Revision 17-1; Effective November 1, 2017

 

3100 DSA Responsibilities

Revision 17-1; Effective November 1, 2017

 

All individuals who receive Community Living Assistance and Support Services (CLASS) program services and Community First Choice (CFC) Personal Assistance Services/Habilitation (PAS/HAB) must choose a direct services agency (DSA) with a valid provider agreement that operates in the catchment area in which the individual lives. Individuals who receive services through the CLASS program may request to transfer to another DSA at any time.

A DSA provides CLASS program services, CFCPAS/HAB services, and CFC emergency response services (ERS) to the individual as outlined in their Individual Plan of Care (IPC), the Individual Program Plan (IPP) for that service, and Individual Program Plan Addendum (IPP-A). An individual may elect to have some or all CLASS program and CFC services delivered by the DSA. Select services may be chosen for self-direction by the individual or legally authorized representative (LAR) using the Consumer Directed Services (CDS) option. For a complete list of CLASS and CFC services available using the CDS option, refer to Section 4000, Consumer Directed Services (CDS).

As outlined in this section, the individual's selected DSA is required to perform the following tasks on behalf of an individual in CLASS on an ongoing basis:

  • provide required documentation to HHSC as is necessary to assess and renew the level of care for the individual;
  • participate in developing a PAS/Habilitation Plan - CLASS/DBMD/CFC  for individuals receiving CFC PAS/HAB services through the DSA to outline the individual's CFC PAS/HAB needs and complete documentation of that plan;
  • participate in developing an IPC that addresses all of the individual's needs that will be met through the provision of CLASS or CFC services;
  • participate in developing the IPP-A using person-centered planning processes for each individual;
  • provide all CLASS and CFC provider-managed services according to the IPP-A and the IPP;
  • monitor the DSA's service provision processes to ensure all services are delivered by qualified service providers in accordance with the IPP-A and IPP; and
  • coordinate with the CMA and other service providers as necessary to ensure IPP-A and IPC revisions are initiated as necessary in response to changes in the individual's needs.

CLASS program and CFC services, as a whole, enhance an individual's integration in the community and prevent admission to an institution while maintaining and improving independent functioning.

 

3110 Base of Operation

Revision 17-1; Effective November 1, 2017

 

CLASS program and CFC providers must have a base of operation that includes a physical location and normal operating hours in each geographic catchment area for which they have a contract to provide CLASS program and CFC services.

  1. A base of operation is a place in which business, clerical or professional activities are conducted. Each base of operation must:
    • maintain individual records for the CLASS program contract in the catchment area;
    • maintain personnel records for personnel who provide CLASS program and CFC services to individuals served in the catchment area;
    • be staffed by qualified employees who have completed CLASS program training and can readily become familiar with the individuals being served in the catchment area; and
    • maintain adequate staff to provide services and to supervise the provision of services within the catchment area.
  2. Providers must identify the base of operation's normal operating hours. If the base of operations is closed during its normal operating hours or between the hours of 8:00 a.m. and 5:00 p.m. Monday through Friday, the provider must:
    • post a notice in a visible location outside the base of operations to provide information regarding how to contact the person in charge; and
    • leave a message on an answering machine or similar electronic mechanism to provide information regarding how to contact the person in charge.

 

3120 DSA Staff Training Requirement

Revision 17-1; Effective November 1, 2017

 

 

 

3121  Initial Training for Direct Contact Staff

Revision 17-1; Effective November 1, 2017

 

Direct contact for the purposes of this manual means face-to-face contact with a CLASS individual a minimum of one time per calendar year. A DSA program director(s) and any DSA staff person who has direct contact with an individual receiving services through the CLASS program must complete one of the following within 60 calendar days of the employee beginning to work with the CLASS program:

  • In-person CLASS Provider Training provided by HHSC.
  • Training developed by the DSA that includes, at a minimum:
    • CLASS program overview;
    • person-centered planning;
    • philosophy and values of community integration;
    • overview of related conditions and CLASS program eligibility criteria;
    • service planning team (SPT) process;
    • utilization review process;
    • consumer directed services; and
    • individuals' rights and responsibilities including:
      • fair hearing process;
      • DSA's complaints process;
      • mandatory participation requirements; and
      • abuse, neglect and exploitation characteristics and reporting information.

The DSA could choose to conduct training at its location to meet the above requirements within 60 days of hiring the service provider. DSA staff that develop the curriculum used for initial training must have attended and successfully completed the CLASS Provider Training. The DSA must have a record to verify that the trainer has attended the CLASS Provider Training. The DSA may choose to send new employees to CLASS Provider Training at the next opportunity offered by HHSC to further reinforce training provided by the DSA.

Documentation of completion of required training must include, at a minimum:

  • CLASS Provider Training completion certificate with the name of the employee, signed by HHSC; or
  • written documentation of completion of the DSA's training that includes:
    • training topics covered;
    • method of training (i.e., reading, video, discussion, etc.);
    • name(s) and qualifications of instructor(s);
    • name of the trainee;
    • date the training was completed;
    • signature and date of the instructor(s); and
    • signature and date of the trainee verifying completion.

If a DSA develops curriculum to meet CLASS training requirements, the curriculum and training materials used must be maintained by the DSA and available to HHSC employees during a contract monitoring review. DSA staff that develop the curriculum used for initial training must have attended and successfully completed the CLASS Provider Training. Verification of the DSA training instructor's completion of CLASS Provider Training must be maintained and available to HHSC employees during a contract monitoring review.

 

3121.1  Initial Training for CFC PAS/HAB or CLASS Transportation-Habilitation and Respite Service Providers

Revision 17-1; Effective November 1, 2017

 

The DSA must ensure CFC PAS/HAB or CLASS habilitation and respite  service providers:

  • receive in-person training in the habilitation activities necessary to meet the needs and characteristics of the individual to whom the service provider is assigned.
    • Training must occur in the individual's home with full participation from the individual, if possible; and
    • Form 3599, Habilitation Service Provider Orientation/Supervisory Visits, is used to document this orientation as stated in the directions for the form; and
  • complete two hours of habilitation training, developed by the DSA, before providing services to an individual in the CLASS program that includes at a minimum:
    • CLASS program overview;
    • overview of related conditions to include:
      • the definition of a related condition; and
      • examples of a related condition.
  • Receive an explanation of commonly performed tasks regarding CFC PAS/HAB.
  • Understand an individual's rights and responsibilities including:
    • DSA's complaints process;
    • mandatory participation requirements; and
    • abuse, neglect and exploitation characteristics and reporting information.
  • Providers of CLASS transportation-habilitation, prevocational and respite services must successfully complete hands-on training in cardiopulmonary resuscitation (CPR) and choking prevention before delivering services, and maintain training status as current while providing CLASS transportation-habilitation services. The training must include an in-person evaluation by a qualified instructor verifying the service provider's ability to perform these actions.
  • If requested by the individual or LAR, providers of CFC PAS/HAB must complete hands-on training in cardiopulmonary resuscitation (CPR) and choking prevention that includes an in-person evaluation by a qualified instructor verifying the service provider's ability to perform these actions. Maintaining training status of CPR training and choking prevention as current is determined by the individual or LAR.

The information specific to related conditions above is contained in the list of ICD-10 approved diagnostic codes for persons with related conditions is located on the HHSC website at: /sites/default/files/documents/doing-business-with-hhs/providers/health/icd10-codes.pdf.

Annual evaluations by the supervisor that take place with the individual/LAR ensures that the needs of the individual are being met. Form 3599 is used to document this evaluation, as stated in the instructions for the form. Documentation of transportation-habilitation, prevocational, and respite service provider training outlined above or any training of CFC PAS/HAB provider requested by the individual or LAR must include a signed certificate of completion stating:

  • training topics covered;
  • method of training (i.e., reading, video, discussion, etc.);
  • name(s) and qualifications of instructor(s);
  • name of the trainee;
  • date the training was completed;
  • signature and date of the instructor(s); and
  • signature and date of the trainee verifying completion.

 

3122  Initial and Annual Training for All DSA Staff

Revision 17-1; Effective November 1, 2017

 

Within 60 calendar days of the employee beginning to work with the CLASS program and every 12 months, all DSA staff must receive training on:

  • Abuse, Neglect and Exploitation (ANE) Prohibited Against Individuals
    • review of the statute on abuse, neglect and exploitation at Human Resources Code, Chapter 48, §48.002 (2, 3 and 4);
    • signs and symptoms of ANE;
    • reporting requirements of ANE; and
    • how to report abuse, neglect and exploitation to DFPS at www.dfps.state.tx.us/Contact_Us/report_abuse.asp.
  • Rights and Responsibilities of Individuals
    • information about the rights of the individual who receives CLASS/CFC services as outlined in the Consumer Rights and Services booklet; and
    • review of CLASS/CFC rules in Chapter 45, Subchapter C, §45.301 and §45.302 concerning the Rights and Responsibilities of an Individual.

DSA staff that develop the curriculum used for initial and annual training must have attended and successfully completed the CLASS Provider Training. Verification of a DSA training instructor’s completion of CLASS Provider Training must be maintained and available to HHSC employees during a contract monitoring review. If a DSA develops curriculum to meet CLASS training requirements, the curriculum and training materials used must be maintained by the DSA and available to HHSC employees during a contract monitoring review.

Any DSA staff person who is responsible for developing the IPP-A, a service IPP, or the, PAS/Habilitation Plan - CLASS/DBMD/CFC must complete person-centered service planning training approved by HHSC depending upon the staff date of hire. If the staff person was hired on or before June 1, 2015, the staff must complete the training by June 1, 2017. If the staff person was hired after June 1, 2015, the staff person must complete the training within two years after the hire date.

 

3123  Types of CFC PAS/HAB or CLASS Transportation-Habilitation Service Providers

Revision 17-1; Effective November 1, 2017

 

The two types of CFC PAS/HAB or CLASS transportation-habilitation service providers are:

  • regular CFC PAS/HAB or CLASS transportation-habilitation service providers who perform all of the CFC PAS/HAB services available within their scope of competency; and
  • special CFC PAS/HAB or CLASS transportation-habilitation services providers who may be used to initiate services or prevent a break in service.

 

3124  Qualifications of CFC PAS/HAB or CLASS Transportation-Habilitation Service Providers

Revision 17-1; Effective November 1, 2017

 

CFC PAS/HAB or CLASS transportation-habilitation services are performed by service providers who:

  • are employed by the DSA;
  • are not spouses of individuals and, if the individual is under 18, are not the parent;
  • have a current, valid Texas driver's license; and
  • maintain vehicle liability insurance in accordance with state law.

 

3125  Required Training for CFC PAS/HAB or CLASS Transportation-Habilitation Service Providers

Revision 17-1; Effective November 1, 2017

 

Before services begin, the CFC PAS/HAB or CLASS transportation-habilitation service provider must meet the supervisor or other staff member qualified to train the habilitation service provider in the specific needs of the individual at the individual’s home. The CFC PAS/HAB or CLASS transportation-habilitation service provider receives a general orientation with the full participation of the individual, if possible, in the CFC PAS/HAB or CLASS transportation-habilitation activities necessary to meet the needs and characteristics of the individual to whom the service provider is assigned. Orientation of the service provider to the specific needs of the individual must be documented on Form 3599, Habilitation Service Provider Orientation/Supervisory Visits.

 

3125.1 Required Training for Certain Special CFC PAS/HAB or Special Transportation-Habilitation Service Providers

Revision 17-1; Effective November 1, 2017

 

Special transportation-habilitation service providers or special CFC PAS/HAB providers who have six continuous months of experience in delivering CFC PAS/HAB or CLASS transportation-habilitation services in any Medicaid program or a program that primarily serves individuals with intellectual disabilities can receive the orientation from the supervisor or other appropriate DSA staff by phone rather than in person.

The individual receiving CFC PAS/HAB services should participate in providing special CFC PAS/HAB providers any training on the activities necessary to meet the needs and characteristics of the individual and the specific needs of the individual at the individual’s home. Orientation of the service provider to the specific needs of the individual must be documented on Form 3599, Habilitation Service Provider Orientation/Supervisory Visits.

After the first orientation to the special CFC PAS/HAB or special CLASS transportation-habilitation activities necessary to meet the needs and characteristics of an individual, the special CFC PAS/HAB or special CLASS transportation-habilitation service provider does not need to be reoriented if the individual’s condition, tasks and hours remain unchanged. There are no limits on the length of time a special CFC PAS/HAB or special CLASS transportation-habilitation service provider may be used. The special CFC PAS/HAB or special CLASS transportation-habilitation service provider may serve the individual without retraining, as long as the individual’s condition, tasks and hours remain unchanged. In addition, there are no restrictions with respect to the amount of time between the service provider’s assignments.

 

3126 Documentation of Required Experience for Special Service Provider Exception

Revision 17-1; Effective November 1, 2017

 

Records provided by the employee, or records provided by a former or current employer that document the time the employee delivered direct care services, may be used to establish that a special CFC/PAS/HAB or special habilitation service provider meets requirements.

 

3200 Eligibility

Revision 17-1; Effective November 1, 2017

 

The DSA is responsible for verifying the individual's eligibility for the CLASS program by ensuring the following criteria are met:

  • the individual is determined by HHSC to meet the diagnostic and functional eligibility criteria for the CLASS program;
  • the individual has been diagnosed prior to age 22 with a related condition. as described in the Texas Approved Diagnostic Codes for Persons with Related Conditions;
  • the individual has a qualifying adaptive behavior level (ABL) of II, III, or IV (i.e., moderate to extreme deficits in adaptive behavior) obtained by administering a standardized assessment of adaptive behavior;
  • the individual demonstrates a need for  CFC PAS/HAB;
  • the individual requires and receives at least one CLASS Program service per month, and one CLASS service per year (monthly monitoring of services by a case manager meets this requirement);
  • the individual has an IPC cost for CLASS program services at or below $114,736.07;
  • the individual is not enrolled in another Medicaid waiver program; and
  • the individual resides in his own home or family home. Note: An individual is not considered to reside in his own home or family home if he is admitted to one of the facilities outlined in Section 2430, Suspension, and Section 3430, Suspension, for more than 180 consecutive calendar days.

Individuals who receive CLASS program and CFC services must maintain continuous eligibility as outlined above. The DSA must assess the individual at the time of enrollment, at least annually, and as necessary when an individual's situation changes that may result in the individual no longer meeting all CLASS eligibility criteria.

The DSA must verify Medicaid eligibility each month by monitoring the Medicaid Eligibility Service Authorization Verification (MESAV) system. The DSA must verify the individual is eligible in the month that is being checked. Documentation of this monthly verification of eligibility for Medicaid must be maintained by the DSA and available for review by HHSC staff. If an individual is found to be ineligible for Medicaid, the DSA must notify the case manager no later than the next business day. The DSA must maintain verifiable evidence of notifying the case manager.

CLASS program and CFC services may be terminated if the individual does not meet all eligibility criteria as outlined in Title 40 of the Texas Administrative Code (TAC) §45.406. For more information regarding termination of services, see Section 3400, Denial, Reduction, Suspension and Termination.

See Appendix V, ID/RC Processing, for additional information and detailed instructions for DSAs.

 

3300 Service Planning

Revision 17-1; Effective November 1, 2017

 

A DSA must ensure a representative from its agency participates as a member of an individual's SPT. A DSA representative must be a:

  • program director or meet program director qualifications;
  • registered nurse (RN); or
  • licensed vocational nurse (LVN).

Meetings of the SPT to develop the IPP-A, the IPP, enrollment IPC and the renewal IPC should be held in the individual’s own home or family home whenever possible. If it is not possible, the SPT must document why the meeting could not be held in the individual’s home and the meeting must be at a time and location that is mutually agreed upon by all mandatory members.

The case manager must use Form 3629, Individual Program Plan Addendum to document use of person-centered planning processes.

The case manager, using the discovery process as the basis for collecting information, develops the person-centered plan with the individual, LAR, the CMA, DSA representative and others, as requested by the individual or LAR.
Examples of the discovery process include, but are not limited to:

  • conversations with the individual, LAR and those who know the individual best, such as a provider staff, caregiver, family member and friend;
  • a method called Planning Alternative Tomorrows with Hope (PATH);
  • methods taught by The Learning Community for Person Centered Practices (TLCPCP);occur with the support of a group of people chosen by the individual (and the LAR on the individual's behalf).

The person-centered planning process

  • accommodates the individual's style of interaction, communication and preferences regarding time and setting;
  • identifies the individual’s strengths, preferences, support needs and desired outcomes;
  • identifies what is important to the individual;
  • identifies and documents the individual’s current and preferred living arrangement;
  • determines the Habilitation (HAB), Personal Assistance Services (PAS), Emergency Response Services (ERS) and Support Management needs of an individual;
  • assesses the individual's needs, functional impairments, ability to perform activities of daily living (ADLs), instrumental activities of daily living (IADLs) and health-related tasks;
  • identifies natural supports available to the individual and needed service system supports;
  • documents the individual’s preferences for when to receive CFC services;
  • documents the risks to the individual’s health and safety, as well as a plan to mitigate those risks;
  • identifies any special needs, requests or considerations staff should know when supporting this individual; and
  • documents the individual’s unmet needs.

Additional guidance and information about person-centered planning can be found at The Learning Community.

The SPT should include, at a minimum, the individual/applicant or LAR, the case manager and a DSA representative. The individual or LAR may request the SPT include professionals who are qualified by certification or licensure, or training and experience in the needs of people with related conditions, or directly involved in the delivery of services and supports to the individual. If licensed or certified professionals attend the SPT meeting, this may be billed as a professional service only when the individual has an identified need for the service, and for actual time spent in the capacity of the respective discipline. The SPT may include any other people requested by the individual or LAR. The SPT will make every effort to accommodate these requests by the individual or LAR.

SPT activities to revise a current IPC may occur via conference call in lieu of a face-to-face meeting. If the individual/LAR requests an in person meeting, SPT members must make every effort to accommodate the request. Participation in an SPT via conference call is not reimbursable to the DSA using CFC PAS/HAB or CLASS transportation-habilitation.

An IPC must be signed in person by the SPT at enrollment and renewal SPT meetings. Revisions of the current service plan may be signed by facsimile.

After all requirements for eligibility are met, and at least annually thereafter, the case manager, the applicant/individual/LAR, DSA representative(s) and other persons as requested by the applicant/individual/LAR must meet to develop Form 3629, Individual Program Plan Addendum and a proposed Form 3621, CLASS/CFC – Individual Plan of Care.

The proposed IPC must specify:

  • the type of CLASS program and CFC services to be provided to the individual;
  • the number of units of each CFC or CLASS program service;
  • the estimated annual cost of all CFC services, other than CFC support management, or CLASS program services; and
  • other services or supports to be provided to the individual through sources other than the CFC or CLASS program.
  • the SPT will participate with the CMA to develop Form 3629.

The SPT will develop Form 8606, Individual Program Plan (IPP).

An IPP is needed for each CLASS program and CFC service listed on the proposed IPC. Each IPP describes:

  • the CLASS program and CFC service to be provided;
  • the frequency of service provision;
  • the duration of services;
  • observable and measurable goals and objectives;
  • the title of person responsible for implementing and monitoring goals and objectives;
  • justification for services based on needs identified by the SPT; and
  • support services provided through non-CFC or non-CLASS resources.

If the individual requests a therapeutic service (e.g., occupational therapy, physical therapy, speech and language pathology, behavioral support, audiology, dietary service, auditory enhancement training or any specialized therapy), the case manager must initiate Form 8606-A, Therapy Justifications – Attachment to IPP, based on the deliberations of the SPT. The case manager must coordinate the completion of Attachment A with the appropriate professional. Since this professional is employed by or contracts with the DSA, assistance from the DSA is vital to ensure the case manager performs this function. The signature date of the professional on Attachment A may precede the date of the IPC that identifies the individual’s need for the service or continuation of the need for the service by no more than 120 days.

Each CLASS program and CFC service must be provided to an individual in accordance with the IPP-A, the individual's IPC and the individual's IPP for that service. A DSA must inform the individual's case manager throughout the IPC year of changes needed to the individual's IPP-A, IPC or IPPs.

On an ongoing basis, the DSA's responsibilities include:

  • participating in the SPT;
  • developing the PAS/Habilitation Plan - CLASS/DBMD/CFC  plan (only applicable to service(s) delivered through the provider-managed service delivery option);
  • developing service backup plans for individuals receiving nursing and/or CFC PAS/HAB  services when the SPT has determined the service is critical to an individual’s health and safety (only applicable to nursing and/or CFC PAS/HAB service(s) delivered through the provider-managed service delivery option);
  • discussing with the individual and the service providers or natural supports identified in the service backup plan to determine whether or not the plan was effective, if the service backup plan is implemented;
  • documenting whether or not the plan was effective,
  • revising the plan with input from the SPT, if the plan was determined to be ineffective;
  • completing Form 8578, Intellectual Disability/Related Condition (ID/RC) Assessment, submitting to HHSC and providing additional information as requested by HHSC for the purposes of authorizing the individual's level of care;
  • delivering an array of CLASS program and CFC services in accordance with the IPP-A, IPC, and the IPP and in coordination with non-CLASS services;
  • providing services to the individual as defined in the IPP-A and the IPP;
  • implementing the individual's observable and measurable goals and objectives;
  • informing the individual of rights and responsibilities, including complaint procedures;
  • reporting the individual's changing needs and goals to the case manager;
  • working with community resources as necessary to ensure the provision of CLASS program and CFC services achieves the goal to provide flexible resources that increase personal independence and integration into the community;
  • coordinating individual providers of CLASS program and CFC services; and
  • documenting the provision of services and providing, based on the schedule in Appendix X of the CLASS Provider Manual, a periodic summary of IPC service accomplishments to the case manager.

 

3310 Enrollment

Revision 17-1; Effective November 1, 2017

 

At the time an applicant receives a written offer of a CLASS program vacancy from HHSC, the applicant must select a DSA within 30 calendar days after the date of the written offer from HHSC. HHSC notifies the selected DSA the applicant has chosen the agency to provide direct services according to the HHSC Selection Determination document.

Within 14 calendar days after receiving Form 3657, Pre-Enrollment Assessment, from the CMA, as evidenced by the fax transmittal date on the documents received from the CMA a DSA staff person must complete an initial face-to-face, in-home visit with the individual/LAR to inform the individual and LAR or person actively involved with the individual, orally and in writing, of the process by which they may file a complaint regarding CLASS Program services or CFC services provided by the DSA.

A DSA representative must also provide the following information regarding required use of the Electronic Visit Verification (EVV).

  • EVV will not change the services the individual receives.
  • The CFC PAS/HAB services provider will need the individual’s permission to use the telephone to call a toll-free number at the start and at the end of work.
  • EVV helps HHSC make sure the individual is receiving authorized services.
  • EVV is mandatory for all DSAs and individuals receiving services from a CFC PAS/HAB services provider, unless the individual receives services through the Consumer Directed Services (CDS) option.
  • Failure to cooperate will result in the suspension or termination of services.
  • If the individual does not have a telephone or does not want the CFC PAS/HAB services provider to use his telephone, a fixed verification device can be placed in the home, which is used only to verify the CFC PAS/HAB services provider’s start and end of work.

If the individual has additional questions, the DSA representative must provide any requested additional information on how EVV works.
Within 14 calendar days after receiving Form 3657 from the CMA, as evidenced by the fax transmittal date on the documents received from the CMA, the DSA must assign a registered nurse or an appropriate licensed professional to perform and complete the following functions:

  • a nursing assessment of the individual using the CLASS/DBMD Nursing Assessment form;
  • an adaptive behavior assessments of the individual, as described in, Intellectual Disability/Related Condition (ID/RC) Assessment instructions;
  • the Related Conditions Eligibility Screening Instrument; and
  • the ID/RC Assessment in accordance with form instructions.

To determine an individual’s adaptive behavior level as part of establishing an individual’s enrollment level of care (LOC), the DSA must complete one of the following ABL assessments according to the publisher's instructions:

  • Inventory for Client and Agency Planning (ICAP);
  • Vineland Adaptive Behavior Scales;
  • Scales of Independent Behavior – Revised (SIB-R); or
  • American Association of Intellectual and Developmental Disabilities (AAIDD) Adaptive Behavior Scales (ABS).

The DSA must ensure:

  • the applicant's physician attests to the applicant's diagnosis on the enrollment ID/RC Assessment;
  • the completed ID/RC Assessment is submitted to HHSC for approval within 30 days of notification of completion of the Pre-Enrollment Assessment conducted by the CMA;
  • the HHSC-approved ID/RC and the completed CLASS/DBMD Nursing Assessment is transmitted to the applicant's CMA within one business day after receiving notification of approval of the ID/RC from HHSC; and
  • a DSA representative is available to participate in the applicant's enrollment SPT meeting as convened by the case manager.

Form Resources

The following forms may need to be completed as part of the enrollment process:

  • Form 2067, Case Information
  • Form 3596, PAS/Habilitation Plan - CLASS/DBMD/CFC
  • Form 3599, Habilitation Service Provider Orientation/Supervisory Visits
  • Form 3621, CLASS/CFC – Individual Plan of Care
  • Form 3625, CLASS/CFC – Documentation of Services Delivered
  • Form 3627, Specialized Nursing Certification
  • Form 3628, Provider Agency Model Service Backup Plan
  • Form 3629, Individual Program Plan Addendum
  • Form 6515, CLASS/DBMD Nursing Assessment
  • Form 8507, Understanding Program Eligibility - CLASS/DBMD
  • Form 8662, Related Conditions Eligibility Screening Instrument
  • Form 8578, Intellectual Disability/Related Condition Assessment
  • Form 8606, Individual Program Plan (IPP)

Submission Standard — ID/RC

The following submission standards apply when submitting ID/RC paperwork to HHSC:

  • Form 8578, Intellectual Disability/Related Condition Assessment
  • Form 8662, Related Conditions Eligibility Screening Instrument
  • assessment scoring summary

Submission Standard — Pre-enrollment

The following submission standards apply when submitting paperwork containing funding proposals for pre-enrolment efforts to HHSC:

  • Form 3625, CLASS/CFC – Documentation of Services Delivered
  • Form 8578, Intellectual Disability/Related Condition Assessment

 

3320 DSA Renewal of Level of Care

Revision 17-1; Effective November 1, 2017

 

Continuing eligibility must be determined at least annually. As with the initial assessment, the DSA RN is required to complete an annual nursing assessment of the individual using the Form 6515, CLASS/DBMD Nursing Assessment form, Form 8578, Intellectual Disability/Related Condition (ID/RC) Assessment, Form 8662, Related Conditions Eligibility Screening Instrument (RCESI) (these documents must be completed every year), and an adaptive behavior level (ABL) assessment if the current one is greater than five years old, or is no longer valid.

Form 8578, Form 8662 and results of the current ABL assessment must be sent to HHSC at least 60 calendar days, but no more than 120 calendar days, before the expiration of an individual's IPC to establish that an individual continues to meet diagnostic/functional eligibility criteria. Once HHSC informs the DSA of the approval of diagnostic/functional eligibility, the DSA must submit a copy of the approved ID/RC and the completed CLASS/DBMD Nursing Assessment to the CMA by the next business day.

If an individual's ABL assessment is more than five years old or the individual's needs significantly change, the DSA must complete one of the following ABL assessments according to the publisher's instructions:

  • Inventory for Client and Agency Planning (ICAP);
  • Vineland Adaptive Behavior Scales;
  • Scales of Independent Behavior – Revised (SIB-R); or
  • American Association of Intellectual and Developmental Disabilities (AAIDD) Adaptive Behavior Scales (ABS).

A DSA representative, as defined in Section 3300, Service Planning, must participate as a member of the SPT to develop:

  • a renewal IPC — the CLASS program services on the proposed renewal IPC must meet the following standards, which:
    • are necessary to protect the individual's health and welfare in the community;
    • address the individual's related condition;
    • are not available to the individual through any other source including the Medicaid state plan, other governmental programs, private insurance or the individual's natural supports;
    • are the most appropriate type and amount of CLASS program and CFC services to meet the individual's needs; and
    • are cost effective.
  • a renewal IPP for each service proposed on the renewal IPC;
  • Form 3596, PAS/Habilitation Plan - CLASS/DBMD/CFC; and
  • a service backup plan for the following services, if the SPT determines the service is critical to the individual's health and safety and if the service is delivered by the DSA:
    • CFC PAS/HAB; and
    • nursing services.

CLASS program and CFC services as a whole enhance an individual's integration in the community and prevent admission to an institution while maintaining and improving independent functioning.

The DSA is responsible for assisting and providing documentation, as requested by the CMA.

A DSA is responsible for verifying in MESAV that each individual’s enrollment, renewal, or revisions IPCs have been authorized by HHSC as documented on the IPC signed by the SPT.

Form Resources

The following forms may need to be completed as part of the renewal process:

  • Form 1740, Service Backup Plan
  • Form 2067, Case Information
  • Form 2124, Community Support Transportation Log
  • Form 3596, PAS/Habilitation Plan - CLASS/DBMD/CFC
  • Form 3598, Individual Transportation Plan
  • Form 3621, CLASS/CFC – Individual Plan of Care
  • Form 3625, CLASS/CFC – Documentation of Services Delivered
  • Form 3628, Provider Agency Model Service Backup Plan
  • Form 3629, Individual Program Plan Addendum
  • Form 6515, CLASS/DBMD Nursing Assessment
  • Form 8578, Intellectual Disability/Related Condition Assessment (Page 1 and Page 3)
  • Form 8598, Non-Waiver Services
  • Form 8606, Individual Program Plan (IPP)
  • Form 8662, Related Conditions Eligibility Screening Instrument

Submission Standard

The following submission standards apply when submitting ID/RC paperwork to HHSC:

  • Form 6515, CLASS/DBMD Nursing Assessment
  • Form 8578, Intellectual Disability/Related Condition Assessment
  • Form 8662, Related Conditions Eligibility Screening Instrument
  • ABL assessment scoring summary

 

3330 Revision

Revision 17-1; Effective November 1, 2017

 

When the DSA is notified of a needed revision to the IPC, the DSA representative must contact the CMA within one business day. The DSA is responsible for assisting and providing documentation, as requested by the CMA to ensure:

  • a proposed IPC revision includes an IPP for each service revised on the proposed IPC and a revised Form 3596, PAS/Habilitation Plan - CLASS/DBMD/CFC, if applicable;
  • Individual Program Plan Addendum is revised to ensure continued accuracy for the individual and to be consistent with the IPC and IPPs; and
  • the CLASS program and CFC services on the proposed IPC revision must meet the following standards:
    • are necessary to protect the individual's health and welfare in the community;
    • address the individual's related condition;
    • are not available to the individual through any other source including the Medicaid state plan, other governmental programs, private insurance or the individual's natural supports;
    • are the most appropriate type and amount of CLASS program and CFC services to meet the individual's needs; and
    • are cost effective.

Within five business days after receipt of the IPP-A, IPP and IPC from the CMA, as evidenced by the fax transmittal date on the documents received from the CMA, the DSA must sign and return the IPP-A, IPP and IPC to the CMA. If any revised services provided by the DSA affect the service backup plan, PAS/Habilitation Plan - CLASS/DBMD/CFC  plan or the IPP-A, the DSA must revise the existing plan to reflect these changes to program services.

A DSA is responsible for verifying in MESAV that each individual’s enrollment, renewal, or revisions IPCs have been authorized by HHSC as documented on the IPC signed by the SPT.

 

3331 Immediate Jeopardy of CLASS Individual

Revision 17-1; Effective November 1, 2017

 

Immediate jeopardy is interpreted as a crisis situation in which the health and safety of an individual is at risk.

During circumstances when the individual's health and safety is placed in immediate jeopardy the DSA must provide the following services:

  • licensed vocational nursing;
  • specialized licensed vocational nursing;
  • registered nursing;
  • specialized registered nursing;
  • CFC PAS/HAB
  • respite;
  • dental treatment; or
  • adaptive aid.

These services must be provided even if they are not included on the individual's IPC. The DSA must, within seven calendar days after providing the service, submit to the CMA:

  • a description of circumstances necessitating the provision of the new service or the increase in the amount of the existing service; and
  • documentation by a registered nurse of the nurse's determination the service was necessary to prevent the individual's health and safety from being placed in immediate jeopardy.

The CMA must use the date which the DSA RN documented determination the individual was subject to immediate jeopardy without the provision of additional habilitation, respite, nursing, dental services, or an adaptive aid that is not included on the individual's IPC as the IPC revision effective date.

Form Resources

The following forms may need to be completed as part of the revision process:

 

3340 Transfer

Revision 15-2; Effective November 20, 2015

 

If an individual plans to move to another CLASS provider, the case manager must provide the individual the most current Selection Determination document for the applicable catchment area. The requirements for the transferring DSA and receiving DSA are provided below.

 

3341 Transferring DSA

Revision 17-1; Effective November 1, 2017

 

The transferring DSA must provide the receiving DSA with the current balance of each service category based on most current CLASS/CFC IPC authorized and actual delivery up to the transfer effective date — Form 3621-T, CLASS/CFC – IPC Service Delivery Transfer Worksheet. The total number of service units provided before the effective date of the transfer is the sum of the number of service units:

  • provided and paid,
  • provided that have been billed but not yet paid, and
  • to be provided until the transfer effective date.

Copies of the identified records must be delivered by the transferring DSA to the receiving DSA within five calendar days of notification by the case manager of the individual's decision to transfer to a different DSA. The records that must be provided include:

  • current CLASS/CFC IPC;
  • current Form 3629, Individual Program Plan Addendum;
  • current Service Planning Team (SPT) notes from the current IPC period;
  • current Individual Program Plan (IPP);
  • current Form 8578, Intellectual Disability/Related Condition Assessment;
  • current Form 8662, Related Conditions Eligibility Screening Instrument;
  • current Form 3596, PAS/Habilitation Plan - CLASS/DBMD/CFC;
  • records of all adaptive aids purchased during the current IPC period;
  • records of all minor home modifications procured for the individual, regardless of date of purchase and cost of each;
  • all IPP Service Summaries performed by the DSA during the current IPC period;
  • current physician's orders;
  • copies of DSA records for 90 calendar days prior to DSA transfer, including:
    • CFC/PAS/HAB or CLASS habilitation;
    • medication administration record;
    • money management;
    • assessments and notes for any services listed on the IPC; and
    • all communications, including:
      • contact notes;
      • progress notes;
      • Form 2067, Case Information;
      • Form 3624, Termination, Reduction or Denial of CLASS;
      • incident reports; and
      • complaints;
  • school/day programming information including:
    • Admission, Review and Dismissal (ARD) notes; and
    • Individual Education Plan (IEP); and
  • current service delivery schedules for all services.

The transferring DSA is required to maintain documentation of the specific records that were delivered to the receiving DSA, as well as the date of the delivery.

 

3342 Receiving DSA

Revision 11-1; Effective June 13, 2011

 

The receiving DSA must initiate services on the transfer effective date, as identified on Form 3621-T, CLASS/CFC – IPC Service Delivery Transfer Worksheet. The total number of service units available to the receiving DSA is the number of service units to be provided from the transfer effective date until the end of the IPC effective period.

The receiving DSA must develop a Form 3628, Provider Agency Model Service Backup Plan, for those services requiring a backup plan as indicated on the IPC.

 

3350 IPP Service Summaries

Revision 17-1; Effective November 1, 2017

 

CLASS service provider(s) must evaluate the effectiveness of CLASS program and CFC services delivered by the DSA. The DSA is responsible for providing an IPP Service Summary to the CMA in accordance with the schedule in Appendix X, Service Summary/Service Review Due Dates Chart, from the effective date of the most recent enrollment or renewal CLASS/CFC IPC. The final review of the IPC year is combined with the meeting of the SPT to develop a renewal IPC and update the IPP-A. The case manager is responsible for documenting the service summary provided by the DSA since the preceding review. The evaluation must include an assessment of the individual's progress, evolving needs and plans to address those needs. The IPP Service Summary must document the service provider’s review of the individual's progress toward achieving the goals and objectives, as described on the IPP for each CLASS program and CFC service listed on the individual's IPC. There is not a HHSC form for the IPP Service Summary; however, the DSA must provide this information in a written format.

A DSA is required to ensure that each CLASS program and CFC service is provided to an individual in accordance with Appendix C of the CLASS Waiver Application, available on the CLASS website at https://hhs.texas.gov/laws-regulations/policies-and-rules/waivers/class-waiver-applications.

An IPP is developed to describe the goals and objectives to be met by the provision of each CLASS program and CFC service on an individual's IPC that are supported by justifications, are measurable, and have timelines. Additionally, a DSA must ensure CLASS program and CFC services are documented in the individual's record, including the progress or lack of progress in achieving goals or outcomes in observable, measurable terms that directly relate to the specific goal or objective addressed.

The DSA must provide the case manager with the IPP Service Summaries from each service listed below provided by the DSA documenting the individual's progress and needs. The service provider of each service listed below completes a service summary for each individual

Within five business days of the service provider completing the IPP service summary, the DSA is responsible for providing copies of the summaries to the case manager, as evidenced by the fax transmittal date on the documents provided to the CMA. The DSA must maintain documentation of transmission of all necessary documents. An IPP service summary for each service listed below must be prepared based on the schedule in Appendix X from the effective date of the most recent enrollment or renewal IPC. The DSA verbally updates the case manager during the renewal SPT meeting with any relevant information regarding services delivered in the last quarter of the IPC year.

The summaries must include quarterly reports from providers of the following services:

  • auditory enhancement training;
  • behavioral support;
  • dietary services;
  • occupational therapy;
  • physical therapy;
  • prevocational services;
  • specialized therapies;
  • speech and language pathology;
  • cognitive rehabilitation therapy;
  • employment assistance; and
  • supported employment services.

Each IPP Service Summary completed by the service provider must include all of the elements listed below:

  • current observable/measurable goals and objectives;
  • frequency and duration of sessions attended;
  • rationale for missed sessions;
  • progress or lack of progress;
  • actions taken, as applicable (e.g., in-servicing, counseling, etc.); and
  • revisions of goals and objectives, as applicable.

Form Resources

The following forms may need to be completed as part of the summary:

 

3400 Denial, Reduction, Suspension and Termination

Revision 17-1; Effective November 1, 2017

 

An individual who has been denied enrollment or terminated from the CLASS program and CFC services, or an individual whose CLASS program and CFC services are denied, reduced, suspended or terminated must be given notice of adverse actions taken by HHSC and is entitled to a fair hearing.

Program services may be terminated if the individual does not comply with the conditions as outlined in 40 TAC §45.406 or violates any of the conditions specified in 40 TAC §45.408. Program services may also be terminated if an individual does not comply with 40 TAC §45.407, or exhibits behavior that places the health and safety of the CMA's case manager or a DSA's service provider in immediate jeopardy as described in 40 TAC §45.409

 

3410 Denial

Revision 17-1; Effective November 1, 2017

 

Denial is an HHSC action that disallows:

  • an individual's request for enrollment in the CLASS program;
  • a service requested on the IPC that was not authorized on a prior IPC; or
  • a portion of the amount or level of the service requested on the IPC that was not authorized on a prior IPC.

 

3411 Denial of a Request for Enrollment into the CLASS Program

Revision 17-1; Effective November 1, 2017

 

HHSC denies an individual's request for enrollment into the CLASS program if:

  • the individual does not meet the eligibility criteria described in §45.201, Eligibility Criteria; or
  • the DSAs serving the catchment area in which the individual resides are not willing to provide CLASS program and CFC services to the individual because they have determined they cannot ensure the individual's health and safety.

If HHSC denies an individual's request for enrollment, HHSC sends written notice to the individual or LAR of the denial of the individual's request for enrollment into the CLASS program and includes in the notice the individual's right to request a fair hearing in accordance with §45.301, Individual's Right to a Fair Hearing. HHSC sends a copy of the written notice to the individual's DSA, CMA and, if selected, Financial Management Services Agency (FMSA).

 

3412 Denial of a CLASS Program or CFC Service

Revision 17-1; Effective November 1, 2017

 

CLASS program and CFC services as a whole enhance an individual's integration in the community and prevent admission to an institution while maintaining and improving independent functioning.

HHSC denies a CLASS program or CFC service on an individual's IPC if services:

  • are not necessary to protect the individual's health and welfare in the community;
  • do not address the individual's related condition;
  • are available to the individual through any other source including the Medicaid state plan, other governmental programs, private insurance or the individual's natural supports;
  • are not the most appropriate type and amount of CLASS program and CFC services to meet the individual's needs; or
  • are not cost effective.

If HHSC determines one or more of the CLASS program or CFC services specified in the IPC do not meet the requirements for an IPC, HHSC:

  • for an enrollment IPC, approves enrollment in CLASS program with the modified IPC;
  • denies the CLASS program or CFC service(s), as appropriate;
  • modifies and authorizes the IPC;
  • sends a copy of the modified IPC to the CMA; and
  • notifies the individual's CMA, in writing, of the action taken.

Form Resources

The following forms may need to be completed as part of a denial of services:

 

3420 Reduction

Revision 17-1; Effective November 1, 2017

 

Reduction is an HHSC action taken because of a review of an IPC that decreases the amount or level of CLASS program or CFC services not authorized by HHSC on a prior IPC.

HHSC will perform a utilization review on all IPCs that meet criteria outlined in Section 5000, Utilization Review (UR). All CLASS program or CFC services and units of service included on a proposed IPC must be justified by the SPT.

HHSC staff review the IPC to ensure the services on the IPC:

  • are necessary to protect the individual's health and welfare in the community;
  • supplement rather than replace the individual's natural supports and other non-CLASS program services and supports for which the individual may be eligible;
  • CLASS program and CFC services as a whole enhance an individual's integration in the community and prevent admission to an institution while maintaining and improving independent functioning;
  • are the most appropriate type and amount of CLASS program and CFC services to meet the individual's needs; and
  • are cost effective.

As necessary during the review of a proposed IPC, HHSC staff will ask case managers to provide additional justification if the initial information submitted with a proposed IPC is not sufficient to demonstrate the need for a proposed CLASS program and CFC service(s). If information submitted to HHSC by the case manager does not provide sufficient information to justify requested CLASS program and CFC services or amounts of CLASS program and CFC services, HHSC will reduce the number of units of CLASS program and CFC services, as necessary, and will send the CMA a copy of the modified IPC.

If an individual's services are reduced, CMA notifies the DSA in writing describing HHSC’s reason for the reduction. The CMA also notifies the DSA if and when the individual chooses to appeal the decision. If the individual or LAR requests a fair hearing within 10 days from date of notification, as specified in the written notice, the DSA must provide the service to the individual in the amount authorized in the prior IPC while the appeal is pending.

Form Resources

The following forms may need to be completed as part of a reduction of services:

 

3430 Suspension

Revision 17-1; Effective November 1, 2017

 

Suspension is an HHSC action that results in temporary loss of the individual's authorized CLASS program or CFC services. An individual may remain on suspension from CLASS for up to 180 calendar days. HHSC may extend an individual's suspension for 30 calendar days upon the CMA's request.

Suspension is an HHSC action taken because of:

  • an individual's admission, for up to180 consecutive calendar days, to one of the following facilities:
    • an ICF/IID licensed or subject to being licensed in accordance with Texas Health and Safety Code, Chapter 252, or certified by HHSC, unless the individual is receiving out-of-home respite in the facility;
    • a nursing facility licensed or subject to being licensed in accordance with Texas Health and Safety Code, Chapter 242, unless the individual is receiving out-of-home respite in the facility;
    • an assisted living facility licensed or subject to being licensed in accordance with Texas Health and Safety Code, Chapter 247;
    • a residential child-care operation licensed or subject to being licensed by the Texas Department of Family and Protective Services (DFPS), unless it is a foster family home or a foster group home;
    • a facility licensed or subject to being licensed by the Texas Department of State Health Services (DSHS);
    • a facility operated by HHSC;
    • a residential facility operated by the Texas Youth Commission; or
    • a jail or prison;
  • an individual leaving the state for up to 180 consecutive calendar days, except for individuals receiving certain services available through the CDS option while the individual is temporarily staying at a location outside the state of Texas. For more information, see Information Letter No. 16-35, Receiving Services Outside the State of Texas in the CLASS and DBMD Programs.

Within two business days of learning of a situation that necessitates an individual's CLASS program and CFC services to be suspended, the DSA must send the CMA written notification using Form 2067, Case Information, including any supporting documentation.

Form Resources

The following forms may need to be completed as part of a suspension of services:

 

3440 Termination

Revision 11-7; Effective November 1, 2017

 

Termination is an HHSC action that results in the loss of the individual's eligibility for authorized services in the CLASS program and CFC services.

 

3441 Termination With Advanced Notice

Revision 11-7; Effective November 1, 2017

 

HHSC terminates an individual's CLASS program and CFC services if:

  • the individual does not meet program eligibility criteria;
  • the individual is admitted for more than 180 consecutive calendar days to one of the following facilities:
    • an ICF/IID licensed or subject to being licensed in accordance with Texas Health and Safety Code, Chapter 252, or certified by HHSC, unless the individual is receiving out-of-home respite in the facility;
    • a nursing facility licensed or subject to being licensed in accordance with Texas Health and Safety Code, Chapter 242, unless the individual is receiving out-of-home respite in the facility;
    • an assisted living facility licensed or subject to being licensed in accordance with Texas Health and Safety Code, Chapter 247;
      • a residential child-care operation licensed or subject to being licensed by the DFPS, unless it is a foster family home or a foster group home;
      • a facility licensed or subject to being licensed by the DSHS;
      • a facility operated by HHSC; or
      • a residential facility operated by the Texas Youth Commission, a jail or prison;
  • the individual leaves the state for more than 180 consecutive calendar days and HHSC has not extended the individual's suspension;
  • DSAs serving the catchment area in which the individual resides are not willing to provide CLASS program and CFC services to the individual on the basis of a reasonable expectation that the individual's medical and nursing needs cannot be met adequately in the individual's residence; or
  • the individual refuses to comply with one or more of the mandatory participation requirements as follows:
    • not completing and submitting an application for Medicaid financial eligibility to HHSC within 30 calendar days after the case manager's initial face-to-face, in-home visit (Note: If an individual or LAR does not submit a Medicaid application to HHSC within 30 calendar days of the case manager's initial face-to-face, in-home visit as required, but is making good faith efforts to complete the application, HHSC may extend this time frame in 30 calendar-day increments.);
    • not participating with the SPT to:
      • develop the IPP-A using the person-centered planning process;
      • develop an enrollment CFC/CLASS IPC; or
      • renew and revise the IPC and IPPs;
    • not reviewing, agreeing to, signing and dating an IPC and IPPs;
    • not using natural supports and other non-CLASS services and supports for which the individual may be eligible before using CLASS and CFC services;
    • not cooperating with the CMA and DSA in the delivery of CLASS and CFC services listed on the individual's IPC, including:
      • not cooperating with the CMA and DSA in scheduling meetings;
      • not attending scheduled meetings with the case manager or service provider;
      • not being available to receive the CLASS and CFC services;
      • not notifying the CMA or DSA in advance if the individual or LAR is unable to attend a scheduled meeting or is unavailable to receive services in the individual's own or family home;
      • not admitting CMA and DSA representatives to the individual's own home or family home for a scheduled meeting or to receive CLASS and CFC services;
    • not cooperating with the DSA's service providers to ensure progress toward achieving the goals and objectives described in the IPP for each CLASS service listed on the IPC;
    • not paying a required copayment in a timely manner as required by HHSC;
    • not completing the procedures for redetermining eligibility for Medicaid as described in the Medicaid for the Elderly and People with Disabilities Handbook;
    • engaging or permitting a person present in the individual's own or family home to engage in criminal behavior in the presence of the case manager or service provider;
    • acting or permitting a person present in the individual's own or family home to act in a manner that is threatening to the health and safety of the case manager or service provider;
    • exhibiting behavior or permitting a person present in the individual's residence to exhibit behavior that places the health and safety of the case manager or service provider in immediate jeopardy;
    • initiating or participating in fraudulent health care practices; or
    • engaging or permitting a person present in the individual's own home or family home to engage in behavior that endangers the individual's health or safety.

Within two business days after the DSA learns of one of the situations described above, the DSA must send the CMA a written notification per Form 2067, Case Information, including supporting documentation. The DSA is responsible for making reasonable attempts to accommodate a face-to-face meeting with the SPT as scheduled by the CMA.

If termination of services is requested based on a determination by the DSA on the basis of a reasonable expectation that the individual's medical and nursing needs cannot be met adequately in the individual's residence, the DSA must provide specific reason(s) to the CMA regarding why the DSA determined it cannot ensure the individual's health and safety.

Prior to termination of services, an individual may choose another DSA. The CMA must provide the most current Selection Determination document in catchment areas with multiple DSAs. If another DSA determines the individual’s medical and nursing needs can be adequately met, the DSA must assist the CMA to develop a transfer IPC as described in Section 3340 of the CLASS Provider Manual.

HHSC notifies the individual's CMA, in writing, of whether it authorizes the proposed termination of CLASS program and CFC services. The DSA is notified by the CMA regarding the termination.

If CLASS program and CFC services are terminated due to an individual's IPC cost being over $114,736.07,  HHSC sends written notice to the individual or LAR of the proposal to terminate CLASS program and CFC services and includes in the notice the individual's right to request a fair hearing. HHSC sends a copy of the written notice to the individual's DSA, CMA and, if selected, FMSA.

HHSC notifies the individual's CMA, in writing, of whether it authorizes the proposed termination of CLASS program and CFC services. The DSA is notified by the CMA regarding the termination.

If the individual or LAR requests a fair hearing before the effective date of a proposed termination of CLASS program and CFC services, the DSA must provide services to the individual in the amounts authorized in the IPC while the appeal is pending.

 

3442 Termination Without Advanced Notice

Revision 17-1; Effective November 17, 2017

 

HHSC terminates an individual's CLASS program and CFC services without advanced notice if any of the following situations exist:

  • the CMA or DSA has factual information confirming the death of the individual;
  • the CMA or DSA receives a clearly written statement signed by the individual that the individual no longer wishes to continue to receive CLASS program and CFC services;
  • the individual's whereabouts are unknown and the post office returns mail directed to him or her by the CMA or DSA, indicating no forwarding address;
  • the CMA or DSA establishes the individual has been accepted for Medicaid services by another state; or
  • an individual or a person in the individual's residence exhibits behavior that places the health and safety of the CMA's case manager or a DSA's service provider in immediate jeopardy. For more information, see Section 3510, Immediate Jeopardy.

Within two business days after the DSA becomes aware of a situation such as described above, the DSA must send the CMA a written notification per Form 2067, Case Information, including supporting documentation.

HHSC notifies the individual's CMA, in writing, of whether it authorizes the termination of CLASS and CFC services. The DSA is notified by the CMA regarding the termination.

HHSC may terminate an individual's CLASS and CFC services if an individual or a person in the individual's residence exhibits behavior that places the health and safety of the case manager or a service provider in immediate jeopardy.

If a CMA or DSA becomes aware of an existing situation that places the health and safety of the individual's case manager or CLASS program or CFC service provider in immediate jeopardy, the CMA or DSA must:

  • immediately file a report with the appropriate law enforcement agency and, if appropriate, make an immediate referral to DFPS;
  • notify the CMA or DSA, as appropriate, and HHSC by telephone of the situation no later than the next business day; and
  • attempt to resolve the situation.

HHSC notifies the individual's CMA, in writing, of whether it authorizes the proposed termination of CLASS and CFC services. The DSA is notified by the CMA regarding the termination.

Form Resources

The following forms may need to be completed as part of termination of services:

 

3500 Service Initiation

Revision 17-1; Effective November 1, 2017

 

A DSA must ensure each CLASS and CFC service is provided to an individual in accordance with the individual's IPP-A, IPC and IPP for each service.

A DSA must have a written process that ensures staff members are or can readily become familiar with individuals to whom they are not ordinarily assigned but to whom they may be required to provide a CLASS and CFC service.

A DSA must inform the individual's case manager of changes needed to the individual's IPC or IPPs.

 

3510 Immediate Jeopardy of CLASS and CFC Providers

Revision 17-1; Effective November 1, 2017

 

HHSC may terminate an individual's CLASS program and CFC services if an individual or a person in the individual's residence exhibits behavior that places the health and safety of the CMA's case manager or a DSA's service provider in immediate jeopardy.

If a CMA or DSA becomes aware of an existing situation that places the health and safety of the individual's case manager or DSA service provider in immediate jeopardy, the CMA or DSA must:

  • immediately file a report with the appropriate law enforcement agency and, if appropriate, make an immediate referral to DFPS; and
  • notify HHSC, CMA and DSA by telephone of the situation no later than one business day after the CMA or DSA becomes aware of the situation.

The CMA and DSA must attempt to resolve the situation. If, after making attempts to resolve the situation, the CMA determines that the situation cannot be resolved, the CMA must, within two business days after the CMA becomes aware of the situation, send a written request to terminate CLASS program and CFC services to HHSC. The written request must be accompanied by:

  • a description of the situation that resulted in the request to terminate the individual's CLASS program and CFC services;
  • a detailed description of the attempts by the CMA to resolve the situation; and
  • if available, a copy of any report issued by a law enforcement agency or DFPS regarding the situation.

HHSC notifies the individual's CMA in writing of whether it authorizes the proposed termination of CLASS program and CFC services.

Upon receipt of a written notice from HHSC authorizing the termination of CLASS program and CFC services, the CMA must, no later than the date of the termination of services, send a written notice to the individual or LAR of such termination. The CMA must provide a hard copy of the termination notice to the individual's DSA and, if selected, FMSA and SFS provider. The CMA must include in the notice the individual's right to request a fair hearing.

The CMA and DSA must maintain documentation of completion of these requirements in the individual's record.

 

3520 Adaptive Aids Costing Less than $500

Revision 17-1; Effective November 1, 2017

 

Once the DSA determines the cost of the requested adaptive aid, the DSA must request in writing that the case manager initiate an IPC revision. The DSA must inform the individual's case manager of the cost of the requested adaptive aid.

HHSC authorizes the IPC submitted by the CMA if, after reviewing the documentation, it determines the requested adaptive aid meets the standards outlined in Appendix I, Adaptive Aids.

The DSA must ensure the individual receives the adaptive aid within 14 business days after the date HHSC authorizes the proposed IPC that includes the recommended adaptive aid; or the effective date of the individual's IPC as determined by the SPT (whichever is later). The DSA must complete Form 8605, Documentation of Completion of Purchase, that serves as the primary document for completion of purchases of authorized adaptive aids/medical supply items or minor home modifications made by the service provider for individuals.

For an adaptive aid that is a medical supply, a DSA must ensure the individual receives the medical supply as follows:

  • for a medical supply that is not immediately needed by the individual, within five business days after the date HHSC authorizes the proposed IPC that includes the recommended adaptive aid; or the effective date of the individual's IPC as determined by the SPT (whichever is later); or
  • for a medical supply that is immediately needed by the individual, within two business days after the date HHSC authorizes the IPC that includes the recommended adaptive aid.

If the DSA cannot provide the adaptive aid in the time frame described, the DSA must:

  • notify the individual and the individual's case manager, orally or in writing, before the 14-day time frame expires, that the adaptive aid will not be provided within the 14-day time frame; and
  • notify the individual and the individual's case manager of a new proposed date for provision of the adaptive aid.

If the DSA cannot provide an adaptive aid that is a medical supply and is not immediately necessary by the individual, the DSA must:

  • notify the individual and the individual's case manager, orally or in writing, before the five-day time frame expires, that the adaptive aid will not be provided within the five-day time frame;
  • provide the reason(s) why the medical supply will not be provided within the five-day time frame; and
  • notify the individual and the individual's case manager of a new proposed date for provision of the medical supply.

 

3530 Adaptive Aid Costing $500 or More

Revision 17-1; Effective November 1, 2017

 

Once the SPT has agreed the individual is in need of an adaptive aid with an anticipated cost that is more than $500, the DSA must request in writing that the case manager initiate an IPC revision including funds for obtaining an assessment of the individual by the appropriate licensed professional as described in Appendix I of CLASS Provider Manual. The assessment must include a description and a recommendation for an adaptive aid that meets the individual’s need(s). This assessment must identify how this adaptive aid will meet the needs of the individual and must include consideration of other alternatives known to the appropriate licensed professional to meet the individual’s need(s). Detailed descriptions, to the extent possible, must accompany the licensed professional’s recommendation for adaptive aids when the cost is more than $500.

After HHSC authorizes the proposed IPC for payment of the adaptive aid assessment, the DSA must obtain the assessment from the appropriate licensed professional that describes the adaptive aid within 30 calendar days. The assessment by the licensed professional that describes the specific need(s) of the individual must include recommendations for the adaptive aid that, in the opinion of the licensed professional, will best meet the needs identified in the assessment.

Based on the recommendations contained in the assessment, the DSA will consult with the appropriate vendor  to determine the most cost-effective item(s) that meet the recommendations in the assessment. The description of the item(s) as contained in the assessment must be used to develop the specifications to obtain bids from all vendors. The DSA must obtain comparable bids for the requested adaptive aid from three vendors within 60 calendar days of obtaining the specifications.

A bid obtained must be based on the specifications and include:

  • the total cost of the requested adaptive aid, which may be from a catalog, website or brochure price list;
  • the amount of any additional expenses related to the delivery of the adaptive aid, including shipping and handling, taxes, installation and other labor charges;
  • the date of the bids;
  • the name, address and telephone number of the vendor, who may not be a relative of the individual;
  • a complete description of the adaptive aid and any associated items or modifications as identified in the completed Form 3660, Request for Adaptive Aids, Medical Supplies, Minor Home Modifications or Dental Services/Sedation, which may include pictures or other descriptive information from a catalog, website or brochure; and
  • the number of hours of the service or training to be provided in person and the hourly rate of the service for interpreter services and specialized training for augmentative communication programs.

The DSA must:

  • obtain the assessment from a licensed professional for the adaptive aid as described in Appendix I, Adaptive Aids;
  • ensure the assessment includes a complete description of the adaptive aid; and
  • provide a copy of the assessment and the specifications to the CMA.

For purchases of an adaptive aid or medical supply costing over $500, the CMA, DSA and individual/legally authorized representative must complete and sign Form 3849-A, Specifications for Adaptive Aids/Medical Supplies/Minor Home Modifications, to signify agreement with the specifications.

The DSA may obtain only one bid or two comparable bids for an adaptive aid if the DSA has written justification for obtaining less than three bids because the adaptive aid is available from a limited number of vendors.

A bid obtained must be based on the specifications and include:

  • the total cost of the requested adaptive aid, which may be from a catalog, website or brochure price list;
  • the amount of any additional expenses related to the delivery of the adaptive aid, including shipping and handling, taxes, installation and other labor charges;
  • the date of the bid;
  • the name, address and telephone number of the vendor, who may not be a relative of the individual;
  • a complete description of the adaptive aid and any associated items or modifications as identified in the completed Form 3660, which may include pictures or other descriptive information from a catalog, website or brochure; and
  • the number of hours of the service or training to be provided in person and the hourly rate of the service for interpreter services and specialized training for augmentative communication programs.

A DSA may obtain only one bid or two comparable bids for an adaptive aid if the DSA has written justification for obtaining less than three bids because the adaptive aid is available from a limited number of vendors.

If a DSA requests to purchase an adaptive aid that is not based on the lowest bid, the DSA must have written justification for payment of a higher bid. The following are examples of justifications that support payment of a higher bid:

  • the higher bid is based on the inclusion of a longer warranty for the adaptive aid; and
  • the higher bid is from a vendor that is more accessible to the individual than another vendor.

Requests for interpreter services or specialized training for augmentative communication devices must include:

  • the total number of hours of the service or training to be provided in-person; and
  • the hourly rate of the service.

If the requested adaptive aid is a vehicle modification, a DSA must obtain proof the individual or individual's family member owns the vehicle for which the vehicle modification is requested. Requests for vehicle modifications to accommodate modifications or additions to the primary transportation vehicle must include an assessment by the appropriate licensed professional as indicated in Appendix I. Additionally, if the vehicle is more than five years old or the mileage on the vehicle odometer exceeds 50,000 miles, the vehicle must pass an inspection performed by an automotive technician certified by The National Institute for Automotive Service Excellence (ASE).

A DSA may not disclose information regarding a submitted bid to any other vendor who has submitted a bid or to a vendor who may submit a bid.

The DSA must request in writing the case manager initiate an IPC revision. At this point, the DSA must inform the individual's case manager of the cost of the requested adaptive aid.

HHSC authorizes the IPC once submitted by the CMA if, after reviewing the documentation, it determines the requested adaptive aid meets the standards outlined in Appendix I, Adaptive Aids.

The DSA must ensure the individual receives the adaptive aid within 30 business days after the date HHSC authorizes the proposed IPC that includes the recommended adaptive aid; or the effective date of the individual's IPC as determined by the SPT (whichever is later). The DSA must complete Form 8605, Documentation of Completion of Purchase, that serves as the primary document for purchases of authorized adaptive aids/medical supply items or minor home modifications made by the service provider for individuals.

For an adaptive aid that is a medical supply, the DSA must ensure the individual receives the medical supply as follows:

  • for a medical supply that is not immediately needed by the individual, within five business days after the date HHSC authorizes the proposed IPC that includes the recommended adaptive aid; or the effective date of the individual's IPC as determined by the SPT (whichever is later); or
  • for a medical supply that is immediately needed by the individual, within two business days after the date HHSC authorizes the IPC that includes the recommended adaptive aid.

If the DSA cannot provide the adaptive aid in the time frame described, the DSA must:

  • notify the individual and the individual's case manager, orally or in writing, before the 30-day time frame expires, the adaptive aid will not be provided within the 30-day time frame; and
  • notify the individual and the individual's case manager of a new proposed date for provision of the adaptive aid.

For an adaptive aid that is a medical supply and not immediately needed by the individual, the DSA must:

  • notify the individual and the individual's case manager, orally or in writing, before the five-day time frame expires the adaptive aid will not be provided within the five-day time frame;
  • provide the reasons why the medical supply will not be provided within the five-day time frame; and
  • notify the individual and the individual's case manager of a new proposed date for provision of the medical supply.

 

3540 Minor Home Modification

Revision 17-1; Effective November 1, 2017

 

Once the SPT has agreed the applicant/individual might require a minor home modification, the DSA must request in writing that the case manager initiate an IPC revision that includes funds for obtaining an assessment of the individual by the appropriate licensed professional to determine the specific minor home modification necessary to meet the needs of the individual, as defined in the assessment.

Once HHSC notifies a DSA through the electronic billing system of a service authorization for an assessment by the appropriate licensed professional of the individual’s need(s), the DSA must obtain the assessment within 30 calendar days after the date HHSC authorizes the IPC.

After HHSC authorizes the proposed IPC for payment for the assessment of the individual, the DSA must obtain the specifications from a person who has experience in home modifications within 30 calendar days.

The DSA must:

  • obtain an assessment of the individual from a licensed professional that describes the specific minor home modification, as described in Appendix II, Minor Home Modification Services. The assessment must include a complete description of the specific need(s) of the individual and recommendations for the minor home modification that will meet the needs identified in the assessment.
  • provide a copy of the assessment to the CMA;
  • obtain the specifications from a person who has experience in constructing home modifications, based on the assessment completed by the professional; and
  • ensure the specifications meet the following standards:
    • include a complete description of the minor home modification and any required installations identified in the specifications;
    • include a drawing or picture of both the existing room, structure or other area and the proposed modification made to scale;
    • be approved in writing by each member of the SPT by completing Form 3849-A, Specifications for Adaptive Aids/Medical Supplies/Minor Home Modifications; and
    • comply with the Texas Accessibility Standards promulgated by the Texas Department of Licensing and Regulation unless:
      • DSA determines it is not structurally feasible to do so and the DSA documents, in writing, the basis for its determination; or
      • the individual or legally authorized representative (LAR) requests, in writing, the specifications not be in compliance with the Texas Accessibility Standards;
  • be approved, in writing, by the individual or LAR and the DSA by completing Form 3849-A, as described in Appendix II; and
  • provide a copy of the specifications to the CMA.

The CMA, DSA and individual/LAR must complete and sign Form 3849-A to signify agreement with the specifications.

The DSA must obtain comparable bids for a minor home modification from three vendors if the modification costs more than $1,000, within 60 calendar days after obtaining the specifications.

A bid obtained must be based on the specifications and include:

  • an itemized list of materials and labor necessary to construct the modification;
  • the cost of each material and labor listed;
  • the date of the bid;
  • the name, address and telephone number of the vendor, who may not be a relative of the individual;
  • a detailed explanation of the vendor's warranty for the modification, if any; and
  • a statement that the minor home modification will be made in accordance with all applicable state and local building codes.

A DSA may obtain one bid or two comparable bids for a minor home modification if the DSA has written justification for obtaining less than three bids because the minor home modification is available from a limited number of vendors.

If a DSA requests to purchase a minor home modification that is not based on the lowest bid, the DSA must have written justification for payment of a higher bid. The following are examples of justifications that support payment of a higher bid:

  • the higher bid is based on the inclusion of a longer warranty for the minor home modification; and
  • the higher bid is from a vendor that is more accessible to the individual than another vendor.

The person who developed the specifications may also offer one of the bids. A DSA may not disclose information regarding a submitted bid to any other vendor who has submitted a bid or to a vendor who may submit a bid.

After the DSA has successfully obtained a sufficient number of bids, the DSA must:

  • select a vendor to complete construction of the minor home modification;
  • obtain written approval for construction of the modification from the owner of the property in question, unless such approval is granted in an applicable lease agreement;
  • ensure the selected vendor obtains any required building permits; and
  • advise the CMA regarding the cost of the minor home modification and the cost of the inspection of the modification, so that an IPC revision can be initiated.

Once HHSC notifies a DSA through the electronic billing system of a service authorization for a planned minor home modification and the cost of the inspection of the modification, the DSA must direct the vendor to begin construction of the modification within seven calendar days after the date HHSC authorizes the proposed IPC; or the effective date of the IPC as determined by the SPT (whichever is later).

A DSA must ensure a minor home modification is completed within 60 calendar days after the date HHSC authorizes the proposed IPC that includes the cost of the modification and inspection or the effective date of the IPC as determined by the SPT (whichever is later).

If the DSA determines the minor home modification will not be completed within the time frame required, the DSA must notify the individual or LAR in writing of a new proposed date of completion. The proposed date may not exceed 30 calendar days after the date outlined before.

The DSA must conduct an in-person inspection of the minor home modification within seven business days after it receives information the modification is completed. The inspection may be performed by the person who developed the specifications unless that person is affiliated with the vendor who completed the minor home modification. The inspection will determine if the:

  • minor home modification has been completed;
  • modification has been made in accordance with the specifications; and
  • quality of workmanship of the modification is adequate.

If the DSA determines the minor home modification meets the conditions of the inspection, the DSA must send a completed Form 8605, Documentation of Completion of Purchase, to the individual's CMA within seven business days after completion of the inspection.

If the DSA determines the minor home modification does not meet the conditions of the inspection, the DSA must ensure the vendor meets the conditions within 30 calendar days after the DSA's determination.

 

3600 CFC PAS/HAB or CLASS Transportation-Habilitation Services Documentation

Revision 17-1; Effective November 1, 2017

 

If the individual receives CFC PAS/HAB or CLASS transportation-habilitation services as part of their service plan, the DSA must document and maintain the following in the individual record (except for items that are not relevant):

  • the need for specific CFC PAS/HAB or CLASS transportation-habilitation tasks;
  • standing physician's orders for any delegated tasks;
  • any training and/or other support provided including support management to the individual to enable the individual to manage their own CFC PAS/HAB or CLASS transportation-habilitation services;
  • conflicts/problems between the individual and the CFC PAS/HAB or CLASS transportation-habilitation staff, and how these conflicts/problems were resolved; and
  • annual documentation of the satisfaction with CFC PAS/HAB or CLASS transportation-habilitation using Form 3599, Habilitation Service Provider Orientation/Supervisory Visits.

Tasks performed by CFC PAS/HAB or CLASS transportation-habilitation provider  must be provided with proper regard for the individual's health, safety, welfare and personal autonomy. CFC PAS/HAB must be performed in a manner that comports with the individual’s personal, cultural or religious preferences.

The DSA must provide CFC PAS/HAB services that meet the individual's needs as specified in the IPC and IPP. The individual or LAR must be afforded an informed choice of settings, techniques and objectives. The individual or LAR may request CFC PAS/HAB services be modified to accommodate individual needs.

CFC PAS/HAB must be provided in community settings; that is, places where the individual lives or works and in settings similar to these. The training must teach skills the individual can practice and apply in daily life.

If any of the following services are provided, the DSA must evaluate and document the effectiveness at least once per quarter:

  • prevocational services;
  • employment assistance; or
  • supported employment services.

The evaluation must include an assessment of the individual's progress, evolving needs and plans to address identified needs.

The DSA must also inform the case manager of any significant changes in the service plan and provide the case manager with service summaries of the individual's progress and needs.

Form Resources

The following forms may need to be completed:

  • Form 2067, Case Information
  • Form 3596, PAS/Habilitation Plan - CLASS/DBMD/CFC
  • Form 3599, Habilitation Service Provider Orientation/Supervisory Visits
  • Form 3621, CLASS/CFC – Individual Plan of Care
  • Form 3625, Documentation of Services Delivered
  • Form 3629, Individual Program Plan Addendum
  • Form 8606, Individual Program Plan (IPP)

 

3700 Money Management/Trust Fund

Revision 17-1; Effective November 1, 2017

 

The SPT will address the individual's need for money management assistance. If an individual requires assistance with money management, this can be addressed during completion of Form 3596, PAS/Habilitation Plan - CLASS/DBMD/CFC.

Individuals receiving CLASS and CFC services will be encouraged to practice responsible personal money management. If the DSA maintains the individual's finances, it must do so in a way that protects the financial interests of the individual receiving CLASS and CFC services.

Individuals receiving CLASS and CFC services will be encouraged and allowed to manage their own finances, whenever possible.

Individuals who are capable of managing their own finances will:

  • receive training by the DSA as needed to enable them to do so; and
  • establish a secure place to store cash.

If the individual does not manage their own funds, the DSA must explain in writing why the individual is unable to perform the activity and what steps are being taken to increase the individual's independence. The provider must also maintain the funds in accordance with trust fund requirements as noted in 40 TAC §19.405, Additional Requirements for Trust Funds in Medicaid-certified Facilities.

 

3800 Changes in Individual Status

Revision 11-1; Effective June 13, 2011

 

The DSA must report changes in an individual's status within 24 hours of awareness of the change to the case manager on Form 2067, Case Information.

The following are examples of changes in the individual's condition or circumstances that require notification to the case manager:

  • the individual no longer needs services;
  • the individual is admitted to the hospital;
  • the individual is discharged from a hospital;
  • problems exist with family relationships that impact service delivery;
  • the individual is evicted or otherwise loses their housing that impacts service delivery;
  • the individual relocates;
  • the individual has an illness or injury that impacts service delivery; and
  • the individual loses Medicaid eligibility.