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

 

Section 1000, Introduction to PASRR

Section 2000, PL1 and PE

Section 3000, Diversion from Nursing Facility Admission

Section 4000, Admission to a Nursing Facility

Section 5000, Habilitation Coordination

Section 6000, Transition from NF to Community

Section 1000, Introduction to PASRR

Revision 19-0; Effective July 7, 2019

 

Preadmission screening and resident review (PASRR) is a federal requirement as 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 the appropriateness of NF admission. 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 contained in:

 

1100 Definitions

Revision 19-0; Effective July 7, 2019

 

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

  1. 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. a. may include a long-term acute care hospital, an emergency room within an acute care hospital or an inpatient rehabilitation hospital; and
    2. b. does not include a stand-alone psychiatric hospital or a psychiatric hospital within an acute care hospital.
  2. 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 may be 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 in accordance with Texas Occupations Code, Chapter 501;
      3. has been issued a provisional license to practice psychology in accordance with Texas Occupations Code, Chapter 501;
      4. is a certified authorized provider as described in 40 TAC §5.161 (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 in accordance with Texas Occupations Code, Chapter 506.
  3. CLO or Community living options — A process by which the LIDDA provides information to an individual and legally authorized representative (LAR) about the range of community living services, supports and programs the individual may be eligible for, and discusses services and supports the individual will need to live in the community, as well as individual preferences and barriers to community living.
  4. CMWC or customized manual wheelchair — In accordance with 40 TAC §19.2703, a wheelchair that consists of a manual mobility base and customized seating system and is adapted and fabricated to meet the individualized needs of an individual.
  5. Collateral contact — A person who is knowledgeable about the individual seeking admission to an NF or the resident, such as family members, previous providers or caregivers, and who may support or corroborate information provided by the individual or resident.
  6. Comprehensive care plan — A plan developed by an NF for a resident.
  7. Day habilitation — Assistance to a person to acquire, 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 a person who cannot 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.
  8. 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) §435.1010.
  9. DID or determination of intellectual disability — An assessment conducted in accordance with 40 TAC §5.155 by an authorized provider to determine if an individual meets the criteria for a diagnosis of intellectual disability.
  10. DME or durable medical equipment — In accordance with 40 TAC §19.2703, 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.
  11. ECC or enhanced community coordinator — A LIDDA staff who meets the qualifications and other requirements described in the performance contract.
  12. Employment assistance — Assistance provided to a person to help the person locate competitive employment in the community, consisting 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.
  13. Enhanced community coordination — Funding available to LIDDAs pursuant to the performance contract for assisting individuals in transitioning from an NF to the community or in diverting from NF admission.
  14. Essential supports — Those supports identified in a transition plan that are critical to an individual’s health and safety and that are directly related to the individual’s successful transition to living in the community from residing in an NF.
  15. Exempted hospital discharge — A category of NF admission that occurs when a physician has certified that an individual who is being discharged from an acute care hospital is likely to require less than 30 days of NF services for the condition for which the individual was hospitalized.
  16. Expedited admission — A category of NF admission that occurs when an individual meets the criteria for one of the following categories: convalescent care, terminal illness, severe physical illness, delirium, emergency protective services, respite or coma.
  17. Habilitation coordination — Assistance for an individual residing in an NF to access appropriate specialized services necessary to achieve a quality of life and level of community participation acceptable to the individual and LAR on the individual’s behalf.
  18. Habilitation coordinator — An employee of a LIDDA who provides habilitation coordination.
  19. Habilitative therapy services — In accordance with 40 TAC §19.2703, assessment and treatment to help an individual 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.
  20. HHSC — Texas Health and Human Services Commission.
  21. HSP or habilitation service plan — A plan developed by the service planning team (SPT) while an individual is residing in an NF that:
    1. is individualized and developed through a person-centered approach;
    2. identifies the individual’s:
      1. strengths;
      2. preferences;
      3. desired outcomes; and
      4. psychiatric, behavioral, nutritional management, and support needs as described in the comprehensive care plan or MDS assessment; and
    3. identifies the specialized services that will accomplish the desired outcomes of the individual, or the LAR’s on behalf of the individual, including amount, frequency and duration of each service.
  22. HSP year or habilitation service plan year — An approximate 12-month period starting on the date of the initial or annual interdisciplinary team (IDT)/SPT meeting.
  23. ID or intellectual disability — As defined in 42 CFR §483.102(b)(3)(i).
  24. IDD habilitative specialized services — The following specialized services available to an individual with ID or DD:
    1. habilitation coordination;
    2. day habilitation;
    3. independent living skills training;
    4. behavioral support;
    5. employment assistance; and
    6. supported employment.
  25. 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 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.
  26. Individual — 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.
  27. Independent living skills training — Individualized activities that are 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.
  28. LA or local authority — In this handbook, LA means a local intellectual and developmental disability authority (LIDDA) and/or a local behavioral health authority (LBHA) or local mental health authority (LMHA).
  29. LAR or legally authorized representative — A person authorized by law to act on behalf of an individual 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.)
  30. LBHA or local behavioral health authority — An entity designated by the executive commissioner of HHSC, in accordance with Texas Health and Safety Code, §533.0356.
  31. LIDDA or local intellectual and developmental disability authority — An entity designated by the executive commissioner of HHSC, in accordance with Texas Health and Safety Code, §533A.035.
  32. LMHA or local mental health authority — An entity designated by the executive commissioner of HHSC, in accordance with Texas Health and Safety Code, §533.035.
  33. 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.
  34. MCO SC or Medicaid managed care organization service coordinator — The staff person assigned by a resident’s Medicaid MCO to ensure access to, and coordination of, needed services.
  35. 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.
  36. MI or mental illness — Serious mental illness, as defined in 42 CFR §483.102(b)(1).
  37. MI specialized services — Specialized services available to a resident with MI, as described in the Texas Resilience and Recovery Utilization Management Guidelines, including:
    1. skills training;
    2. medication training;
    3. psychosocial rehabilitation;
    4. case management;
    5. psychiatric diagnostic interview exam; and
    6. supported housing, which includes alternate placement assistance and transitioning to the community.
  38. NF or nursing facility — A Medicaid-certified facility that is licensed in accordance with the Texas Health and Safety Code, Chapter 242.
  39. NF PASRR support activities — Consistent with 40 TAC §19.2703, 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 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.
  40. NF specialized services — The following specialized services available to a resident with ID or DD:
    1. habilitative therapy services;
    2. CMWC; and
    3. DME.
  41. PASRR — Preadmission Screening and Resident Review. Required by 42 CFR 483.100-138.
  42. PE or PASRR level II evaluation — A face-to-face evaluation:
    1. of an individual 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 individual has MI, ID or DD and, if so, to:
      1. assess the individual's need for care in an NF;
      2. assess the individual's need for specialized services; and
      3. identify alternate placement options.
  43. PL1 or PASRR level I screening — The process of screening an individual seeking admission to an NF to identify whether the individual is suspected of having MI, ID or DD.
  44. 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.
  45. Referring entity — The entity that refers an individual to an NF, such as a hospital, attending physician, LAR or other personal representative selected by the individual, a family member of the individual, or a representative from an emergency placement source, such as law enforcement.
  46. Relocation specialist — An employee or contractor of an MCO who provides outreach and relocation activities to individuals in NFs who express a desire to transition to the community.
  47. Resident — A person who resides in an NF and receives services provided by professional nursing personnel of the facility.
  48. 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 status, 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.
  49. RN or registered nurse — A person licensed to practice professional nursing as an RN in accordance with Texas Occupations Code, Chapter 301.
  50. Service coordination — Assistance in accessing medical, social, educational and other appropriate services and supports, including alternate placement assistance, that will help a person achieve a quality of life and community participation acceptable to the person and LAR on the person's behalf.
  51. Service coordinator — An employee of a LIDDA who provides service coordination.
  52. Specialized services — The following support services, other than NF services, that are identified through the PE or resident review and may be provided to a resident who has a PE or resident review that is positive for MI, ID or DD: a. NF specialized services; b. IDD habilitative specialized services; and c. MI specialized services.
  53. 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 an individual.
    1. The team must include:
      1. the individual;
      2. the individual’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 individual is transitioning to the community;
      4. the MCO service coordinator, if the individual does not object;
      5. while the individual is in an NF:
        1. an NF staff person familiar with the individual’s needs; and
        2. a person providing a specialized service to the individual or a representative of a provider agency that is providing specialized services for the individual;
      6. if the individual 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 individual has MI.
    2. Other participants on the SPT may include:
      1. a concerned person whose inclusion is requested by the individual 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.
  54. 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 at which people without disabilities are employed. Assistance consists of 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.
  55. Surrogate decision maker — An actively involved family member of a resident who has been identified by an IDT, in accordance with Texas Health and Safety Code §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 individual lives or will live.
  56. Transition plan — A plan developed by the SPT that describes the activities, timetable, responsibilities, services and essential supports involved in assisting an individual to transition from residing in an NF to living in the community.

Section 2000, PL1 and PE

Revision 19-0; Effective July 7, 2019

 

2100 Purpose of PASRR

Revision 19-0; Effective July 7, 2019

 

PASRR screening and evaluation must be administered to identify:

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

 

2200 Referring Entity

Revision 19-0; Effective July 7, 2019

 

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

PASRR requires that all people seeking admission to an NF have a PASRR Level 1 Screening (PL1) form completed prior to admission, and the referring entity 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 19-0; Effective July 7, 2019

 

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 19-0; Effective July 7, 2019

 

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

 

2320 PL1 Screening Form

Revision 19-0; Effective July 7, 2019

 

The PL1 Screening form contains the following sections:

 

2320.1 PL1 Submission

Revision 19-0; Effective July 7, 2019

 

The PL1 Screening form can only be submitted in the LTC online portal by a LIDDA/LMHA/LBHA or NF. Following successful submission, the LTC online portal will issue alerts based on the information contained within Section C of the completed form.

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

 

2320.2 Positive PL1

Revision 19-0; Effective July 7, 2019

 

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

 

2320.3 Negative PL1

Revision 19-0; Effective July 7, 2019

 

If the RE selects “No” to all three fields within Section C, PASRR Screen, then the PL1 status is considered negative for suspicion of an MI, ID or DD. A negative PL1 screening will formally end the PASRR process for a person.

 

2330 Admission Types

Revision 19-0; Effective July 7, 2019

 

There are three types of NF admissions:

 

2330.1 Exempted Hospital Discharge

Revision 19-0; Effective July 7, 2019

 

Exempted hospital discharge occurs when a physician has certified that a person being discharged from an acute care hospital is likely to require less than 30 days of NF services for the condition for which 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 will only require a PASRR evaluation if their stay in the NF exceeds 30 days. If the person's stay exceeds 30 days, the LTC online portal will send an alert to the LIDDA/LMHA/LBHA.

 

2330.2 Expedited Admission

Revision 19-0; Effective July 7, 2019

 

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

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 will determine when the PE is completed 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 19-0; Effective July 7, 2019

 

Preadmission occurs when a person is being admitted 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/LBHA with a copy of the PL1. The person may not be admitted to an NF until the LIDDA/LMHA/LBHA completes a PASRR evaluation.

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 an NF. It is important to note that the information entered in the PE for a preadmission is used by Texas Medicaid & Healthcare Partnership (TMHP) to determine MN for a person whose PE is positive. An MN determination is critical for people who want to divert from an NF admission directly into a community setting.

 

2340 Admission Type on PL1

Revision 19-0; Effective July 7, 2019

 

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.

Section F from the PL1.

TMHP 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.

After completing the PL1, the RE has the final responsibility of sending the completed paper PL1 Screening form to the appropriate party for submission to the LTC online portal. The chart below summarizes to which party the PL1 is sent depending upon 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 Referring Entity LIDDA if positive for ID/DD LMHA/LBHA if positive for MI
Negative Preadmission Referring Entity NF
Expedited Admission Referring Entity NF
Exempted Hospital Discharge Referring Entity NF
Change of Ownership (CHOW) The old NF contract/vendor number becomes the referring entity to the new contract number. The new contract number
NF to NF Transfers The discharging facility becomes the referring entity to the admitting facility. The admitting facility

 

2400 PASRR Level II Evaluation (PE)

Revision 19-0; Effective July 7, 2019

 

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

 

2410 Purpose, PASRR Status, and Staff Qualifications

Revision 19-0; Effective July 7, 2019

 

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

 

2410.1 PASRR Positive

Revision 19-0; Effective July 7, 2019

 

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

 

2410.2 PASRR Negative

Revision 19-0; Effective July 7, 2019

 

When the PE does not confirm a person has an MI, ID or DD, the PASRR status for the person is PASRR negative, even when the PL1 is positive.

 

2410.3 Staff Qualifications

Revision 19-0; Effective July 7, 2019

 

The qualifications for staff completing a PE is contained in 26 TAC, Chapter 303, §303.303 (relating to Qualifications and Requirements for Staff Person Conducting a PE or Resident Review).

 

2420 LTC Online Portal Notification

Revision 19-0; Effective July 7, 2019

 

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

The LIDDA/LMHA/LBHA will not receive an automatic alert notification if the LIDDA/LMHA/LBHA submitted the positive PL1 for preadmission into the LTC online portal.

 

2420.1 Timing of Alert is Based on Admission Type

Revision 19-0; Effective July 7, 2019

 

The type of admission from the PL1 determines when an alert will be sent to the LIDDA/LMHA/LBHA to conduct a PE. The timings for alerts are explained in the LTC Preadmission Screening and Resident Review (PASRR) User Guide for Local Authorities.

The LIDDA/LMHA/LBHA must:

 

2420.2 Change of Ownership (CHOW) Extensions

Revision 19-0; Effective July 7, 2019

 

A CHOW occurs when an 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/LBHA receives multiple alerts to complete a PE. The LIDDA may request an extension to the seven-day time frame to complete the PE. To request an extension, the LIDDA/LMHA/LBHA must contact the HHSC PASRR Unit at PASRR.support@hhsc.state.tx.us.

 

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

Revision 19-0; Effective July 7, 2019

 

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

*Information on whether the person has a prior PE is available by checking in the LTC online portal. Note that at this point, a LIDDA can only view a prior PE within the LIDDA’s local service area. If the Client Assignment and Registration (CARE) System shows the person was served by another LIDDA after 2015, the LIDDA receiving the alert should contact the other LIDDA to inquire about previous PEs, diagnostics and service plans.

**If the PL1 indicates 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 19-0; Effective July 7, 2019

 

If the person has full Medicaid benefits and is 21 or older, the LIDDA must be prepared to assign a habilitation coordinator if the person has a positive PE.

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 LIDDA(s).

 

2430 Completing and Submitting the PE

Revision 19-0; Effective July 7, 2019

 

LIDDAs are responsible for completing a PE for people who are suspected of having ID or DD.

LMHAs or LBHAs are responsible for completing a PE for people suspected of having an MI.

Both the LIDDA and LMHA/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, 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. Conducting a state-wide historical record review in accordance with Section 2430.3, Documentation Review for PE Completion.
  2. Contacting the RE or NF to make sure the person is still in the RE location or the NF before traveling to the RE location or NF to complete the PE and confirming the person is available and alert for the evaluation.
  3. Traveling 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. Bringing a release of confidential information to obtain the person’s/LAR’s consent to obtain additional information as needed from collateral contacts.
  5. Meeting 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. Notifying 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. Using 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. Submitting the PE into the LTC online portal within seven 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 19-0; Effective July 7, 2019

 

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

 

2430.2 Person/LAR Refuses to Participate in PE

Revision 19-0; Effective July 7, 2019

 

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/LAR in explaining the process to the person/LAR. If the person or LAR continues to refuse, the LIDDA will complete the PE solely from chart review and will document the person’s/LAR’s refusal in a comment field located within Section F1000 of the PE.

 

2430.3 Documentation Review for PE Completion

Revision 19-0; Effective July 7, 2019

 

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 (CMBHS), if available, LTC online portal and Service Authorization System Online (SASO)), 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 such as previous placement in settings, such as:

Documentation gathering and record review should include but not be limited to:

 

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

Revision 19-0; Effective July 7, 2019

 

Information about most of the community programs listed in Section F0700 of the PE are contained in the documents that are provided to the person and LAR as part of CLO (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.

 

2430.5 Presenting Information about Community Services as Part of the PE

Revision 19-0; Effective July 7, 2019

 

Person’s PE is Positive for ID or DD

For a person whose diagnosis of ID or DD has been confirmed, the staff conducting the PE must present community living options (CLO) in accordance with Section 5810.3, CLO Materials Provided to Individual/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 CLOs.

 

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

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.
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 ensures the assigned HC:

  • 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 HC 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 will inform 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 will inform 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.

 

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 the person’s LAR, Appendix II, Long Term Services and Supports, in the LIDDA Handbook.

If the person wants to pursue community living after receiving information about long term services and supports, then the PE staff will arrange for the person to be referred to the regional ADRC and, if appropriate, Every Child, Inc.

 

2430.6 PE for Resident Review

Revision 19-0; Effective July 7, 2019

 

When a resident with ID or DD who has been residing in an NF experiences a significant change in medical status, the NF will submit 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 will issue an alert to the LIDDA to conduct a resident review within seven calendar days after receiving the alert.

The LIDDA will use the same form used to conduct a PE and submit the resident review in the same manner as the PE on the LTC online portal. The resident review is conducted to:

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.

 

2430.7 When a DID is Required to Adequately Complete the PE

Revision 19-0; Effective July 7, 2019

 

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:

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 in accordance with rules governing diagnostic assessment (40 TAC, Chapter 5, Subchapter D).

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

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

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.

 

2430.8 PE Submission

Revision 19-0; Effective July 7, 2019

 

The LIDDA will:

 

2430.9 Specialized Services Recommendation Mapping

Revision 19-0; Effective July 7, 2019

 

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. 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 LTC Preadmission Screening and Resident Review (PASRR) User Guide for Local Authorities.

The entity that completes the PE will 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.

 

2430.10 Fair Hearing Related to Negative PE

Revision 19-0; Effective July 7, 2019

 

If a person or LAR of a person whose PE is negative requests a fair hearing, HHSC will notify the LIDDA, which must provide information or material supporting a negative PE determination. The LIDDA must submit to HHSC all requested material or information related to 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.

 

2430.11 PE Retention Period

Revision 19-0; Effective July 7, 2019

 

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

 

2500 PASRR Initial IDT/SPT Meeting

Revision 19-0; Effective July 7, 2019

 

For any person with a positive PE for ID or DD, the NF will convene 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, LMHA/LBHA representation is also required at the IDT.

The IDT will review the results of the person’s CLO to determine where the person is best served, as well as review and discuss which of the PE’s recommended specialized services that the person/LAR wants to receive.

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

Excluding a person’s/LAR’s refusal of specialized services, or in cases in which there is no funding for specialized services, if there is not consensus among all IDT members regarding whether a person should receive an NF specialized service, then obtaining an assessment for the NF specialized service is strongly encouraged. The assessment will indicate whether the person can benefit from the specific NF specialized service.

 

2510 NF Enters Initial IDT/SPT Meeting Information

Revision 19-0; Effective July 7, 2019

 

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

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

 

2520 Confirmation of IDT/SPT Meeting Information

Revision 19-0; Effective July 7, 2019

 

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, a LIDDA must check the LTC online portal and take one of the following three actions in the chart below, as appropriate.

Action 1

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

  • contact the NF and request that the NF conduct another IDT 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 IDT.
Action 2

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

  • If the NF corrected the information in the LTC online portal within seven 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 IDT.
  • If the NF does not correct the information in the LTC online portal within seven days, the LIDDA must document in the LTC online portal in Section A3500 disagreement with whichever of the following that continues to be incorrect:
    • the specialized services listed in the LTC online portal; or
    • the LIDDA representative’s attendance at IDT.
Action 3

If a LIDDA representative participated in the IDT and agrees with the information the NF entered in the LTC online portal related to the specialized services and the LIDDA’s attendance at the IDT, 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 IDT.

 

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 19-0; Effective July 7, 2019

 

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 and 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:

Section 3000, Diversion from Nursing Facility Admission

Revision 19-0; Effective July 7, 2019

 

3100 Diversion Coordinator Duties

Revision 19-0; Effective July 7, 2019

 

A 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:

 

3200 Diverting from NF Admission

Revision 19-0; Effective July 7, 2019

 

HHSC may make available a targeted NF HCS diversion slot to an individual with ID or DD who is determined to be at imminent risk of a long term stay in an NF. After a positive PL1 for preadmission is completed and entered in the LTC online portal, a LIDDA must conduct a PE on the individual to determine if the individual:

 

3210 Criteria for Diverting from NF Admission

Revision 19-0; Effective July 7, 2019

 

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

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

 

3220 Requesting a Targeted NF HCS Diversion Slot

Revision 19-0; Effective July 7, 2019

 

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

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

 

3230 Enrolling in HCS as a Diversion to NF Admission

Revision 19-0; Effective July 7, 2019

 

A LIDDA enrolls an individual in the HCS program as an alternative to NF admission, in accordance with the requirements in the HCS rules, LIDDA Handbook and this section. A LIDDA ensures an assigned SC or enhanced community coordinator (ECC) completes the following:

 

3230.1 Enhanced Community Coordination Funds

Revision 19-0; Effective July 7, 2019

 

Enhanced community coordination funds are available to LIDDAs through the HHSC/LIDDA performance contract for an individual who is enrolling in HCS as a diversion to NF admission. The purpose of the funds is to enhance an individual’s natural supports and promote successful community living. Funds are intended to pay for:

A LIDDA should contact its HHSC contract manager to discuss how to access funds.

 

3240 Post Enrollment in HCS as a Diversion to NF Admission

Revision 19-0; Effective July 7, 2019

 

For one year after an individual has enrolled in the HCS program as a diversion to NF admission, an SC or ECC must:

Section 4000, Admission to a Nursing Facility

Revision 19-0; Effective July 7, 2019

 

4100 Eligibility for Habilitation Coordination Funded by Medicaid

Revision 19-0; Effective July 7, 2019

 

An individual is eligible for habilitation coordination funded by Medicaid if the individual:

 

4200 Assignment of Habilitation Coordinator

Revision 19-0; Effective July 7, 2019

 

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

The HC 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 CARE, previous LIDDA services, previous service plans) before the initial IDT meeting.

 

4300 Initial IDT/SPT Meeting

Revision 19-0; Effective July 7, 2019

 

The HC must attend the individual’s initial IDT meeting. The PE evaluator shares the results of the 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 HC and IDT members should determine whether 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 PASRR Comprehensive Service Plan (PCSP) form.

 

4310 Attendance at Initial IDT/SPT Meeting

Revision 19-0; Effective July 7, 2019

 

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

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

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

**An HC’s attendance at the initial IDT/SPT meeting is reimbursed through the habilitation coordination reimbursement rate if the HC and individual are face-to-face.

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

 

4400 Requesting Authorization for Habilitation Coordination

Revision 19-0; Effective July 7, 2019

 

 

 

4410 IDT Agrees to Habilitation Coordination

Revision 19-0; Effective July 7, 2019

 

If the IDT agrees to the provision of habilitation coordination for an eligible individual, the HC requests authorization for habilitation coordination in accordance with the Habilitation Coordination Billing Guidelines.

 

4420 Refusal of Habilitation Coordination

Revision 19-0; Effective July 7, 2019

 

If an eligible individual/LAR does not want habilitation coordination, the HC:

 

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

Revision 19-0; Effective July 7, 2019

 

If the IDT agrees to the provision of habilitation coordination for an individual, the HC convenes the first SPT meeting immediately after the initial IDT meeting.

At the first SPT meeting, the HC 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:

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:

 

4510 Specialized Services Requiring an Assessment

Revision 19-0; Effective July 7, 2019

 

An assessment is required for:

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

 

4520 Specialized Services that Do Not Require an Assessment

Revision 19-0; Effective July 7, 2019

 

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

 

4530 Frequency and Duration of Habilitation Coordination

Revision 19-0; Effective July 7, 2019

 

The duration of habilitation coordination is “while the individual 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 in accordance with the requirements in rule and Section 5100, Required Face-to-Face Visits.

 

4600 Initiating IDD Habilitative Specialized Services after First SPT Meeting

Revision 19-0; Effective July 7, 2019

 

The LIDDA is responsible for initiating IDD habilitative specialized services within 20 business days after the date of the IDT meeting. “Initiating” means to take necessary action that will result in an individual receiving an assessment or the specialized service in a timely manner.

 

4700 Providing Habilitation Coordination

Revision 19-0; Effective July 7, 2019

 

The HC provides ongoing habilitation coordination in accordance with Section 5000, Habilitation Coordination, continuing 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.

Section 5000, Habilitation Coordination

Revision 19-0; Effective July 7, 2019

 

5100 Required Face-to-Face Visits

Revision 19-0; Effective July 7, 2019

 

An HC meets face-to-face with an individual monthly, or more frequently if needed, unless the only specialized service the individual is receiving is habilitation coordination, in which case the HC meets face-to-face with the individual at least quarterly. Based on these requirements, the SPT determines the frequency of face-to-face visits. A face-to-face meeting with the individual must include the provision of at least one of the habilitation coordination activities described in this section.

 

5200 Assess/Reassess Habilitative Needs

Revision 19-0; Effective July 7, 2019

 

An HC must assess and periodically reassess an individual’s habilitative service needs by gathering information from the individual and other appropriate sources, such as the LAR, family members, social workers and service providers, to determine the individual’s habilitative needs and the specialized services that will address those needs.

An HC must complete Form 1064, Habilitative Assessment, for the individual:

The HC will ensure the completed assessment is sent to each SPT member at least 10 business days before the first quarterly SPT meeting following the initial IDT/SPT meeting and before the annual IDT/SPT.

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

 

5210 Reviewing Assessments

Revision 19-0; Effective July 7, 2019

 

An HC 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:

*An individual can benefit from a specialized service if the service will help the individual acquire new skills, maintain skills, or delay or slow the loss of skills or functioning.

Reviewing assessments provides a more comprehensive understanding of an individual’s strengths, preferences and service needs, and helps SPT members outline services to meet the individual’s identified goals and objectives. As the facilitator of the SPT meeting, the HC must ensure the needs identified in all assessments are addressed.

HHSC encourages the HC to bring copies of all current assessments to the SPT meeting, so that the SPT can review and discuss recommendations. The HC must provide copies of assessments to the 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:

 

5300 SPT Meetings

Revision 19-0; Effective July 7, 2019

 

An HC must convene and facilitate SPT meetings as described in this section for an individual receiving habilitation coordination.

By facilitating the SPT meeting, the HC assists SPT members to accomplish their responsibilities, which are to:

For an SPT meeting convened by the HC, the HC 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 HC must ensure the member’s name is included on the sign-in sheet. The HC must maintain all sign-in sheets.

 

5310 First SPT Meeting

Revision 19-0; Effective July 7, 2019

 

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

 

5320 Quarterly SPT Meetings

Revision 19-0; Effective July 7, 2019

 

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 after the three-month mark.

The HC must maintain the every-three-month base schedule even if a particular quarterly SPT meeting takes place within two weeks before or after the three-month mark. HHSC permits an HC to revise an individual’s schedule for quarterly SPT meetings to accommodate alignment with the NF’s service planning schedule. Revising an individual’s schedule for quarterly SPT meetings requires detailed documentation in the HC’s progress notes. The HC 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 19-0; Effective July 7, 2019

 

During each quarterly SPT meeting, the SPT must:

If Form 1057 requires revisions based on the quarterly SPT meeting, the HC must revise Form 1057 as needed within 10 days after the meeting.

 

5320.2 Documenting Summary of Quarterly SPT Meeting

Revision 19-0; Effective July 7, 2019

 

The HC 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 19-0; Effective July 7, 2019

 

Within five days after a quarterly SPT meeting, the HC will enter in the LTC online portal all required information on the PASRR Comprehensive Service Plan (PCSP) form.

 

5330 Update SPT Meetings

Revision 19-0; Effective July 7, 2019

 

An HC must convene an update SPT meeting between quarterly SPT meetings when necessary, such as when there is a change in the individual’s service needs, medical condition, or if requested by the individual or LAR.

 

5330.1 Update SPT Meeting Because of a Change in Medical Condition or a Change in Service

Revision 19-0; Effective July 7, 2019

 

An HC must convene an update SPT meeting if:

The HC 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 HC must revise Form 1057 or Form 1063, as needed, within 10 days after the meeting.

Within five days after an update SPT meeting is held per the information in this section, the HC enters in the LTC online portal all required information on the PCSP form.

 

5330.2 Update SPT Meeting for an Issue Not Addressed in Section 5330.1

Revision 19-0; Effective July 7, 2019

 

An HC convenes an update SPT meeting to address any outstanding issue that is unrelated to an issue identified in Section 5330.1, Update SPT Meeting Because of a Change in Medical Condition or a Change in Service.

The HC 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 HC must revise Form 1057 or Form 1063, as needed, within 10 days after the meeting.

A PCSP form is not required for an update SPT meeting held per the information in this section.

 

5340 Annual IDT/SPT Meeting

Revision 19-0; Effective July 7, 2019

 

 

 

5340.1 Annual IDT/SPT Meeting

Revision 19-0; Effective July 7, 2019

 

An annual IDT/SPT meeting is held for an individual regardless of whether the individual is receiving habilitation coordination or any other specialized service. The HC is responsible for inviting all SPT members to the annual IDT/SPT meeting.

Note: If the individual has refused habilitation coordination, then there is no SPT for that individual, but the HC still must attend the annual IDT meeting.

The IDT/SPT members will discuss Form 1064, Habilitative Assessment, conducted by the HC and all recommended specialized services and decide:

The HC must confirm the annual IDT/SPT meeting information in the LTC online portal on the PCSP form in accordance with Section 2520, Confirmation of IDT/SPT Meeting Information.

 

5340.2 HC Preparation for Annual IDT/SPT Meeting

Revision 19-0; Effective July 7, 2019

 

An HC must complete Form 1064, Habilitative Assessment, for the individual no earlier than 60 days before the scheduled annual IDT/SPT meeting regardless of whether the individual is receiving habilitation coordination or any other specialized service. The HC provides a copy of the completed Form 1064 to all IDT/SPT members at least 10 business days before the annual IDT/SPT meeting.

 

5340.3 IDT Agrees to Habilitation Coordination

Revision 19-0; Effective July 7, 2019

 

If the IDT agrees to the provision of habilitation coordination for the individual, the HC requests a renewal authorization for habilitation coordination in accordance with the Habilitation Coordination Billing Guidelines.

 

5340.4 Refusal of Habilitation Coordination

Revision 19-0; Effective July 7, 2019

 

If an eligible individual/LAR does not want habilitation coordination:

 

5340.5 Annual SPT Meeting

Revision 19-0; Effective July 7, 2019

 

If the IDT agrees to the provision of habilitation coordination for an individual, the HC convenes the annual SPT meeting immediately following 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 19-0; Effective July 7, 2019

 

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

 

5360 Determination that Participation in SPT Meeting is Not Necessary

Revision 19-0; Effective July 7, 2019

 

If an HC 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 HC must:

 

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

Revision 19-0; Effective July 7, 2019

 

This section provides guidance when an HC receives information from an individual or LAR that they will not attend a scheduled SPT meeting.

 

5400 Develop and Revise Habilitation Service Plan and Individual Profile

Revision 19-0; Effective July 7, 2019

 

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

 

5410 Person-centered Planning

Revision 19-0; Effective July 7, 2019

 

Person-centered planning helps an individual figure out and describe what they need from services and from the service provider. The goal is to improve the individual’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 individual and the individual’s LAR.

For more information about person-centered planning, including training, see HHS website.

 

5420 Discovery Process

Revision 19-0; Effective July 7, 2019

 

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 to 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 HC talks to the individual or those who know the individual best. It is necessary to record the information learned so that it can be used when developing or updating Form 1057, Habilitation Service Plan (HSP). An HC leads the discovery process, advocating on behalf of the individual whose services and supports are being planned.

 

5430 Developing Habilitation Service Plan and Individual Profile

Revision 19-0; Effective July 7, 2019

 

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

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 individual’s needs, achieve the desired outcomes, and maximize the individual’s ability to live successfully in the most integrated setting possible. 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 individual’s desired outcomes.

The HSP year:

At a minimum, for each specialized service agreed upon during the IDT meeting, the HSP must indicate either:

 

5430.1 Specialized Services Requiring an Assessment

Revision 19-0; Effective July 7, 2019

 

An assessment is required for:

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

 

5430.2 Specialized Services that Do Not Require an Assessment

Revision 19-0; Effective July 7, 2019

 

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

 

5430.3 Frequency and Duration of Habilitation Coordination

Revision 19-0; Effective July 7, 2019

 

The duration for habilitation coordination is “while the individual 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 in accordance with 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 19-0; Effective July 7, 2019

 

If barriers are identified during CLO and described in Sections 6 or 7 of Form 1054, Community Living Options, the HC initiates as a topic of discussion at an SPT meeting about the 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 individual 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 an individual’s transition to the community is an inability to navigate public transportation, then the individual may benefit from receiving independent living skills training with an outcome of learning how to use the public bus system.

The HC 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 19-0; Effective July 7, 2019

 

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 within 10 days following the SPT meeting in which the revisions were agreed upon.

 

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

Revision 19-0; Effective July 7, 2019

 

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.

Note: The assessment results may impact the provision of an IDD habilitative specialized service. For example, if the individual is receiving day habilitation five days per week and a therapy assessment shows he or she needs 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 individual’s record.

 

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

Revision 19-0; Effective July 7, 2019

 

An assessment must be conducted for behavioral support, employment assistance and supported employment. The information included in a completed assessment indicates whether the individual 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.

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

 

5440.3 Revising the HSP to Address Barriers Identified During CLO

Revision 19-0; Effective July 7, 2019

 

If barriers are identified during CLO and described in Sections 6 or 7 of Form 1054, Community Living Options, the HC initiates at an SPT meeting a discussion of the 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 individual 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 an individual’s transition to the community is an inability to navigate public transportation, then the individual may benefit from receiving independent living skills training with an outcome of learning how to use the public bus system.

The HC 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 19-0; Effective July 7, 2019

 

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

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:

Note: It is unlikely the annual IDT/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/SPT meeting to take place as early as 344 days after the initial or previous annual IDT/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 19-0; Effective July 7, 2019

 

A complete habilitation packet for an individual has:

 

5460.1 Individual Profile

Revision 19-0; Effective July 7, 2019

 

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

Section 1, Individual’s Information — This section gathers identifying information about an individual as well as contact information for the individual, LAR and primary contact, if any, and information about an individual’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 individual’s life and who can provide information about the individual, such as family, friends, mentor and clergy.

Section 4, Profile Information — This section provides an overall profile of an individual’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 individual’s strengths and what others like and admire about the individual.

These are my preferences and what is important to me: A descriptive narrative about what is important to the individual. “Important to” reflects what is important from the individual’s perspective and is based on the individual’s words and behavior. When words or behavior are in conflict, listen to the behavior. The information might include important relationships, how the individual prefers to interact, things the individual likes to do or not do, preferred routines, relevant background information that may affect how services should be delivered and what the individual wants to do in the future. Remember, the individual’s response is limited to the knowledge and experiences he or she has to date. Additional efforts should be explored to increase his or her awareness of additional possibilities and experiences to increase his or her 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 individual, 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 individual. All specific areas listed below must be addressed and include specificity about health needs, risk factors and special instructions for those who support the individual. See Appendix IV, Risk Factors, for more information about identifying risks.

Historical information: Include background information that continues to significantly affect the individual or his or her services.

 

5460.2 Habilitation Service Plan

Revision 19-0; Effective July 7, 2019

 

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

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

Section 2, Discovery — This section describes all the ways information was gathered to discover an individual’s desires and preferences, such as observation of the individual and conversations with the individual/LAR and those who know the individual best, such as an 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 individual and the HC. The duration of habilitation coordination while the individual is residing 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 which may be either at least monthly or at least quarterly.

This section also lists all the activities to be coordinated and monitored by the HC. 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 HC. The PASRR rules provide a definition of “nursing facility PASRR support activities” and includes the following examples of support activities:

Note: The examples above are not all inclusive. A support activity can be any type of activity that supports the individual 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 individual 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 individual receives that will help the individual 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/natural support listed, a description is necessary of how the specialized service or resource/natural support helps the individual achieve the outcome.

Note: While an 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 individual 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 individual during the HSP year, including:

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 an HC presents CLO to the individual/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 individual/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 for which 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 HC to affirm that the HSP was developed based on IDT or SPT decisions and includes the HC’s printed name, signature and date.

 

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

Revision 19-0; Effective July 7, 2019

 

An HC 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 when they are developed and whenever they are revised.

An HC must share an individual’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 19-0; Effective July 7, 2019

 

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 individual, then:

 

5500 Assisting with Access to Needed Specialized Services

Revision 19-0; Effective July 7, 2019

 

 

 

5510 Initiating IDD Habilitative Specialized Services

Revision 19-0; Effective July 7, 2019

 

An HC is responsible for initiating IDD habilitative specialized services identified on an individual’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 individual 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 19-0; Effective July 7, 2019

 

An HC must document the initiation and delivery of all specialized services agreed upon in an IDT meeting or an SPT meeting.

The HC 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:

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 in accordance with the performance contract.

 

5530 Accessing Other Habilitative Programs

Revision 19-0; Effective July 7, 2019

 

An HC must assist an individual to access needed specialized services and other habilitative programs and services that can provide services to address the individual’s needs and achieve outcomes identified in the HSP.

 

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

Revision 19-0; Effective July 7, 2019

 

If an individual is denied a specialized service and the individual/LAR wants to appeal the denial, the HC is responsible for assisting the individual/LAR with completing Form 2361, PASRR Specialized Services Fair Hearing Request, to request a fair hearing.

 

5600 Coordination

Revision 19-0; Effective July 7, 2019

 

An HC is responsible for:

 

5700 Monitoring and Follow-up Activities

Revision 19-0; Effective July 7, 2019

 

An HC must provide monitoring and follow-up activities to determine:

Monitoring may be accomplished through a combination of:

The HC must share with the SPT the results of the HC’s monitoring and follow-up activities.

 

5800 Community Living Options (CLO), Visits to Community Programs, and Educational Opportunities

Revision 19-0; Effective July 7, 2019

 

 

 

5810 Presenting CLO

Revision 19-0; Effective July 7, 2019

 

An HC provides information and discusses with an individual and LAR about the range of community living services, supports and alternatives, identifying the services and supports the individual will need to live in the community (whether or not the individual/LAR has chosen to transition to community living) and identifying and addressing barriers to community living. This activity is referred to as “CLO.”

CLO must be presented in a manner that allows the person and his or her 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 individual’s or LAR’s full understanding of CLO, the HC 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 19-0; Effective July 7, 2019

 

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

Note: CLO is presented anytime a PE is completed, including for a resident review or Change of Ownership (CHOW).

 

5810.2 Six-Month Base Schedule

Revision 19-0; Effective July 7, 2019

 

The HC presents CLO to the individual/LAR six months after the initial CLO and at least every six months thereafter while the individual continues to reside in the NF. The HC must ensure the CLO presentation occurs no more than 30 days before the scheduled second quarterly SPT or annual IDT/SPT, so that it can be discussed during the meeting. The HC 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/LAR

Revision 19-0; Effective July 7, 2019

 

The HC 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 individual and his or her LAR fully understand the materials and each of the individual’s community options:

*CLO booklets are available by ordering from Pinnacle Cart.

 

5820 Documenting CLO

Revision 19-0; Effective July 7, 2019

 

The HC documents the CLO presentation and discussion on Form 1054, Community Living Options.

Note: The HC 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 HC Actions Following CLO

Revision 19-0; Effective July 7, 2019

 

The HC complies with the requirements in this section following:

 

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

Revision 19-0; Effective July 7, 2019

 

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

The HC must:

 

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

Revision 19-0; Effective July 7, 2019

 

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

The HC must:

if the individual 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 individual/LAR has selected a community program, the HC must:

 

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

Revision 19-0; Effective July 7, 2019

 

For an individual who has not refused habilitation coordination, if the individual/LAR does not want to transition, is undecided or the desire of the individual/LAR cannot be determined, the HC must:

 

5840 Exploring Community Programs

Revision 19-0; Effective July 7, 2019

 

An HC arranges exploratory visits to community programs for an individual, if requested, and addresses concerns about community living from the individual and LAR. Additionally, the HC may assist an individual 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 19-0; Effective July 7, 2019

 

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

 

5900 Explanation of Rights

Revision 19-0; Effective July 7, 2019

 

An HC must initially, and annually thereafter, provide an individual and LAR an oral and written explanation of the individual’s rights contained in the “Your Rights in Local Authority Services” booklet.

Section 6000, Transition from NF to Community

Revision 19-0; Effective July 7, 2019

 

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

Revision 19-0; Effective July 7, 2019

 

 

 

6110 Assigning a Service Coordinator or Enhanced Community Coordinator

Revision 19-0; Effective July 7, 2019

 

When an HC notifies the appropriate LIDDA staff that an individual/LAR wants to transition to the community and has selected a community program, the LIDDA must assign a service coordinator (SC) or an enhanced community coordinator (ECC) to begin transition planning with the individual and LAR.

Within seven days after notification by an HC:

 

6110.1 Unassigning a Service Coordinator or Enhanced Community Coordinator

Revision 19-0; Effective July 7, 2019

 

If, during transition planning, an individual indicates that he or she is no longer interested in transitioning to the community, the LIDDA unassigns the SC/ECC and ensures the unassignment is reflected in CARE screen 490.

Before being unassigned, the SC/ECC notifies the RS and the HC that the individual is no longer interested in transitioning to the community.

 

6120 Working with the Relocation Specialist

Revision 19-0; Effective July 7, 2019

 

The SC/ECC reviews the relocation assessment and evaluation and contacts the RS and MCO SC to invite them to 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 individual objects.

 

6130 Relocation Specialist and MCO SC Responsibilities

Revision 19-0; Effective July 7, 2019

 

The MCO SC and RS, as members of the SPT, assist an individual with accessing:

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 SC/ECC with a copy of the completed STS form signed by the MCO, the RS and the SC/ECC.

Note: For individuals transitioning to the HCS program, the SC/ECC is responsible for completing and submitting the assessment for TAS funding. For individuals transitioning to the CLASS, DBMD or 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 individual’s new address on relocation day to ensure all services are in place and to assist in setting up the household, as needed.

 

6140 Enhanced Community Coordination Funds to Assist with Certain Costs Related to Transitioning

Revision 19-0; Effective July 7, 2019

 

Enhanced community coordination funds are available to LIDDAs through the HHSC/LIDDA performance contract for an individual who is transitioning to the community. The purpose of the funds is to enhance an individual’s natural supports and promote successful community living. Funds are intended to pay for:

A LIDDA should contact its HHSC contract manager to discuss how to access funds.

 

6200 Transition Planning

Revision 19-0; Effective July 7, 2019

 

An SC/ECC is responsible for:

For an SPT meeting convened by the SC/ECC, the SC/ECC 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 SC/ECC must ensure that member’s name is included on the sign-in sheet. The SC/ECC must maintain all sign-in sheets.

 

6210 SPT Meeting Participation by Service Coordinator/Enhanced Community Coordinator and Habilitation Coordinator

Revision 19-0; Effective July 7, 2019

 

 

 

6210.1 Service Coordinator/Enhanced Community Coordinator Participation

Revision 19-0; Effective July 7, 2019

 

An SC/ECC must participate in person or by phone at all quarterly SPT meetings convened by the HC.

 

6210.2 Habilitation Coordinator Participation

Revision 19-0; Effective July 7, 2019

 

An HC must participate in person or by phone at all SPT meetings convened by the SC/ECC.

 

6300 Developing and Revising the Transition Plan

Revision 19-0; Effective July 7, 2019

 

In conjunction with the SPT, the SC/ECC develops and revises, as needed, an individual’s Form 1053, Transition Plan. The SC/ECC must develop Form 1053, or revise it, as needed, within 10 days after the SPT meeting.

 

6310 Transition Plan

Revision 19-0; Effective July 7, 2019

 

Information documented on Form 1053, Transition Plan.

Section 1, Individual Information — Name on the individual, CARE ID, Medicaid number and date.

Section 2, Community Program Choice — This section identifies the community program selected by the individual/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 face-to-face meetings between the individual and the SC/ECC, which are pre-printed on the form. The duration of service coordination is throughout the transition process, and the frequency of face-to-face visits is at least monthly. This section also lists all the activities to be coordinated and monitored by the SC/ECC during the transition process.

Section 4, Identified Supports — This section describes all supports the individual 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 individual’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 of time in which a post-move monitoring visit must be conducted by an SC/ECC.

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 an individual. Complete the information 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 SC/ECC to affirm that the Transition Plan was developed based on SPT decisions and includes the SC’s printed name, signature and date.

 

6320 Barriers Preventing a Transition to the Community

Revision 19-0; Effective July 7, 2019

 

The SC/ECC must:

 

6330 Documents in an Individual’s Transition Packet

Revision 19-0; Effective July 7, 2019

 

A complete transition packet for an individual has:

 

6340 Individual Profile

Revision 19-0; Effective July 7, 2019

 

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

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

 

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

Revision 19-0; Effective July 7, 2019

 

The SC/ECC is responsible for providing a copy of the individual’s Form 1053, Transition Plan, to all SPT members when it is developed and whenever it is revised.

An SC/ECC must share an individual’s transition packet with an SPT member upon request.

 

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

Revision 19-0; Effective July 7, 2019

 

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

 

6400 Pursuing the Selected Community Medicaid Program for Transition

Revision 19-0; Effective July 7, 2019

 

If the individual/LAR chooses the:

 

6500 Transitioning to the HCS Program

Revision 19-0; Effective July 7, 2019

 

HHSC may make available a targeted NF HCS transition slot for an individual 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 19-0; Effective July 7, 2019

 

An individual is eligible for a targeted NF HCS transition slot if:

 

6520 Requesting a Targeted NF HCS Transition Slot

Revision 19-0; Effective July 7, 2019

 

If a LIDDA determines that an individual meets the criteria for a targeted NF HCS transition slot, the SC/ECC notifies the diversion coordinator to request a targeted NF HCS transition slot for the individual by completing and submitting Form 1046, Request for HCS Adult NF Transition Slot, in accordance with 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 individual meets the criteria for the targeted NF HCS transition slot, HHSC will send a letter to the LIDDA authorizing the LIDDA to offer the individual the opportunity to enroll in HCS. The LIDDA enrolls the individual in the HCS program in accordance with 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 19-0; Effective July 7, 2019

 

For an individual transitioning to the community by enrolling in the HCS program, the SC/ECC:

 

6600 Transitioning to a Community Medicaid Program

Revision 19-0; Effective July 7, 2019

 

When a slot has been offered to an individual who has selected a community Medicaid program that is not HCS, the SC/ECC:

 

6700 Transition Day

Revision 19-0; Effective July 7, 2019

 

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 SC/ECC is encouraged to be present as well.

 

6800 Post-transition to HCS Program

Revision 19-0; Effective July 7, 2019

 

 

 

6810 Post-move Monitoring Visits

Revision 19-0; Effective July 7, 2019

 

For an individual who transitioned to the HCS program, an SC/ECC must:

*The SC/ECC 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 days after enrolling in HCS.

 

6820 Monitoring Activities for One Year Post-move

Revision 19-0; Effective July 7, 2019

 

For at least one year after an individual has transitioned to the HCS program, an SC/ECC must:

 

6900 Post-transition into a Medicaid Community Program

Revision 19-0; Effective July 7, 2019

 

For an individual who has transitioned to a Medicaid community program that is not HCS, an SC/ECC must:

The SC/ECC 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 individual enrolled in the CLASS, DBMD or ICF program. The LIDDA may use enhanced community coordination funds if an ECC conducts the activities described in this section.

Appendices

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 LTC Preadmission Screening and Resident Review (PASRR) User Guide for Local Authorities, 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.

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

Revisions

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.

Contact Us

For questions about the Intellectual and Developmental Disability Preadmission Screening and Resident Review (IDD-PASRR) Handbook, email: PASRR.support@hhsc.state.tx.us

For technical or accessibility issues with this handbook, email: Editorial_Services@hhsc.state.tx.us