDAs, LMHAs and LBHAs; and
  • 26 TAC Chapter 554, Subchapter BB, for NFs. This handbook provides additional instructions and procedures for LIDDAs in implementing PASRR requirements.

1100, Definitions

Revision 23-1; Effective Dec. 20, 2023

The following words and terms, when used in this handbook, have the following meanings unless the context clearly indicates otherwise.

  1. Actively involved person — A person who has significant, ongoing and supportive involvement with a person receiving services, as determined by the SPT based on the person’s:
    1. observed interactions with the person receiving services;
    2. availability to the person receiving services for assistance or support when needed; and
    3. knowledge of, sensitivity to, and advocacy for the person's needs, preferences, values, and beliefs.
  2. Acute care hospital — A facility in which a person receives short-term treatment for a severe physical injury or episode of physical illness, an urgent medical condition or recovery from surgery and:
    1. may include a long-term acute care hospital, an emergency room within an acute care hospital or an inpatient rehabilitation hospital; and
    2. does not include a stand-alone psychiatric hospital or a psychiatric hospital within an acute care hospital.
  3. Amount—The amount of a specialized service a person will receive; for example, two hours.
  4. Behavioral support — Specialized interventions by a qualified service provider to assist a person to increase adaptive behaviors and to replace or modify maladaptive behaviors that prevent or interfere with the person's inclusion in home and family life or community life.
    1. Behavioral support includes:
      1. assessing and analyzing assessment findings so that an appropriate behavior support plan is designed;
      2. developing an individualized behavior support plan consistent with the outcomes identified in the Habilitation Service Plan (HSP);
      3. training and consulting with family members or other providers and, as appropriate, the person; and
      4. monitoring and evaluating the success of the behavior support plan and modifying the plan as necessary.
    2. A qualified service provider of behavioral support:
      1. is a licensed psychologist;
      2. is licensed as a psychological associate per Texas Occupations Code, Chapter 501;
      3. has been issued a provisional license to practice psychology per Texas Occupations Code, Chapter 501;
      4. is a certified authorized provider as described in 26 TAC Section 304.302 (relating to Certified Authorized Provider);
      5. is a licensed clinical social worker (LCSW);
      6. is a licensed professional counselor (LPC); or
      7. is licensed as a behavior analyst per Texas Occupations Code, Chapter 506.
  5. Business day—Any day except Saturday, Sunday, or a national or state holiday listed in Texas Government Code Section 662.003(a) or (b).
  6. Calendar day—Any day, including weekends and holidays.
  7. CLO or community living options — A process where the LIDDA give information to a person and their legally authorized representative (LAR) about the range of community living services, supports and programs the person may be eligible for. The LIDDA discusses services and supports the person will need to live in the community, as well as individual preferences and barriers to community living.
  8. CMWC or customized manual wheelchair — Per 26 TAC Section 54.2703, a wheelchair that consists of a manual mobility base and customized seating system. It is adapted and fabricated to meet the individualized needs of a person.
  9. Collateral contact — A person who is knowledgeable about the person seeking admission to a nursing facility (NF) or the resident, such as family members, previous providers or caregivers, and who may support or corroborate information provided by the person or resident.
  10. Comprehensive care plan — A plan developed by a NF for a resident.
  11. Day habilitation — Aid to a person to get, retain or improve self-help, socialization, and adaptive skills necessary to live successfully in the community and participate in home and community life. Day habilitation provides:
    1. individualized activities consistent with achieving the outcomes identified in the person's service plan;
    2. activities necessary to reinforce therapeutic outcomes targeted by other support providers and other specialized services;
    3. services in a group setting, other than the person's residence, for typically up to five days a week, six hours per day on a regularly scheduled basis;
    4. personal assistance for someone unable to manage personal care needs during the day habilitation activities; and
    5. transportation during the day habilitation activity necessary for a person's participation in the day habilitation activities.
  12. DD or developmental disability — A disability that meets the criteria described in the definition of "persons with related conditions" in 42 Code of Federal Regulations (CFR) Section 435.1010.
  13. DID or determination of intellectual disability — An assessment conducted per 26 TAC Section 304.301 by an authorized provider to determine if a person meets the criteria for a diagnosis of intellectual disability.
  14. Diversion Plan— a plan developed by the SPT that describes the activities, timetable, responsibilities, services, and essential supports involved in assisting a person with remaining in the community when they may be at risk for NF or other institutional admission.
  15. DME or durable medical equipment — Per 26 TAC Section 554.2703, the following items, including any accessories and adaptations needed to operate or access the item:
    1. a gait trainer;
    2. a standing board;
    3. a special needs car seat or travel restraint;
    4. a specialized or treated pressure-reducing support surface mattress;
    5. a positioning wedge;
    6. a prosthetic device; and
    7. an orthotic device.
  16. Duration—How long a person will receive a specialized service; for example, six months.
  17. Employment assistance — Assistance given to a person to help them locate competitive employment in the community. This consists of a service provider performing the following activities:
    1. identifying a person's employment preferences, job skills and requirements for a work setting and work conditions;
    2. locating prospective employers offering employment compatible with a person's identified preferences, skills and requirements;
    3. contacting a prospective employer on behalf of a person and negotiating the person's employment;
    4. transporting the person to help the person locate competitive employment in the community; and
    5. participating in SPT meetings.
  18. Enhanced community coordination (ECC) — Funding available to LIDDAs pursuant to the performance contract for assisting persons in transitioning from a NF to the community or in diverting from NF admission.
  19. ECC coordinator — A LIDDA staff who meets the qualifications and requirements described in the performance contract. 
  20. Essential supports — Those supports identified in a transition plan that are critical to a person’s health and safety and are directly related to the person’s successful transition to living in the community from residing in an NF.
  21. Exempted hospital discharge — A category of NF admission that occurs when a physician has certified that a person who is being discharged from an acute care hospital is likely to require less than 30 days of NF services for the condition that they were hospitalized.
  22. Expedited admission — A category of NF admission that occurs when a person meets the criteria for one of the following categories: convalescent care, terminal illness, severe physical illness, delirium, emergency protective services, respite or coma.
  23. Frequency—How often a person receives a specialized service. For example, twice a week.
  24. Habilitation coordination — Assistance for a person living in an NF to access appropriate specialized services necessary to achieve a quality of life and level of community participation acceptable to the person and LAR on the person's behalf.
  25. Habilitation coordinator — An employee of a LIDDA who provides habilitation coordination.
  26. Habilitative therapy services — Per 26 TAC Section 554.2703, assessment and treatment to help a person learn, keep or improve skills and functioning of daily living affected by a disabling condition. Habilitative therapy services are limited to:
    1. physical therapy;
    2. occupational therapy; and
    3. speech therapy.
  27. HHSC — Texas Health and Human Services Commission.
  28. HSP or habilitation service plan — A plan developed by the service planning team (SPT) while a person is living in an NF that:
    1. is individualized and developed through a person-centered approach;
    2. identifies the person’s:
      1. strengths;
      2. preferences;
      3. desired outcomes; and
      4. psychiatric, behavioral, nutritional management and support needs as described in the NF comprehensive care plan or Minimum Data Set (MDS) assessment; and
    3. identifies the specialized services that will accomplish the desired outcomes of the person or LAR, including amount, frequency and duration of each service.
  29. HSP year — An approximate 12-month period starting on the date of the initial or annual interdisciplinary team (IDT)/SPT meeting.
  30. ID or intellectual disability — As defined in 42 CFR Section 483.102(b)(3)(i).
  31. IDD—Intellectual and developmental disabilities.
  32. IHSS or IDD habilitative specialized services — The following specialized services available to a person with ID or DD:
    1. day habilitation;
    2. independent living skills training;
    3. behavioral support;
    4. employment assistance; and
    5. supported employment.
  33. IDT or interdisciplinary team — A team consisting of:
    1. a resident with MI, ID or DD;
    2. the resident's LAR, if any;
    3. a registered nurse (RN) from the NF with responsibility for the resident;
    4. a representative of:
      1. the LIDDA, if the resident has ID or DD;
      2. the LMHA or LBHA, if the resident has MI; or
      3. the LIDDA and the LMHA or LBHA, if the resident has MI and DD, or MI and ID; and
    5. others as follows:
      1. a concerned person whose inclusion is requested by the resident or LAR;
      2. a person specified by the resident, LAR, NF, LIDDA, LMHA or LBHA, as applicable, who is professionally qualified, certified or licensed with special training and experience in the diagnosis, management, needs and treatment of people with MI, ID or DD; and
      3. a representative of the appropriate school district if the resident is school age and inclusion of the district representative is requested by the resident or LAR.
  34. Individual or Person — A person:
    1. whose active PASRR evaluation (PE) or resident review is positive for ID or DD;
    2. who is 21 or older; and
    3. who is a Medicaid recipient.
  35. Independent living skills training — Individualized activities consistent with the HSP and provided in a person's residence and at community locations, such as libraries and stores. These activities include:
    1. habilitation and support activities that foster or facilitate improvement or maintenance of the person's ability to perform functional living skills and other daily living activities;
    2. activities for the person's family that help preserve the family unit and prevent or limit out-of-home placement of the person; and
    3. transportation to facilitate the person's employment opportunities and participation in community activities, and between the person's residence and day habilitation site.
  36. LA or local authority — In this handbook, LA means a local intellectual and developmental disability authority (LIDDA) or a local behavioral health authority (LBHA) or local mental health authority (LMHA).
  37. LAR or legally authorized representative — A person authorized by law to act on behalf of a person seeking admission to an NF or resident about a matter described by this chapter, and who may be the parent of a minor child, the legal guardian or the surrogate decision maker. See limitations on authority of surrogate decision maker in the definition of “surrogate decision maker.” Also, see Appendix III, Legal Authority to Make Decisions .
  38. LBHA or local behavioral health authority — An entity designated by the executive commissioner of HHSC, per Texas Health and Safety Code, Section 533.0356.
  39. LIDDA or local intellectual and developmental disability authority — An entity designated by the executive commissioner of HHSC, per Texas Health and Safety Code, Section 533A.035.
  40. LMHA or local mental health authority — An entity designated by the executive commissioner of HHSC, per Texas Health and Safety Code, Section 533.035.
  41. LTC online portal or long-term care online portal — A web-based application used by Medicaid providers to submit forms, screenings, evaluations and other information.
  42. MCO SC or managed care organization service coordinator — The staff person assigned by a resident’s MCO to ensure access to, and coordination of, needed services.
  43. MDS assessment or Minimum Data Set assessment — A standardized collection of demographic and clinical information that describes a resident's overall condition, which a licensed NF in Texas is required to submit for a resident admitted into the facility.
  44. MI or mental illness — Serious mental illness, as defined in 42 CFR Section 483.102(b)(1).
  45. MI specialized services — Specialized services available to a resident with MI, if eligible, as described in the Texas Resilience and Recovery Utilization Management Guidelines, including:
    1. skills training and development;
    2. medication training and support;
    3. psychosocial rehabilitation;
    4. Routine case management;
    5. psychiatric diagnostic interview examination; 
    6. crisis intervention; and
    7. day programs for acute needs.
  46. NF or nursing facility — A Medicaid-certified facility that is licensed per the Texas Health and Safety Code, Chapter 242.
  47. NF baseline care plan—A plan developed, per 26 TAC Section 554.802(a), by an NF within 48 hours of a resident’s admission and that includes the minimum healthcare information necessary to properly care for a resident, including PASRR recommendations. The NF baseline care plan is only in place until there is an NF comprehensive care plan. 
  48. NF comprehensive care plan—A plan, defined in 26 TAC Section 554.2703(3), that is developed by an NF for a resident within seven days after completing the comprehensive assessment. It includes measurable short-term and long-term objectives and time frames to meet a resident's medical, nursing, rehabilitative, psychosocial, dietary, activity, and resident's rights needs.
  49. NF PASRR support activities — Consistent with 26 TAC Section 554.2703, actions an NF takes in coordination with a LIDDA, LMHA or LBHA to facilitate the successful provision of IDD habilitative specialized services or MI specialized services, including:
    1. arranging transportation for a resident to participate in an IDD habilitative specialized service or an MI specialized service outside the facility;
    2. sending a resident to a scheduled IDD habilitative specialized service or MI specialized service with food and medications required by the resident; and
    3. stating in the NF comprehensive care plan an agreement to avoid, when possible, scheduling NF services at times that conflict with IDD habilitative specialized services or MI specialized services.
  50. NF specialized services — The following specialized services available to a resident with ID or DD:
    1. habilitative therapy services;
    2. CMWC; and
    3. DME.
  51. PASRR — Preadmission screening and resident review. Required by 42 CFR 483.100-138.
  52. PE or PASRR level II evaluation — A face-to-face evaluation:
    1. of a person seeking admission to an NF who is suspected of having MI, ID or DD; and
    2. performed by a LIDDA, LHMA or LBHA to determine if the person has MI, ID or DD and, if so, to:
      1. assess the person's need for care in an NF;
      2. assess the person's need for specialized services; and
      3. identify alternate placement options.
  53. PL1 or PASRR level I screening — The process of screening a person seeking admission to an NF to identify whether the person is suspected of having MI, ID or DD.
  54. Preadmission process — A category of NF admission:
    1. from a community setting, such as a private home, an assisted living facility, a group home, a psychiatric hospital or jail, but not an acute care hospital or another NF; and
    2. that is not an expedited admission or an exempted hospital discharge.
  55. RE or referring entity — The entity that refers a person to an NF, such as a hospital, attending physician, LAR or other personal representative selected by the person, a family member of the person, or a representative from an emergency placement source, such as law enforcement.
  56. Relocation specialist — An employee or contractor of an MCO who provides outreach and relocation activities to people in NFs who express a desire to transition to the community.
  57. Resident — A person who resides in an NF and receives services provided by professional nursing personnel of the facility.
  58. Resident review — A face-to-face evaluation of a resident performed by a LIDDA, LMHA or LBHA:
    1. for a resident with MI, ID or DD who experienced a significant change in condition, to:
      1. assess the resident's need for continued care in an NF;
      2. assess the resident's need for specialized services; and
      3. identify alternate placement options; and
    2. for a resident suspected of having MI, ID or DD, to determine whether the resident has MI, ID or DD and, if so:
      1. assess the resident's need for continued care in an NF;
      2. assess the resident's need for specialized services; and
      3. identify alternate placement options.
  59. RN or registered nurse — A person licensed to practice professional nursing as an RN per Texas Occupations Code, Chapter 301.
  60. Service coordination — Help in accessing medical, social, educational and other appropriate services and supports. This includes alternate placement assistance that will help a person achieve a quality of life and community participation acceptable to the person and LAR.
  61. Service coordinator — An employee of a LIDDA who provides service coordination.
  62. Significant change in condition—When a person experiences a major decline or improvement in status that:
    1. will not normally resolve itself without further intervention by NF staff or by implementing standard disease-related clinical interventions;
    2. has an impact on more than one area of the person’s health status; and
    3. requires review or revision of the NF comprehensive care plan.
  63. Specialized services — The following support services, that are not NF services, and are identified through the PE or resident review and provided to a resident who has a PE or resident review that is positive for MI, ID or DD:  
    1. NF specialized services; 
    2. IDD habilitative specialized services; and 
    3. MI specialized services.
  64. SPT or service planning team — A team convened by a LIDDA staff person that develops, reviews and revises the HSP and the transition plan for a person receiving services.
    1. The team must include:
      1. the person receiving services;
      2. the person's LAR, if any;
      3. the habilitation coordinator for discussions and service planning related to specialized services or the service coordinator for discussions related to transition planning if the person is transitioning to the community;
      4. the MCO SC, if the person does not object;
      5. while the person is in an NF:
        1. an NF staff person familiar with the person’s needs; and
        2. a person providing a specialized service to the person receiving services or a representative of a provider agency that is providing specialized services for the person;
      6. if the person is transitioning to the community:
        1. a representative from the community program provider, if one has been selected; and
        2. a relocation specialist; and
      7. a representative from the LMHA or LBHA, if the person has MI.
    2. Other participants on the SPT may include:
      1. a concerned person whose inclusion is requested by the person receiving services or the LAR; and
      2. at the discretion of the LIDDA, a person who is directly involved in the delivery of services to people with ID or DD.
  65. Supported employment — Assistance to sustain competitive employment for a person who, because of a disability, requires intensive, ongoing support to be self-employed, work from the person's residence or perform in a work setting where people without disabilities are employed. Assistance includes the following activities:
    1. making employment adaptations, supervising and providing training related to the person's assessed needs;
    2. transporting the person to support the person to be self-employed, work from the person's residence or perform in a work setting; and
    3. participating in SPT meetings.
  66. Surrogate decision maker — An actively involved person who has been identified by an IDT, per Texas Health and Safety Code Section 313.004, and who is available and willing to consent to medical treatment on behalf of the resident. Note: A surrogate decision maker is authorized to make decisions related to NF specialized services. A surrogate decision maker is not authorized to make decisions related to IDD habilitative specialized services or decisions related to community programs or where the person lives or will live.
  67. Transition plan — A plan developed by the SPT that describes the activities, timetable, responsibilities, services and essential supports involved in helping a person transition from residing in an NF to living in the community. 
     

2100, Purpose of PASRR

Revision 22-1; Effective Nov. 28, 2022

PASRR screening and evaluation must be administered to identify:

  • people seeking admission to a nursing facility (NF) who have MI, ID or DD;
  • the appropriateness of placement in the NF; and
  • eligibility for specialized services.

The process begins with the referring entity, the first entity (RE)  that considers admission into an NF for a person.

2200, Referring Entity

Revision 22-1; Effective Nov. 28, 2022

An RE is a person or entity who refers someone to a NF for admission. The most common referring entities are hospital discharge planners. Other referring entities can be:

  • Acute care hospitals
  • Psychiatric hospitals
  • NFs (limited to when a NF resident is discharging from one NF and admitting directly to another NF)
  • LARs or family members
  • Physicians (including office staff)
  • Assisted living facilities
  • Group homes
  • Hospice providers
  • Home health agencies
  • LBHAs
  • LMHAs
  • LIDDAs
  • Adult protective services staff
  • State supported living centers
  • Emergency placement sources (e.g., law enforcement agency)
  • Community healthcare providers

PASRR requires that all people seeking admission to an NF have a PASRR Level 1 Screening (PL1) form completed prior to admission, and the RE is responsible for completing the paper version of the form.

The PL1 documents the suspicion of an MI, ID or DD based on information available to the RE. The RE responds to the questions regarding a diagnosis provided within Section C of the PL1 form.

2300, PASRR Level 1 Screening (PL1)

Revision 22-1; Effective Nov. 28, 2022

This section provides an overview of the PL1 Screening and its role in the PASRR process. The PL1 Screening form may be downloaded from the Texas Medicaid & Healthcare Partnership (TMHP).

2310 Purpose

Revision 22-1; Effective Nov. 28, 2022

The PL1 Screening form is designed to identify people suspected of having an MI, ID, or DD who are seeking admission to a NF. The PL1 screens for possible eligibility for PASRR specialized services and is the first step toward enabling people to be served  per their unique needs.

2320 PL1 Screening Form

Revision 22-1; Effective Nov. 28, 2022

The PL1 Screening form contains the following sections:

  • Section A:
    • Submitter Information (NF and LA only) — Identifies contact information for the person submitting the PL1 into the LTC online portal.
    • Referring Entity Information — Contains information about the person who performed the PL1 Screening.
  • Section B:
    • Personal Information — Contains information about the person who is being screened. This section also contains fields used to update the PL1 due to a death or discharge.
  • Section C:
    • PASRR Screen — Completed for all people seeking admission to a NF. The PL1 documents the suspicion of an MI, ID or DD based on information available to the RE.
    • Local Authority Information — Documents information about the LIDDA, LMHA, or LBHA associated with the PL1 submission.
  • Section D:
    • Nursing Facility Choices — Documents the person’s or LAR's choice(s) of NFs for admission.
  • Section E:
    • Alternate Placement Preferences — Documents the person’s or LAR’s alternate placement preferences.
    • Alternate Placement Disposition — Documents to which alternate placement program the person was admitted. 

Note: See Section 2320.2, Positive PL1 for more instructions about how to complete Section E of the PL1 if positive.  

  • Section F:
    • Admission Category — Documents the NF admission type for the person.

2320.1 PL1 Submission

Revision 22-1; Effective Nov. 28, 2022

Only LIDDA, LMHA, LBHA, or NF can submit the PL1 Screening form in the LTC online portal. Following successful submission, the LTC online portal will issue alerts based on the information in Section C of the completed form.

Note: When the PL1 is positive and the admission type is preadmission, the LIDDA, LMHA, or LBHA must enter the PL1 in the LTC online portal within three business days of receipt from the RE.

2320.2 Positive PL1

Revision 22-1; Effective Nov. 28, 2022

If the RE selects “Yes” to any of the fields in Section C, PASRR Screen, then the PL1’s status is considered positive for suspicion of an MI, ID or DD. A positive PL1 triggers an alert to the LIDDA, LMHA, or LBHA, or both, via the LTC online portal to proceed to the next step of the PASRR process — the PASRR evaluation (PE).

When the LIDDA, LMHA or LBHA receives a PL1 Screening form from the RE, the LIDDA, LHMA or LBHA must:

  • Review the PL1 Screening form to confirm the RE has completed the required fields before submitting the PL1 screening form on the LTC Online Portal.  
  • If Section E fields E0100-E0400, or any other required field of the PL1 screening form, is not completed, the LIDDA, LMHA, or LBHA should contact the RE for the information needed to complete the required fields. 
  • Enter the information received for Section E fields E0100-E0400, which are enabled and required for the PL1 screening form to be submitted. 

 
The nursing facility is responsible for entering the RE’s initial report in Section E of the PL1 if the admission type is exempted hospital discharge or expedited admission. If the person’s alternate placement preferences change after the PL1 submission, these changes should be documented in the PE, in the initial CLO done at the time of PE, and on the PCSP form. 

Note: If the applicable “Section E” tab fields are not completed for a PL1 screening form submission, the PL1 screening form submission will not submit. The Texas Health and Human Services Commission made these system changes to ensure that the person’s alternate placement disposition is documented and available on the LTC Online Portal at the time of discharge.
 

2320.3 Negative PL1

Revision 22-1; Effective Nov. 28, 2022

If the RE selects “No” to all three fields in Section C, PASRR Screen, then the PL1 status is considered negative for suspicion of an MI, ID or DD. The NF admits a person with a negative PL1 screening and the PASRR process formally ends.

2320.4 Additional PL1 Responsibilities 

Revision 22-1; Effective Nov. 28, 2022

LIDDAs, LMHAs and LBHAs are also responsible for inactivating a PL1 screening form when a person is either not admitted to the NF or passes away before being admitted to the NF. This is the only time LIDDAs, LMHAs, and LBHAs are responsible for inactivating a PL1 screening form. 

To inactivate a PL1 screening form, the LIDDA, LMHA and LBHA must:

  • Complete Section B fields B0650-0655 – Discharge or deceased.
  • If field B0650 indicates that the person is deceased, then the Section E tab will not be enabled for data entry and the P1 screening form will submit.  
  • If field B0650 indicates the person was discharged, fields E0500-E0900 (Alternate Placement Disposition) are enabled and required for the PL1 Screening form to be submitted.  

If the applicable “Section E” tab fields are not completed for a PL1 screening form submission or updated for a discharge, the PL1 screening form submission or update will not submit.  The Texas Health and Human Services Commission made these system changes to ensure that the person’s alternate placement disposition is documented and available on the LTC Online Portal at the time of discharge.
 

2330 Admission Types

Revision 22-1; Effective Nov. 28, 2022

There are three types of NF admissions:

  • exempted hospital discharge;
  • expedited admission; and
  • preadmission.

2330.1 Exempted Hospital Discharge

Revision 22-1; Effective Nov. 28, 2022

Exempted hospital discharge occurs when a physician has certified that a person being discharged from an acute care hospital is likely to need less than 30 days of NF services for the condition that the person was hospitalized. An example of this type of admission would be for a person who falls, breaks a hip and goes into the NF for rehabilitation services.

The RE (acute care hospital) provides the NF with a copy of the PL1. The NF enters the PL1 into the LTC online portal upon the person’s admission.

A person in this category with a positive PL1 only requires a PASRR evaluation if their stay in the NF exceeds 30 days. If the person's stay exceeds 30 days, the LTC online portal sends an alert to the LIDDA, LMHA, or LBHA to complete a PE.

2330.2 Expedited Admission

Revision 22-1; Effective Nov. 28, 2022

Expedited admission occurs when a person meets the criteria for any of the following seven categories:

  • Convalescent Care
  • Terminal Illness
  • Severe Physical Illness
  • Delirium
  • Emergency Protective Services
  • Respite
  • Coma

The RE provides the NF with a copy of the PL1. The NF enters the PL1 into the LTC online portal upon the person’s admission.

The length of stay or the type of expedited admission  determines when the LTC online portal sends an alert to the LIDDA, LMHA, or LBHA to complete a PE for a person. For example, a person admitted who is in a coma will not receive a PE until they regain consciousness.

2330.3 Preadmission

Revision 22-1; Effective Nov. 28, 2022

Preadmission occurs when admitting a person from a place other than an acute care hospital, such as a community setting like home, hospice, group home, psychiatric hospital or jail. If the RE is a family member, LAR, other personal representative selected by the person or an emergency placement source, the RE may request assistance from the LIDDA, LMHA, LBHA, or NF to complete the PL1.

If the PL1 is positive (see Section 2320.2, Positive PL1), the RE provides the LIDDA, LMHA, or LBHA with a copy of the PL1. The person may not be admitted to a NF until the LIDDA, LMHA, or LBHA completes a PE.

If the PL1 is negative (see Section 2320.3, Negative PL1), the RE provides the NF with a copy of the PL1 when the person presents at the NF for admission.

Medical necessity (MN) is the determination that a person requires the level of care provided at a NF. It is important to note that the information entered in the PE for a preadmission is used by TMHP to determine MN for a person whose PE is positive. An MN determination is critical for people who want to admit to a NF or divert from a NF admission and instead go directly into a community setting.

2340 Admission Type on PL1

Revision 22-1; Effective Nov. 28, 2022

A part of completing the PL1 requires the RE to determine the admission type or category based on the answers to Section F of the PL1 Screening form.

Admission Type: PL1 Completed By: PL1 Submitted By:
Positive Preadmission RE LIDDA if positive for ID/DD, LMHA or LBHA if positive for MI
Negative Preadmission RE NF
Expedited Admission RE NF
Exempted Hospital Discharge RE NF
Change of Ownership (CHOW) The old NF contract or vendor number becomes the RE to the new contract number. The new contract number
NF to NF Transfers The discharging facility becomes the RE to the admitting facility. The admitting facility

The LTC online portal determines admission type or category by responses in Section F of the PL1. If the response in F0100 is “0” (meaning No) and the response in F0200 is “0” (meaning not expedited admission), then the admission category is considered “preadmission” by default.

2350 PL1 Submission

Revision 22-1; Effective Nov. 28, 2022

After completing the PL1, the RE has the final responsibility to send the completed paper PL1 Screening form to the appropriate party for submission to the LTC online portal. The chart below summarizes which party the PL1 is sent depending on the admission type in Section F and positive or negative status in Section C of the PL1 Screening form.

Admission Type: PL1 Completed By: PL1 Submitted By:
Positive Preadmission RE LIDDA if positive for ID/DD, LMHA or LBHA if positive for MI
Negative Preadmission RE NF
Expedited Admission RE NF
Exempted Hospital Discharge RE NF
Change of Ownership (CHOW) The old NF contract/vendor number becomes the RE to the new contract number. The new contract number
NF to NF Transfers The discharging facility becomes the RE to the admitting facility. The admitting facility

2400, PASRR Level II Evaluation

Revision 22-1; Effective Nov. 28, 2022

This section provides an overview of the PE form and its purpose in the PASRR process. Refer to Appendix I, Resources for detailed information on completing a PE, and steps for submitting a PE into the LTC online portal.

2410 Purpose, PASRR Status, and Staff Qualifications

Revision 22-1; Effective Nov. 28, 2022

The PE confirms if a person has a diagnosis of MI, ID or DD through document review and interviews. The PE is conducted for people with a positive PL1. If a PL1 indicates negative suspicion for a PASRR condition, a PE may also be performed upon request from HHSC or a NF. The PE is administered to identify:

  • if a person has an MI, ID or DD;
  • if a person’s total needs can be met in appropriate community settings; 
  • a person’s need for specialized services; and
  • for preadmissions, if a person meets medical necessity and can be admitted to the NF.

2410.1 PASRR Positive

Revision 22-1; Effective Nov. 28, 2022

When the PE confirms a person has an MI, ID or DD, the PASRR determination for the person is PASRR positive.

2410.2 PASRR Negative

Revision 22-1; Effective Nov. 28, 2022

When the PE does not confirm a person has an MI, ID or DD, the PASRR determination for the person is PASRR negative.

2410.3 Staff Qualifications

Revision 22-1; Effective Nov. 28, 2022

The qualifications for staff completing a PE are in 26 TAC, Chapter 303, Section 303.303, relating to Qualifications and Requirements for Staff Person Conducting a PE or Resident Review.

2420 LTC Online Portal Notification

Revision 22-1; Effective Nov. 28, 2022

The LIDDA, LMHA or LBHA receives an automatic alert notification in the LTC online portal generated by a NF’s submission of a positive PL1 into the LTC online portal for an expedited admission or an exempted hospital discharge.

The LIDDA, LMHA or LBHA will not receive an automatic alert notification if the LIDDA, LMHA or LBHA submitted the positive PL1 for preadmission into the LTC online portal. The RE provides a copy of the PL1 to the LIDDA, LMHA or LBHA. This serves as the alert to the LIDDA, LMHA or LBHA to conduct the PE.

2420.1 Timing of Alert is Based on Admission Type

Revision 22-1; Effective Nov. 28, 2022

The type of admission from the PL1 determines when an alert will be sent to the LIDDA, LMHA or LBHA to conduct a PE. The timings for alerts are explained in the Long-Term Care (LTC) Preadmission Screening and Resident Review (PASRR) User Guide (PDF).

The LIDDA, LMHA or LBHA must:

  • check the LTC online portal daily for PE alerts;
  • have a single, identified fax line to receive PL1 forms from REs; and
  • check the fax line daily to ensure all requests to conduct a PE are acted on promptly.

2420.2 Change of Ownership Extensions

Revision 22-1; Effective Nov. 28, 2022

A change of ownership (CHOW) occurs when a NF is purchased by another facility, entity or corporation. When a CHOW takes place, a new contract number is assigned. Once the new contract number is assigned, the NF being purchased must enter a new PL1 for every resident in the NF within 90 calendar days after the new contract number’s effective date.

Depending on the NF’s census and the number of PASRR positive residents, the LIDDA, LMHA or LBHA may receive multiple alerts to complete PEs. The LIDDA, LMHA or LBHA may request an extension to the seven-day time frame to complete all the PEs for that NF. The LIDDA, LMHA or LBHA must contact the HHSC PASRR Unit at PASRR.support@hhsc.state.tx.us to request an extension.

2420.3 Information Gathered by a LIDDA Following an Alert to Conduct a PE

Revision 22-1; Effective Nov. 28, 2022

A LIDDA that receives an alert in the LTC online portal to conduct a PE or resident review must determine:

  • if the person has a prior PE*;
  • if the person has transferred from another NF (this information is on the PL1)**; and
  • if the person has full Medicaid benefits through***:
    • being eligible for Supplemental Security Income; or
    • being eligible for Medicaid benefits if institutionalized.

*Information on if the person has a prior PE is available by checking in the LTC online portal.  A LIDDA can view a prior PE within the LIDDA’s local service area, as well as PEs completed by other LIDDAs. 

Note: The LIDDA staff who completes PEs must use a different email or login from any existing login. The staff given “PE Evaluator” permission can see any form types for a specific person across local service areas. This must be the ONLY permission assigned to this login.

**If the PL1 shows that the person transferred from another NF in Texas, the receiving LIDDA will contact the transferring LIDDA and request relevant records of the person, including previous PEs, assessments and service plans, be sent to the receiving LIDDA.

***Information about whether a person has full Medicaid benefits is available through discussions with the NF’s business office.

2420.4 Using Information Gathered by a LIDDA Following an Alert to Conduct a PE

Revision 22-1; Effective Nov. 28, 2022

If the person has Medicaid benefits* and is 21 or older, the LIDDA must be prepared to assign a habilitation coordinator if the person has a positive PE. *Refer to Section 4910, Medicaid Eligibility Guidelines for information about eligible Medicaid types.

If one LIDDA receives a request for records from another LIDDA that received an alert to conduct a PE, then the LIDDA receiving the request must send all available requested records within two business days after the request was made.

A LIDDA that received an alert to conduct a PE must ensure the staff conducting the PE is provided all relevant records sent by other LIDDAs.

2430 Completing and Submitting the PE

Revision 22-1; Effective Nov. 28, 2022

The LIDDA is responsible for completing a PE for a person whose PL1 indicates the person is suspected of having ID or DD.

The LMHA or LBHA is responsible for completing a PE for a person whose PL1 indicates the person is suspected of having an MI.

Both the LIDDA and LMHA or LBHA are responsible for completing their respective part of a PE for people suspected of having a dual diagnosis (ID/DD and MI).

Note: While an LMHA and LBHA generally have the same responsibilities as a LIDDA for completing and submitting a PE, this handbook is intended to provide instructions and procedures for LIDDAs in implementing PASRR requirements. From this point forward, this handbook will no longer reference LMHA, LBHA or MI unless it is within the context of a person with dual diagnoses, meaning ID/DD and MI.

The LIDDA uses documentation reviews, interviews with the person, family interviews, interviews with others who know or have known the person, and NF staff interviews to complete the PE. The LIDDA has the following responsibilities when completing a PE:

  1. Conduct a state-wide historical record review per Section 2430.3, Documentation Review for PE Completion.
  2. Contact the RE or NF to make sure the person is still in the  location submitted on the PL1 and is available and alert before traveling to the location to complete the PE.
  3. Travel to the NF to conduct the PE for exempted hospital discharge admissions and expedited admissions or, for preadmissions, to the location of the person in the community to conduct the PE, and carrying proper identification provided by the LIDDA.
  4. Bring a release of confidential information to obtain the person’s or LAR’s consent to obtain additional information as needed from collateral contacts.
  5. Meet face-to-face with the person within 72 hours after notification from the LTC online portal or receiving a copy of the PL1 from the RE.
  6. Notify HHS Complaint and Incident Intake at 800-458-9858 immediately if they are prevented from seeing a person or reviewing the person’s medical record.
  7. Use the medical information or documentation in the person’s NF record to confirm whether the person has a diagnosis for ID or DD. The LIDDA should seek assistance and clarification of documentation from available medical staff as needed and record only what is documented in the medical record. The LIDDA must document on the PE what information and documentation were used to complete the evaluation.
  8. Submit the PE into the LTC online portal within seven calendar days after notification.

The PE can be completed on the paper or electronic version, but ultimately the information collected must be submitted on the LTC online portal by the LIDDA within the seven-day time frame.

2430.1 Interpreter Services

Revision 22-1; Effective Nov. 28, 2022

The person or LAR should be given the opportunity for interpreter services. The LIDDA must arrange or work in cooperation with the RE, NF and person or LAR for interpreter services as needed.

2430.2 Person or LAR Refuses to Participate in PE

Revision 22-1; Effective Nov. 28, 2022

If a person or LAR refuses participation in the PE, the LIDDA should request assistance from NF staff that have the greatest knowledge and rapport with the person or LAR in explaining the process . If the person or LAR continues to refuse to participate, the LIDDA completes the PE solely from chart review and  documents the person’s or LAR’s refusal in a comment field located within Section F1000 of the PE.

2430.3 Documentation Review for PE Completion

Revision 22-1; Effective Nov. 28, 2022

When investigating a person’s history for a PE, the LIDDA should search all applicable service records, including those available in online databases (such as CARE System, Clinical Management for Behavioral Health Services , if available, LTC online portal and Service Authorization System Online ), for evidence of previous diagnostic testing or services received in previous settings.

Investigating these systems can provide the LIDDA with insight on where to look for records and may yield valuable information about previous placement in settings, including:

  • Home and Community-based Services (HCS); 
  • Community Living Assistance and Support Services (CLASS); 
  • Deaf Blind with Multiple Disabilities (DBMD);
  • Texas Home Living (TxHmL);
  • Home and Community Based Services (HCBS) Waiver/STAR+PLUS Waiver;
  • Intermediate care facility for individuals with an intellectual disability or related condition (ICF/IID);
  • state supported living center (SSLC);
  • state hospital; and 
  • Department of Family and Protective Services (DFPS) programs and residential operations.

Documentation gathering and record review should include:

  • school records;
  • diagnostic records;
  • medical records;
  • previous PEs, service plans and assessments; and
  • all relevant records from other LIDDAs.

2430.4 Information about Certain Community Programs in Section F0700 of the PE

Revision 22-1; Effective Nov. 28, 2022

Information about most of the community programs listed in Section F0700 of the PE are in the documents provided to the person and LAR as part of the community living options (CLO) presentation. See Section 2430.5, Presenting Information about Community Services as Part of the PE, below. However, the programs in the bulleted list below that are in F0700 are either no longer available or may not apply to the person. The staff conducting the PE should use the following information to describe those programs to the person and LAR.

  • F0700D “Community Based Alternative (CBA) Program” — This program is now called “STAR+PLUS HCBS Program” or “STAR+PLUS Waiver.”
  • F0700K “In Home and Family Support Services” — This program no longer exists.
  • F0700O “STAR+PLUS” — This is a Medicaid managed care program. Generally, all eligible people are automatically enrolled in STAR+PLUS. For “STAR+PLUS HCBS Program” or “STAR+PLUS Waiver,” use F0700D.
  • F0700V “Other community-based services” — An example of this is Community First Choice (CFC) services.

2430.5 Presenting Information about Community Services as Part of the PE

Revision 22-1; Effective Nov. 28, 2022

Person’s PE is Negative for ID or DD

For a person whose PE is negative for ID or DD, the staff conducting the PE must provide and explain to the person and LAR Appendix II, Long Term Services and Supports, in the LIDDA Handbook. Note: This process is in lieu of presenting the full community living options (CLO)  required for someone who is PASRR positive.

If the person wants to pursue community living after receiving information about long term services and supports, then the PE staff must arrange for the person to be referred to the regional Aging and Disability Resource Center (ADRC) and, if appropriate, the family-based alternatives contractor.
 

Person’s PE is Positive for ID or DD

For a person whose diagnosis of ID or DD is confirmed, the staff conducting the PE must present community living options (CLO) per Section 5810.3, CLO Materials Provided to Individual or LAR, and Section 5820, Documenting CLO. The staff must document the CLO discussion on Form 1054, Community Living Options.

CLO must be presented in a manner that allows the person and their LAR to fully understand the options available. Therefore, CLO duration may vary but should last as long as needed to completely and meaningfully present all available community options.

If the person wants to pursue community living at the end of the CLO presentation and:

the person’s admission type is “preadmission” and the person is eligible for a targeted NF HCS diversion slot as described in Section 3210, Criteria for Diverting from NF Admission, then …
  • instead of admitting to the NF …

the PE staff:

  • notifies the diversion coordinator within seven calendar days to request a targeted NF HCS diversion slot from HHSC per Section 3220, Requesting a Targeted NF HCS Diversion Slot; and
  • provides the diversion coordinator a copy of the completed CLO.
the person is eligible for habilitation coordination per Section 4100, Eligibility for Habilitation Coordination Funded by Medicaid, and the person has selected a community program, then …before the IDT meeting …

the PE staff ensures the assigned habilitation coordinator (HC):

  • receives a copy of the completed CLO; and
  • is informed of the community program selected by the person/LAR; and
  • is instructed to notify the appropriate LIDDA staff that the person or LAR wants to transition to the community and has selected a community program so that an SC/ECC can be assigned to begin transition planning
the person is eligible for habilitation coordination per Section 4100 but the person has not selected a community program, then …before the IDT meeting …

the PE staff arrange assigned habilitation coordinator:

  • receives a copy of the completed CLO; and
  • is informed that the person doesn’t know which community program to pursue.
the person is not eligible for habilitation coordination because the person is 20 or younger, then …immediately following submission of the PE …the PE staff will arrange for the person to be referred to Every Child, Inc.
the person is not eligible for habilitation coordination because the person is not a Medicaid recipient, then …immediately following submission of the PE …

the PE staff will arrange for the person to be referred:

  • to the regional Aging and Disability Resource Center (ADRC); and
  • for a LIDDA intake, if appropriate.

If the person is unsure about, or doesn’t want to pursue, community living at the end of the CLO presentation and:

the person is eligible for habilitation coordination per Section 4100, then …before the IDT meeting …the PE staff ensures the assigned habilitation coordinator receives a copy of the completed CLO.
the person is not eligible for habilitation coordination because the person is 20 or younger, then …immediately following completion of the CLO …the PE staff informs the person and LAR that they may contact Every Child, Inc. if they want to pursue community living in the future.
the person is not eligible for habilitation coordination because the person is not a Medicaid recipient, then …immediately following completion of the CLO …

the PE staff informs the person and LAR that they may contact the following entities if they want to pursue community living in the future:

  • the regional ADRC; and
  • the LIDDA.

2430.6 Completing Section F, Return to Community Living

Revision 22-1; Effective Nov. 28, 2022

The LIDDA must complete Section F of the PE to record the individual’s:

  • previous community living experiences;
  • alternate placement preferences;
  • alternate placement options;
  • barriers to community living;
  • supports needed for successful community living; and 
  • referrals made for alternate placement.

To complete Section F of the PE, the LIDDA selects the program of interest from the available drop-down menu. After the LIDDA has made the referral to the program the individual is interested in, the LIDDA adds the date the referral was made, the phone number of the person the referral was made to, and any other comments related to the referral. 

2430.7 PE for Resident Review

Revision 22-1; Effective Nov. 28, 2022

When a resident with ID or DD who has been living in a NF experiences a significant change in condition, the NF submits an updated Minimum Data Set (MDS) assessment referred to as a Significant Change in Status Assessment (SCSA) into the LTC online portal. When an SCSA is submitted, the LTC online portal issues an alert to the LIDDA to conduct a resident review within seven calendar days after receiving the alert.

Before conducting the resident review, the LIDDA must contact the NF to determine if the change affects the resident’s PASRR eligibility or specialized services. A significant change in condition may require new, different, or fewer specialized services than the resident had been receiving. If the change does not meet the definition of a significant change in condition, the LIDDA is not required to conduct a resident review. The LIDDA must determine if a resident review is required based on the information provided by the NF.

If the LIDDA determines the change is not significant and does not conduct a resident review, the LIDDA must document the justification for its decision by adding a note to the history section of the current PE and in a progress note in the individual’s record.

The LIDDA uses the same form used to conduct a PE and submit the resident review the same way as the PE on the LTC online portal. The resident review is conducted to:
 

  • assess the resident's need for continued care in a NF;
  • assess the resident's need for specialized services as the need may have changed due to the significant change in condition; and
  • identify alternate placement options.

The NF must convene the IDT meeting within 14 calendar days after the LTC online portal generates an automated notification to the LIDDA to conduct a resident review. The LIDDA should coordinate with the NF to schedule the initial IDT and SPT meeting and must document attempts to facilitate timely meetings if the NF convenes the initial IDT meeting after more than 14 calendar days.

2430.8 When a DID is Required to Adequately Complete the PE

Revision 22-1; Effective Nov. 28, 2022

If, during a PE, a LIDDA suspects a person of having a diagnosis of ID or DD but is unable to confirm the diagnosis due to lack of records or access to family history, the LIDDA must ensure compliance with the following procedure.

The LIDDA must ensure staff conducting the PE:

  • completes a “referral” in section F1000 of the PE:
    • in F1000A, by marking 19 for “Other”;
    • in F1000B, by entering a statement that the person/resident is being referred for a determination of intellectual disability (DID);
    • in F1000C, by entering the phone number of the LIDDA staff completing the PE or resident review;
    • in F1000D, by entering the “date of referral” for the DID; and
    • by marking the PE or resident review negative to indicate the person’s or resident’s diagnosis cannot be confirmed (i.e., in Section B, fields B0100 and B0200, enter “No”); and
  • does not send the person or LAR a notice of denial of eligibility for specialized services and an opportunity for a fair hearing.

The LIDDA must, within 45 calendar days after the “date of referral” entered in Section F, field F1000D, ensure a DID is conducted for the person per rules governing diagnostic assessment (26 TAC Chapter 304).

The LIDDA must submit a copy of the written DID report to the PASRR unit by the Secure File Transfer Protocol file folder named “PASRR Reporting” within 30 calendar days after the DID is conducted. 

If the DID report indicates the person does not have ID or DD, the LIDDA must:

  • enter a note on the previously completed negative PE by clicking on the “add note” button on the yellow Form Action bar of the PE and state that the person does not have ID or DD per the result of the DID; and
  • send the person or LAR a of:
    • denial of specialized services because the person does not have a diagnosis of ID or DD per CFR Section 483.102(b)(1); and
    • an opportunity for a fair hearing.

If the DID report indicates the person has ID or DD, then within seven calendar days after the DID report is completed, the LIDDA must complete a new PE for the person and mark it positive to indicate the person has ID or DD.

2430.9 PE Submission

Revision 22-1; Effective Nov. 28, 2022

The LIDDA must:

  • Enter the data recorded from the PE into the LTC online portal.
  • Retain a copy of the PE in the person’s record.

2430.10 Specialized Services Recommendation Mapping

Revision 22-1; Effective Nov. 28, 2022

When the LIDDA staff enters the PE in the LTC online portal and checks boxes to indicate areas of support the person may need in Section B, Specialized Services Determination/Recommendations, of the PE, the LTC online portal automatically populates the associated specialized services in B0500 Recommended Services Provided/Coordinated by the Local Authority and B0600 Recommended Services Provided/Coordinated by the Nursing Facility. 

These auto-populated specialized services help ensure the LIDDA includes all specialized services recommended for the person and are displayed in the Recommended Specialized Services section. For a complete list of the specialized services mapping, refer to the Long-Term Care (LTC) Preadmission Screening and Resident Review (PASRR) User Guide (PDF).

The entity that completes the PE must complete Form 1014, Pre-Admission Screening and Resident Review (PASRR) Evaluation Summary Report. Only one form should be completed per person. For a person whose PE is positive for ID or DD, a LIDDA must complete Form 1014 following the completion of a PE. Form 1014 is used to summarize the recommended specialized services for a person who is eligible for specialized services. For a person who has a dual diagnosis (ID/D and MI), the LIDDA should take the lead on completing Form 1014. Detailed step-by-step instructions on how to complete the form are found at the link to the form above.

2430.11 Fair Hearing Related to Negative PE

Revision 22-1; Effective Nov. 28, 2022

If a person or LAR of a person whose PE is negative requests a fair hearing, HHSC notifies the LIDDA, which must provide information or material supporting a negative PE determination. The LIDDA must submit to HHSC all requested material or information about the fair hearing by the date established by the HHSC staff assembling the PE Fair Hearing Packet. The LIDDA also must attend the fair hearing in person or by phone.

2430.12 PE Retention Period

Revision 22-1; Effective Nov. 28, 2022

HHSC currently requires a LIDDA to keep all handwritten PE documentation in the person’s record indefinitely. The electronic version of the PE is retained in the LTC online portal system.

2430.13 Preadmissions Involving Two LIDDAs

Revision 22-1; Effective Nov. 28, 2022

When a person in one LIDDA’s service area plans to move to a NF in different LIDDA’s service area, follow the following process.

The transferring LIDDA:

  • receives a positive PL1 completed by the RE;
  • submits the PL1 into the LTC online portal within one business day of receipt;
  • completes and submits the PE per rule and policy;
  • confirms that medical necessity (MN) is approved in the LTC online portal;
  • notifies the admitting NF that it can proceed with the admission; and
  • sends copies of the submitted PL1 and PE to the receiving LIDDA and notifies the receiving LIDDA within two business days that the person has been admitted to a NF in the receiving LIDDA’s service area.

After receiving the PL1 and PE from the transferring LIDDA, the receiving LIDDA:

  • submits a new PL1 within one business day of receipt, changing only the date of assessment (A0600) and signature date (A1200B) to the current date; and
  • completes and submits a new PE per rule and policy, including conducting CLO.

After the NF certifies in the LTC online portal that it can meet the needs of the individual, the receiving LIDDA and admitting NF will have access to view the PL1 and PE in the LTC online portal.

During this process, it is imperative that the LIDDAs and NFs maintain communication about the status of the individual’s move. A person or LAR may change their mind and select an alternate placement or a different NF. All parties involved should be aware of where the person is living.

2500, PASRR Initial IDT and SPT Meeting

Revision 22-1; Effective Nov. 28, 2022

For any person with a positive PE for ID or DD, the NF  convenes an IDT meeting. A LIDDA representative is a required member of the IDT, and HHSC strongly encourages the LIDDA representative be the LIDDA staff who conducted the PE. The NF is responsible for scheduling, conducting and documenting the IDT meeting. For a person with a positive PE for ID/DD and MI, both LIDDA and LMHA or LBHA representation is required. However, the LIDDA assumes primary responsibility for completion of required PASRR processes during the initial IDT and SPT meeting.

The IDT reviews the results of the person’s CLO to determine if the person’s total needs can be met in appropriate community settings, as well as reviews and discusses which of the PE’s recommended specialized services the person or LAR wants to receive.

Note: For a person who is eligible for habilitation coordination, the habilitation coordinator must be present at the IDT meeting.

2510 NF Enters Initial IDT and SPT Meeting Information

Revision 22-1; Effective Nov. 28, 2022

The NF enters the following information from the IDT meeting in the LTC online portal on the PASRR Comprehensive Service Plan (PCSP) form after the IDT meeting:

  • the date of the IDT meeting;
  • the names and titles of the IDT members in attendance;
  • all specialized services agreed upon during the IDT meeting, if any; and
  • the determination of whether the person is best served in a facility or community setting.

Note: The specialized services agreed upon during the IDT meeting for a person with a positive PE for ID or DD who:

  • has Medicaid and is 21 or older are documented on the PCSP form in the Specialized Services Information section, fields A2800 NF Specialized Services, A2900 Durable Medical Equipment (DME), and A3000 IDD Specialized Services, as appropriate, and in field A3100 MI Specialized Services if the person also has MI.
  • does not have Medicaid or is 20 or younger are documented on the PCSP form in the Comments section, field A3200 Nursing Facility Comments. If the person will be receiving the service through other funding sources, the NF is responsible for identifying the funding source or entity that will provide the specialized service in the comments field.

2520 Confirmation of IDT and SPT Meeting Information

Revision 22-1; Effective Nov. 28, 2022

A LIDDA must check the LTC online portal and take one of the following three actions in the chart below, as appropriate. They must do this within five business days after receiving notification from the LTC online portal that the NF entered information from an initial or annual IDT meeting into the PCSP form.

Actions
1

If a LIDDA representative did not participate in the IDT meeting, the LIDDA must:

  • contact the NF and request that the NF conduct another IDT meeting that includes a LIDDA representative; and
  • document in the LTC online portal in Section A3500 disagreement with the:
    • specialized services listed in the LTC online portal; and
    • LIDDA representative’s attendance at the IDT meeting.
2

If a LIDDA representative participated in the IDT meeting, but determines the information the NF entered in the LTC online portal about  the specialized services or the LIDDA’s attendance at the IDT meeting is incorrect, the LIDDA must contact the NF to address the discrepancy. They must allow seven calendar days for the NF to correct the information in the LTC online portal.

  • If the NF corrects the information in the LTC online portal within seven calendar days, the LIDDA must document in the LTC online portal in Section A3500 agreement with the:
    • specialized services listed in the LTC online portal; and
    • LIDDA representative’s attendance at the IDT meeting.
  • If the NF does not correct the information in the LTC online portal within seven calendar days, the LIDDA must document in the LTC online portal in Section A3500 disagreement with whichever of the following is still incorrect:
    • the specialized services listed in the LTC online portal; or
    • the LIDDA representative’s attendance at the IDT meeting.
3

If a LIDDA representative participated in the IDT meeting and agrees with the information the NF entered in the LTC online portal about the specialized services and the LIDDA’s attendance at the IDT meeting, the LIDDA must document in the LTC online portal in Section A3500 agreement with the:

  • specialized services listed in the LTC online portal; and
  • LIDDA representative’s attendance at the IDT meeting.

For instructions on confirming the IDT form, refer to the LTC Preadmission Screening and Resident Review (PASRR) User Guide for Local Authorities.

2600, Initiating NF Specialized Services

Revision 22-1; Effective Nov. 28, 2022

If funding for NF specialized services is available (i.e., Medicaid), the NF is responsible for the successful submission of a complete and accurate prior authorization request for NF specialized services in the LTC online portal within 20 business days after the date of the IDT meeting. The NF must start providing a habilitative therapy service within three business days after receiving approval from HHSC in the LTC online portal. Additionally, the NF must:

  • order all DME devices and CMWCs per NF rules in 26 TAC Section 554.2754(e);
  • provide ongoing habilitative therapy services as approved by HHSC; and
  • document annually on the PCSP form in the LTC online portal all NF specialized services, IDD habilitative specialized services, and MI specialized services being provided to a person.

3100, Diversion Coordinator Duties

Revision 22-1; Effective Nov. 28, 2022

A local intellectual and developmental disability authority (LIDDA) designates a qualified staff as the diversion coordinator pursuant to the performance contract. A LIDDA must ensure that the diversion coordinator performs the following duties:

  • identify available community living options, services and supports to assist individuals to successfully live in the community;
  • provide information and assistance to service coordinators , habilitation coordinators , and other LIDDA staff who are facilitating diversion for people at risk of admission to a nursing facility (NF) and for people transitioning to the community from a NF;
  • coordinate educational activities for service coordinators, habilitation coordinators and other LIDDA staff about available community services and strategies to avoid NF admission;
  • coordinate educational activities for referring entities about available community resources, services and strategies to avoid NF admission;
  • within 45 to 75 calendar days after a person is admitted into a NF, review the person’s admission to ensure that community living options, services and supports that could provide an alternative to NF services have been explored and if not, refer the person to  their habilitation coordinator for that purpose;
  • identify, arrange and coordinate access to community services as a diversion to NF admission for a person who has chosen community living during the PE process; and
  • request a targeted NF Home and Community-based Services (HCS) diversion slot for a person as described in Section 3220, Requesting a Targeted NF HCS Diversion Slot, or transition slot as described in Section 6500, Transitioning to the HCS Program.

3200, Diverting from NF Admission

Revision 22-1; Effective Nov. 28, 2022

HHSC may make available a targeted NF HCS diversion slot to a person with intellectual disability (ID) or developmental disability (DD) who is determined to be at imminent risk of a long term stay in a NF. After a positive PASRR Level 1 (PL1) screening for preadmission is completed and entered in the Long-Term Care (LTC) online portal, a LIDDA must conduct a PASRR Evaluation (PE) on the person to determine if the person:

  • has ID or DD; and
  • meets medical necessity.

3210 Criteria for Diverting from NF Admission

Revision 23-1; Effective Dec. 20, 2023

To be eligible for a targeted NF HCS diversion slot, a diversion coordinator must document the following:

  • the person is at imminent risk of a long term stay in a NF;
  • the person has a PE, conducted within the past 21 calendar days, that indicates he or she  has ID or DD, meets NF medical necessity and is appropriate for community placement;
  • the person has a diagnosis that will meet HCS diagnostic eligibility criteria, meaning he or she has an intermediate care facility (ICF) Level of Care (LOC) I or VIII*; and
  • other adequate and appropriate community resources, excluding SSLCs, are unavailable to meet the person’s needs after attempts to obtain community-based services and supports, such as:
    • for a person 21 years or older:
      • Medicaid State Plan services;
      • community-based intermediate care facilities for people with an intellectual disability or related conditions (ICF/IIDs) with six beds or fewer; and
      • general revenue-funded services; or
    • for a person 20 years or younger:
      • Medicaid State Plan services;
      • supports through the local school district;
      • general revenue-funded services; and
      • community-based ICF/IIDs with six beds or fewer unless out-of-home placement is not desired.

*If a LIDDA determines that the person meets the criteria for both ICF LOC I and VIII, then the LIDDA documents “ICF LOC I.” If the person only meets the criteria for ICF LOC VIII, then the LIDDA documents “ICF LOC VIII.”

3220 Requesting a Targeted NF HCS Diversion Slot

Revision 22-1; Effective Nov. 28, 2022

If a LIDDA determines that a person meets the criteria for a targeted NF HCS diversion slot, the diversion coordinator requests a targeted NF HCS diversion slot for the person by completing and submitting Form 1047, Request for HCS Targeted NF Diversion Slot, per the form’s instructions.

Upon receipt, HHSC staff reviews the completed Form 1047. HHSC staff may request more information or documentation. Within three business days after receipt of Form 1047 and any necessary additional documentation, HHSC determines whether the person meets the criteria for a targeted NF HCS diversion slot.

  • If it is determined the person does not meet the criteria, HHSC will notify the LIDDA and the person or legally authorized representative (LAR) in writing of the denial of an offer of a targeted NF HCS diversion slot within one business day. HHSC will   provide the person or LAR with an opportunity for a fair hearing.
  • If it is determined the person meets the criteria and a targeted NF HCS diversion slot is immediately available, HHSC will send a letter authorizing the LIDDA to offer the person the opportunity to enroll in HCS.

3230 Enrolling in HCS as a Diversion to NF Admission

Revision 23-1; Effective Dec. 20, 2023

A LIDDA enrolls a person in the HCS program as an alternative to NF admission, per the requirements in the HCS rules, LIDDA Handbook, and this section. A LIDDA ensures an assigned enhanced community coordination (ECC) coordinator completes the following:

  • develops and revises as necessary a diversion plan, using Form 1050, Nursing Facility or Crisis Diversion Plan, with the person and LAR;
  • develops Form 8665, Person-Directed Plan, per the HCS program rules, using all available assessments and to include the person’s:
    • strengths and preferences; and
    • medical, nursing, nutritional management, clinical and other support needs; 
  • conducts a pre-move site review using Form 1042, Pre-Move Site Review, to:
    • ensure any concerns of the program provider, staff or family member are being addressed; and
    • determine whether all essential supports identified on Form 1050, Nursing Facility or Crisis Diversion Plan, are in place before the person enrolls in HCS; and
  • completes the following activities before the person enrolls in HCS if, during the pre-move site review, any one of the essential supports is not in place or if issues are raised about the suitability of the site
    • convenes the SPT to resolve the issues; and
    • conducts another pre-move site review following resolution.
       

3230.1 Enhanced Community Coordination Funds

Revision 23-1; Effective Dec. 20, 2023

Enhanced community coordination (ECC) funds are available to LIDDAs through the  performance contract for a person enrolling in HCS as a diversion to NF admission. The purpose of the funds is to enhance a person’s natural supports and promote successful community living. Funds are intended to pay for:

  • one-time emergency assistance, such as:
    • rental or utility assistance;
    • nutritional supplements;
    • clothing; and
    • medication;
  • items to address a person’s special needs, including minor home modifications not funded by other sources;
  • transportation to and from trial visits with community providers; and
  • educational tuition assistance, such as for vocational programs through community colleges so a person can develop job skills.

A LIDDA should contact IDDMFPSupport@hhs.texas.gov to discuss processes and how to access funds prior to any purchases.

3240 Post Enrollment in HCS as a Diversion to NF Admission

Revision 23-1; Effective Dec. 20, 2023

For one year* after a person has enrolled in the HCS program as a diversion to NF admission, an enhanced community coordination (ECC) coordinator must:

  • conduct at least three onsite visits of community service delivery sites at the intervals described below to determine whether supports continue to be in place and any areas of concern are being addressed using Form 1043, Post-Move Monitoring: 
    • within the first seven calendar days after enrollment in the HCS program;
    • between eight and 45 calendar days after enrollment in the HCS program; and
    • between 46 and 90 calendar days after enrollment in the HCS program. 
    • Note: More frequent onsite visits may be required to determine whether supports continue to be in place and any areas of concern are being addressed during the first 90 calendar days after enrolling in HCS.
  • conduct monthly in-person visits with the person, or more frequently if determined by the HCS SPT based on risk factors, and monitor the delivery of all services and supports;
  • conduct HCS service planning team (SPT) meetings quarterly, or more frequently if there is a change in the person’s needs or if requested by the person or LAR;
  • revise the HCS person-directed plan (PDP), as necessary, and coordinate the person’s services and supports;
  • ask about any recent hospitalizations, emergency department contacts, increased physician visits or other crises, including medical crises, and if the person experiences such, convene the HCS SPT to identify all necessary revisions to the HCS PDP to address other need for services;
  • ensure the person receives timely assessments of behavioral, medical, nursing, specialized therapies and nutritional management needs, as necessary, and as indicated on the HCS PDP;
  • record health care status sufficient to readily identify when changes in the person's status occurs;
  • conduct service planning, ensure the program provider’s implementation of services, and monitor all services identified on the HCS PDP, including:
    • reviewing the HCS program provider’s implementation plans and provider records;
    • visiting service delivery sites as needed to determine the person’s needs are being met; and
    • monitoring critical incidents involving the person and convening the HCS SPT to develop a plan for needed prevention or intervention services for the person; and
  • monitor the person while on suspension from the HCS program at least monthly, maintain communication with the program provider and provide reports to HHSC upon request.

*If, after one year of ECC, the SPT feels the person requires further enhanced monitoring, the ECC coordinator must contact IDDMFPSupport@hhs.texas.gov for further guidance.
 

4100, Eligibility for Habilitation Coordination Funded by Medicaid

Revision 22-1; Effective Nov. 28, 2022

A person is eligible for habilitation coordination funded by Medicaid if he or she:

  • has an active PASRR Evaluation (PE) or resident review that is positive for intellectual disability (ID) or developmental disability (DD);
  • is a Medicaid recipient;
  • is 21 or older; and
  • is living in a nursing facility (NF)

Note: Receiving hospice services does not affect a person’s eligibility for habilitation coordination or other PASRR specialized services, if the interdisciplinary team (IDT) agrees the person would benefit from specialized services.

4200, Assignment of Habilitation Coordinator

Revision 22-1; Effective Nov. 28, 2022

A local intellectual and developmental disability authority (LIDDA) must assign a habilitation coordinator  to an eligible person within two business days after the PE is entered in the Long-Term Care (LTC) online portal. The habilitation coordinator must attend the person’s initial IDT meeting along with the LIDDA representative who is a required member of the IDT. See Section 2500, PASRR Initial IDT and SPT Meeting, and Section 4300, Initial IDT and SPT Meeting. If the assigned habilitation coordinator functions in another LIDDA capacity, the habilitation coordinator will indicate all represented functions on the sign-in sheet.

The habilitation coordinator must review the individual’s PE, Form 1054, Community Living Options, completed by the PE evaluator, and any other available supporting documentation (e.g., diagnostic information in the Client Assignment and Registration system (CARE), previous LIDDA services, previous service plans) before the initial IDT meeting.

4300, Initial IDT and SPT Meeting

Revision 22-1; Effective Nov. 28, 2022

The habilitation coordinator must attend the individual’s initial IDT meeting. The PE evaluator, or LIDDA representative, if the person who completed the PE is not in attendance, shares the results of the Community Living Options (CLO) presented during the PE (i.e., completed Form 1054, Community Living Options). If barriers are identified in Sections 6, 7 or 8 of Form 1054, then the habilitation coordinator and IDT members should determine if provision of any specialized service could help eliminate barriers. If so, the specialized service is considered recommended and must be identified as such on the PCSP form.

4310 Attendance at Initial IDT and SPT Meeting

Revision 22-1; Effective Nov. 28, 2022

At the initial IDT and SPT meeting for an individual, the following LIDDA staff are in attendance:

  • the LIDDA staff representative who is a required member of the IDT (HHSC strongly encourages this LIDDA staff representative be the LIDDA staff who conducted the PE)*; and
  • the assigned habilitation coordinator**.

The assigned habilitation coordinator can be designated as the LIDDA required member of the initial IDT if the habilitation coordinator completed the PE.

*Attendance at the initial IDT and SPT meeting as a required IDT member is an activity that is included in the PE reimbursement rate.

**A habilitation coordinator's attendance at the initial IDT and SPT meeting is reimbursed through the habilitation coordination reimbursement rate if the habilitation coordinator and individual are face-to-face.

Note: Following an initial IDT and SPT meeting, a LIDDA must comply with Section 2520, Confirmation of IDT and SPT Meeting Information.

4400, Requesting Authorization for Habilitation Coordination

Revision 22-1; Effective Nov. 28, 2022

4410 IDT Agrees to Habilitation Coordination

Revision 22-1; Effective Nov. 28, 2022

If the IDT agrees to the provision of habilitation coordination for an eligible person, the habilitation coordinator requests authorization for habilitation coordination per the Habilitation Coordination Billing Guidelines.

4420 Refusal of Habilitation Coordination

Revision 22-1; Effective Nov. 28, 2022

If an eligible person or LAR does not want habilitation coordination, the HC:

  • requests authorization for habilitation coordination per the Habilitation Coordination Billing Guidelines to fund the habilitation coordinator’s attendance at the IDT meeting; and
  • uses Form 1044, Refusal of Habilitation Coordination, to document the refusal of habilitation coordination, gets necessary signatures, provides the person or LAR a copy of the completed form and maintains the original completed form in the person’s record.

Note: The habilitation coordinator must complete Form 1064, Habilitative Assessment for a person who has refused habilitation coordination.

4500, Developing Individual Profile and Habilitation Service Plan at First SPT Meeting

Revision 22-1; Effective Nov. 28, 2022

If the IDT agrees to the provision of habilitation coordination for a person, the habilitation coordinator convenes the first SPT meeting immediately after the initial IDT meeting.

At the first SPT meeting, the habilitation coordinator continues the discovery process and develops and uses Form 1063, Individual Profile – Nursing Facility, and Form 1057, Habilitation Service Plan (HSP). This section describes developing an individual profile and an HSP at the first SPT meeting. Although Section 5400, Develop and Revise Habilitation Service Plan and Individual Profile, describes the process for developing and revising an HSP and individual profile, a fully robust HSP and individual profile are not expected by the end of the first SPT meeting.

Information from the following sources is discussed with the SPT and included in the HSP and individual profile where appropriate:

  • the PE or resident review;
  • the CLO that was conducted during the PE;
  • CARE (e.g., diagnostic data, previous LIDDA services);
  • previous service plans; and
  • other available supporting documentation, including previous assessments such as those listed in Section 5210, Reviewing Assessments.

Also included in the HSP are all specialized services, including habilitation coordination, agreed upon during the IDT meeting. At a minimum, for each specialized service agreed upon during the IDT meeting, the HSP must indicate either:

  • an assessment will be conducted; or
  • the amount, frequency and duration of the specialized service to be provided.

The habilitation coordinator must complete the HSP and individual profile, and send them to the members of the SPT, within 10 calendar days following the first SPT meeting.

The habilitation coordinator should ask the NF to include all PASRR specialized services identified on the HSP in the NF baseline care plan or NF comprehensive care plan, whichever is most current. The habilitation coordinator must request a copy of the NF baseline care plan or comprehensive care plan from the NF.
 

4510 Specialized Services Requiring an Assessment

Revision 22-1; Effective Nov. 28, 2022

An assessment is required for:

  • all NF specialized services; and
  • the following intellectual and developmental disability (IDD) habilitative specialized services:
    • behavioral support;
    • employment assistance; and
    • supported employment.

The HSP must state an outcome that supports starting an assessment.

When there is lack of consensus among all IDT members about whether a person should receive a NF specialized service or an IDD habilitative specialized service (IHSS), then obtaining an assessment for the specialized service is required. The assessment will indicate whether the person can benefit from the specific NF specialized service or IHSS.

An assessment is not completed for a person who refuses specialized services or in cases in which there is no funding for specialized services.
 

4520 Specialized Services that Do Not Require an Assessment

Revision 22-1; Effective Nov. 28, 2022

For independent living skills training and day habilitation, the SPT identifies for inclusion in Section 5 of Form 1057, Habilitation Service Plan (HSP):

  • the outcome(s); and
  • the amount, frequency and duration based on the person's identified needs, interests and desired outcomes.

4530 Frequency and Duration of Habilitation Coordination

Revision 22-1; Effective Nov. 28, 2022

The duration of habilitation coordination is “while the person is living in the nursing facility,” which is pre-printed on Form 1057, Habilitation Service Plan (HSP). The frequency of habilitation coordination is determined by the SPT per the requirements in rule and Section 5100, Required Face-to-Face Visits.

4700, Providing Habilitation Coordination

Revision 22-1; Effective Nov. 28, 2022

The habilitation coordinator provides ongoing habilitation coordination per Section 5000, Habilitation Coordination. They continue  the discovery process and revising Form 1057, Habilitation Service Plan (HSP), with the SPT as assessments become available and as the individual’s needs change or are more fully realized.

4800, Additional LIDDA Responsibilities

Revision 22-1; Effective Nov. 28, 2022

4810 Determining Guardianship

Revision 22-1; Effective Nov. 28, 2022

The habilitation coordinator determines if a person  has a legal guardian and verifies that letters of guardianship are current by requesting a copy of the letters of guardianship or by contacting the court. If the person has a current legal guardian, then all forms must be signed by the guardian. If the person does not have a legal guardian, then all forms must be signed by the him or her.

If the guardianship information is not current, the habilitation coordinator should obtain signatures of both the individual and the person listed as guardian, until appropriate steps can be taken to verify current guardianship.

For more information, see Section 5920, Activities Related to Guardianship.

4820 Communication of Complaint Process

Revision 22-1; Effective Nov. 28, 2022

The habilitation coordinator ensures that the person or LAR is informed orally and in writing of the processes for:

  1. filing complaints about services delivered by the LIDDA, such as habilitation coordination, service coordination, and IHSS, with:
    • the LIDDA; and 
    • the IDD Ombudsman at 800-252-8154; 
  2. filing complaints about the provision of NF specialized services with:
    • the LIDDA; and
    • HHSC Complaint and Incident Intake at 800-458-9858; and
  3. reporting an allegation of abuse, neglect, or exploitation to DFPS at 800-647-7418.

Each LIDDA must develop a process for receiving and resolving complaints about a provider of NF specialized services, MI specialized services, or the LIDDA’s provision of IHSS, habilitation coordination or service coordination. This process must include the LIDDA's phone number and the toll-free number to the IDD Ombudsman.

The processes for people and LARs to request a review of their concerns or dissatisfaction must be easily understood. The policy must explain how the person or LAR may receive assistance to request the review, the time frames for the review, and the method that the person or LAR is informed of the outcome of the review. The LIDDA must present this policy in the languages that the person and LAR are most comfortable.
 

4900, Medicaid and Medicare

Revision 22-1; Effective Nov. 28, 2022

4910 Medicaid Eligibility Guidelines

Revision 22-1; Effective Nov. 28, 2022

HHSC requires all people to meet Medicaid eligibility for PASRR. Eligibility must be attained and maintained for the person to continue receiving PASRR specialized services. People eligible for certain types of Medicaid coverage are eligible for PASRR. However, not all types of Medicaid coverage ensure eligibility.

Every person certified for Medicaid benefits has a "TOA code" and a "program code" assigned to their Medicaid record. See the table below for the appropriate coverage codes for participation in PASRR. CARE Screen C63 (Medicaid Eligibility Search), Screen 192 and Screen 193 (Medicaid Eligibility Information) can be used to verify a person’s current and past Medicaid records.

Required Medicaid Codes

TOA CodeProgram CodeTOA CodeProgram CodeTOA CodeProgram Code
TA01META83MATP47MA
TA02META86MATP48MA
TA03META88METP50ME
TA04METP03METP51ME
TA05METP07MATP52MA
TA06METP08MATP53MA
TA07METP10METP54MA
TA08METP11METP55MA
TA09METP12METP56MA
TA10METP13METP57MA
TA12METP15METP58MA
TA15METP16METP70MA
TA16METP17METP87ME
TA17METP18METP88MA
TA18METP19METP90MA
TA19MATP20MATP91MA
TA20MATP21METP92MA
TA21METP22METP93MA
TA22METP29MATP94MA
TA24METP30METP95MA
TA25METP31MATP96MA
TA26METP32MATP97MA
TA27METP33MATP98MA
TA31MATP34MATP99MA
TA62MATP35MATPALMA
TA66MATP36MATPASMA
TA67MATP37MATPDEMA
TA74MATP38METPINME
TA75MATP39METPIWME
TA76MATP40MATPPMMA
TA77MATP41METPRIME
TA78MATP42MATPSPMA
TA79MATP43MATPSSME
TA80MATP44MATPWAME
TA81MATP45MATPWIME
TA82MATP46ME  

Contact your local HHSC office by calling 211, or visiting the HHSC website for specific questions about Medicaid coverage. 

4920 Responsibility to Reestablish Medicaid Eligibility

Revision 22-1; Effective Nov. 28, 2022

If a person loses Medicaid eligibility or is delayed in having Medicaid eligibility determined or re-determined, a NF and LIDDA may be unable to receive authorizations or bill for PASRR specialized services, including habilitation coordination. It is the responsibility of the representative payee to contact the appropriate entity to determine the necessary action to reinstate benefits.

If the individual or family is the representative payee, the habilitation coordinator must assist, if requested.

If the NF is the representative payee, the NF is responsible for ensuring action is taken to reestablish Medicaid eligibility. In most circumstances, assisting people with Medicaid eligibility determinations, re-determinations, and MCO selection is allowable as a medically related social service, which is a service provided by the NF that help the individual in attaining the highest practicable physical, mental, or psychosocial well-being.

If needed, the LIDDA is expected to work with the NF to help a person reestablish Medicaid eligibility. Failure of a representative payee to help reestablish Medicaid eligibility may be reported to HHSC Complaint and Incident Intake.

To minimize billing issues about habilitation coordination, LIDDAs should review the service authorization in Medicaid Eligibility Service Authorization Verification (MESAV) to verify that the person is admitted into the correct Medicaid program.

4930 MCO Selection

Revision 22-1; Effective Nov. 28, 2022

STAR+PLUS is the Texas Medicaid managed care program for people who live in NFs. A NF resident must select a STAR+PLUS managed care organization (MCO). If a NF resident fails to select an MCO, the resident will be assigned an MCO.  

A person enrolled with an MCO is assigned a service coordinator. The MCO service coordinator has responsibility for coordinating and ensuring the delivery of NF add-on services and acute care services. An MCO service coordinator must conduct quarterly visits with the individual. MCO service coordinators also work with the individual, families, habilitation coordinators, and other service coordinators or case managers to ensure a smooth transition to the community, when appropriate. The individual’s MCO service coordinator should be a part of the care planning process and is a member of the IDT and SPT, if the individual does not object. The habilitation coordinator should ask the individual or LAR, if applicable, directly whether they are okay with or object to the MCO service coordinator’s attendance at IDT and SPT meetings and must document evidence of this discussion in the individual’s record. 

4930.1 Individual Does Not Have an MCO

Revision 22-1; Effective Nov. 28, 2022

If a LIDDA becomes aware that a person is not assigned an MCO, the LIDDA must contact the NF and request the NF give information and guidance to the person or LAR on how to select and enroll in an MCO. The LIDDA must not delay transition planning activities if the person does not have an MCO and is ready to transition to the community.

Note: As part of medically related social services, a NF may provide information to a person or the person’s LAR about available MCOs and guidance on how to enroll in the preferred MCO. A NF may not choose an MCO on behalf of the individual.

4940 Individual is Dual Eligible

Revision 22-1; Effective Nov. 28, 2022

Many people who live in NFs are eligible for both Medicaid and Medicare. A NF stay for a person admitting from an acute care hospital may initially be funded by Medicare. However, the person’s Medicaid eligibility, and therefore their eligibility for PASRR, does not change. If the person is Medicaid-eligible and meets the other criteria for habilitation coordination, he or she must not be refused access to those services whether or not the current stay is paid for by Medicare or Medicaid. 

5100, Required Face-to-Face Visits

Revision 22-1; Effective Nov. 28, 2022

The habilitation coordinator meets face-to-face* with a person monthly, or more frequently if needed, unless the only specialized service the person receives is habilitation coordination. In this case the habilitation coordinator meets face-to-face with the person  at least quarterly. Based on these requirements, the service planning team (SPT) determines the frequency of face-to-face visits. A face-to-face meeting with the person must include the provision of at least one of the habilitation coordination activities described in this section.

*HHSC may waive the face-to-face requirement for habilitation coordination in extenuating circumstances including natural disasters, pandemics, or other declared emergencies. HHSC will provide policy guidance about face-to-face flexibilities through rule making, broadcasts, information letters or other communications.

5200, Assess or Reassess Habilitative Needs

Revision 22-1; Effective Nov. 28, 2022

The habilitation coordinator must assess and periodically reassess a person’s habilitative service needs by gathering information from the person and other appropriate sources, such as the legally authorized representative (LAR), family members, social workers and service providers. This will determine the person’s habilitative needs and the specialized services that will address those needs.

The habilitation coordinator must complete Form 1064, Habilitative Assessment, for the person, whether or not the he or she  will receive or has refused habilitation coordination:

  • within 75 calendar days following the initial interdisciplinary team (IDT) meeting; and
  • between 10 and 60 calendar days before the scheduled annual IDT meeting.

The habilitation coordinator ensures the completed assessment is sent to each SPT member at least 10 business days before the first quarterly SPT meeting after the initial IDT and SPT meeting and before the annual IDT and SPT meeting. 

Based on formal and informal assessments, the SPT determines if a person’s current specialized services need to be discontinued or if a new specialized service needs to be added.

5210 Reviewing Assessments

Revision 22-1; Effective Nov. 28, 2022

The habilitation coordinator reviews all applicable and available assessments and makes available copies of the assessments to each member of the SPT for review. If an assessment indicates:

  • the person can benefit from the specialized service,* the habilitation coordinator  monitors to determine that the service begins in the amount, frequency and duration identified on the assessment;
  • the person cannot benefit from the specialized service, the habilitation coordinator convenes the SPT to discuss how the identified outcome can be met; and
  • an outcome or goal that was not previously identified, the habilitation coordinator convenes the SPT to discuss the newly identified outcome or goal.

*A person can benefit from a specialized service if the service will help the person acquire new skills, maintain skills, or delay or slow the loss of skills or functioning.
Reviewing assessments provides a more comprehensive understanding of a person’s strengths, preferences and service needs, and helps SPT members outline services to meet the person’s identified goals and objectives. As the facilitator of the SPT meeting, the habilitation coordinator must ensure the needs identified in all assessments are addressed.
HHSC encourages the habilitation coordinator to bring copies of all current assessments to the SPT meeting, so that the SPT can review and discuss recommendations. The habilitation coordinator must provide copies of assessments to the nursing facility (NF). It is recommended for assessments to be grouped together to make maximum use of the quarterly SPT for review and discussion.
Functional assessments to consider as part of Form 1057, Habilitation Service Plan (HSP), and the NF comprehensive care planning process include, but are not limited to:

  • PASRR Evaluation (PE) or resident review;
  • MDS assessment;
  • Form 1064, Habilitative Assessment;
  • therapy  assessments;
  • psychiatric assessments;
  • behavior support assessments;
  • community participation and independent living skills training assessments;
  • medical and other clinical assessments; and
  • assessments conducted before admission to an NF, if still applicable (e.g., CFC Personal Assistance Services/Habilitation (PAS/HAB) assessment).

5300, SPT Meetings

Revision 22-1; Effective Nov. 28, 2022

The habilitation coordinator must convene and facilitate SPT meetings as described in this section for a person receiving habilitation coordination.

The habilitation coordinator must ensure that all members of the SPT receive sufficient notice to participate in the SPT meeting (at least 10 business days before the scheduled SPT meeting).

By facilitating the SPT meeting, the habilitation coordinator helps SPT members accomplish their responsibilities, which are to:

  • ensure that the person, whether or not they have an LAR, participates in the SPT to the fullest extent possible and receives the support necessary to do so, including communication supports;
  • review all available assessments to determine the person’s need for specialized services;
  • develop Form 1057, Habilitation Service Plan (HSP), for the person;
  • review and monitor identified risk factors, such as choking, falling and skin breakdown, and report to the proper authority (e.g., HHS Complaint and Incident Intake) if they are not addressed;
  • make timely referrals, service changes, and revisions to Form 1057, as needed; and
  • considering the person’s preferences, monitor to determine if he or she is given opportunities for engaging in integrated activities:
    • with residents of the NF who do not have ID or DD; and
    • in community settings with people who do not have a disability.

For an SPT meeting convened by the habilitation coordinator, the habilitation coordinator must ensure a sign-in sheet is provided to document the attendance of each participant, as well as the meeting date. If an SPT member participated by phone, the habilitation coordinator must ensure the member’s name is included on the sign-in sheet. The habilitation coordinator must maintain all sign-in sheets.

5310 First SPT Meeting

Revision 22-1; Effective Nov. 28, 2022

See Section 4500, Developing Individual Profile and Habilitation Service Plan at First SPT Meeting.

5320 Quarterly SPT Meetings

Revision 22-1; Effective Nov. 28, 2022

The initial or annual SPT meeting date sets the base schedule for the quarterly SPT meetings held between it and the next annual SPT meeting. A quarterly SPT meeting should take place three months after the first SPT meeting or the previous quarterly SPT meeting, no more than two weeks before or two weeks after the three-month mark, as set by the base schedule. Note that the base schedule only resets annually and does not reset with each quarterly SPT meeting.

The habilitation coordinator must maintain the every-three-month base schedule regardless of when a particular quarterly SPT meeting takes place. HHSC permits a habilitation coordinator to revise a person’s schedule for quarterly SPT meetings to accommodate alignment with the NF’s care plan meeting schedule, if the new date is within two weeks of the base schedule. Revising a person’s schedule for quarterly SPT meetings requires detailed documentation in the habilitation coordinator’s progress notes. The habilitation coordinator is responsible for coordinating with the NF so that the quarterly SPT meetings coincide with the NF’s quarterly service planning schedule.

5320.1 Required Activities during a Quarterly SPT Meeting

Revision 22-1; Effective Nov. 28, 2022

During each quarterly SPT meeting, the SPT must:

  • review all assessments conducted since the last SPT meeting to determine:
    • if the person is receiving all necessary specialized services and in the appropriate amount, frequency and duration; and
    • if all identified outcomes are being addressed;
  • review each specialized service being provided to the person to evaluate the effectiveness and adequacy of specialized services, including reviewing the written reports submitted by SPT members that are providers specialized  services as required by Section 5350, SPT Member that is a Provider of a Specialized Service;
  • discuss the progress, or lack of progress, in achieving all outcomes identified on Form 1057, Habilitation Service Plan (HSP), including if the person is maintaining progress toward outcomes; and
  • if CLO was conducted since the last quarterly SPT meeting, review and discuss the person’s completed Form 1054, Community Living Options, including addressing barriers to transitioning to the community or selecting a community program, if identified in Sections 6 or 7 of Form 1054 or by the SPT.

If Form 1057 or Form 1063, Individual Profile – Nursing Facility requires revisions based on the quarterly SPT meeting, the habilitation coordinator must revise Form 1057 or Form 1063 as needed and send it to the SPT members. They must do this within 10 calendar days after the meeting.

5320.2 Documenting Summary of Quarterly SPT Meeting

Revision 22-1; Effective Nov. 28, 2022

The habilitation coordinator must summarize the SPT discussions and decisions at a quarterly SPT meeting in a progress note.

5320.3 Documenting Specialized Services in the LTC Online Portal

Revision 22-1; Effective Nov. 28, 2022

Within five calendar days after a quarterly SPT meeting, the habilitation coordinator enters in the Long-Term Care (LTC) online portal all required information on the PASRR Comprehensive Service Plan (PCSP) form.

5330 Update SPT Meetings

Revision 22-1; Effective Nov. 28, 2022

The habilitation coordinator must convene an update SPT meeting: 

  • if the person experiences a change in medical condition that will affect the person’s specialized services;
  • if a change in the person’s specialized services is necessary; 
  • if a recent assessment shows:
    • the person cannot benefit from a specialized service; or
    • an outcome or goal that was not previously identified.

The habilitation coordinator must summarize the SPT discussions and decisions at an update SPT meeting in a progress note.

If Form 1057, Habilitation Service Plan (HSP), or Form 1063, Individual Profile – Nursing Facility, requires revisions based on the update SPT meeting, the habilitation coordinator must revise Form 1057 or Form 1063, as needed, and send it to the SPT members, within 10 calendar days after the meeting.
Within five calendar days after an update SPT meeting is held per the information in this section, the habilitation coordinator enters in the LTC online portal all required information on the PCSP form.

5340 Annual IDT and SPT Meeting

Revision 22-1; Effective Nov. 28, 2022

5340.1 Annual IDT/SPT Meeting

Revision 22-1; Effective Nov. 28, 2022

An annual IDT and SPT meeting is held for a person even if the person is receiving habilitation coordination or any other specialized service. The habilitation coordinator is responsible for inviting all SPT members to the annual IDT and SPT meeting.

Note: If the person has refused habilitation coordination, then there is no SPT for them, but the habilitation coordinator still must attend the annual IDT meeting. The NF is responsible for inviting IDT members to the annual IDT meeting.  
The IDT and SPT members must discuss Form 1064, Habilitative Assessment, conducted by the habilitation coordinator and all recommended specialized services and decide:

  • the specialized services the person (or LAR on the persons behalf) wants to receive;
  • whether the person is best served in the NF or the community; and
  • whether the person wants to transition to the community.

The habilitation coordinator must confirm the annual IDT and SPT meeting information in the LTC online portal on the PCSP form per Section 2520, Confirmation of IDT and SPT Meeting Information.

5340.2 Preparation for Annual IDT and SPT Meeting

Revision 22-1; Effective Nov. 28, 2022

The habilitation coordinator must complete Form 1064, Habilitative Assessment, for the person between 10 and 60 calendar days before the scheduled annual IDT and SPT meeting regardless of if the person is receiving habilitation coordination or any other specialized service. The habilitation coordinator provides a copy of the completed Form 1064 to all IDT and SPT members at least 10 business days before the annual IDT and SPT meeting.

5340.3 IDT Agrees to Habilitation Coordination

Revision 22-1; Effective Nov. 28, 2022

If the IDT agrees to the provision of habilitation coordination for the person, the habilitation coordinator requests a renewal authorization for habilitation coordination per the Habilitation Coordination Billing Guidelines.

5340.4 Refusal of Habilitation Coordination

Revision 22-1; Effective Nov. 28, 2022

If an eligible person or LAR does not want habilitation coordination:

  • the habilitation coordinator requests authorization for habilitation coordination per the Habilitation Coordination Billing Guidelines to fund the habilitation coordinator’s attendance at the IDT meeting; and
  • the habilitation coordinator uses Form 1044, Refusal of Habilitation Coordination, to document the refusal of habilitation coordination, obtains necessary signatures, provides the person or LAR a copy of the completed form and maintains the original completed form in the person’s record.

5340.5 Annual SPT Meeting

Revision 22-1; Effective Nov. 28, 2022

If the IDT agrees to the provision of habilitation coordination for an person, the habilitation coordinator convenes the annual SPT meeting immediately after the annual IDT meeting. An annual SPT meeting is conducted as described in  Section 5320, Quarterly SPT Meetings.

5350 SPT Member that is a Provider of a Specialized Service

Revision 22-1; Effective Nov. 28, 2022

Each SPT member that is a provider of specialized services must:

  • submit to the habilitation coordinator a copy of all assessments of the person completed by the provider;
  • at least five calendar days before a quarterly or annual SPT meeting, submit to the habilitation coordinator a written report describing the person’s progress or lack of progress;
  • provide the habilitation coordinator with a copy of the provider’s implementation plan for the person’s specialized service if requested; and
  • actively participate in an SPT meeting, in person or by phone, unless the habilitation coordinator determines active participation by the provider is not necessary. (See Section 5360, Determination that Participation in SPT Meeting is Not Necessary, below.)

5360 Determination that Participation in SPT Meeting is Not Necessary

Revision 22-1; Effective Nov. 28, 2022

If the habilitation coordinator determines active participation by a provider of a specialized service is not necessary, as described above in Section 5350, SPT Member that is a Provider of a Specialized Service, the habilitation coordinator must:

  • base the determination on:
    • the information in the written report submitted per Section 5350 above; and
    • the needs of the SPT; and
  • document the reasons for exempting participation.

5370 Guidance for Convening SPT Meeting When an Individual or LAR Does Not Want to Attend

Revision 22-1; Effective Nov. 28, 2022

This section gives guidance when the habilitation coordinator receives information from a person or LAR that they will not attend a scheduled SPT meeting.

  • Offer to reschedule the SPT meeting. Ask the person or LAR for a date and time they prefer and work with them to reschedule.
  • Provide adequate notice of the meeting. “Adequate notice” may mean something different to each person or LAR. An LAR may need several weeks’ notice. For a person who is disturbed by SPT meeting preparations, one hour may be adequate notice.
  • Offer to change the location of the SPT meeting. A person may prefer the meeting in their room instead of a conference room.
  • Offer the person or LAR the opportunity to participate by phone.
  • Offer to have other SPT members participate by phone if the meeting is too crowded for the person or LAR. Note that a provider agency representative may attend for two or more service providers if the representative is knowledgeable about the person’s services, implementation plans, progress or lack of progress, and satisfaction with services.
  • If a person or LAR states that the SPT meeting should proceed without them, the habilitation coordinator must find out what topics they want discussed at the meeting and afterward share with the person or LAR a summary of the discussion and the results of the SPT meeting.
  • If a person absolutely refuses to attend or participate in SPT meetings, the habilitation coordinator must initiate an SPT discussion about why the person refuses to attend or participate. The SPT members must attempt to identify and resolve barriers.

5400, Develop and Revise Habilitation Service Plan and Individual Profile

Revision 22-1; Effective Nov. 28, 2022

The habilitation coordinator must develop and revise a person’s Form 1057, Habilitation Service Plan (HSP), and Form 1063, Individual Profile – Nursing Facility, with the SPT as needed. Form 1057 and Form 1063 are individualized and developed through a person-centered process using ongoing discovery per each form’s instructions.

5410 Person-Centered Planning

Revision 22-1; Effective Nov. 28, 2022

Person-centered planning helps a person discover and describe what they need from services and from the service provider. The goal is to improve the person’s quality of life by making sure their preferences are articulated and honored. This includes convening an SPT meeting at a time that is convenient for the person and the LAR.

See the HHS website for more information about person-centered planning, including training.

5420 Discovery Process

Revision 22-1; Effective Nov. 28, 2022

Discovery is the process of listening to people and learning about what they want from their lives. It is getting to know people so that their personal outcomes, preferences, choices and abilities are understood, documented and  form the foundation for planning their services and supports. Discovery is the basis for person-centered planning and service delivery. It is an ongoing process that occurs each time the habilitation coordinator talks to the person or those who know the person best. The habilitation coordinator  leads the discovery process, advocating on behalf of the person whose services and supports are being planned, and records the information learned so that it can be used when developing or updating Form 1057, Habilitation Service Plan (HSP).

5430 Developing Habilitation Service Plan and Individual Profile

Revision 22-1; Effective Nov. 28, 2022

Form 1057, Habilitation Service Plan (HSP), and Form 1063, Individual Profile – Nursing Facility, identify a person’s strengths, preferences, psychiatric, behavioral, nutritional management and support needs, and desired outcomes. This information is gathered through discovery and through other sources, such as:

  • the PE;
  • records from the NF and previous providers;
  • Client Assignment and Registration system (CARE) (e.g., diagnostic data, previous local intellectual and developmental disability (LIDDA) services); and
  • previous ISPs and HSPs.

The HSP also address barriers to transitioning to the community or selecting a community program. These barriers are identified in Sections 6 or 7 of the most recent Form 1054, Community Living Options. The SPT may also identify and address barriers.

The HSP identifies the services and supports that are needed to meet the person’s needs, achieve the desired outcomes, and maximize the person’s ability to live successfully in the most integrated setting appropriate to their needs. The HSP must include all specialized services (including habilitation coordination) agreed upon during an IDT meeting or an SPT meeting within the HSP year, including the person’s desired outcomes.

The HSP year:

  • begin date is the date of the initial IDT and SPT meeting; and
  • end date is the 365th day following the begin date or 366th day in a leap year.
  • At a minimum, for each specialized service agreed upon during the IDT meeting, the HSP must indicate either:
  • an assessment will be conducted; or
  • the amount, frequency and duration of the specialized service to be provided.

 

5430.1 Specialized Services Requiring an Assessment

Revision 22-1; Effective Nov. 28, 2022

An assessment is required for:

  • all NF specialized services; and
  • the following IDD habilitative specialized services:
    • behavioral support;
    • employment assistance; and
    • supported employment.

The HSP must state an outcome that supports initiating an assessment.

5430.2 Specialized Services that Do Not Require an Assessment

Revision 22-1; Effective Nov. 28, 2022

For independent living skills training and day habilitation, the SPT identifies for inclusion in Section 5 of the HSP:

  • the outcome(s); and
  • the amount, frequency and duration based on the person's identified needs, interest and desired outcomes.

5430.3 Frequency and Duration of Habilitation Coordination

Revision 22-1; Effective Nov. 28, 2022

The duration for habilitation coordination is “while the person is residing in the nursing facility,” which is pre-printed on Form 1057, Habilitation Service Plan (HSP). The frequency of habilitation coordination is determined by the SPT per  the requirements in rule and Section 5100, Required Face-to-Face Visits.

5430.4 Barriers to Transitioning to the Community or Selecting a Community Program Identified During CLO

Revision 22-1; Effective Nov. 28, 2022

If barriers are identified during CLO and described in Sections 6 or 7 of Form 1054, Community Living Options, the habilitation coordinator initiates at an SPT meeting a discussion of  possible solutions to the barriers, how the SPT can implement the solutions and any follow-up activities. If the SPT identifies an additional barrier to the person’s transitioning to the community, the SPT must identify possible solutions to the barrier, how the SPT can implement the solutions (including who and when) and any follow-up activities.

Solutions to a barrier can include the provision of a specialized service or an additional outcome for an existing specialized service. For example, if a barrier to a person’s transition to the community is an inability to navigate public transportation, then the person may benefit from receiving independent living skills training with an outcome of learning how to use the public bus system.

The habilitation coordinator documents all identified barriers (i.e., from Sections 6 or 7 of Form 1054 and barriers identified by the SPT) and the solutions and follow-up actions for implementation in Section 7 of Form 1057, Habilitation Service Plan (HSP).

5440 Revising the Habilitation Service Plan and Individual Profile

Revision 22-1; Effective Nov. 28, 2022

Form 1057, Habilitation Service Plan (HSP), and Form 1063, Individual Profile – Nursing Facility, are reviewed at least quarterly and revised as necessary. Revisions to Form 1057 or Form 1063 must be completed and sent to the SPT members within 10 calendar days following the SPT meeting in which the revisions were agreed upon.

5440.1 Revising the HSP Because an Assessment for a NF Specialized Service is Completed

Revision 22-1; Effective Nov. 28, 2022

An assessment must be conducted for all NF specialized services. The results of an assessment are reflected in Section 6 of Form 1057, Habilitation Service Plan (HSP) as follows.

  • If the person can benefit from the service, the HSP includes:
    • the amount, frequency and duration from the assessment, except for CMWC or DME; and
    • the goals from the assessment.
  • If the person cannot benefit from the service, the HSP will indicate “discontinued.”

Note: The assessment results may impact the provision of an IDD habilitative specialized service. For example, if the person is receiving day habilitation five days per week and a therapy assessment shows they need therapy two days per week, then the amount or frequency of day habilitation may need to be reduced to allow for the provision of therapy.

A copy of all assessments for NF specialized services must be maintained in the person's record.

5440.2 Revising the HSP Because an Assessment for an IDD Habilitative Specialized Service is Completed

Revision 22-1; Effective Nov. 28, 2022

An assessment must be conducted for behavioral support, employment assistance and supported employment. The information included in a completed assessment indicates whether the person can benefit from the specialized service, and if so, should identify the necessary amount, frequency and duration for the service.

The results of an assessment are reflected in Section 5 of Form 1057, Habilitation Service Plan (HSP) in the appropriate outcome action plan as follows.

  • If the person can benefit from the service, the HSP includes the amount, frequency and duration. If the assessment identifies an additional outcome, include the additional outcome in Section 5 of the HSP as an additional outcome action plan if agreed to by the SPT.
  • If the person cannot benefit from the specialized service, the assessment should state why. This information is included in Section 5 of the HSP in the appropriate outcome action plan, and the HSP will indicate “discontinue.”
  • Assessment results may impact the provision of another IDD habilitative specialized service. Additionally, following delivery of an IDD habilitative specialized service, the SPT may revise the amount, frequency and duration to better reflect the person’s identified needs, interest and desired outcomes.

A copy of all assessments for behavioral support, employment assistance and supported employment must be maintained in the person's record.

5440.3 Revising the HSP to Address Barriers Identified During CLO

Revision 22-1; Effective Nov. 28, 2022

If barriers are during CLO and described in Sections 6 or 7 of Form 1054, Community Living Options, the habilitation coordinator initiates at an SPT meeting a discussion of  possible solutions to the barriers, how the SPT can implement the solutions and any follow-up activities. If the SPT identifies an additional barrier to the person transitioning to the community, the SPT must identify possible solutions to the barrier, how the SPT can implement the solutions (including who and when) and any follow-up activities.

Solutions to a barrier can include the provision of a specialized service or an additional outcome for an existing specialized service. For example, if a barrier to a person’s transition to the community is an inability to navigate public transportation, then the person may benefit from receiving independent living skills training with an outcome of learning how to use the public bus system.

The habilitation coordinator documents all identified barriers (i.e., from Sections 6 or 7 of Form 1054 as well as barriers identified by the SPT) and the solutions and follow-up actions for implementation in Section 7 of Form 1057, Habilitation Service Plan (HSP).

5450 New Habilitation Service Plan for Next HSP Year

Revision 22-1; Effective Nov. 28, 2022

Following an annual SPT meeting, the habilitation coordinator must complete a new Form 1057, Habilitation Service Plan (HSP), for the next HSP year that includes all new and ongoing information, such as:

  • outcomes and the specialized services and natural supports that help the person achieve the outcomes, including amount, frequency and duration;
  • NF and MI specialized services, including amount, frequency and duration;
  • barriers preventing transition to the community or selection of a community program identified during a CLO or by the SPT; and
  • informational and educational opportunities that have been offered to the person and LAR but have not yet occurred.

Discontinued specialized services and barriers that have been resolved are not included in the new HSP for the next HSP year.

The new HSP year:

  • begin date is the date of the annual IDT and SPT meeting; and
  • end date is the 365th day following the begin date or 366th day in a leap year.

Note: It is unlikely the annual IDT and SPT meeting date will occur exactly 12 months after the initial or previous annual IDT/SPT meeting date. The LTC online portal allows for an annual IDT and SPT meeting to take place as early as 334 calendar days after the initial or previous annual IDT and SPT meeting. This means the HSP year will not always be a full 12-month period.

5460 Documents in an Individual’s Habilitation Packet

Revision 22-1; Effective Nov. 28, 2022

A complete habilitation packet for a person has:

  • Form 1063, Individual Profile – Nursing Facility (see Section 5460.1, Individual Profile, below);
  • Form 1057, Habilitation Service Plan (HSP) (see Section 5460.2, Habilitation Service Plan); and
  • the following attachments:
    • the most current Form 1054, Community Living Options; and
    • the  NF baseline care plan or comprehensive care plan, whichever is most current.

5460.1 Individual Profile

Revision 22-1; Effective Nov. 28, 2022

Information documented on Form 1063, Individual Profile – Nursing Facility.

Section 1, Individual’s Information — This section gathers identifying information about a person as well as contact information for the person, LAR and primary contact, if any, and information about a person’s language preferences, ambulation abilities and accommodation needs.

Section 2, Nursing Facility and LIDDA Information — This section gathers name and contact information for NF and LIDDA staff.

Section 3, People Important to the Individual — The section identifies the important people in the person’s life and who can provide information about the person, such as family, friends, mentor and clergy.

Section 4, Profile Information — This section provides an overall profile of a person’s strengths, preferences and needs, learned during the discovery process.

These are my strengths and what people like and admire about me: A descriptive narrative about the person’s strengths and what others like and admire about the person.

These are my preferences and what is important to me: A descriptive narrative about what is important to the person. “Important to” reflects what is important from the person’s perspective and is based on the person’s words and behavior. When words or behavior are in conflict, listen to the behavior. The information might include important relationships, how the person prefers to interact, things the person likes to do or not do, preferred routines, relevant background information that may affect how services should be delivered and what the person wants to do in the future. Remember, the person’s response is limited to the knowledge and experiences they have to date. Additional efforts should be explored to increase awareness of o possibilities and experiences to increase  options of choice. This section could also include personal preferences (e.g., sleep with the light on, blackout curtains needed on windows, baths in the evenings only).

This is what others need to know and do to support me in the following areas: A descriptive narrative about what is important for the person, as identified by those who know him or her best. “Support me” reflects information that is important for the service provider to know and understand about the person. All specific areas listed below must be addressed and include specificity about health needs, risk factors and special instructions for those who support the person. See Appendix IV, Risk Factors, for more information about identifying risks.

  • Communication — A descriptive narrative about how the person communicates and how to best communicate with the person. Describe the person’s communication-related needs. For instance, what is the person’s primary or preferred method of communication? How does the person communicate or express a need (gestures, sounds, facial expressions, adaptive equipment, etc.)? What is the best way to determine if the person is expressing satisfaction, happiness, comfort or agreement, as opposed to dissatisfaction, unhappiness, discomfort or disagreement? Among those who know the person best, who seems better able to interpret what the person is trying to communicate? What is the best way for others to learn how to communicate effectively with the person?
  • Nursing Care — A description of the person’s nursing-related needs, such as assistance taking medication, suctioning, wound care and oxygen. Describe how staff should attend to the person’s nursing needs.
  • Clinical (Behavioral/Mental Health) — A description of the person’s behavioral health and mental health-related needs. What kind of behavior supports does the person need? Does the person need counseling services or psychiatric services for medication management?
  • Medical and Dental — A description of all medical and dental concerns, diagnoses and routine procedures (e.g., medication management, blood work, history of constipation, dental cleaning, x-ray or sedation needs).
  • Adaptive Aids and Medical Supplies — A description of the adaptive aids (e.g., wheelchair, walker, shower chair) and medical supplies (e.g., briefs, test strips) needed by the person and how they are funded (e.g., Medicaid, personal funds) or obtained (e.g., leased, purchased).
  • Nutrition Management — A description of the person’s nutritional-related needs (e.g., thickened, pureed, textured, use of supplements, food allergies or restrictions, choking risk).
  • Supervision Needs — A description of the person’s supervision needs. Consider if there are any personal issues that might present risk for harm in the person’s living arrangement (e.g., daily rituals, threats of suicide or physical harm to self or others, inability to handle a personal crisis). Describe the supports needed to address any risks, such as line of sight, one-to-one, limited proximity or door alarm. Is the person currently receiving these supports?
  • Other things people need to know about me, if any.
  • Risk factors not otherwise addressed above, such as those related to safety or exploitation.

Historical information: Include background information that continues to significantly affect the person or their services.

5460.2 Habilitation Service Plan

Revision 22-1; Effective Nov. 28, 2022

Information documented on Form 1057, Habilitation Service Plan (HSP).

Section 1, Individual Information — This section gathers identifying information about a person and identifies the HSP year and plan date.

Section 2, Discovery — This section describes all the ways information was gathered to discover a person’s desires and preferences, such as observation of the person and conversations with the person or LAR and those who know the person best, such as a NF staff, caregiver, family member or friend.

Section 3, Changes Made to the HSP — This section is where changes to the HSP made within the previous 12 months are described.

Section 4, Habilitation Coordination Plan — This section describes the habilitation coordination plan, including duration and frequency of face-to-face meetings between the person and the habilitation coordinator. The duration of habilitation coordination is while the person is living in the NF and is pre-printed on the form. The frequency of face-to-face visits is determined by the SPT within the constraints of Section 5100, Required Face-to-Face Visits, and  may be either at least monthly or at least quarterly.

This section also lists all the activities to be coordinated and monitored by the habilitation coordinator. The first two activities are pre-printed because they are mandatory. If the NF agreed to provide NF PASRR support activities, then each support activity to be provided by the NF must be listed as an activity that will be monitored by the habilitation coordinator. The PASRR rules provide a definition of “NF PASRR support activities” and includes the following examples of support activities:

  • arranging transportation for [a person ] to participate in an IHSS or a MI specialized service outside the [NF];
  • sending a person to a IHSS service or MI specialized service with food and medications required by the person; and
  • stating in the NF comprehensive care plan an agreement to avoid, when possible, scheduling NF services at times that conflict with IHSS or MI specialized services.

Note: The examples above are not all inclusive. A support activity can be any type of activity that supports the person to receive specialized services.

Section 5, Outcome Action Plan — A separate outcome action plan is needed for each identified outcome. An outcome identifies what the person wants to do, achieve, change, maintain or experience. For an identified outcome, the outcome action plan must identify all specialized services and other resources and natural supports the person receives that will help the person achieve the outcome. Each outcome action plan provides space to identify IDD habilitative specialized services, NF specialized services, MI specialized services and other resources/natural supports, as necessary and unique to the outcome. For each specialized service and resources or natural support listed, a description is necessary of how the specialized service or resource or natural support helps the person achieve the outcome.

Note: While a NF specialized service or MI specialized service may be listed in a particular outcome action plan, all NF specialized services and MI specialized services for the person must be included in Section 6 of the HSP.

Section 6, NF Specialized Services to be Monitored by the SPT — This section is for recording all NF specialized services and MI specialized services provided to the person during the HSP year, including:

  • the goals for the service as identified by the licensed therapist on the therapy assessment or as identified by the LMHA or LBHA staff;
  • the amount, frequency and duration of the service; and
  • if the service was discontinued during the HSP year, and if so the date of discontinuance.

The form allows the user to add lines for more than one NF specialized service and MI specialized service.

Section 7, Preference Regarding Transitioning — Each time the habilitation coordinator presents CLO to the person or LAR during the HSP year, the CLO date is included in this section of the HSP. Also included in this section are barriers to preventing a transition to the community from Section 6 of Form 1054, Community Living Options, or barriers to selecting a community program from Section 7 of Form 1504, if any. If there are barriers, the SPT’s proposed solutions and follow-up activities are also included in this section of the HSP. The SPT may identify additional barriers.

Section 8, Educational Activities — This section is used to describe all CLO educational, informational, and support activities offered to the person, LAR, and actively involved people. If an offered activity was attended, the information about attendance is also included in this section.

Section 9, Documentation of Exploration of Community Programs — This section is used to describe the community living settings where a visit is planned or has occurred. When the visit has occurred, a summary of the outcome of the visit is included in this section.

Section 10, HC Signature — This section is for the habilitation coordinator to affirm that the HSP was developed based on IDT or SPT decisions and includes the habilitation coordinator’s printed name, signature and date.

5470 Sharing the Habilitation Service Plan, Individual Profile and Habilitation Packet

Revision 22-1; Effective Nov. 28, 2022

The habilitation coordinator is responsible for providing a copy of the current Form 1057, Habilitation Service Plan (HSP), and Form 1063, Individual Profile – Nursing Facility, to all SPT members within 10 calendar days after the SPT meeting during which they were developed  or revised.

The habilitation coordinator must share a person’s habilitation packet with an SPT member upon request.

5480 SPT Member Believes HSP or Individual Profile Does Not Accurately Reflect SPT Decisions or Information about the Individual

Revision 22-1; Effective Nov. 28, 2022

If an SPT member believes Form 1057, Habilitation Service Plan (HSP), or Form 1063, Individual Profile – Nursing Facility, does not accurately reflect an SPT decision or information about the person, then:

  • if the habilitation coordinator agrees with the SPT member, the habilitation coordinator corrects Form 1057 or Form 1063 to accurately reflect the SPT decision or person’s information; or
  • if the habilitation coordinator does not agree with the SPT member, the habilitation coordinator presents the issue to the SPT to resolve the discrepancy. 

5500, Assisting with Access to Needed Specialized Services

Revision 22-1; Effective Nov. 28, 2022

5510 Initiating IDD Habilitative Specialized Services

Revision 22-1; Effective Nov. 28, 2022

The habilitation coordinator is responsible for initiating IDD habilitative specialized services identified on a person’s Form 1057, Habilitation Service Plan (HSP), within 20 business days after the date of an IDT meeting or SPT meeting of any kind. “Initiating” means to take necessary action that will result in the person receiving specialized services in a timely manner.

Note: The NF is responsible for requesting NF specialized services in the LTC online portal within 20 business days after the date of an IDT meeting or SPT meeting.

5520 Monitoring the Initiation and Delivery of all Specialized Services

Revision 22-1; Effective Nov. 28, 2022

The habilitation coordinator must document the initiation and delivery of all specialized services agreed upon in an IDT meeting or an SPT meeting.

The habilitation coordinator must report to Complaint and Incident Intake (800-458-9858) a noncompliant entity (i.e., LIDDA, NF or LMHA/LBHA) if the entity fails to:

  • initiate or request a specialized service by the 20th business day after the service was agreed to in an IDT meeting or SPT meeting; or
  • deliver a specialized service:
    • for NF therapy services — within three business days after receiving approval from HHSC in the LTC online portal;
    • for behavioral support, employment assistance and supported employment — within three business days after the habilitation coordinator receives the completed assessment; and
    • for independent living skills training and day habilitation — within 20 business days after the service was agreed to in an IDT meeting or SPT meeting.

Note: In addition to a report to Complaint and Incident Intake for a noncompliant entity, as noted above, a LIDDA is responsible for submitting monthly noncompliance reports to HHSC per the performance contract.

5530 Accessing Other Habilitative Programs

Revision 22-1; Effective Nov. 28, 2022

The habilitation coordinator must help a person access needed specialized services and other habilitative programs and services that can provide services to address the person’s needs and achieve outcomes identified in the HSP.

5540 Assisting Individual or LAR with Requesting a Fair Hearing for Denial of NF Specialized Services

Revision 22-1; Effective Nov. 28, 2022

If a person is denied a specialized service and the person or LAR wants to appeal the denial, the habilitation coordinator is responsible for helping the person or LAR with requesting a fair hearing. Form 2361, PASRR Specialized Services Fair Hearing Request may be used for this purpose.

5600, Coordination

Revision 22-1; Effective Nov. 28, 2022

The habilitation coordinator is responsible for:

  • coordinating with other habilitative programs and services that can address needs and achieve outcomes identified in Form 1057, Habilitation Service Plan (HSP);
  • facilitating the coordination of a person’s HSP and the NF comprehensive care plan; and
  • coordinating with the NF in accessing medical, social, educational and other appropriate services and supports that will help a person achieve a quality of life acceptable to the person and LAR .

5700, Monitoring and Follow-up Activities

Revision 22-1; Effective Nov. 28, 2022

The habilitation coordinator must provide monitoring and follow-up activities to determine:

  • whether a person receives the specialized services agreed upon in an IDT or SPT meeting and follow up when delays occur;
  • whether a person’s Form 1057, Habilitation Service Plan (HSP), is fully implemented;
  • a person’s and LAR’s satisfaction with all specialized services; and
  • a person’s progress or lack of progress toward achieving goals and outcomes identified in Form 1057.

Monitoring  is accomplished through a combination of:

  • observation of the person receiving services;
  • conversations with the person, LAR, NF staff or provider; and
  • review of documentation, service delivery logs or written reports from a provider.

When monitoring progress or lack of progress and satisfaction, the habilitation coordinator must be sure to include the perspective of the person and LAR.

The habilitation coordinator must share the results of the habilitation coordinator’s monitoring and follow-up activities with the STP .

5800, Community Living Options, Visits to Community Programs, and Educational Opportunities

Revision 22-1; Effective Nov. 28, 2022

5810 Presenting CLO

Revision 22-1; Effective Nov. 28, 2022

The habilitation coordinator provides information and discusses with a person and LAR the range of community living services, supports and alternatives. They identify the services and supports the person will need to live in the community, if the person or LAR has chosen to transition to community living, and identify and address barriers to community living. This activity is referred to as “CLO.”

Present CLO in a manner that allows the person and LAR to fully understand the options available. Therefore, CLO duration may vary but should last as long as needed to completely and meaningfully present all available community living options. If there are barriers to the person’s or LAR’s full understanding of CLO, the habilitation coordinator must document these barriers in Form 1054, Community Living Options, and how they will be addressed in Form 1057, Habilitation Service Plan (HSP).
 

5810.1 When CLO is Presented

Revision 22-1; Effective Nov. 28, 2022

CLO is presented at the following times regardless of whether the person is receiving or has refused habilitation coordination*:

  • Six months after the initial CLO (which was presented during the PE) and at least every six months thereafter. HHSC recommends that CLO be completed no more than 30 days before the scheduled second quarterly SPT meeting or annual IDT and SPT meeting, so that it can be discussed during the meeting.
  • When requested by the person or LAR.
  • When the habilitation coordinator is notified or becomes aware that the person or LAR is interested in speaking with someone about transitioning to the community.
  • When notified by HHSC that the person’s response in Section Q of the MDS assessment indicates the person is interested in speaking with someone about transitioning to the community.    

Note: CLO is presented anytime a PE is completed, including for a resident review or change of ownership.

*Some people and LARs who have refused habilitation coordination or are not interested in transitioning to the community may be reluctant to receive CLO every six months. As part of a person-centered approach, the habilitation coordinator should remain sensitive to the person’s or LAR’s preferences, ensure the person and LAR understand the importance of presenting CLO, and conduct CLO activities in a way that is responsive to the person’s or LAR’s concerns.

5810.2 Six-month Base Schedule

Revision 22-1; Effective Nov. 28, 2022

The habilitation coordinator presents CLO to the person or LAR six months after the initial CLO and at least every six months thereafter while the person continues to reside in the NF. The habilitation coordinator must maintain the every-six-month base schedule beginning with the initial CLO, even if an additional CLO was presented before the next six-month CLO is due.

5810.3 CLO Materials Provided to Individual or LAR

Revision 22-1; Effective Nov. 28, 2022

The habilitation coordinator uses the following materials to present CLO and explains each of the materials using the person’s preferred method of communication, taking the time necessary to ensure that the person and  LAR fully understand the materials and each of the person’s community options:

*CLO booklets are available by ordering from Pinnacle Cart.

5820 Documenting CLO

Revision 22-1; Effective Nov. 28, 2022

The HC documents the CLO presentation and discussion on Form 1054, Community Living Options. The habilitation coordinator must fill out Section 4 on Form 1054 whether the person is interested in transitioning to the community or not.

Note: The habilitation coordinator also documents barriers from Sections 6 or 7 of Form 1054 in Section 7 of Form 1057, Habilitation Service Plan (HSP). See Section 5460.2, Habilitation Service Plan.

5830 Habilitation Coordinator Actions Following CLO

Revision 22-1; Effective Nov. 28, 2022

The habilitation coordinator complies with the requirements in this section following:

  • the habilitation coordinator’s receipt of CLO information from the PE evaluator per Section 2430.5, Presenting Information about Community Services as Part of the PE; and
  • the habilitation coordinator’s presentation of CLO to the person or LAR.

5830.1 Individual or LAR Wants to Transition and has Selected a Community Program

Revision 22-1; Effective Nov. 28, 2022

If a person wants to transition to the community and has selected a community program, the habilitation coordinator must, within three business days after receipt of CLO information from the PE evaluator, or within three business days after the habilitation coordinator’s presentation of CLO,

  • send a referral using Form 1579, Referral for Relocation Services, to the person’s  managed care organization (MCO) (see Appendix II, MCO Contact Information) so that a relocation specialist (RS) can be assigned and an assessment and evaluation completed within 14 calendar days; and
  • notify the appropriate LIDDA staff to assign a service coordinator (SC) or an enhanced community coordinator (ECC) to begin transition planning with the person and LAR.

The habilitation coordinator must:

  • ensure receipt of the RS’s assessment and evaluation;
  • review the RS’s assessment and evaluation to determine if specialized services can help the person transition to the community and, if so, follow up with an SPT meeting to discuss the issue;
  • ensure the assigned SC/ECC receives a copy of the RS’s assessment and evaluation;
  • share a copy of the person’s habilitation packet with the RS and SC/ECC; and
  • inform the RS of the name and contact information of the SC/ECC who will be facilitating transition planning for the person.

5830.2 Individual or LAR Wants to Transition, but has NOT Selected Community Program

Revision 22-1; Effective Nov. 28, 2022

If a person wants to transition to the community, but has not selected the community program to pursue, the habilitation coordinator must, within three business days after receipt of CLO information from the PE evaluator or after the habilitation coordinator’s presentation of CLO, send a referral, using Form 1579, Referral for Relocation Services, to the person’s MCO (see Appendix II, MCO Contact Information) so that an RS can be assigned and an assessment and evaluation completed within 14 calendar days.
The habilitation coordinator must:

  • ensure receipt of the RS’s assessment and evaluation;
  • review the RS’s assessment and evaluation to determine if specialized services can help the person transition to the community and, if so, follow up with an SPT meeting to discuss the issue;
  • share a copy of the person’s habilitation packet with the RS;
  • work with the RS to help the person and LAR in selecting a community program that best suits the person’s needs. Note: Waiver comparison chart is available here; and
  • if the person has not refused habilitation coordination, ensure that if barriers to selecting a community program are identified in Section 7 of the completed Form 1054, Community Living Options, they are included in Section 7 of Form 1057, Habilitation Service Plan (HSP) for SPT discussion.

When the person or LAR has selected a community program, the habilitation coordinator must:

  • notify the appropriate LIDDA staff to assign an SC or an ECC to begin transition planning with the person and LAR;
  • share with the SC/ECC:
    • a copy of the RS’s assessment and evaluation; and
    • a copy of the person’s habilitation packet; and
  • inform the RS of the name and contact information of the SC/ECC who will be facilitating transition planning for the person.

5830.3 Individual or LAR Does Not Want to Transition, is Undecided or Desire of Individual or LAR Cannot be Determined

Revision 22-1; Effective Nov. 28, 2022

For a person who has not refused habilitation coordination, if the person or LAR does not want to transition, is undecided or the desire of the person or LAR cannot be determined, the habilitation coordinator must:

  • ensure that if barriers preventing a transition to the community are identified in Section 6 of Form 1054, Community Living Options, they are included in Section 7 of Form 1057, Habilitation Service Plan (HSP);
  • ensure the barriers are discussed at the next quarterly SPT meeting with the SPT identifying possible solutions to the barriers, how the SPT can implement the solutions and any needed follow-up activities; and
  • document the resolutions and actions for implementation in Section 7 of Form 1057.

5840 Exploring Community Programs

Revision 22-1; Effective Nov. 28, 2022

The habilitation coordinator arranges exploratory visits to community programs for a person, if requested, and addresses concerns about community living from the person and LAR. Additionally, the habilitation coordinator may assist a person and LAR with exploring different types of community programs using print and digital media, such as brochures, magazines, DVDs, virtual visit apps and virtual tours.

5850 Educational Opportunities

Revision 22-1; Effective Nov. 28, 2022

The habilitation coordinator offers a person and LAR the educational and informational opportunities that are required to be arranged by the LIDDA semiannually pursuant to the performance contract. The habilitation coordinator must document that the offer was made, including the specific educational or informational opportunity (i.e., description, location, date and time).

5900, Additional Habilitation Coordinator Responsibilities

Revision 22-1; Effective Nov. 28, 2022

5910 Explanation of Rights

Revision 22-1; Effective Nov. 28, 2022

The habilitation coordinator must initially, and annually thereafter, provide a person and LAR an oral and written explanation of the person’s rights contained in the “Your Rights in Local Authority Services” booklet.

Rights booklets are available on the HHS website. Rights booklets may also be ordered by sending an email to OmbudsmanIDD@hhs.texas.gov.

The habilitation coordinator must document every time the habilitation coordinator gives the written and oral explanations to the person, LAR, or actively involved person. The documentation must be signed by the person or LAR and the habilitation coordinator.

5920 Activities Related to Guardianship

Revision 22-1; Effective Nov. 28, 2022

5920.1 Individual Has a Guardian

Revision 22-1; Effective Nov. 28, 2022

The habilitation coordinator must determine annually if the letters of guardianship for a person are current. The letter of guardianship is required to be renewed in the county court annually. The habilitation coordinator annually must request the current letter of guardianship and keep a copy in the person’s record.

The habilitation coordinator must document in the HSP whether the letter of guardianship is current.

If the letter of guardianship is not current, the habilitation coordinator must provide a reminder to the guardian that a renewal needs to be completed and document that the guardian was provided this reminder.

5920.2 Individual Does Not Have a Guardian

Revision 22-1; Effective Nov. 28, 2022

If a person does not have a guardian and may benefit from having one, the habilitation coordinator, along with the SPT, must assess if the person needs a guardian or would benefit from a less restrictive alternative to guardianship, and must document this discussion. If the SPT believes guardianship is the least restrictive option, the habilitation coordinator makes appropriate referrals, such as to the local probate court.

See Appendix III, Legal Authority to Make Decisions, for information about types of guardianship and alternatives. 
 

6100, Assigning a Service Coordinator or Enhanced Community Coordinator and Working with the Relocation Specialist

Revision 23-1; Effective Dec. 20, 2023

6110 Assigning an Enhanced Community Coordination (ECC) Coordinator

Revision 23-1; Effective Dec. 20, 2023

When the habilitation coordinator notifies the appropriate local intellectual and developmental disability authority (LIDDA) staff that a person or legally authorized representative (LAR) wants to transition to the community and has selected a community program, the LIDDA must assign an ECC coordinator to begin transition planning with the person and LAR.

Within seven calendar days after notification by the habilitation coordinator:

  • the LIDDA assigns an ECC coordinator to the person and ensures the assigned ECC coordinator is identified in the Client Assignment and Registration system (CARE) screen 490; and
  • the assigned ECC coordinator meets in person with the person and LAR to describe the transition planning process and gain an understanding of the person’s and LAR’s perspective of community living.
     

6110.1 Unassigning an ECC Coordinator

Revision 23-1; Effective Dec. 20, 2023

If, during transition planning, a person indicates that they are no longer interested in transitioning to the community, the LIDDA unassigns the ECC coordinator and ensures the un-assignment is reflected in CARE screen 490.

Before being unassigned, the ECC coordinator notifies the relocation specialist (RS) and the habilitation coordinator that the person is no longer interested in transitioning to the community.

6120 Working with the Relocation Specialist

Revision 23-1; Effective Dec. 20, 2023

The ECC coordinator reviews the relocation assessment and evaluation and contacts the RS and managed care organization (MCO) service coordinator (SC) to invite them to service planning team (SPT) meetings for transition planning. The RS becomes a member of the SPT.

Note: The MCO SC is already an SPT member and is invited to all SPT meetings unless the person objects. The habilitation coordinator should ask the person or LAR, if applicable, directly whether they are okay with or object to the MCO service coordinator’s attendance at interdisciplinary team (IDT) and service planning team (SPT) meetings and must document evidence of this discussion in the person’s record. 

6130 Relocation Specialist and MCO SC Responsibilities

Revision 23-1; Effective Dec. 20, 2023

The MCO SC and RS, as members of the SPT, assist a person with accessing:

  • housing, transportation, medical, dental and prescriptions, depending on the program the person chooses; and
  • Supplemental Transition Support (STS) funding if the person qualifies.

STS is available to pay for essential items not covered by Transition Assistance Services (TAS), which is a waiver program service. STS may be used when TAS funds have been exhausted. The RS will provide the ECC coordinator with a copy of the completed STS form signed by the MCO, the RS and the ECC coordinator.

Note: For people transitioning to the Home and Community-based Services (HCS) program, the ECC coordinator is responsible for completing and submitting the assessment for TAS funding. For people transitioning to the Community Living Assistance and Support Services (CLASS), Deaf Blind with Multiple Disabilities (DBMD) or Home and Community Based Services (HCBS) (STAR+PLUS Waiver) program, the RS is responsible for completing and submitting the assessment for TAS funding.

The MCO SC and RS are required to be present at the person's new address on relocation day to ensure all services are in place and to assist in setting up the household, as needed. The ECC coordinator is encouraged to be there as well.

6140 Enhanced Community Coordination Funds 

Revision 23-1; Effective Dec. 20, 2023

Enhanced community coordination (ECC) funds are available to LIDDAs through the performance contract for a person who is transitioning to the community. The purpose of the funds is to enhance a person’s natural supports and promote successful community living. Funds are intended to pay for:

  • one-time emergency assistance, such as:
    • rental or utility assistance;
    • nutritional supplements;
    • clothing; and
    • medication;
  • items to address a person's special needs, including minor home modifications not funded by other sources;
  • transportation to and from trial visits with community providers; and
  • educational tuition assistance, such as vocational programs through community colleges so a person can develop job skills.

A LIDDA should contact IDDMFPSupport@hhs.texas.gov to discuss processes and how to access funds prior to any purchases.

6200, Transition Planning

Revision 23-1; Effective Dec. 20, 2023

An ECC coordinator is responsible for:

  • convening and facilitating SPT meetings, as necessary, to conduct transition planning and to develop and implement the person’s Form 1053, Transition Plan, regardless of the program chosen by the person;
  • ensuring that the members of the SPT (specifically providers of specialized services, the nursing facility and the MCO) receive sufficient notice to participate in the SPT meeting (at least 10 business days before the scheduled SPT meeting); 
  • ensuring the SPT uses the relocation assessment and evaluation, other assessments (e.g., medical and behavioral), and the latest Form 1054, Community Living Options, to guide the development of Form 1053;
  • documenting the SPT discussions and decisions in a progress note;
  • developing and revising the Transition Plan per Section 6300, Developing and Revising the Transition Plan; and
  • coordinating with the MCO SC and RS, as needed, in accessing community resources the person may need or be eligible for, including transportation, housing, medical, dental and other services.

For an SPT meeting convened by the ECC coordinator, the ECC coordinator must ensure a sign-in sheet is provided to document the attendance of each participant, as well as the meeting date. If an SPT member participated by phone, the ECC coordinator must ensure that member’s name is included on the sign-in sheet. The ECC coordinator must maintain all sign-in sheets.
 

6210 SPT Meeting Participation

Revision 23-1; Effective Dec. 20, 2023

6210.1 ECC Coordinator Participation

Revision 23-1; Effective Dec. 20, 2023

The ECC coordinator must participate in person or by phone at all SPT meetings convened by the habilitation coordinator.

6210.2 Habilitation Coordinator Participation

Revision 23-1; Effective Dec. 20, 2023

The habilitation coordinator must participate in person or by phone at all SPT meetings convened by the ECC coordinator.

6210.3 Program Provider and Relocation Specialist Participation

Revision 23-1; Effective Dec. 20, 2023

The ECC coordinator and habilitation coordinator must ensure the community program provider and RS are invited to all SPT meetings, including those convened by the habilitation coordinator. However, the program provider and RS are only required to attend SPT meetings convened by the ECC coordinator related to transition planning.

6300, Developing and Revising the Transition Plan

Revision 23-1; Effective Dec. 20, 2023

In conjunction with the SPT, the ECC coordinator develops and revises, as needed, a person’s Form 1053, Transition Plan. The ECC coordinator must develop Form 1053, or revise it as needed, and send it to the SPT members within 10 calendar days after the SPT meeting.

6310 Transition Plan

Revision 23-1; Effective Dec. 20, 2023

Information documented on Form 1053, Transition Plan.

Section 1, Individual Information — Name of the person, CARE ID, Medicaid number and date.

Section 2, Community Program Choice — This section identifies the community program selected by the person or LAR, the name of the responsible party for requesting a slot and the projected date of request.

Section 3, Service Coordination Plan — This section describes the service coordination plan, including duration and frequency of in-person meetings between the person and the ECC coordinator, which are pre-printed on the form. The duration of service coordination is throughout the transition process, and the frequency of in-person visits is at least monthly. This section also lists all the activities to be coordinated and monitored by the ECC coordinator during the transition process.

Section 4, Identified Supports — This section describes all supports the person needs to live in the community, whether they are essential or non-essential, whether the selected living option provides the support, the due-date for the provision of non-essential support, and the name of the responsible party for ensuring the support is provided.

Section 5, Plan for Choosing a Program Provider — This section has a summary of the person's or LAR’s plan for choosing a program provider, such as conducting interviews and trial visits with potential program providers, the name of the responsible party for implementing the plan, and the projected date of completion.

Section 6, Barriers to Transitioning to a Program — The barriers listed in this section originate in Section 8 of Form 1054, Community Living Options, and additional barriers may be identified by the SPT. As transition planning progresses, some of the barriers may change and some will be resolved. This section also describes the SPT’s possible solutions to the barriers, how the SPT can implement the solutions, and any needed follow-up activities.

Section 7, Transitioning from the Nursing Facility — This section identifies the selected program provider and the projected move date. It also includes the pre-move preparations that must be arranged before the day of transition and the name of the responsible party for ensuring the arrangement is made.

Section 8, Post-Move Monitoring Dates — This section auto-populates the period in which post-move monitoring visits must be conducted by an ECC coordinator.

Section 9, Community Living Data — This section is for listing all community living information, including names, contacts, addresses and phone numbers. It serves as a quick reference for important information related to serving a person. This information must be included as it becomes known.

Section 10, Agreements — This section describes the agreements between the LIDDA and the community program provider.

Section 11, Service Coordinator Signature — This section is for the ECC coordinator to affirm that the Transition Plan was developed based on SPT decisions and includes the ECC coordinator’s printed name, signature and date.

6320 Barriers Preventing a Transition to the Community

Revision 23-1; Effective Dec. 20, 2023

The ECC coordinator must:

  • ensure that if barriers preventing a transition to the community are identified in Section 8 of Form 1054, Community Living Options, they are included in Section 6 of Form 1053, Transition Plan, in addition to any barriers the SPT may identify;
  • ensure the SPT discusses the barriers, possible solutions to the barriers, and how the SPT can implement the solutions and any needed follow-up activities; and
  • document the resolutions and actions for implementation in Section 6 of Form 1053.

6330 Documents in an Person's Transition Packet

Revision 23-1; Effective Dec. 20, 2023

A complete transition packet for a person has:

6340 Individual Profile

Revision 23-1; Effective Dec. 20, 2023

Form 1063, Individual Profile – Nursing Facility, is addressed in Section 5460.1, Individual Profile, and is developed and revised by the habilitation coordinator.

Note: If revisions to the person’s Form 1063 are necessary based on discussions during an SPT meeting convened by the ECC coordinator, then the habilitation coordinator is responsible for making the necessary revisions and sharing the revised Form 1063 with the ECC coordinator and the other SPT members.

6350 Sharing the Transition Plan, Individual Profile, and Transition Packet

Revision 23-1; Effective Dec. 20, 2023

The ECC coordinator is responsible for providing a copy of the person’s Form 1053, Transition Plan, to all SPT members within 10 calendar days after the SPT meeting during which it was developed or revised.

The ECC coordinator must also share a person’s transition packet with an SPT member upon request.

6360 SPT Member Believes Transition Plan Does Not Accurately Reflect SPT Decisions

Revision 23-1; Effective Dec. 20, 2023

If an SPT member believes Form 1053, Transition Plan, does not accurately reflect SPT decisions, then:

  • if the ECC coordinator agrees with the SPT member, the ECC coordinator corrects Form 1053 to accurately reflect the SPT decision; or
  • if the ECC coordinator does not agree with the SPT member, the ECC coordinator presents the issue to the SPT to resolve the discrepancy.
     

6400, Pursuing the Selected Community Medicaid Program for Transition

Revision 23-1; Effective Dec. 20, 2023

Based on the Medicaid program the person or LAR chooses, the ECC coordinator is responsible for the following:

  • HCS-- Notifying the diversion coordinator to request a transition slot from HHSC as described in Section 6500, Transitioning to the HCS Program. 
  • CLASS or DBMD--  Working with the RS to request a slot through the CLASS or DBMD interest list unit at HHSC.
  • STAR+PLUS HCBS--  Working with the RS and MCO SC to arrange for the person to enroll in the STAR+PLUS HCBS program.

6500, Transitioning to the HCS Program

Revision 22-1; Effective Nov. 28, 2022

HHSC may make available a targeted nursing facility (NF) HCS transition slot for a person who meets the criteria described in Section 6510, Criteria for Transitioning to the HCS Program, below.

6510 Criteria for Transitioning to the HCS Program

Revision 22-1; Effective Nov. 28, 2022

A person is eligible for a targeted NF HCS transition slot if:

  • the person has a PASRR Evaluation (PE) that was conducted when the person was admitted to the NF and the PE is positive for intellectual disability (ID) or developmental disability (DD);
  • it is after the 30th day of the person’s admission if the person was admitted to the NF for rehabilitative purposes;
  • the person is at least 21 years old;
  • the person currently lives in a NF; and
  • the person has expressed a desire to live in a community setting.

6520 Requesting a Targeted NF HCS Transition Slot

Revision 22-1; Effective Nov. 28, 2022

If a LIDDA determines that a person meets the criteria for a targeted NF HCS transition slot and the person or LAR wants to enroll in HCS, the  diversion coordinator requests a targeted NF HCS transition slot for the person by completing and submitting Form 1046, Request for HCS Adult NF Transition Slot, per the form’s instructions.

Upon receipt, HHSC staff reviews the completed Form 1046. HHSC staff may request additional information or documentation. If HHSC determines the person meets the criteria for the targeted NF HCS transition slot, HHSC will send a letter to the LIDDA authorizing the LIDDA to offer the person the opportunity to enroll in HCS. The LIDDA enrolls the person in the HCS program per the requirements in the HCS rules, LIDDA Handbook and Section 6530, Transitioning to the Community by Enrolling in HCS, below.

6530 Transitioning to the Community by Enrolling in HCS

Revision 23-1; Effective Dec. 20, 2023

For a person transitioning to the community by enrolling in the HCS program, the ECC coordinator:

  • facilitates trial visits to HCS program providers in the community for the person, including overnight or weekend visits where feasible, as requested by the person or LAR;
  • develops and revises, as necessary, Form 8665, Person-Directed Plan, using all available assessments, and to include the person’s:
    • strengths and preferences; and
    • medical, nursing, clinical, nutritional management and other support needs;
  • conducts a pre-move site review using Form 1042, Pre-Move Site Review, to:
    • ensure any concerns of the program provider, staff or family member are being addressed; and
    • determine whether all essential supports identified on Form 1053, Transition Plan, are in place before the person transitions; and
  • completes the following activities before the person transitions if, during the pre-move site review, any one of the essential supports is not in place or if issues are raised about the suitability of the site:
    • convenes the SPT to resolve the issues; and
    • conducts another pre-move site review following resolution.

When a person expresses the desire to transition from an NF to a home in another LIDDA’s service area, the sending LIDDA’s ECC coordinator must invite the receiving LIDDA to all transition planning meetings.

The sending and receiving LIDDAs must work together to ensure essential supports are in place prior to the person’s discharge from the NF. This includes scheduling the pre-move visit at a time when the receiving LIDDA’s ECC coordinator is available to be present.

The transfer of LIDDAs must not occur until all essential supports have been verified through a pre-move visit.

6540, Transition Day

Revision 23-1; Effective Dec. 20, 2023

The MCO SC and RS are expected to be present at the new address on transition day to ensure all services are in place and to assist in setting up the household, as needed. The ECC coordinator is encouraged to be present as well.

 

6600, Post-Transition to the HCS Program

Revision 23-1; Effective Dec. 20, 2023

6610 Post-Move Monitoring Visits

Revision 23-1; Effective Dec. 20, 2023

For a person who transitioned to the HCS program, an ECC coordinator must:

  • conduct and document on Form 1043, Post-Move Monitoring, at least three onsite post-move monitoring visits of community service delivery sites* during the first 90 calendar days after the person’s move at the following times**:
    • within the first seven calendar days after enrollment in the HCS program;
    • between eight and 45 calendar days; and
    • between 46 and 90 calendar days; and
  • during the post-move monitoring visits:
    • assess whether essential supports identified in Form 1053, Transition Plan, are in place;
    • ensure concerns of the program provider, staff or family member are being addressed;
    • identify gaps in care; and
    • address such gaps, if any, to reduce the risk of crisis, re-admission to an NF or other negative outcome.

*The ECC coordinator must conduct post-move monitoring at all sites where essential supports are provided.
**More frequent onsite visits may be required to determine whether supports continue to be in place and any areas of concern are being addressed during the first 90 calendar days after enrolling in HCS.

6620 Monitoring Activities for One Year Post-Move

Revision 23-1; Effective Dec. 20, 2023

For one year* after a person has transitioned to the HCS program, an ECC coordinator must:

  • conduct monthly in-person visits with the person, or more frequently if determined by the HCS SPT based on risk factors, and monitor the delivery of all services and supports;
  • conduct HCS SPT meetings quarterly, or more frequently if there is a change in the person’s needs or if requested by the person or LAR;
  • revise Form 8665, Person-Directed Plan, as necessary, and coordinate the person’s services and supports;
  • inquire about any recent hospitalizations, emergency department contacts, increased physician visits or other crises, including medical crises, and if the person experiences such, convene the HCS SPT to identify all necessary revisions to the person’s Form 8665 to address additional need for services;
  • ensure the person receives timely assessments of behavioral, medical, nursing, professional therapies and nutritional management needs, as necessary, and as indicated on Form 8665;
  • record health care status sufficient to readily identify when changes in the person’s status occurs;
  • conduct service planning, ensure the program provider’s implementation of services, and monitor all services identified on Form 8665, including:
    • reviewing the HCS program provider’s implementation plans and provider records;
    • visiting service delivery sites, as needed, to determine the person’s needs are being met; and
    • monitoring critical incidents involving the person and convening the HCS SPT to develop a plan for needed prevention or intervention services for the person; and
  • monitor the person while on suspension from the HCS program at least monthly, maintain communication with the program provider, and provide reports to HHSC upon request.

*If, after one year of ECC, the SPT believes the individual requires further enhanced monitoring, the ECC coordinator must contact IDDMFPSupport@hhs.texas.gov for further guidance.
 

6700, Transitioning to a Community Medicaid Program

Revision 23-1; Effective Dec. 20, 2023

When a slot has been offered to a person who has selected a community Medicaid program that is not HCS, the ECC coordinator:

  • facilitates trial visits to providers in the community for the person and LAR, as requested by the person or LAR;
  • assists with service planning by:
    • making available to the entity responsible for service planning all available assessments; and
    • addressing the person’s:
      • strengths and preferences; and
      • medical, nursing, clinical, nutritional management and support needs; 
    • conducting a pre-move site review using Form 1042, Pre-Move Site Review, to:
      • ensure any concerns of the program provider, staff or family member are being addressed; and
      • determine whether all essential supports identified on Form 1053, Transition Plan, are in place before the person transitions; and
  • completes the following activities before the person transitions if, during the pre-move site review, any one of the essential supports is not in place or if issues are raised about the suitability of the site:
    • convenes the SPT to resolve the issues; and
    • conducts another pre-move site review following resolution.

6710, Transition Day

Revision 23-1; Effective Dec. 20, 2023

The MCO, SC and RS are expected to be present at the new address on transition day to ensure all services are in place and to assist in setting up the household, as needed. The ECC coordinator is encouraged to be present as well.
 

6800, Post-Transition into a Community Medicaid Program

Revision 23-1; Effective Dec. 20, 2023

For a person who has transitioned to a Medicaid community program that is not HCS, an ECC coordinator must:

  • conduct and document on Form 1043, Post-Move Monitoring, at least three onsite post-move monitoring visits of community service delivery sites during the first 90 calendar days after the person’s move at the following times:
    • within the first seven calendar days after transition;
    • between eight and 45 calendar days; and
    • between 46 and 90 calendar days; and
  • during the post-move monitoring visits:
    • assess whether essential supports identified in Form 1053, Transition Plan, are in place;
    • ensure any concerns of the program provider, staff or family member are being addressed;
    • identify gaps in care; and
    • address such gaps, if any, to reduce the risk of crisis, re-admission to an NF or another negative outcome.

The ECC coordinator should conduct additional post-move monitoring visits, if indicated.

The LIDDA may not use targeted case management funding for an SC’s activities described in this section if the person is enrolled in the CLASS or DBMD. The LIDDA may use ECC funds if an ECC coordinator conducts the activities described in this section.

6900, Readmission to a Nursing Facility

Revision 23-1; Effective Dec. 20, 2023

If a person who has, at any time, received 365 days of enhanced community coordination (ECC) is readmitted to a nursing facility (NF) and wishes to return to the community, the ECC coordinator must determine: 

  • if the person was in the NF for more than 30 calendar days; or
  • if the person experienced a significant change of condition* during readmission to the NF.
  • If the ECC coordinator determines the readmission exceeded 30 calendar days or the person experienced a significant change of condition, the ECC coordinator must:
  • when appropriate, facilitate trial visits to program providers in the community for the person, including overnight or weekend visits where feasible, as requested by the person or LAR;
  • develop and revise, as necessary, Form 8665, Person-Directed Plan, using all available assessments, and include the person’s:
    • strengths and preferences; and
    • medical, nursing, clinical, nutritional management and any other support needs;
  • conduct a pre-move site review using Form 1042, Pre-Move Site Review, to:
    • ensure any concerns of the program provider, staff or family member are being addressed; and
    • determine whether all essential supports identified on Form 1053, Transition Plan, are in place before the person transitions; and
  • complete the following activities before the person transitions if, during the pre-move site review, any one of the essential supports is not in place or if issues are raised about the suitability of the site:
    • convene the SPT to resolve the issues; and
    • conduct another pre-move site review following resolution.
  • conduct and document on Form 1043, Post-Move Monitoring, at least three onsite post-move monitoring visits of community service delivery sites during the first 90 calendar days after the person’s move at the following times:
    • within the first seven calendar days after enrollment in the HCS program;
    • between eight and 45 calendar days after enrollment in the HCS program;
    • between 46 and 90** calendar days after enrollment in the HCS program; and
  • during the post-move monitoring visits:
    • assess whether essential and non-essential supports identified in Form 1053, Transition Plan, are in place;
    • document and address all concerns of the environment, program provider, staff or family member on Form 1043;
    • document all identified gaps in care on Form 1043; and
    • address such concerns and gaps, if any, to reduce the risk of crisis, re-admission to an NF or other negative outcome.

* Significant change of condition: any change requiring additional services, equipment, or minor home modifications (e.g., new enteral feeding tube, respiratory equipment, wheelchair).

**If, by the 60th day after the person returns to the community, the SPT believes the person may require more than 90 days of enhanced monitoring, the ECC coordinator must contact IDDMFPSupport@hhs.texas.gov for further guidance.

If a qualified person who has transitioned to the community is admitted or readmitted to an NF, and has never received ECC, an ECC coordinator must initiate one year of ECC as described in Section 6000 of this handbook, relating to monitoring activities for NF transitions.

If a person is readmitted to an NF while receiving their initial 365 days of ECC, ECC will resume upon discharge to the community, however, the 365-day time frame does not re-start after the discharge. For example, if a person is admitted to an NF on day 181 of ECC and is put on suspension, when the person discharges from the NF, ECC resumes on day 182.

A person who is readmitted to an NF for the purpose of respite does not qualify for ECC upon discharge unless the person is already receiving ECC at the time of readmission.
 

7000, Required PASRR Training

Revision Notice 22-1; Effective Nov. 28, 2022

Local intellectual and developmental disability authorities (LIDDAs) must ensure that PASRR evaluators, habilitation coordinators, and service coordinators conducting transition planning are trained per 26 Texas Administrative Code (TAC) Chapter 303.

Required HHSC-developed trainings related to PASRR can be found on the HHS Learning Portal PASRR Training page. To access training, create a user login and follow the instructions to complete the courses.

7100, Required Training for a Habilitation Coordinator

7100, Required Training for a Habilitation Coordinator  

Revision 22-1; Effective Nov. 28, 2022

7110 Training Completed Prior to Habilitation Coordination

Revision 22-1; Effective Nov. 28, 2022

LIDDAs must develop trainings at a local level to ensure, before providing habilitation coordination, a habilitation coordinator receives trainings that address:

  • appropriate LIDDA policies, procedures, and standards; 
  • HHSC rules relating to PASRR, the provision of specialized services, and other HHSC rules affecting the LIDDA, including: 
    • 26 TAC Chapter 303, related to PASRR; and
    • 26 TAC Chapter 554, Subchapter BB, Nursing Facility (NF) Responsibilities Related to PASRR. 
  • HHSC's IDD PASRR Handbook;
  • developing and implementing a Habilitation Service Plan (HSP); 
  • conducting assessments, service planning, coordination, and monitoring; 
  • providing crisis prevention and management;
  • community support services;
  • presenting community living options using HHSC-developed materials and forms, and offering educational opportunities and informational activities about community living options; 
  • arranging visits to community providers; 
  • accessing specialized services for a person; 
  • the rights of a person with an intellectual disability (ID), including the right to live in the least restrictive setting appropriate to the person's individual needs and abilities and in a variety of living situations, as described in the Persons with an Intellectual Disability Act, Texas Health and Safety Code Chapter 592 and in an HHSC-developed rights handbook; and
  • advocacy for individuals with ID or developmental disability (DD).

In addition to the trainings above, LIDDAs must also ensure the following trainings are completed before habilitation coordinators provide services: 

  • HHSC computer-based training, An Overview of the PASRR Process ; and
  • additional trainings designated by HHSC. Please refer to Section 7200, HHSC-developed Training. 

7120 Training Completed Within the First 60 days of Habilitation Coordination

Revision 22-1; Effective Nov. 28, 2022

LIDDAs must ensure a habilitation coordinator completes the following training within the first 60 days of performing habilitation coordination duties: 

  • All HHSC-developed training related to habilitation coordination.
  • Person-centered thinking training.

Note: A supervisor, team lead, or quality monitoring staff person who has successfully completed the trainings in this section must review and sign off on work completed by a habilitation coordinator until the habilitation coordinator completes the trainings required in this section. Habilitation coordinators must complete all trainings in Section 7110, Training Completed Prior to Habilitation Coordination, before providing habilitation coordination. 

 

7200, HHSC-Developed Training

Revision 22-1; Effective Nov. 28, 2022

All new PASRR staff regardless of role or function are required to complete the online course entitled An Overview of the PASRR Process

Additionally, the following instructor-led courses are required based upon the functions the staff person performs for the LIDDA:

  • If new staff performs or supervises habilitation coordination duties, they must successfully complete Service Planning and Monitoring.
  • If new staff performs or supervises PASRR service coordination/enhanced community coordination (SC/ECC) duties, they must successfully complete Transition and Diversion.
  • If new staff performs or supervises staff who conduct PASRR evaluations (PEs), they must successfully complete PL1 and PE.
     

Appendix I, Resources

Revision 19-0; Effective July 7, 2019

Referring Entity References and Online Training Resources

Training designed to give PASRR referring entities the information, tools and resources needed to successfully complete the PASRR Level 1 Screening (PL1) may be accessed via the Texas Health and Human Services Learning Portal and enrolling in the course titled “PASRR Referring Entity (Online).”

Training designed to give a comprehensive knowledge for the PL1 may be accessed via the Texas Health and Human Services Learning Portal and enrolling in the course titled “PASRR PL1 (Online).”

Written step-by-step instructional guides regarding how to complete the PL1 form may be found by navigating to the PASRR Forms and Instructions page and clicking on one of the following hyperlinks:

LIDDA/LMHA/LBHA Training Materials

The LTC online portal can be accessed here. A log-on identification number is required to access the LTC online portal for alerts, PASRR Level II Evaluation (PE) submissions and corrections. Access details can be found in the Long-Term Care (LTC) User Guide for Preadmission Screening and Resident Review (PASRR)[PDF], which also provides information for LIDDAs and LMHAs/LBHAs for using the LTC online portal to submit all PASRR screenings and evaluations.

Written step-by-step instructional guides regarding how to complete the PE form may be found by navigating to the PASRR Forms and Instructions page or by clicking on of the following hyperlink:

Appendix II, MCO Contact Information

Revision 19-0; Effective July 7, 2019

Relocation Referrals

The following chart contains the email address for each STAR+PLUS managed care organization (MCO). A local intellectual and developmental disability authority (LIDDA) uses the appropriate email address to send a completed Form 1579, Referral for Relocation Services, as an attachment.

MCO Name Relocation referrals should be sent to:
Amerigroup STAR+PLUS starplusservicecoordination@amerigroup.com
Cigna-Health Spring Transition_MFP_Team@healthspring.com
Molina Healthcare of Texas Molina.STARPLUS@Molinahealthcare.com
Superior Health Plan nursing.facility@superiorhealthplan.com
United Healthcare Community Plan etxcilfax@uhc.com

MCO Service Coordination Contact Information

If the LIDDA has already made a referral for relocation services and needs assistance from the MCO, the LIDDA should contact the MCO service coordinator (SC).

If the LIDDA is unable to locate or contact the MCO SC directly, then the LIDDA should contact the MCO service coordination hotline using the chart below.

MCO Name STAR+PLUS Service Coordination Hotline
Amerigroup STAR+PLUS 1-800-315-5385, Ext. 35765
Amerigroup STAR+PLUS IDD 1-866-696-0710, Ext. 36171
Cigna-Health Spring 1-877-725-2688
Molina Healthcare of Texas 1-866-409-0039
Superior Health Plan 1-877-277-9772
United Healthcare Community Plan 1-800-349-0550

Appendix III, Legal Authority to Make Decisions

Revision 19-0; Effective July 7, 2019

Below is a general description of the types of legal authority available to make decisions on behalf of another person or to support a person to make his or her own decisions. More information about some of these options and guardianship is available at: https://hhs.texas.gov/laws-regulations/legal-information/guardianship.

Option Definition Enabling Statute
Supported Decision Making

A process of supporting and accommodating an adult with a disability to enable the adult to make life decisions, including decisions related to where the adult wants to live; the services, supports and medical care the adult wants to receive; whom the adult wants to live with and where the adult wants to work, without impeding the self-determination of the adult.

A supported decision maker does not have the authority to make a decision on behalf of the person.

Texas Estates Code §1357.002(3)
Surrogate Decision Maker

"Surrogate decision-maker" means a person with decision-making capacity who is identified as the person who has authority to consent to medical treatment on behalf of an incapacitated patient in certain facilities (hospital, nursing facility) who needs medical treatment.

A surrogate decision maker is authorized to consent to only medical treatment on behalf of the person.

Texas Health and Safety Code §313.002 (10)
Guardianship of Person

A guardian of the person is appointed by a court to act on behalf of an incapacitated person and, considering the preferences of the person, decides:

  • Where the person will live.
  • Whether to limit contact with family and friends.
  • What medical or psychological treatment the person will receive.
  • Where the person can go.
  • What personal rights the person will have (e.g., drive a car, have a cell phone, date) within the limitations of the court order.
Texas Estates Code Chapter 1151. Rights, Powers, and Duties Under Guardianship
Guardianship of Estate

A guardian of the estate is appointed by a court to act on behalf of an incapacitated person and decides (with court approval):

  • What should be done with the person’s property.
  • Which bills to pay and when.
  • How to invest the person’s money.
  • Whether to enter into a contract to buy or sell property.
Texas Estates Code Title 3. Guardianship and Related Procedures
Medical Power of Attorney

A competent adult person may execute a medical power of attorney for someone to make any or all health care decisions on behalf of the person in accordance with the person’s wishes, including religious and moral beliefs, when the person is no longer capable of making them for himself or herself.

Someone with medical power of attorney is authorized to make only health care decisions on behalf of a person in the event the person becomes incapacitated.

Texas Health and Safety Code §166.164
Durable Power of Attorney

A competent adult person may execute a durable power of attorney, which will continue in the event of future incapacity of the person in designating an agent who is empowered to take certain actions regarding the person’s property.

Someone with durable power of attorney is not authorized to make medical and other health care decisions for the person.

Texas Probate Code §481
Advanced Medical Directives A competent adult person may execute an advanced medical directive, which is “an instruction...to administer, withhold, or withdraw life-sustaining treatment in the event of a terminal or irreversible condition.” Health and Safety Code Chapter 166

Appendix IV, Risk Factors

Revision 19-0; Effective July 7, 2019

Identifying and managing risks are part of providing services and supports to people with intellectual and developmental disabilities. Depending on their individual circumstances, people who receive institutional and community services can be at risk of adverse outcomes. Identifying risks is an important part of mitigating future risks and adverse outcomes to the individual.

Identifying and Planning to Mitigate Risk at the Individual Level

Effective risk management begins with assessment and service planning centered around the individual’s needs and preferences. Potential risks are identified and documented, and individualized mitigation strategies are mapped out. Ongoing documentation of services targeted to address risk and negotiations around risk provide evidence of risk management.

Risk Management Begins with the Individual Assessment Process

Just as service planning begins with a needs assessment, risk management should begin with an effort to identify potential and perceived risks to the individual. In many cases, these risks are directly linked to the disability-specific needs identified during the assessment process. However, the presence and projected consequences of such risks may not always be documented in an individual’s record. Risk identification is more than a conversation between an individual, their family members, service providers, case managers and others. It also involves a comprehensive documentation of that conversation. Such documentation provides the context and rationale for elements in the service plan and provides evidence that a risk management process is in place.

Behavioral Risks

Some people with disabilities may place themselves and others at greater risk through their behavior. Behavioral risks include:

  • poor decision-making about safety and health issues, as a result of a brain injury or cognitive limitation;
  • violent or criminal behavior;
  • substance abuse; and
  • suicide.

Risks to Personal Safety

Many people who are elderly or who have severe disabilities are vulnerable to abuse and exploitation. They are often dependent on others for assistance with everyday activities, such as eating or bathing, as well as with participation in the community. Thus, they face the additional risks of neglect, abuse and financial exploitation. In addition, personal safety, including safe evacuation, can be compromised by mobility and cognitive impairments. Other personal safety risks can include unsanitary or unsafe housing and social isolation.

Additional information is available here (PDF).

For information about medical and health related risks, see the Common Risk Factors and Basic Clinical Guidelines to Gauge Level of Risk (PDF) chart.

Forms

ES = Spanish version available.

Form Title
1014 Pre-Admission Screening and Resident Review (PASRR) Evaluation Summary Report  
1042 Pre-Move Site Review  
1043 Post-Move Monitoring  
1044 Refusal of Habilitation Coordination ES
1046 Request for HCS Adult NF Transition Slot  
1047 Request for HCS Targeted NF Diversion Slot  
1048 Summary Sheet for Services to Individuals with IDD in a Nursing Facility  
1050 Nursing Facility or Crisis Diversion Plan  
1053 Transition Plan  
1054 Community Living Options  
1057 Habilitation Service Plan (HSP)  
1063 Individual Profile – Nursing Facility  
1064 Habilitative Assessment  
1579 Referral for Relocation Services ES
2358 Habilitation Coordination Authorization Request  
2361 PASRR Specialized Services Fair Hearing Request  
8665 Person-Directed Plan ES

23-1, Updates to Sections 1000, 3000 and 6000

Revision 23-1; Effective Dec. 20, 2023

The following changes were made.

SectionTitleChange
1100DefinitionsUpdates language throughout definitions. Changes ECC or Enhanced Community Coordinator to ECC coordinator. Adds the term person to the definition of individual.
3210Criteria for Diverting from NF AdmissionUpdates definitions. 
3230Enrolling in HCS as a Diversion to NF AdmissionUpdates language. Adds guidance concerning pre-move site review.
3230.1Enhanced Community Coordination FundsUpdates language. Adds new process for accessing ECC funds.
3240Post Enrollment in HCS as a Diversion to NF AdmissionRe-orders monitoring duties to list chronologically. Updates language for inclusivity. Adds guidance for ECC lasting for more than 365 days. 
6110Assigning a Service Coordinator or Enhanced Community CoordinatorEdits title to Assigning an Enhanced Community Coordination (ECC) Coordinator and updates language.
6110.1Unassigning a Service Coordinator or Enhanced Community CoordinatorEdits title to Unassigning an ECC Coordinator and updates language. 
6120Working with the Relocation SpecialistUpdates language.
6130Relocation Specialist and MCO SC ResponsibilitiesUpdates language. Adds guidance regarding relocation day.
6140Enhanced Community Coordination Funds to Assist with Certain Costs Related to TransitioningEdits title to Enhanced Community Coordination Funds  and updates language. Adds new process for accessing ECC funds.
6200Transition PlanningUpdates language.
6210.1Service Coordinator/Enhanced Community Coordinator ParticipationEdits title to ECC Coordinator Participation. Updates language. 
6210.2Habilitation Coordinator ParticipationUpdates language. 
6210.3Program Provider and Relocation Specialist ParticipationUpdates language.
6300Developing and Revising the Transition PlanUpdates language.
6310Transition PlanUpdates language.
6320Admission Type on PL1Updates language.
6330PL1 SubmissionAdds section.
6340Individual ProfileUpdates language. 
6350Sharing the Transition Plan, Individual Profile, and Transition PacketUpdates language.
6360SPT Member Believes Transition Plan Does Not Accurately Reflect SPT DecisionsUpdates language.
6400Pursuing the Selected Community Medicaid Program for TransitionUpdates language. Removes ICF/IID from list of non-HCS community programs eligible for ECC.
6530Transitioning to the Community by Enrolling in HCSUpdates language. Adds guidance related to transfer of LIDDAs.
6540Transition DayChanges title to Transitioning to a Community Medicaid Program. Moves existing information to section 6540. Incorporates information previously in section 6600. Updates language.
6600Transitioning to a Community Medicaid Program Edits title to Post-Transition to the HCS Program. Moves existing information to section 6700. Incorporates information previously in section 6800.
6610Post-Move Monitoring VisitsAdds new section using information previously in section 6810. Updates language.
6620Monitoring Activities for One Year Post-MoveAdds new section using information previously in section 6820. Updates language. 
6700Transition Day Changes title to Transitioning to a Community Medicaid Program. Moves existing information to section 6540. Incorporates information previously in section 6600. Updates language.
6710Transition DayAdds new section using information previously in section 6700. Updates language. 
6800Post-Transition to HCS Program Edits title to Post-Transition into a Community Medicaid Program. Moves existing information section 6600. Incorporates information previously in section 6900. Updates language. Removes ICF/IID from transition options for ECC.
6820Monitoring Activities for One Year Post-MoveDeletes section and moves information to new section 6620.
6900Post-Transition into a Medicaid Community Program Edits title to Readmission to a Nursing Facility. Moves existing information to section 6800. Adds new information on providing guidance for when ECC should be restarted.

 

22-1, Updates to IDD PASRR Handbook

Revision 22-1; Effective Nov. 28, 2022

The following changes were made.

Section Title Change
1000 Introduction to PASRR Updates Texas Administrative Code (TAC) references. 
1100 Definitions  Updates definitions. 
2000 PL1 and PE Edits throughout section to update acronyms and section numbers and make clarifications such as adding “calendar” to days. 
2100 Purpose of PASRR Updates language.
2200 Referring Entity Updates and adds new text.    
2300 PASRR Level 1 Screening (PL1) Updates title by removing (PL1).
2310 Spousal Co-Payment Incorporates policy from MEPD and TW Bulletin 22-09,  2. Spousal Impoverishment Dependent Allowance, released on June 1, 2022.
2320 PL1 Screening Form Incorporates policy from MEPD and TW Bulletin 22-09,  2. Spousal Impoverishment Dependent Allowance, released on June 1, 2022.
2320.1 PL1 Submission Updates and adds new text.    
2320.2 Positive PL1  Adds new information after enhancement in LTC online portal and additional instructions how to complete section E of PL1 if positive for PASRR. 
2320.3 Negative PL1 Updates language.
2320.4 Additional PL1 Responsibilities Adds new section.
2330 Admission Types  
2330.1 Exempted Hospital Discharge Updates language.
2330.2 Expedited Admission Updates admission information relating to the LTC online portal.
2330.3 Preadmission Updates language.
2340 Admission Type on PL1 Updates language.
2350 PL1 Submission Adds section.
2400 PASRR Level II Evaluation (PE) Updates language and removes (PE) from title.
2410 Purpose, PASRR Status, and Staff Qualifications Updates language about performing PE for people with positive P1.
2410.1 PASRR Positive Updates determination status language.
2410.2 PASRR Negative Updates determination status language.
2410.3 Staff Qualifications Updates language.
2420 LTC Online Portal Notification Updates P1 automatic alert process.
2420.1 Timing of Alert is Based on Admission Type Updates language and link.
2420.2 Change of Ownership (CHOW)  Extensions Changes title to Change of Ownership Extensions. Updates language.
2420.3 Information Gathered by a LIDDA Following an Alert to Conduct a PE Adds note about PE Evaluator login information in LTC online portal. 
2420.4 Using Information Gathered by a LIDDA Following an Alert to Conduct a PE Adds reference to Section 4910, Medicaid Eligibility Guidelines.
2430 Completing and Submitting the PE Updates language and list of LIDDA requirements.
2430.1 Interpreter Services Edits language.
2430.2 Person/LAR Refuses to Participate in PE Changes title to Person or LAR Refuses to Participate in PE. Edits language.
2430.3 Documentation Review for PE Completion Removes some acronyms and updates language.
2430.4 Information about Certain Community Programs in Section F0700 of the PE Edits language.
2430.5 Presenting Information about Community Services as Part of the PE Moves title and information about Person’s PE is Negative for ID or DD.
2430.6 PE for Resident Review  Changes title to Completing Section F, Return to Community Living. Adds new section related to Section F of the PE. Moves original section 2430.6 information to 2430.7.
2430.7 When a DID is Required to Adequately Complete the PE  Changes title to PE for Resident Review. Includes original and updated text formerly under section 2430.6. Clarifies information about expectations and process when completing PE for resident review. 
2430.8 PE Submission  Changes title to When a DID is Required to Adequately Complete the PE. Moves information that was previously under section 2430.7.
2430.9 Specialized Services Recommendation Mapping. Changes title to PE Submission. Moves information that was previously under section 2430.8 and updates language.
2430.10 Fair Hearing Related to Negative PE Changes title to Specialized Services Recommendation Mapping. Moves information that was previously under section 2430.9 and updates language.
2430.11 PE Retention Period Removes outdated information related to the replacement Medicaid card and aligns the MBI and MBIC sections. Adds related policy. (MBI/MBIC)
2430.12 PE Retention Period Removes link to MIPPA application processing instructions. (MSP)
2430.13 Preadmissions involving Two LIDDAs Incorporates policy from MEPD and TW Bulletin 21-22, 1. Eligibility for Federal Benefits for Afghan Evacuees, released on Nov. 1, 2021. (All Programs). Clarifies existing glossary definitions.
2500 PASRR Initial IDT/SPT Meeting Incorporates policy from MEPD and TW Bulletin 22-09, 2. Spousal Impoverishment Dependent Allowance, released on June 1, 2022.
2510 NF Enters Initial IDT/SPT Meeting Information Changes title to NF Enters Initial IDT and SPT Meeting Information.
2520 Confirmation of IDT/SPT Meeting Information Changes title to Confirmation of IDT and SPT Meeting Information. Edits text.
2600 Initiating NF Specialized Services Edits text.
3000 Diversion from NF Admission Updates and makes minor edits throughout section.  
3100 Diversion from Nursing Facility Admission Edits language.
3200 Diverting from NF Admission Edits language.
3210 Criteria for Diverting from NF Admission Edits language.
3220 Requesting a Targeted NF HCS Diversion Slot Edits language.
3230 Enrolling in HCS as a Diversion to NF Admission Edits language and clarifies where essential supports are identified.
3230.1 Enhanced Community Coordination Funds Edits language.
3240 Post Enrollment in HCS as a Diversion to NF Admission Edits language.
4000 Admission to a NF Updates and makes minor edits throughout section. 
4100 Eligibility for Habilitation Coordination Funded by Medicaid Adds note about hospice services not affecting person’s eligibility for Habilitation Coordination or PASRR specialized services. 
4200 Assignment of Habilitation Coordinator Edits language.
4300 Program Overview Changes title to Initial IDT and SPT Meeting. Edits language.
4310 Budgeting Concepts Changes title to Attendance at Initial IDT and SPT Meeting. Edits language.
4400 Eligibility Income Budgeting Updates and makes minor edits throughout section.
4410 Budgeting Steps Edits language.
4420 Charts for Premium Amounts Adds note about need for Habilitative Assessment Form 1064 even if the person has refused Habilitation Coordination. 
4500 Developing Individual Profile and Habilitation Service Plan at First SPT meeting Adds expectation that habilitation coordinators complete and send individual profile and habilitation service plan to SPT members within 10 calendar days following SPT meetings. Also adds expectation that habilitation coordinators ask NF to ensure all PASRR specialized services are in NF comprehensive care plans. 
4510 Specialized Services Requiring an Assessment Updates language. Clarifies when lack of IDT/SPT consensus to obtain an assessment for specialized services. Assessments are not completed for people refusing services or when there is no funding. 
4520 Specialized Services that Do Not Require an Assessment Edits language.
4530 Frequency and Duration of Habilitation Coordination Edits language.
4600 Initiating IDD Habilitative Specialized Services after First SPT Meeting Edits language.
4700 Providing Habilitation Coordination Edits language.
4800 2022 Income and Resources Reference Chart Adds new section
4810 Determining Guardianship Adds new section on determining guardianship for people in the PASRR program. 
4820 Communication of Complaint Process Adds new section about the complaint process in the PASRR program. 
4900 Medicaid and Medicare Adds new section related to Medicaid and Medicare. 
4910 Medicaid Eligibility Guidelines Adds new section. Includes chart of TOA and program codes to determine PASRR eligibility. 
4920 Responsibility to Reestablish Medicaid Eligibility Adds new section about LIDDA responsibility to help in reestablishing Medicaid eligibility for people in the PASRR program. 
4930 Individual Does Not Have an MCO Adds new section for people who need to select an MCO. 
4930.1 Spousal Co-Payment Adds new section to help a person who does not have an MCO assigned. 
4940 Individual is Dual Eligible Adds new section for a person who is dual eligible for both Medicaid and Medicare. 
5000 Habilitation Coordination  Updates section. 
5100 Required Face-to-Face Visits Adds language about HHSC’s ability to waive face-to-face requirements if an emergency is declared. 
5200 Assess/Reassess Habilitative Needs Changes title to Assess or Reassess Habilitative Needs. Edits language.
5210 Reviewing Assessments Edits language.
5300 SPT Meetings Adds new expectation that habilitation coordinator must ensure all SPT members receive a notice of 10 business days to participate in meetings. 
5310 First SPT Meeting Updates revision notice and effective date.
5320 Quarterly SPT Meetings Adds clarifications to timeline expectations about quarterly SPT meetings.  
5320.1 Required Activities during a Quarterly SPT Meeting Edits language.
5320.2 Documenting Summary of Quarterly SPT Meeting Edits language.
5320.3 Replacement Medicaid Card Edits language.
5330 Update SPT Meetings Updates list. Include information for completing ANSA or address any outstanding issues 
5330.1 Update SPT Meeting Because of a Change in Medical Condition or a Change in Service Removes title of section. Information remained in section 5330. 
5330.2 Update SPT Meeting For An Issue Not Addressed in Section 5330.1 Removes title and section information.
5340 Annual IDT/SPT Meeting Changes title to Annual IDT and SPT Meeting.
5340.1 Annual IDT/SPT Meeting Changes title to Annual IDT and SPT Meeting. Edits language. 
5340.2 HC Preparation for Annual IDT/SPT Meeting Changes title to Preparation for Annual IDT and SPT Meeting. Edits language. 
5340.3 IDT Agrees to Habilitation Coordination Edits language.
5340.4 Refusal of Habilitation Coordination Edits language.
5340.5 Annual SPT Meeting Edits language.
5350 SPT Member that is a Provider of a Specialized Service Edits language.
5360 Determination that Participation in SPT Meeting is Not Necessary Edits language.
5370 Guidance for Convening SPT Meeting When an Individual or LAR Does Not Want to Attend Edits language.
5400 Develop and Revise Habilitation Service Plan and Individual Profile Edits language.
5410 Person-centered Planning Replaces “Federal Poverty Income Limit (FPIL)” with “Federal Poverty Level (FPL)”. Updates for plain language. (MBI, MBIC)
5420 Discovery Process Edits language.
5430 Developing Habilitation Service Plan and Individual Profile Edits language.
5430.1 Specialized Services Requiring an Assessment Edits language.
5430.2 Specialized Services that Do Not Require an Assessment Edits language.
5430.3 Barriers to Transitioning to the Community or Selecting a Community Program Identified During CLO Edits language.
5430.4 Charts for Premium Amounts Edits language.
5440 Revising the Habilitation Service Plan and Individual Profile Edits language.
5440.1 Revising the HSP Because an Assessment for an NF Specialized Service is Complete Removes outdated information related to the replacement Medicaid card and aligns the MBI and MBIC sections. Adds related policy. (MBI/MBIC)
5440.2 Revising the HSP Because an Assessment for an IDD Habilitative Specialized Service is Completed Edits language.
5440.3 Revising the HSP to Address Barriers Identified During CLO Edits language.
5450 New Habilitation Service Plan for Next HSP Year Edits language.
5460 2022 Income and Resources Reference Chart Edits language.
5460.1 Individual Profile Edits language.
5460.2 Habilitation Service Plan Edits language.
5470 Sharing the Habilitation Service Plan, Individual Profile and Habilitation Packet Edits language.
5480 SPT Member Believes HSP or Individual Profile Does Not Accurately Reflect SPT Decisions or Information about the Individual Edits language.
5500 Assisting with Access to Needed Specialized Services Updates revision number and effective date.
5510 Initiating IDD Habilitative Specialized Services Edits language.
5520 Monitoring the Initiation and Delivery of all Specialized Services Edits language.
5530 Accessing Other Habilitative Programs Edits language.
5540 Assisting Individual/LAR with Requesting a Fair Hearing for Denial of NF Specialized Services Changes title to Assisting Individual or LAR with Requesting a Fair Hearing for Denial of NF Specialized Services. Edits language.
5600 Coordination Edits language.
5700 Monitoring and Follow-up Activities Updates language to include need for habilitation coordinator to include the perspective of the person and LAR when monitoring for progress or satisfaction. 
5800 Community Living Options (CLO), Visits to Community Programs, and Educational Opportunities Changes title to Community Living Options, Visits to Community Programs, and Educational Opportunities.
5810 Presenting CLO Edits language.
5810.1 When CLO is Presented Updates language for clarifications about CLO timeline and expectations if individual is not interested in habilitation coordination or transition to the community. 
5810.2 Six-Month Base Schedule Changes title to Six-month Base Schedule. Edits to clarify CLO timeline. 
5810.3 CLO Materials Provided to Individual/LAR Changes title to CLO Materials Provided to Individual or LAR. Edits language.
5820 Documenting CLO Updates language to clarify that section 4 of CLO form 1054 should be filled out even if the individual is not interested in transition. 
5830 HC Actions Following CLO Changes title to Habilitation Coordinator Actions Following CLO. Edits language.
5830.1 Individual/LAR Wants to Transition and has Selected a Community Program Changes title to Individual/LAR Wants to Transition and has Selected a Community Program. Edits language.
5830.2 Individual/LAR Wants to Transition, but has NOT Selected Community Program Changes title to Individual or LAR Wants to Transition but has NOT Selected Community Program. Edits language.
5830.3 Individual/LAR Does Not Want to Transition, is Undecided or Desire of Individual/LAR Cannot be Determined Changes title to Individual or LAR Does Not Want to Transition, is Undecided or Desire of Individual or LAR Cannot be Determined. Edits language.
5840 Exploring Community Programs Edits language.
5850 Educational Opportunities Edits language.
5900 Explanation of Rights Changes title to Additional Habilitation Coordinator Responsibilities.
5910 Explanation of Rights Clarifies program information. Adds related policy. (All Programs)
5920 Activities Related to Guardianship Clarifies program information. Adds related policy. (All Programs)
5920.1 Individual Has a Guardian Adds policy for electronic correspondence. (All Programs)
5920.2 Individual Does Not Have a Guardian Adds new section with information for a person who does not have a guardian. 
6000 Transition From NF to Community Edits text.
6110 Assigning a Service Coordinator or Enhanced Community Coordinator Updates language and clarifies timeline for assigning an SC/ECC is seven calendar days.
6110.1 Unassigning a Service Coordinator or Enhanced Community Coordinator Updates and clarifies language.
6120 Working with the Relocation Specialist Adds clarity that habilitation coordinator should ask person or LAR directly whether they object to MCO service coordinator attendance at meetings. 
6130 Relocation Specialist and MCO SC Responsibilities Updates and clarifies language.
6140 Enhanced Community Coordination Funds to Assist with Certain Costs Related to Transitioning Edits language.
6200 Transition Planning Adds new expectation for habilitation coordinators. Must give SPT members a 10-business day notice before SPT meetings. 
6210 SPT Meeting Participation by Service Coordinator/Enhanced Community Coordinator and Habilitation Coordinator Changes title to SPT Meeting Participation.
6210.1 Service Coordinator/Enhanced Community Coordinator Participation Edits language.
6210.2 Habilitation Coordinator Participation Edits language.
6210.3 Program Provider and Relocation Specialist Participation  Adds new section. Reminds habilitation coordinators to invite the community program provider and the RS t o all SPT meetings. 
6300 Developing and Revising the Transition Plan Directs SC/ECC to send Transition Plan to the SPT members within 10 calendar days after the SPT meeting.
6310 Transition Plan Edits language.
6320 Barriers to Preventing a Transition to the Community Updates revision number and effective date.
6330 Documents in an Individual’s Transition Packet Updates revision number and effective date.
6340 Individual Profile Edits language.
6350 Sharing the Transition Plan, Individual Profile, and Transition Packet  Adds expectation to send documents to SPT members within 10 calendar days after meetings. 
6360 SPT Member Believes Transition Plan Does Not Accurately Reflect SPT Decision Updates revision number and effective date. 
6400 Pursuing the Selected Community Medicaid Program for Transition Updates language and clarifies SC/ECC responsibilities.
6500 Transitioning to the HCS Program Edits language.
6510 Criteria for Transitioning to the HCS Program Edits language.
6520 Requesting a Targeted NF HCS Transition Slot Clarifies process and updates language.
6530 Transitioning to the Community by Enrolling in HCS Updates language and includes weekend trial visits.
6600 Transitioning to the Community by Enrolling in HCS Edits language.
6700 Transition Day Updates revision number and effective date.
6800 Post-transition to HCS Program Changes title to Post-Transition to HCS Program
6810 Post-move Monitoring Visits Changes title to Post-Move Monitoring Visits and clarifies timelines are based on calendar days.
6820 Monitoring Activities for One Year Post-move Changes title to Monitoring Activities for One Year Post-Move and updates language.
6900 Post-transition into a Medicaid Community Program Changes title to Post-Transition to a Medicaid Community Program and clarifies timelines are based on calendar days.
7000 Required PASRR Training New Section specific to training requirements about PASRR. 
7100 Required Training for a Habilitation Coordinator Adds information related to training requirements for habilitation coordinators. 
7110 Training Completed Prior to Habilitation Coordination  Adds information about the list of required trainings that need to be completed before habilitation coordination.
7120 Training Completed Within the First 60 Days of Habilitation Coordination  Adds information about list of required trainings that need to be completed within the first 60 days of habilitation coordination. Supervisors must sign off on all work until trainings completed. 
7200 HHSC-developed Training Changes title to HHSC-Developed Training. Adds information specific about HHSC trainings in the learning portal. 

 

19-0, New Handbook

Effective July 7, 2019

The Intellectual and Developmental Disability Preadmission Screening and Resident Review (IDD-PASRR) Handbook contains policies and procedures regarding the responsibilities of local intellectual and developmental disability authorities related to the PASRR program.