Revision 09-1

 

 

§47.57 Service Delivery Options

 

An individual receiving PHC Program services has a choice of one of the following three service delivery options.

(1) Agency option. In the agency option:

(A) the provider is responsible for personnel decisions, such as selecting, supervising, and dismissing the attendant who provides services to the individual, with input from the individual;

(B) the provider is responsible for:

(i) recruitment of attendants and substitute attendants (a responsibility the individual may share);

(ii) payroll for attendants and substitute attendants; and

(iii) filing tax-related reports of attendants and substitute attendants;

(C) the provider is the employer of record of attendants and substitute attendants; and

(D) the provider is responsible for providing substitute attendants.

(2) Consumer directed services (CDS) option. In the CDS option, as described in Chapter 41 of this title (relating to Consumer Directed Services Option):

(A) the individual recruits, hires, manages, and fires attendants;

(B) the individual is the employer of record of his or her attendant and substitute attendant;

(C) the individual is responsible for providing substitute attendants; and

(D) the consumer directed services agency (CDSA) is responsible for financial management services, including:

(i) registering as the individual's employer-agent with the Internal Revenue Service and the Texas Workforce Commission;

(ii) managing payroll for attendants and substitute attendants, including filing tax-related reports;

(iii) tracking expenditures; and

(iv) submitting quarterly expenditure reports to the employer and case manager; and

(E) the CDSA is not required to be licensed under Chapter 97 of this title (relating to Licensing Standards for Home and Community Support Services Agencies) when performing the functions described in subparagraph (D) of this paragraph.

(3) Service responsibility option (SRO). In the SRO, as described in Chapter 43 of this title (relating to Service Responsibility Option):

(A) the individual selects, manages, supervises, and dismisses attendants;

(B) the provider is the employer of record for the attendant and substitute attendant;

(C) the provider is responsible for:

(i) providing substitute attendants if necessary;

(ii) managing payroll for attendants and substitute attendants; and

(iii) filing tax-related reports of attendants and substitute attendants;

(D) the individual and supervisor must negotiate the frequency of supervisory visits;

(E) the individual is responsible for the new attendant orientation; and

(F) the provider is required to be licensed under Chapter 97 of this title if performing the functions described in subparagraph (C) of this paragraph.

 

§47.59 Support Consultation

 

(a) Support consultation is an optional service available when the consumer directed services (CDS) option or service responsibility option (SRO) is chosen by an individual.

(b) Support consultation in CDS:

(1) is provided by a DADS-certified support advisor and provides a level of assistance and training beyond that provided by the consumer directed services agency (CDSA) through financial management services; and

(2) helps an employer to meet the required employer responsibilities of the CDS option to successfully deliver program services.

(c) Support consultation in the SRO provides the required SRO orientation and additional support when needed by an individual to effectively carry out individual responsibilities under the SRO.

 

§47.61 Service Initiation

 

(a) Service initiation. The provider must initiate services:

(1) for routine referrals described in §47.43 of this chapter (relating to Referrals):

(A) for FC services, within 14 days after the following, whichever is later:

(i) the referral date on DADS' authorization for community care services form; or

(ii) the date the provider receives DADS' authorization for community care services form, unless the provider fails to stamp the receipt date on the form, in which case the referral date is used to determine timeliness; or

(B) for PHC and CAS, within seven days after provider receipt of DADS' authorization for community care services form; and

(2) for expedited referrals described in §47.43 of this chapter, on the date negotiated between the case manager and provider.

(b) Notification of service initiation. Within 14 days after initiating services, the provider must send service initiation to the case manager.

(c) Delay in service initiation. A provider may delay service initiation only for reasons not directly caused by the provider, or reasons beyond its control, such as natural or other disasters. The provider must continue efforts to initiate services and set a date, if possible, for service initiation. The provider must document any failure to initiate services by the applicable due date in subsection (a) of this section, including:

(1) the reason for the delay, which must be beyond the provider’s control;

(2) either the date the provider anticipates it will initiate services, or specific reasons why the provider cannot anticipate a service initiation date; and

(3) a description of the provider's ongoing efforts to initiate services.

(d) Documentation of service initiation. The provider must maintain documentation of service initiation in the individual's file.

 

§47.63 Service Delivery

 

(a) Service interruptions. A service interruption occurs when, on a particular day or time when services are scheduled:

(1) the client requests that:

(A) no hours of service be provided; or

(B) fewer hours of service than reflected in the service schedule be provided; or

(C) a specific attendant not provide services to the client;

(2) the client is not at home when services are scheduled;

(3) services are suspended as described in §47.71 of this chapter (relating to Suspensions); or

(4) services are not delivered for other reasons beyond the control of the provider agency, such as acts of nature and other disasters.

(b) Delivery of services.

(1) The provider agency must ensure:

(A) services are delivered according to the service plan described in §47.45 of this chapter (relating to Pre-Initiation Activities);

(B) all authorized and scheduled services are provided to a client, except in the case of a service interruption, as defined in subsection (a) of this section; and

(C) a client does not receive, during a calendar month, more than five times the weekly authorized hours on the Texas Department of Human Services' (DHS's) Authorization for Community Care Services form.

(2) The provider agency must not exceed the weekly authorized hours except in the case of a temporary increase:

(A) due to unusual circumstances and client need; and

(B) requested by the client.

(C) This paragraph does not apply to the circumstances described in subsection (d) of this section.

(c) Service interruption documentation.

(1) In the case of a priority client, the provider agency must document all service interruptions by the 30th day after the beginning of the service interruption.

(2) In the case of a non-priority client, the provider agency must document all service interruptions that exceed 14 consecutive days by the 30th day after the day service interruption exceeds 14 consecutive days.

(A) For a fixed service schedule, the service interruption begins on the first day services are scheduled but not delivered.

(B) For a variable service schedule, the service interruption begins the Sunday following the week the client did not receive all the weekly hours on a service plan approved by the client.

(3) The reason documented must be a reason listed in subsection (a) of this section.

(4) If the provider agency learns of a service interruption after the deadlines listed in paragraphs (1) and (2) of this subsection, the provider agency must document the following as soon as the provider agency learns of the service interruption:

(A) the reason for the service interruption. The reason documented must be a reason listed in subsection (a) of this section;

(B) the reason for the delay in documenting the service interruption; and

(C) the date the provider agency learned of the service interruption.

(d) Service delivery outside the client's home.

(1) The provider agency may develop a service plan that includes services regularly delivered at a location other than the client's home. The service plan must not exceed the weekly hours authorized on DHS's Authorization for Community Care Services form.

(2) The provider agency may deliver services outside the client's home when the service plan does not include the regular delivery of such services.

(3) The provider agency:

(A) may deliver services outside the client's home only if the client requests such services.

(B) is not required to pay for expenses incurred by attendants delivering services outside the client's home.

(C) must:

(i) make a reasonable effort to deliver services at a location other than the client's home when requested by the client;

(ii) maintain written justification if the client's request was not granted; and

(iii) document in the client's file:

(I) each instance when a client requested services at a location other than the home;

(II) whether the client's request was granted;

(III) what services were provided; and

(IV) where the services were delivered.

(e) Service delivery documentation.

(1) The provider agency must document the delivery of services, including:

(A) the provider agency name;

(B) the provider agency vendor number;

(C) the attendant name;

(D) the client name;

(E) the DHS client number;

(F) the specific service delivery period, including month, day, and year, as applicable;

(G) the tasks assigned;

(H) the units of service delivered;

(I) the dates services were delivered;

(J) certification that the attendant delivered the documented tasks.

(i) For electronic service delivery documentation systems, each person delivering services inputs a unique identifier to certify the services delivered.

(ii) For paper service delivery documentation systems, each person delivering services signs the timesheet to certify the services delivered.

(I) The attendant must sign his or her name or a mark representing his or her name on the timesheet to certify that it is correct. Initials are not an acceptable substitute for a signature.

(II) An attendant who is unable to sign the timesheet may designate another person to sign the timesheet. The provider agency must maintain written documentation of the:

(-a-) reason the attendant is unable to sign the timesheet; and

(-b-) identity of the person authorized to sign the timesheet on behalf of the attendant.

(2) Paper service delivery documentation must be a single document with a specific service delivery period not exceeding one calendar month.

(f) Documentation of service delivery. The provider agency must maintain documentation of service delivery in the client file. The provider agency must be able to identify all attendants delivering tasks to the client.

 

§47.65 Supervisory Visits

 

(a) Supervisory visits. A supervisor must conduct in-person supervisory visits to assess and document on a single form whether:

(1) the service delivery plan is adequate;

(2) the individual continues to need the services;

(3) the individual needs a service delivery plan change;

(4) the attendant continues to be competent to provide the authorized tasks; and

(5) the attendant is delivering the authorized tasks.

(b) Frequency. A supervisor must establish the frequency of in-person supervisory visits, based on the specific needs of the individual, the attendant, or both. The frequency of in-person supervisory visits must be at least annually.

(c) Documentation of supervisory visits. The provider must maintain documentation of each supervisory visit in the individual's file.

(d) Combining a supervisory visit and a new attendant orientation. A supervisor may conduct a scheduled supervisory visit and a new attendant orientation at the same time.

 

§47.67 Service Delivery Plan Changes

 

(a) Increase in hours or terminations.

(1) A provider must submit written notification to the case manager within seven days after learning of any change that may:

(A) require an increase in hours in the individual's service delivery plan; or

(B) result in the termination of services due to the individual receiving no personal care tasks, except for FC services.

(2) The notification must include the:

(A) date the provider learned of the need for the change;

(B) reason for the change;

(C) type of change (including the number of hours of service); and

(D) signature and date of the provider representative.

(b) Decrease in hours. The provider must develop a new service delivery plan, as described in §47.45(a)(2) of this chapter (relating to Pre-Initiation Activities), within 21 days of the provider identifying the need for an ongoing decrease in hours from the service delivery plan currently approved by the individual.

(c) Immediate increase in hours of service.

(1) The provider must notify the case manager, or designee, of the reason an individual requires an immediate increase in hours of service, and must obtain approval from DADS of both the number of additional hours of service to be provided the individual and the effective date of the change.

(2) The provider must implement the immediate increase in hours of service on the negotiated effective date of the change.

(3) The provider must document the immediate increase in hours of service. Documentation must include:

(A) the date the provider received approval for the change;

(B) the name of the DADS staff who approved the change;

(C) the effective date of the change; and

(D) the number of hours of service authorized.

(4) The provider must maintain documentation of service delivery plan changes:

(A) in the individual's file; and

(B) according to the terms of the contract.

(d) Implementation of service delivery plan changes. The provider must implement the service delivery plan change on the following date, whichever is later:

(1) the authorization begin date on DADS' authorization for community care services form; or

(2) five days after the date the provider receives DADS' authorization for community care services form, unless the provider fails to stamp the receipt date on the form, in which case the authorization begin date on the form will be used to determine timeliness.

(e) Delay in implementation of service delivery plan changes. If a provider does not implement a service delivery plan change on the effective date of the change, the provider must set a new implementation date. The provider must document by the next working day any failure to implement a service delivery plan change on the effective date of the change. The documentation must include:

(1) the reason for the failure to timely implement the service delivery plan change; and

(2) the new implementation date.

 

§47.69 Transfers

 

(a) Negotiation of an individual's transfer from one provider to another. The providers involved in an individual's transfer must coordinate with the case manager to negotiate the transfer date.

(b) Initiation of services. The receiving provider must initiate services on the negotiated date. The negotiated date is the begin date on DADS' authorization for community care services form.

(c) Evaluation and service delivery plan. On or before the begin date, the receiving providerm must:

(1) conduct an evaluation, as described in §47.45 of this chapter (relating to Pre-Initiation Activities); and

(2) develop a service delivery plan, as described in §47.45 of this chapter.

 

§47.71 Suspensions

 

(a) Required suspensions. A provider must suspend services if:

(1) an individual temporarily or permanently leaves the contracted service delivery area;

(2) the individual moves to a location where services cannot be provided under the PHC Program;

(3) the individual dies;

(4) the individual is admitted to an institution, which is a:

(A) hospital;

(B) nursing facility;

(C) state school;

(D) state hospital;

(E) intermediate care facility serving persons with mental retardation or a related condition; or

(F) correctional facility.

(5) the individual requests that services end;

(6) the Health and Human Services Commission denies the individual's Medicaid eligibility (not applicable to FC services); or

(7) the individual or someone in the individual's home exhibits reckless behavior, which may result in imminent danger to the health and safety of the individual, the attendant, or another person, in which case the provider must make an immediate referral to:

(A) the Texas Department of Family and Protective Services or other appropriate protective services agency;

(B) local law enforcement, if appropriate; and

(C) the individual's case manager.

(b) Optional suspensions. The provider may suspend services if:

(1) the individual or someone in the individual's home engages in discrimination against a provider or DADS employee in violation of applicable law; or

(2) the individual refuses services for more than 30 consecutive days.

(c) Notification of service suspension. The provider must notify the case manager of any suspension by the first working day after the provider suspends services. The notice must include:

(1) the date of service suspension;

(2) the reason(s) for the suspension;

(3) the duration of the suspension, if known; and

(4) for a suspension under subsection (a)(7) or (b) of this section, a written explanation of the circumstances surrounding the suspension.

(d) Interdisciplinary Team (IDT) meeting. The provider must convene an IDT meeting, as described in §47.49 of this chapter (relating to Interdisciplinary Team), if services are suspended under subsection (a)(7) or (b) of this section.

(e) Resuming services after suspension. This subsection does not apply to paragraphs (a)(7) or (b)(1) of this section.

(1) A provider must resume services after suspension on the earliest of the following:

(A) upon the individual's return home, or the date the provider becomes aware of the individual's return home, if applicable;

(B) on the date specified in writing by the case manager;

(C) as a result of a recommendation by the IDT; or

(D) upon the provider's receipt of notification from the case manager that the provider must resume services pending the outcome of an appeal.

(2) The provider must notify the case manager of the date services resume within seven days after that date.

 

§47.72 Compliance with Program Requirements

 

(a) Termination of services. DADS may terminate services to an individual who has had services suspended on more than three occasions as described in §47.71(a)(7) or (b)(1) of this subchapter (relating to Suspensions).

(b) Right of appeal. An individual for whom services have been terminated may appeal this decision by requesting a fair hearing as described at 1 TAC Chapter 357 (relating to Hearings).

 

§47.73 Annual Reauthorization for Community Attendant Services (CAS)

 

(a) Reauthorization request.

(1) Upon receipt of the annual DADS authorization for community care services form, a provider must request annual reauthorization for all CAS.

(2) The provider must send the following to the regional nurse to obtain annual reauthorization:

(A) DADS' authorization for community care services form received from the case manager; and

(B) a signed statement indicating whether the supervisor agrees or disagrees with the tasks and hours indicated on DADS' authorization for community care services form, and if the supervisor disagrees, the statement must provide the specific reasons for disagreeing with the hours and tasks on this form.

(b) Reauthorization request due date. The provider must submit the information described in subsection (a)(2) of this section to the regional nurse within 14 days after one of the following dates, whichever is later:

(1) the referral date on DADS' authorization for community care services form; or

(2) the date the provider receives DADS' authorization for community care services form, unless the provider fails to stamp the receipt date on the form, in which case the referral date will be used to determine timeliness.

(c) Authorization determination. DADS makes the authorization determination and notifies the provider before the annual reauthorization is due.

(d) Documentation of annual reauthorization. The provider must maintain documentation of the written request for reauthorization for CAS in the individual's file.

 

§47.75 Complaints

 

A provider must comply with the complaint procedures described in:

(1) §49.17 of this title (relating to Complaint Procedures);

(2) §49.18 of this title (relating to Client Rights and Responsibilities);

(3) §97.249 of this title (relating to Reportable Conduct); and

(4) §97.250 of this title (relating to Investigations).