Revision 08-1

 

 

§46.11 Contracting Requirements

 

(a) General contracting requirements. A facility must meet all provisions described in this chapter and Chapter 49 of this title (relating to Contracting for Community Care Services).

(b) Assisted living services contracting requirements. To qualify to provide assisted living services under contract with the Texas Department of Human Services (DHS), a facility must comply with the following requirements:

(1) The facility must be licensed as defined in §92.4 of this title (relating to Types of Assisted Living Facilities). The facility must be allowed under licensure to provide the required services described in §46.41 of this chapter (relating to Required Services). Due to the licensure requirements, Type C and Type E facilities are not able to provide the required services under this chapter.

(2) The facility must have a separate contract for each facility that provides assisted living services.

(3) The facility must specify the number of beds for DHS clients in its contract, as follows:

(A) The facility must ensure that the number of beds contracted are in rooms that meet the requirements in §46.13 of this chapter (relating to Housing Options).

(B) The facility must ensure the number of DHS clients served by the facility does not exceed the number of contracted DHS beds.

(C) The facility may adjust the number of beds for DHS clients by contract amendment.

(4) The facility must comply with all other applicable DHS rules and regulations.

(c) Disclosure statement requirements. The facility must ensure that the Assisted Living Disclosure Statement, as required by Chapter 92 of this title (relating to Licensing Standards for Assisted Living Facilities), does not conflict with the program requirements.

(d) Client referrals. The facility must accept all DHS referrals unless:

(1) the referral would cause the facility to exceed licensed capacity;

(2) the referral would cause the facility to exceed the number of beds for DHS clients that the facility has specified in itscontract; or

(3) the facility is unable to meet the client's needs and has followed the procedures described in §46.35 of this chapter (relating to Interdisciplinary Team).

(e) Contract assignment. In addition to the procedures described in §49.5 of this title (relating to Contract Assignment), thefacility must follow the procedures described in §46.71 of this chapter (relating to Trust Fund Procedures for Client Discharge)for assignment of the trust fund account and records.

 

§46.13 Housing Options

 

(a) Setting. A facility must specify in the contract the type(s) of setting(s) it uses to provide assisted living services accordingto the following guidelines:

(1) Assisted living apartment. An assisted living apartment setting is a living unit that is a private space with living and sleeping areas, a kitchen, a bathroom, and adequate storage space. The bedroom must be single occupancy, except when the participant requests double occupancy in writing. The living unit must have private kitchen and bath facilities.

(A) Size. Assisted living apartments must have a minimum of 220 square feet, not including the bathroom. Current contracted assisted living apartments that do not meet the square footage requirement may remain at their current size unless the apartment is remodeled. Remodeling includes:

(i) the construction, removal, or relocation of walls and partitions;

(ii) the construction of foundations, floors, or ceiling-roof assemblies;

(iii) the expansion or alteration of safety systems, including:

(I) sprinkler;

(II) fire alarm; and

(III) emergency systems; or

(iv) the conversion of space in a facility to a different use.

(B) Kitchen. The kitchen is an area equipped with a sink, refrigerator, a cooking appliance, adequate space for food preparation, and storage space for utensils and supplies. The cooking appliance must be a stove, microwave, or built-in surface unit. The cooking appliance must be able to be removed or disconnected.

(C) Bathroom. The bathroom must be a separate room in the individual's living area with a toilet, sink, and an accessible bath.

(2) Residential care apartment. A residential care apartment setting is a living unit that is a private space with connected sleeping, kitchen, and bathroom areas and adequate storage space. The bedroom must be double occupancy. The living unit must have private kitchen and bath facilities.

(A) Size. Residential care apartments must have a minimum of 350 square feet of space per client. Indoor common areas used by Texas Department of Human Services (DHS) clients must be included in computing the minimum square footage. The portion of the common area allocated must not exceed usable square footage divided by the maximum number of individuals who have access to the common areas.

(B) Kitchen. The kitchen is an area equipped with a sink, refrigerator, a cooking appliance, adequate space for food preparation, and storage space for utensils and supplies. The cooking appliance must be a stove, microwave, or built-in surface unit. The cooking appliance must be able to be removed or disconnected.

(C) Bathroom. The bathroom must contain a toilet, sink, and an accessible bath.

(3) Residential care non-apartment. A residential care non-apartment setting is a living unit that does not meet either the definition of an assisted living apartment or a residential care apartment. A residential care non-apartment must be double occupancy.

(A) The facility that specifies the residential care non-apartment setting must be a freestanding building not physically attached to another licensed facility.

(B) The facility must be licensed as an assisted living facility with a capacity of 16 or fewer beds.

(4) Personal Care 3. A Personal Care 3 setting is only available in the Community Based Alternatives (CBA) Assisted Living/Residential Care (AL/RC) Program, and must meet the following qualifications:

(A) The facility must be licensed for four to 16 beds in a residential care non-apartment setting.

(B) The facility must provide 60% or more of its CBA clients with a single occupancy bedroom.

(C) The facility must maintain a minimum staffing ratio of one direct care staff member for every:

(i) four clients, including private pay clients, during the day and evening shifts; and

(ii) eight clients, including private pay clients, during the night shift.

(D) Sixty percent or more of the total clients served each month must require one-to-one staff assistance. One-to-one assistance is determined by a value of three or more on the DHS Client Assessment, Review, and Evaluation form in one or more of the following activities of daily living:

(i) transferring;

(ii) eating; or

(iii) toileting.

(b) Occupancy. The facility must provide each client with a private (singe occupancy) or semi-private (double occupancy) living unit.

 

§46.15 Additional Services and Fees

 

(a) The facility may charge the client or the client's representative for additional items or services that the Texas Departmentof Human Services (DHS) does not require the facility to provide. The client or the client's representative must request andapprove the additional items or services in writing.

(b) The facility must not charge the client or the client's representative for any service provided to the client as requiredby its contract with DHS.

(c) The facility must inform the client or the client's representative of the additional items or services and the charges forthose items or services at the following times:

(1) at admission;

(2) before a change in the additional items, services, or charges; and

(3) when the client requests the additional items or services.

(d) The facility may charge the client or the client's representative for additional items or services, including:

(1) private telephone;

(2) television and/or radio for personal use;

(3) cable television services;

(4) personal comfort items, including smoking materials, notions and novelties, and confections;

(5) cosmetics and grooming items and services in excess of those required;

(6) personal clothing;

(7) personal reading material;

(8) gifts purchased on behalf of a client;

(9) flowers and plants;

(10) social events and entertainment outside the scope of the required activities program;

(11) the cost of being a single occupant in a double occupancy room, except for:

(A) a therapeutically required single occupancy room, such as isolation for infection control; or

(B) services provided in the assisted living apartment setting, as defined in §46.13(a)(1) of this chapter (relating to Housing Options);

(12) specially prepared or alternative food requested instead of the food generally prepared by the facility;

(13) the actual amount of the fee charged by the bank for checks written by the client or the client's representative that are returned for non-sufficient funds;

(14) charges for damage to the facility beyond expected wear and tear. The facility must not charge a security/damage deposit to DHS clients; and

(15) pet deposit. A pet deposit does not apply to service animals. A service animal is any guide dog, signal dog, or other animal trained to provide assistance to an individual with a disability.

 

§46.17 Termination of Contract

 

(a) General requirements for termination. The Texas Department of Human Services (DHS) will terminate the facility's contractas described in Chapter 49 of this title (relating to Contracting for Community Care Services) or as otherwise described inthis chapter or the facility's contract with DHS.

(b) Physical location. DHS will terminate the facility's contract if the facility loses the right to occupy the physical premisesidentified as the service delivery location. The contract termination is effective on the date the facility loses its rightto occupy the physical premises, unless DHS notifies the facility of a later termination date. DHS will not pay for servicesprovided after the termination date.

(c) Payment suspension. DHS may suspend the facility's payments if the contract is terminated for any reason at any time otherthan the last day of a month. Payments will remain suspended until the facility has refunded all unearned copayment and roomand board payments and all trust fund balances to all clients served.

 

§46.19 Recordkeeping

 

(a) General documentation requirements. The facility must maintain the documentation described in Chapter 49 of this title (relatingto Contracting for Community Care Services).

(b) Record retention requirements. The facility must retain records for the time periods described in §69.205 of this title (relatingto Contractor's Records).

(c) Daily service delivery documentation. The facility must document the client's daily service delivery.

(1) The daily service delivery documentation must contain the:

(A) client name;

(B) facility vendor number issued by Texas Department of Human Services (DHS);

(C) coverage period of the daily service delivery documentation;

(D) tasks assigned;

(E) tasks performed during the coverage period;

(F) signature of the facility manager or supervisor; and

(G) date of signature of the facility manager or supervisor.

(2) The daily service delivery documentation must be on a single document. If services delivered during the coverage period exceed the space on the single document, the facility may use multiple pages. The daily service delivery document must clearly indicate the number of pages used for the coverage period.

(d) Daily census documentation. The facility must document the daily census of clients.

(1) The daily census documentation must contain the:

(A) name of the facility;

(B) facility vendor number issued by DHS;

(C) coverage period of the daily census documentation;

(D) name of each client served during the coverage period;

(E) daily status of each client for each day during the coverage period. Types of daily status are:

(i) admission;

(ii) discharge;

(iii) present;

(iv) personal leave;

(v) institutional leave;

(vi) emergency care (emergency care applies only to the Community Care for Aged and Disabled (CCAD) Residential Care (RC) program); and

(vii) ineligible emergency care (ineligible emergency care applies only to the CCAD RC program);

(F) total of each type of daily status during the coverage period;

(G) signature of the authorized timekeeper; and

(H) date of the authorized timekeeper's signature.

(2) The daily census documentation must be on a single document. If the number of clients served during the coverage period exceeds the space on the single document, the facility may use multiple pages. The daily census document must clearly indicate the number of pages used for the coverage period.

(e) Financial records. The facility must maintain financial records:

(1) to support its billings to DHS for payment under §46.21 of this chapter (relating to Reimbursement);

(2) to document reimbursements made by DHS. The documentation must include:

(A) amount of reimbursement;

(B) voucher number;

(C) warrant number;

(D) date of receipt; and

(E) any other information necessary to trace deposits of reimbursements and payments made from the reimbursements in the facility's accounting system.

(3) in accordance with generally accepted accounting principles (GAAP) and DHS procedures. A facility's financial records must include but are not limited to the following:

(A) deposit slips, bank statements, cancelled checks, and receipts;

(B) purchase orders;

(C) invoices;

(D) journals and ledgers;

(E) timesheets and payroll and tax records;

(F) inventory records for food and other supplies;

(G) Internal Revenue Service, Department of Labor, and other government records and forms;

(H) records of insurance coverage, claims, and payments (for example, medical, liability, fire and casualty, and worker's compensation);

(I) equipment inventory records;

(J) records of the facility's internal accounting procedures;

(K) chart of accounts, as defined by GAAP; and

(L) records of the facility's company policies.

(f) Subcontractor records. If a provider agency utilizes a subcontractor, the provider agency must maintain records of the subcontractor'sactivities. Maintenance of all records to support subcontractor claims is the responsibility of the provider agency.

(g) Registered nurse access. The facility must allow the home and community support services agency's registered nurse accessto the client's medical and service plan records for use in the assessment.

 

§46.21 Reimbursement

 

(a) The facility must bill for services provided as described in Chapter 49 of this title (relating to Contracting for CommunityCare Services).

(b) The Department of Aging and Disability Services (DADS) will pay for eligible services provided and billed in compliance with this chapter.

(c) A unit of service is one billable day of authorized service delivered to a client.

(d) The facility must agree to accept the unit rate authorized by DADS, plus any applicable room and board payments, as paymentin full for services required by DADS.

(e) The unit rate reimbursed by DADS includes any copayment. The combined reimbursement from DADS and the client or the client'srepresentative for the required services described in §46.41 of this chapter (relating to Required Services) must not exceedthe unit rate plus room and board specified for each type of setting. The unit rate does not include charges for servicesdescribed in §46.15 of this chapter (relating to Additional Services and Fees).

(f) The facility must deduct the copayment amount from reimbursement claims submitted to DADS.

(g) The facility must not bill DADS for the day of discharge, unless the discharge is due to the death of the client.

(h) The facility must bill the double occupancy (Residential Care Apartment) rate for clients in the single occupancy (AssistedLiving Apartment) setting who request double occupancy.

(i) The facility must bill DADS for the balance of the bedhold charge for any clients whose daily copayment is less than the maximumbedhold charge allowed by DADS.

(1) The facility must determine the client's daily copayment amount by dividing the client's monthly copayment charge by the number of days in the month.

(2) The facility must deduct the client's daily copayment amount from the bedhold rate and submit the claim to DADS.

(3) This subsection does not apply to the Community Based Alternatives (CBA) Assisted Living/Residential Care (AL/RC) Program.

(j) The facility may bill DADS for emergency care provided to clients for:

(1) up 60 days per authorization for eligible clients; or

(2) five days for a client ineligible for emergency care.

(k) The facility must not bill for services provided before or after the authorized effective dates for CBA AL/RC or CommunityCare for Aged and Disabled (CCAD) Residential Care (RC) services, as those dates are determined by DADS.

(l) When the facility requests a level of care reset, the facility may bill DADS at the new payment rate effective the date of the new assessment. The facility may request only two level of care resets during each calendar year for eachCBA client for the following time periods:

(1) January through June; and

(2) July through December.

(m) CCAD RC services will be reimbursed at the double occupancy rate, regardless of the actual occupancy.

 

§46.23 Monitoring Reviews

 

Monitoring reviews are conducted through an on-site review and in accordance with Chapter 49 of this title (relating to Contracting for Community Care Services). The Texas Department of Human Services (DHS) reviews records on a regular and systematic basis, and as often as DHS deems necessary. DHS conducts the following types of monitoring:

(1) Compliance monitoring. Compliance monitoring is a review to determine if the facility is delivering services according tothe rules in this chapter. Compliance monitoring includes:

(A) review of consumer satisfaction surveys conducted;

(B) review of client records;

(C) interviews with clients and staff;

(D) observation of clients and staff; and

(E) consultations with others as appropriate.

(2) Fiscal monitoring. Fiscal monitoring is a review of documentation that supports the facility's billing. The facility is liablefor recoupment of payment if monitoring errors indicate the monthly claims do not correspond with the daily census documentationand daily service delivery documentation. Fiscal monitoring includes:

(A) Financial errors. DHS applies the error to the entire unit of service. Financial errors include:

(i) The facility is reimbursed for services, but the daily census documentation and the daily service delivery documentation are missing for the period for which services are reimbursed. DHS applies the error to the total number of units reimbursed for the billing period for which forms are missing.

(ii) The facility is reimbursed for units that exceed the units recorded on daily census documentation and daily service delivery documentation. DHS applies the error to the total number of units reimbursed in excess of units recorded.

(iii) The facility is reimbursed for units of service and the client did not receive services. DHS applies the error to the total number of units reimbursed for the days the client did not receive services.

(iv) The facility is reimbursed for units of service and the client was Medicaid ineligible. DHS applies the error to the total number of units reimbursed for the days the client was Medicaid ineligible. This does not apply to the Community Care for Aged and Disabled (CCAD) Residential Care (RC) program.

(B) Administrative errors. Documentation is reviewed for administrative errors as they exist at the time DHS staff arrive to conduct the monitoring review. DHS applies the error to the administrative portion of the unit of service. The administrative portion is 12% of the paid unit rate. Administrative errors include:

(i) The facility enters a date of signature on the daily census documentation that is before the date the last day services are provided. DHS applies the error to the total number of units reimbursed after the signature date.

(ii) The facility fails to sign the daily census documentation. DHS applies the error to the total number of units reimbursed on the unsigned form.

(iii) The facility fails to enter a date of signature on the daily census documentation to certify total number of units provided to the client. DHS applies the error to the number of units reimbursed on the undated form.

(iv) The facility corrects the date of signature on the daily census documentation, but fails to initial the correction. DHS applies the error to the total number of units reimbursed after the earliest signature date.

(v) The facility uses a signature stamp on the daily census documentation, but fails to initial the stamped signature. DHS applies the error to the total number of units reimbursed on the signature stamped form.

(vi) The facility makes an illegible entry or illegible correction to any portion of the record of time on the daily census documentation. DHS applies the error to the total number of units reimbursed for the days in which entries are illegible.

(vii) The facility enters an illegible date of signature or makes an illegible correction to the date of signature on the daily census documentation. DHS applies the error to the total number of units on the form.

(viii) The facility fails to complete the entire daily census documentation in ink, as described in §49.11(d) of this title (relating to Record Documentation Requirements). DHS applies the error to the total number of units reimbursed that were not completed in ink.

(ix) The facility uses a method other than crossing out and initialing to change an entry on the daily census documentation. DHS applies the error to the total number of units reimbursed that were corrected in a manner other than crossing out and initialing.

(x) The facility fails to list the client on the daily census documentation, but the client was listed on the daily service delivery documentation. DHS applies the error to the total number of units reimbursed for the period the client was left off the daily census documentation.

(xi) The facility leaves the daily status blank on the daily census documentation, but daily activity can be verified on the daily service delivery documentation. DHS applies the error to the total number of units reimbursed for which the daily status is left blank on the daily census documentation.

 

§46.25 Complaints

 

A facility must comply with the complaint procedures described in §49.13 of this title (relating to Client Rights and Responsibilities) and §49.14 of this title (relating to Complaint Procedures).

 

§46.27 Reimbursement Methodology for Residential Care

 

(a) General requirements. The Texas Department of Human Services (DHS), or its designee, applies the general principles of costdetermination as specified in §20.101 of this title (relating to Introduction).

(b) Cost reporting.

(1) Providers must follow the cost-reporting guidelines as specified in §20.105 of this title (relating to General Reporting and Documentation Requirements, Methods, and Procedures).

(2) All contracted providers must submit a cost report unless the number of days between the date the first DHS client received services and the provider's fiscal year end is 30 days or fewer.

(3) The provider may be excused from submitting a cost report if circumstances beyond the control of the provider make cost report completion impossible, such as the loss of records due to natural disasters or removal of records from the provider's custody by any regulatory agency. Requests to be excused from submitting a cost report must be received by the Texas Health and Human Services Commission's (HHSC) Rate Analysis department before the due date of the cost report.

(c) Reimbursement determination.

(1) Reporting and verification of allowable costs.

(A) Providers are responsible for reporting only allowable costs on the cost report, except where cost report instructions indicate that other costs are to be reported in specific lines or sections. Only allowable cost information is used to determine recommended reimbursements. DHS or its designee excludes from reimbursement determination any unallowable expenses included in the cost report and makes the appropriate adjustments to expenses and other information reported by providers. The purpose is to ensure that the database reflects costs and other information that are necessary for the provision of services and that are consistent with federal and state regulations.

(B) Individual cost reports may not be included in the database used for reimbursement determination if:

(i) there is reasonable doubt as to the accuracy or allowability of a significant part of the information reported; or

(ii) an auditor determines that reported costs are not verifiable.

(C) When material pertinent to proposed reimbursements is made available to the public, the material will include the number of cost reports eliminated from reimbursement determination for the reason stated in subparagraph (B)(i) of this paragraph.

(2) Residential care reimbursement. Recommended per diem reimbursement for residential care is determined as follows.

(A) Reported allowable expenses are combined into four cost areas:

(i) attendant;

(ii) other direct care;

(iii) facility; and

(iv) administration and transportation.

(B) Facility, transportation (vehicle), and administration expenses are lowered to reflect expenses for a provider at the lower of:

(i) 85% occupancy rate; or

(ii) the overall average occupancy rate for licensed beds in facilities included in the database during the cost-reporting periods included in the base. The occupancy adjustment is applied if the provider's occupancy rate is below 85% or the overall average, whichever is lower. The occupancy adjustment is determined by the individual provider occupancy rate being divided by .85 or the average occupancy rate of all providers in the database.

(C) Payroll taxes and employee benefits are allocated to each salary line item on the cost report on a pro rata basis based on the portion of that salary line item to the amount of total salary expense for the appropriate group of staff. Employee benefits will be charged to a specific salary line item if the benefits are reported separately. The allocated payroll taxes and employee benefits are Federal Insurance Contributions Act or Social Security, Medicare contributions, Workers' Compensation Insurance, the Federal Unemployment Tax Act, and the Texas Unemployment Compensation Act.

(D) Allowable salaries paid to the director, administrator, assistant administrator, owner, or partner who works for the Residential Care contracted provider may be limited to the 90th percentile of an array of salary costs for the director, administrator, assistant administrator, owner, or partner.

(E) The attendant cost area from subparagraph (A)(i) of this paragraph will be calculated as specified in §20.112 of this title (relating to Attendant Compensation Rate Enhancement).

(F) The following applies to the cost areas from subparagraph (A)(ii)-(iv) of this paragraph:

(i) Each provider's total reported allowable costs, excluding depreciation and mortgage interest, are projected from the historical cost-reporting period to the prospective reimbursement period as described in §20.108 of this title (relating to Determination of Inflation Indices). The prospective reimbursement period is the period of time that the reimbursement is expected to be in effect.

(ii) Cost area per diem expenses are calculated by dividing total reported allowable costs for each cost area by the total days of service. Cost area per diem expenses are rank ordered from low to high to produce projected per diem expense arrays.

(iii) Reimbursement is determined by selecting from each cost area the median day of service and the corresponding per diem expense times 1.07. The resulting cost area amounts are totaled to determine the per diem reimbursement.

(iv) The client is required to pay the room and board portion of the per diem reimbursement. DHS will pay the services portion of the per diem reimbursement.

(3) Exceptions to the reimbursement determination methodology. Reimbursement may be adjusted in accordance with §20.109 of this title (relating to Adjusting Reimbursement When New Legislation, Regulations, or Economic Factors Affect Costs) when new legislation, regulations, or economic factors affect costs.

(d) Authority to determine reimbursement. The authority to determine reimbursement is specified in §20.101 of this title.

(e) Allowable and unallowable costs. In determining whether a cost is allowable or unallowable, providers must follow the guidelinesas specified in §20.102 of this title (relating to General Principles of Allowable and Unallowable Costs) and §20.103 of thistitle (relating to Specifications for Allowable and Unallowable Costs). In addition to these sections, the following allowableand unallowable costs are applicable in the Community Care for Aged and Disabled Residential Care program.

(1) Allowable costs. Medical supplies required to provide residential care services are allowable. Allowable medical costs include supply costs associated with the administration of medications, such as medication cups, syringes for insulin injections, stethoscopes, blood pressure cuffs, and thermometers.

(2) Unallowable costs. Unallowable costs include prescription drugs; non-legend drugs; medical records costs; and compensation for physicians, pharmacists, and medical directors.

(f) Reporting revenue. Revenues must be reported on the cost report in accordance with §20.104 of this title (relating to Revenues).

(g) Reviews and field audits of cost reports. Desk reviews or field audits are performed on cost reports of all contracted providers.The frequency and nature of the field audit are determined by DHS or its designee to ensure the fiscal integrity of the program.Desk reviews and field audits will be conducted in accordance with §20.106 of this title (relating to Basic Objectives andCriteria for Audit and Desk Review of Cost Reports), and providers will be notified of the results of a desk review or a fieldaudit in accordance with §20.107 of this title (relating to Notification of Exclusions and Adjustments). Providers may requestan informal review and, if necessary, an administrative hearing to dispute an action taken under §20.110 of this title (relatingto Informal Reviews and Formal Appeals).