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Form H1700-3 is completed by the managed care organization (MCO) registered nurse (RN) service coordinator (SC) to document STAR+PLUS Home and Community Based Services (HCBS) program applicant or member nursing services. It is a tool to document the proposed nursing service plan for the individual service plan (ISP) year.
Form H1700-3 is used to:
- identify an applicant or member's nursing needs; and
- document if nursing services are delivered to applicant or member by:
- direct nursing performed by a Home and Community Support Services Agency (HCSSA) nurse or Consumer Directed Services (CDS) nurse and documented on the STAR+PLUS HCBS program ISP.
- weekly paid Health Maintenance Activities (HMAs) or delegated nursing task(s) as indicated on Form H2060-A, Addendum to Form H2060, or Form H6516, Community First Choice Assessment;
- the member or applicant himself or herself;
- informal support;
- third party resources (TPR) including:
- Medicare Home Health;
- Private insurance; or
- Medicaid Home Health (state plan);
- nurse or designated staff at:
- an Adult Foster Care (AFC);
- an Assisted Living Facility (ALF);
- a Day Activity and Health Services (DAHS) facility;
- a school or other educational setting; or
- other facility such as a wound care of dialysis center.
Form H1700-3 is not used to document time spent by the MCO RN SC for face-to-face service coordination contacts with the applicant or member, including initial assessment, annual reassessment and assessment for a change in services. It is not used to document nursing hours for RN training and supervision of an attendant for delegated nursing tasks.
When to Prepare
Form H1700-3 is completed for all STAR+PLUS HCBS program applicant or members at:
- initial assessment;
- a change affecting the delivery of nursing as entered in Column B, Direct STAR+PLUS HCBS program nursing, or in Column C, Paid HMA and delegated tasks; or
- annual reassessment.
Number of Copies
The original/electronic Form H1700-3 is placed in the member's case record.
The MCO keeps Form H1700-3 according to the retention requirements found in all Medicaid Managed Care contracts and federal regulations. The MCO keeps all originals/electronic copies of this form in the applicant’s or member’s case record for five years after services are terminated.
I. Identifying Information
1. Applicant/Member Name — Enter the name of the applicant or member, as shown on Form H1700-1, Individual Service Plan.
2. Medicaid Number or SSN — Enter the nine-digit Medicaid number, as entered on Form H1700-1. If the applicant or member does not have a Medicaid number, enter the Social Security number.
3. Medical Assistance Only (MAO) — Check the appropriate Yes or No box to indicate if the applicant or member’s Medicaid is the MAO eligibility type.
4. Start Date — Enter the start date. Enter the date in mm/dd/yyyy format or by clicking the drop-down option.
- For an initial ISP, enter the proposed start date of STAR+PLUS HCBS program services.
- For an ISP change, enter the date change to the form takes effect.
- For a reassessment, enter the ISP start date.
5. Review Type (select one) — Check the reason for completing the form:
- Initial – Select for an initial assessment of an applicant or member for the STAR+PLUS HCBS program;
- ISP Change – Select for an ISP change; or
- Reassessment – Select for an annual reassessment of the member for STAR+PLUS HCBS.
6. Consumer Directed Services (CDS) Nursing — Check the appropriate Yes or No box to indicate if the applicant or member is receiving nursing services through the CDS service delivery option.
Note: For members using the CDS option, the MCO SC completes Form 1585, Acknowledgement of Responsibility for Exemption from Nursing Licensure for Certain Services Delivered through Consumer Directed Services, with the member or authorized representative (AR). Form 1585 acknowledges responsibility of the employer to take responsibility for training and supervising an attendant for some specific nursing tasks. The SC and member or AR sign the form.
II. Nursing Tasks
Nursing services are those services that are within the scope of the Texas Nursing Practice Act and are provided by an RN or by a licensed vocational nurse (LVN) (under supervision of an RN) licensed to practice in Texas. Nursing services through the STAR+PLUS HCBS program provide ongoing services for chronic conditions lasting greater than 60 days, such as medication administration and supervising delegated tasks as well as nursing tasks an applicant or member requires that exceed the allowable nursing benefit available under State Plan services.
All STAR+PLUS HCBS program members meet medical necessity for a nursing facility level of care, as established on the Medical Necessity and Level of Care (MN/LOC) assessment, and therefore, will have one or more skilled nursing needs documented on this form.
Determinations of nurse delegated tasks and HMAs must be made in accordance with Texas Board of Nursing rules found in Title 22 Texas Administrative Code, §224 and 225. The MCO SC, in concurrence with HCSSA RN, determines if nursing tasks may be an HMA or be delegated to an attendant. The RN responsible for training and supervision of a delegated task makes the final delegation determination.
Attendant services such as bathing, toileting, walking and other activities of daily living (ADLs) are identified on Form H2060, Needs Assessment Questionnaire and Task/Hour Guide, or Form H6516. Tasks identified on Form H2060 and Form H6516 as purchased personal assistance services (PAS) must not be identified or purchased as an HMA or delegated task.
Column A. Nursing Tasks and HMAs
Identify the need for the tasks based on:
- nursing judgment of the assessing RN;
- the MN/LOC; and
- one or more of the following:
- practitioner's orders;
- documentation in the clinical record;
- report of the applicant or member or informal support.
Task 1. Administration of medications by any route —This includes administration of prescription and over-the-counter medications via any route. All parts integral to medication administration are documented in Task 1. For example, flushing a gastrostomy tube after medication administration is included in this task.
Task 2. Prefilling medication boxes/syringes —This task includes prefilling of medication boxes and syringes. Reminding the applicant or member to take medications from a pre-filled box is not a nursing task. The applicant’s or member’s need for reminding to take medications is documented on Form H2060 or Form H6516 when PAS are authorized. If informal support is reminding an applicant or member to take medications, Form H1700-B, Non-STAR+PLUS HCBS Program Services, should identify the informal support person and the tasks they complete.
Task 3. Tube feeding —This task includes feeding through an enteral tube. All parts integral to tube feeding are included in Task 3. For example, checking for residual or flushing a gastrostomy tube after feeding is included in this task. Flushing a gastrostomy tube after medication administration is not included in this task.
Task 4. Tracheostomy care —This task includes, but is not limited to, changing inner cannula, dressing/ties, cleaning, suctioning and tasks related to managing the airway for an applicant/member with a tracheostomy.
Task 5. Ventilator care —This task includes attention to ventilator settings, connections, modes and alarms. Do not include noninvasive ventilation such as Bi-level Positive Airway Pressure/Continuous Positive Airway Pressure (BPAP/CPAP) in this task.
Task 6. Wound care —This task includes wound care procedures and changing an enteral tube site dressing. This task does not include treatment of a stage 1 decubitus or prophylactic and palliative skin care including the application of non-medicated creams or treatments of minor abrasions or cuts. The administration of topical medication is documentedunder Task 1.
Task 7. Elimination —This task includes the administration of a urinary toileting program or a bowel continence program. To be considered a urinary toileting program or a bowel continence program, the task must be individualized and based on an assessment by the ordering practitioner. A urinary toileting program or bowel continence program may include intermittent catheterization, scheduled prompted voiding, enemas, digital stimulation, or manual evacuation. This task may also include nursing interventions that may be required for alternate forms of elimination such as changing an indwelling urinary catheter or attention to a new colostomy. The administration of suppositories is documented under Task 1.
Note: The following tasks are identified on Form H2060 or Form H6516 under the task/activity of toileting: changing diapers, changing external catheter, emptying catheter bag, changing colostomy bag and assistance with toileting hygiene. These tasks should not be purchased as a skilled nursing task or delegated as HMA, if they are purchased on Form H2060 or Form H6516.
Task 8. Collecting, reporting and documenting data —This task includes collecting, reporting and documenting data with specific parameters established by the ordering practitioner for the applicant or member, such as intake and output, blood pressure, blood sugar and seizure activity. This task may also include collecting, reporting and documenting data specific to an applicant’s or member’s diagnosis or condition as requested by the ordering practitioner. Also included in this task is collecting, reporting and documenting data indicative of an applicant’s or member's disease progression by a skilled nurse, such as assessment of neurological, cardiac and respiratory status, assessment of signs and symptoms of infection, and response to interventions.
Task 9. Health teaching and reinforcement of health teaching —This task includes health teaching performed by an RN. It is also used to document reinforcement of health teaching planned by an RN and implemented by an LVN. Health teaching and reinforcement of health teaching must be specific to the applicant’s or member’s diagnosis and condition, and as requested by the ordering practitioner. Health teaching must not be open-ended or without relation to the applicant’s or member’s specific current health needs. To document health teaching and reinforcement of health teaching as a task in this section, the teaching and reinforcement of health teaching must be directed to the applicant or member, the applicant’s or member’s non-paid family members or other informal support.
Task 10. Other (specify) — If there is a nursing task, other than the tasks listed in Tasks 1-9, specify the task and enter here. Examples may include skilled nasal suctioning, turning and repositioning an applicant or member on a ventilator, and skilled intervention related to BPAP/CPAP.
11. Managed Care Organization RN Service Coordinator Comments — The MCO RN SC provides additional documentation of the applicant’s or member's nursing needs and how the needs are met. Examples of comments to document include:
- explanation of the change in the applicant’s or member's condition or the change in nursing tasks performed by family or informal support that triggered the completion of this form;
- communication between the Home and Community Support Services Agency (HCSSA) RN and MCO RN SC demonstrating concurrence for nursing tasks delegated or determined to be an HMA;
- documentation of nursing for acute conditions or exacerbations of chronic conditions lasting less than 60 days and thus not anticipated to last the full ISP year. For example, if the member has nursing visits through Medicare or State Plan Medicaid, document the reason here and indicate the anticipated time frame. A check would be entered in Column F and an explanation entered here;
- identification of nursing tasks performed by a CDS attendant when the employer assumes responsibility for these tasks;
- explanation of the type of setting for any nursing tasks marked in Column K, Other; and
- explanation of the reason a task is checked in more than one column. For example, Task 1, Administration of medications by any route, may be performed by informal support when the applicant or member is at their residence and checked in Column D. It may also be performed at DAHS when an applicant or member is in that setting. A check would be entered in both columns and an explanation entered in this section.
Section II Nursing Tasks, Columns B-K
Column B, Direct STAR+PLUS HCBS program nursing — Enter a mark in the appropriate box in this column for the HCSSA nurse or the CDS nurse performance of nursing tasks in rows 1-10.
Column C, Paid HMA and delegated tasks — Enter a mark in this column for the performance of HMAs and delegated tasks performed by a paid attendant.
- For an MAO applicant or member, if a mark is entered in this column, time for weekly paid HMA and delegated tasks must be entered in Section II of Form H2060-A.
- For a member or applicant who receive PAS through Community First Choice (CFC), if a mark is entered in this column, time for weekly paid HMA and delegated tasks must be entered on Form H6516, Section V.
Tasks entered in this column must not be listed in Texas Administrative Code §225.13, Tasks Prohibited from Delegation. For applicants or members choosing the agency service delivery option or the service responsibility option (SRO):
- Delegated nursing tasks — The MCO SC can identify potential delegated nursing tasks and discuss with the HCSSA RN. The HCSSA RN makes the delegation assessment and determination for an applicant or member.
- HMAs — The MCO SC, in concurrence with the HCSSA RN, determines tasks that can be HMAs for an applicant or member. Document these discussions between the MCO SC and the HCSSA RN in Comments, MCO RN Service Coordinator Comments.
For applicants or members choosing the CDS service delivery option, the SC identifies the nursing tasks performed by a paid attendant, and enters a mark in this column.
Note: This column does not apply to applicants or members residing in an ALF or AFC because PAS is included in the ALF and AFC daily rate.
Column D, Applicant/Member — Enter a mark in this column for nursing tasks performed by the applicant or member for himself or herself.
Column E, Informal Support — Enter a mark in this column for nursing tasks performed by informal support. Informal support includes non-paid family members, friends, neighbors and community organizations. Enter a mark in this column for nursing task(s) performed by informal support that have been determined to be an HMA (per Texas Board of Nursing rules). If a mark is entered in this column, the nursing tasks and HMAs must be entered on Form H1700-B, under Informal/Community Supports.
Column F, Third Party Resources — Enter a mark in this column for nursing performed by any third party resource, including:
- Medicare Home Health;
- Medicaid Home Health;
- VA or TRICARE; and
- private insurance.
If a mark is entered in this column, the nursing tasks and HMAs must entered on Form H1700-B, under Medicare and Other Payers, or Medicaid State Plan Services.
Column G, Adult Foster Care — If a mark is entered in this column, AFC must be selected on Form H1700-1.
- For applicants or members who reside in an AFC operated by an RN, enter a check in this column for nursing tasks performed by the AFC nurse.
- For applicants or members who reside in an AFC not operated by an RN, nursing needs can be identified as an HMA; purchased as nursing services on the ISP; provided by a third party resource; met by a nurse at DAHS; or a combination of these options, and are entered in the appropriate column on this form.
Column H, Assisted Living Facility — If a mark is entered in this column, Assisted Living must be selected on Form H1700-1. For applicants or members who reside in an ALF, the administration of all of their medications is coordinated by the ALF and is excluded from Column B of this form.
Column I, Day Activity and Health Services — Enter a mark in this column for nursing tasks performed by a nurse or designated staff at a DAHS facility. If a mark is entered in this column, the nursing tasks and HMAs must be entered on Form H1700-B under Medicaid State Plan Services.
Column J, School — Enter a mark in this column for nursing tasks performed by a nurse or designated staff at a school or other educational setting. If a mark is entered in this column, the nursing tasks and HMAs must be entered on Form H1700-B under Services Provided in an Educational Setting.
Column K, Other — Enter a mark in this column for nursing tasks performed by a nurse or designated staff at a setting not previously listed such as a wound care or dialysis center. If a mark is made in this column, specify the setting in 11. Managed Care Organization RN Service Coordinator Comments.
1. MCO RN SC Certification — This signature attests to the MCO RN certification statement above the signature (The identified skilled nursing tasks are necessary to ensure the applicant or member’s health and safety, and are appropriate to meet the needs of the applicant or member in the community setting).
1a. The MCO RN SC prints his name.
1b. The MCO RN SC signs his name.
1c. The MCO RN SC enters the date the form is signed. Enter the date in mm/dd/yyyy format or by clicking the drop-down option.
2. Member/Authorized Representative Acknowledgement — The applicant, member or Authorized Representative (AR) prints his name, signs and dates this form. This signature attests to the Member/Authorized Representative Acknowledgement statement above the signature (I have participated in the process of service planning for nursing needs, reviewed this proposed Nursing Service Plan, and understand how nursing needs will be met). Written signature is required at the initial assessment and annual reassessment. For an ISP change, the MCO must obtain written or verbal approval. For verbal approval, the name of the individual providing verbal approval and the date of verbal approval must be documented on the Member/Authorized Representative signature line.
2a. The member or AR prints his name.
2b. The member or AR signs his name.
2c. The member or AR enters the date the form is signed. Enter the date in mm/dd/yyyy format or by clicking the drop-down option.