Revision 09-1

 

 

§47.1 Purpose

 

(a) This chapter establishes the requirements for a provider contracting to provide community-based services to an individual through the DADS PHC Program. PHC Program services may be provided through a home and community support services agency, the service responsibility option (SRO), or the consumer directed services (CDS) option of service delivery. The SRO is described in Chapter 43 of this title (relating to Service Responsibility Option) and the CDS option is described in Chapter 41 of this title (relating to Consumer Directed Services Option).

(b) The requirements in this chapter apply to PHC services, FC services, and CAS, unless otherwise specified in the text.

 

§47.3 Definitions

 

The following words, terms, and phrases have the following meanings when used in this chapter, unless the context clearly indicates otherwise:

(1) ADL — Activity of daily living. An activity that is essential to daily self care, including bathing, dressing, grooming, routine hair and skin care, meal preparation, feeding, exercising, toileting, transferring, and ambulation. An ADL does not include a service that must be provided or supervised by licensed personnel.

(2) Attendant — A person who provides authorized tasks to an individual.

(3) CAS — Community attendant services. A service under the PHC Program providing in-home attendant services to individuals with an approved medical need for assistance with personal care tasks. CAS (formerly known as §1929(b) or frail elderly) are provided under Title XIX of the federal Social Security Act (relating to Grants to States for Medical Assistance Programs) at 42 U.S.C. §1396t (relating to Home and Community Care for Functionally Disabled Elderly Individuals.

(4)Case manager — A DADS employee who is responsible for case management activities. Activities include eligibility determination, individual registration, assessment and reassessment of an individual's needs, service delivery plan development, and intercession on the individual's behalf.

(5) Contract — The formal, written agreement between DADS and a provider to provide PHC Program services to an individual eligible under this chapter in exchange for reimbursement.

(6) Contract manager — A DADS employee who is responsible for the overall management of the contract with the provider.

(7) Days — Any reference to days means calendar days, unless otherwise specified in the text. Calendar days include weekends and holidays.

(8) DADS — The Department of Aging and Disability Services.

(9) Expedited referral — An oral request from a case manager to a provider when the case manager determines that an individual's needs require that pre-initiation activities be completed in less than 14 days. The completion date is negotiated between the case manager and provider.

(10) Facsimile notice — Written information sent to a designated number via facsimile.

(11) FC service — Family Care services. A service under the PHC Program providing in-home attendant services to eligible adults. FC services are provided under Title XX of the federal Social Security Act (relating to Block Grants to States for Social Services) at 42 U.S.C. §1397 et seq.

(12) Functional limitation — An individual's requirement for assistance with one or more ADLs caused by a physical limitation or disability.

(13) Imminent danger — An immediate, real threat to a person's safety.

(14) Individual — A person who is enrolled in the PHC Program and, unless the context indicates otherwise, the person's representative.

(15) Medical need — A medical diagnosis that results in a functional limitation.

(16) Non-priority — The eligibility status for service delivery as determined by the case manager for an individual who does not meet the criteria described in §48.2918(d) of this title (relating to Primary Home Care or Community Attendant Services). Services delivered to such an individual may be referred to as non-priority services, and an attendant who serves such an individual may be referred to as a non-priority attendant.

(17) Notice — Includes oral, facsimile, secure e-mail and written notice.

(18) Oral notice — Directly speaking with a person. Oral notice does not include a message left by voice mail.

(19) PHC Program — Primary Home Care Program. A DADS attendant care services program. CAS, PHC, and FC are the three types of services available under the PHC Program.

(20) PHC services — A service under the PHC Program providing in-home attendant services to an individual with an approved medical need for assistance with personal care tasks. PHC services are provided under Title XIX of the federal Social Security Act, at 42 U.S.C. §1396a (relating to State plans for medical assistance).

(21) Practitioner — A person who holds a doctor of medicine or doctor of osteopathy degree and is currently licensed in Texas, Louisiana, Arkansas, Oklahoma or New Mexico; a physician assistant currently licensed in Texas; or a registered nurse approved by the Texas Board of Nursing to practice as an advanced practice nurse.

(22) Practitioner's statement — DADS' Practitioner's Statement of Medical Need form.

(23) Priority — The eligibility status for service delivery as determined by the case manager for an individual who meets the criteria described in §48.2918(d) of this title. Services delivered to such an individual may be referred to as priority services, and an attendant who serves such an individual may be referred to as a priority attendant.

(24) Provider — A licensed home and community support services agency that has a contract.

(25) Reckless behavior — Acting with conscious indifference to the consequences.

(26) Regional nurse — A DADS employee who is responsible for authorizing an individual to receive CAS.

(27) Representative — An individual's spouse, other responsible party, designated representative, or legally authorized representative.

(28) Routine referral — A written request from the case manager to a provider to evaluate an individual for service delivery when the case manager determines that the individual's needs do not require an expedited referral.

(29) Secure e-mail notice — Written information sent via electronic mail using sufficient precautions to protect the privacy and security of identifying information in compliance with the requirements of the Health Insurance Portability and Privacy Act of 1996.

(30) Service delivery plan — A single document that is agreed upon and signed by an individual and a provider containing the elements described in §47.45(a)(2) of this chapter (relating to Pre-Initiation Activities). A single document may be more than one page.

(31) Service schedule — A schedule for delivering attendant services containing the elements described in §47.45(a)(2)(C)(iii) of this chapter.

(32) Signature — A person's name written in longhand or a mark representing his or her name on a document to certify it is correct. Initials are not an acceptable substitute for a signature if the person has the ability to write in longhand.

(33) Supervisor — A provider employee who:

(A) coordinates the delivery of services in an individual's service delivery plan;

(B) supervises attendants; and

(C) meets the requirements for a supervisor in accordance with §97.404 of this title (relating to Standards Specific to Agencies Licensed to Provide Personal Assistance Services).

(34) Working day — Any day except a Saturday, Sunday, or state holiday.

(35) Written — Information recorded on paper or other legible document.

(36) Written notice — Written information sent via mail, facsimile, secured email, or hand delivered.

(37) Utilization review — A planned, systematic review of service utilization to evaluate efficiency, quality, and appropriateness of services and service delivery plans. Utilization review may include routinely scheduled review of services or providers, or may be focused on an identified issue.