Revision 16-1

 

 

§98.200 Applicability

 

Subchapter H of this chapter applies only to a DAHS facility that contracts with DADS to provide DAHS under Title XIX or Title XX of the Social Security Act.

 

§98.201 Eligibility Requirements for Participation

 

The client must meet eligibility requirements described in §48.2915 of this title (relating to Day Activity and Health Services). The physician providing the physician's order cannot be the facility owner or have a significant financial or contractual relationship with the facility.

 

§98.202 Program Overview

 

(a) A DAHS facility must:

(1) contract with DADS to provide day activity and health services (DAHS);

(2) provide services at least 10 continuous hours each day, five days a week (Monday through Friday), except for published holidays;

(3) serve eligible clients, unless a DAHS facility is at licensed capacity;

(4) participate in the Child and Adult Care Food Program (CACFP). The DAHS facility must submit documentation of participation in the CACFP to DADS. Documentation consists of a copy of the CACFP agreement or a copy of the approval letter for participation in the CACFP, or both;

(5) advise the individual of his rights in a language he understands and provide him with a signed copy. The DAHS facility must maintain the original in the record; and

(6) comply with complaint procedures in community services generic contracting rules §49.18(a)(4) and §49.18(b)-(c) of this title (relating to Client Rights and Responsibilities), and §49.17 of this title (relating to Complaint Procedures).

(b) DADS reserves the right to deny any DAHS facility a contract if it is not in the best interest of DADS.

 

§98.203 Written Referrals for Services

 

(a) DAHS facilities receive written referrals from caseworkers based on the following priorities:

(1) client's choice;

(2) physician's choice, if stated; and

(3) rotation of eligible providers.

(b) When a DAHS facility receives a referral from the caseworker, the DAHS facility nurse must make every effort to request prior approval for the client within 14 days after the referral date on DADS' authorization for community care services form.

(c) If the DAHS facility cannot request prior approval within 14 days, the DAHS facility must notify the caseworker about the reason for delay. This notification must be sent on DADS' Case Information form within 14 days after the referral date.

(d) Within the same 14 days after receipt of DADS' authorization for community care services form from the caseworker and before requesting prior approval, the nurse must conduct a health assessment/plan of care with the client, using DADS' Client Health Assessment/Plan of Care form. If the client is unable to participate due to cognitive impairment, the client's responsible party should participate.

(e) If the nurse cannot conduct the health assessment within 14 days after the referral date, the DAHS facility must notify the caseworker about the reason for delay on DADS' Case Information form within the 14-day period.

(f) Within the same 14 days after receipt of DADS' authorization for community care services form from the caseworker, the nurse must obtain a physician's order for the client by sending DADS' Physician's Order for Day Activity and Health Services form to the client's physician. The nurse sends a copy of DADS' Client Health Assessment/Plan of Care form to the physician.

(g) If the DAHS facility cannot obtain physician's orders within 14 days after the referral date, the DAHS facility must notify the caseworker about the reason for delay. The notification must be sent on DADS' Case Information form within the 14-day period. DADS' Case Information form must include the date of the health assessment/plan of care and must be dated after the health assessment/plan of care date, if one has been conducted.

(h) If the physician fails to date DADS' Physician's Order for Day Activity and Health Services form or if the signature date is illegible, the DAHS facility stamp-in date will be considered the date of the physician's order. The date stamp must include the day, month, year, and the name of the DAHS facility. An abbreviated name or initials are acceptable.

 

§98.204 DAHS Facility-Initiated Referrals

 

(a) The applicant may be admitted to a day activity and health services DAHS facility as soon as verbal physician's orders are obtained if he appears to:

(1) be Medicaid eligible; and

(2) meet the medical/functional need criteria based on the information collected on DADS' Client Health Assessment/Plan of Care form.

(b) When a DAHS facility initiates a referral:

(1) the DAHS facility interviews the applicant to determine whether he appears to be Medicaid eligible. The DAHS facility determines Medicaid eligibility by reviewing the information on the applicant's Medical Care Identification Card;

(2) the nurse:

(A) conducts a health assessment/plan of care to determine whether the applicant appears to have a medical need for the service. The nurse determines medical need by completing DADS' Client Health Assessment/Plan of Care form; and

(B) obtains verbal or written physician orders, if the applicant appears to meet the medical/functional need criteria;

(3) the DAHS facility verbally notifies the DADS caseworker or intake unit of the placement the day the applicant contacts the DAHS facility. The DAHS facility follows up the notification in writing within seven days using DADS' Case Information form. This verbal notification is a request for community services and supports.

(c) The DAHS facility must request written prior approval for the applicant from the regional nurse within 30 days after the date of the physician orders.

(d) If the DAHS facility fails to submit prior approval forms or additional documentation within required time frames, if the additional documentation is not adequate, or if the applicant is determined ineligible by the DADS caseworker, the regional nurse cancels the DAHS facility-initiated prior approval and the DAHS facility is not reimbursed for services.

(e) If DADS' Client Health Assessment/Plan of Care form or Physician's Order for Day Activity and Health Services form is missing, or if any of the critical omissions or errors stated in paragraphs (1)-(9) of this subsection have occurred in the required documentation, the DAHS facility cannot obtain prior approval.

(1) The nurse fails to sign or date DADS' Client Health Assessment/Plan of Care form or omits the registered nurse/licensed vocational nurse credentials that should follow his signature.

(2) Documentation on DADS' Client Health Assessment/Plan of Care form does not support the medical eligibility criteria specified in §98.201 of this title (relating to Eligibility Requirements for Participation).

(3) Items A, B, in Sections II and III of DADS' Client Health Assessment/Plan of Care form are not completed or completed incorrectly and medical need cannot be determined.

(4) DADS' Physician's Order for Day Activity and Health Services form does not include the MD or DO credential of the physician who signed the form.

(5) DADS' Physician's Order for Day Activity and Health Services form does not include the license number of the physician who signed it.

(6) The physician who signed the order is excluded from participation in Medicare or Medicaid.

(7) The physician's signature is not on DADS' Physician's Order for Day Activity and Health Services form.

(8) The physician's signature date is missing or illegible and the DAHS facility's stamped date is missing from DADS' Physician's Order for Day Activity and Health Services form.

(9) The DAHS facility's stamped date used instead of the physician's date on DADS' Physician's Order for Day Activity and Health Services form does not include the provider agency's name, abbreviated name, or initials.

 

§98.205 Initiation of Services

 

(a) The DAHS facility must initiate services within seven days after the beginning date of coverage in Item 4 of DADS' Authorization for Community Care Services.

(b) If the DAHS facility does not initiate services within the seven-day period, the DAHS facility must notify the caseworker, using DADS' Case Information form, by the eighth day after the beginning date of coverage in Item 4 of DADS' Authorization for Community Care Services. DADS' Case Information form must include the reasons for the delay and the date when services are scheduled to begin.

(c) The DAHS facility must complete and return DADS' authorization for community care services form to the caseworker within 14 days after the beginning date of coverage in Item 4 of DADS' authorization for community care services form. The DAHS facility must indicate the date services were initiated, the schedule for delivering services, and the total units authorized for the client.

 

§98.206 Program Requirements

 

The DAHS facility must provide services that include the following:

(1) Nursing services. Nursing services must include:

(A) assessing, observing, evaluation and documenting a client's health condition and instituting appropriate nursing intervention to stabilize or improve a client's condition or prevent complications;

(B) assisting the client to order, maintain, or administer prescribed medications or treatments, as indicated by physician's orders;

(C) counseling the client on his health need and illness and involving significant others in the discussions of his immediate and long-term health goals; and

(D) providing or supervising personal care services to enable the client to restore, maintain or improve his ability to perform personal care tasks. For purposes of this requirement, personal care is defined as assistance in dressing, eating, grooming, bathing, toileting, transferring/ambulation or assistance with self- administering medication.

(2) Physical rehabilitative services. Physical rehabilitative services must include:

(A) restorative nursing; and

(B) group and individual exercises, including range of motion exercises.

(3) Nutrition/food service. Nutrition/food service in DAHS facilities is provided under 1 TAC Chapter 378, Subchapter A, concerning the Child and Adult Care Food Program (CACFP) and must include:

(A) one hot noon meal served between the hours of 11 a.m. and 1 p.m. The meal must:

(i) be suitable in quantity and adequacy to attain and maintain nutritional requirements, including those of special needs clients. The CACFP staff monitor the adequacy of a meal by totaling the amount of food produced and cooked by the number of adults fed to determine if the average amount of food meet the following food components: two ounces of meat, 1/2 cup of fruit/vegetables, one cup of milk and two servings of bread; and

(ii) supply 1/3 of the recommended daily allowance for adults as recommended by the United States Department of Agriculture;

(B) special diets as required by the client's plan of care;

(C) a supplementary mid-morning and mid-afternoon snack;

(D) dietary counseling and nutrition education for the client and his family; and

(E) assisting the client with his meals if necessary. This includes:

(i) food texture modification, including grinding meats and mashing vegetables for clients having trouble chewing; and

(ii) food management, including spoon feeding, bread buttering and milk opening for clients with hand deformities, paralysis or hand tremors.

(4) Other supportive services in DAHS facilities. Other supportive services must include:

(A) community interaction, cultural enrichment, educational or recreational activities and other social activities on site or in the community in a planned program to meet the social needs and interests of the clients;

(B) providing at least three social activities per day; and

(C) posting a monthly activity calendar at least one week in advance.

(5) Transportation services in DAHS facilities.

(A) Transportation services must include:

(i) transportation to and from the DAHS facility; and

(ii) transportation to and from a DAHS facility approved to provide therapies, if the client requires specialized services on days of attendance at the day activity and health services DAHS facility.

(B) If the DAHS facility provides transportation for a client to a non-therapy medical DAHS facility, the DAHS facility can claim the time spent in transport as part of the unit of services.

(C) If the DAHS facility does not provide transportation, the DAHS facility must coordinate transportation with other resources.

(D) Vehicles used for transportation services must be properly operated and maintained and have proper heating and cooling systems to maintain reasonable temperature levels inside the vehicle.

 

§98.207 Suspension of Day Activity and Health Services

 

(a) The DAHS facility must suspend services before the end of the prior approval period if one or more of the circumstances specified in paragraphs (1)-(10) of this subsection occur:

(1) the client leaves the state or moves outside the geographic area served by the DAHS facility;

(2) the client dies;

(3) the client is admitted to a hospital, nursing home, state school or state hospital;

(4) the client requests that services end;

(5) the physician requests that services end;

(6) the Health and Human Services Commission (HHSC) denies the client's Medicaid/Title XX eligibility;

(7) DADS enforces sanctions against the DAHS facility by terminating the contract;

(8) the client threatens the health and safety of himself or others;

(9) the client is absent from the DAHS facility for 15 consecutive days;

(10) the client becomes ineligible for Medicaid. Each month the DAHS facility must verify that a client has a current HHSC Medical Care Identification Card.

(b) No later than the first DADS workday after services are suspended, the DAHS facility must verbally notify the caseworker or staff in the caseworker's office about the reason the DAHS facility suspended services. Written notification on DADS' Case Information form must be sent to the caseworker within seven workdays after the incident that was reported verbally.

 

§98.208 Notifications

 

(a) If a client becomes ill or injured at the DAHS facility, the director/nurse must notify a relative or other responsible person the same day of the occurrence. Clients with communicable diseases cannot attend the DAHS facility until the physician has released the client. Examples of communicable disease are lice and scabies.

(b) No later than the DADS workday after becoming aware of changes in the client's status or condition, the DAHS facility must verbally notify the caseworker or staff in the caseworker's office about any change that may require a change in the client'splan of care, units, or service termination. The DAHS facility must follow up this verbal notification in writing, to the caseworker, using DADS' Case Information form. Written notification must occur within seven days after verbal notification.

(c) If a client is absent from a regularly scheduled program, DAHS facility staff must contact the client or someone knowledgeable about his condition the same day that the absence occurs. If DAHS facility staff are unable to contact the client or someone knowledgeable about his condition, staff document this in the client's record.

(d) The DAHS facility must verbally notify DADS by the next DADS workday and in writing within seven days after verbal notification of the following changes in DAHS facility operations:

(1) change in operation, telephone number and location of administrative office;

(2) change in hours of operation; and

(3) change in director, activities director, nurse or membership of governing board.

 

§98.209 Record Maintenance

 

(a) Personnel records. The DAHS facility must keep personnel records in a central location in the DAHS facility. Personnel records include staff qualifications, performance reports, attendance, and staff development records. The DAHS facility must maintain these documents and records according to the retention requirements. The DAHS facility must document staff coverage for days when regular staff are away from the DAHS facility on sick or vacation leave.

(b) Attendance records. The DAHS facility must use DADS forms to maintain a daily record of attendance and transportation to and from the DAHS facility, including the time each client began receiving services and the time he left the DAHS facility's care. If transportation is provided by the DAHS facility, driver's transportation records must be used. Arrival and departure times must be documented for clients not using DAHS facility-provided transportation.

(c) Transportation records. The DAHS facility driver must maintain accurate daily transportation and mileage records, and records of expenses for purchase of gas and oil.

 

§98.210 Administrative Errors and Corrections

 

(a) Administrative errors include the following:

(1) The DAHS facility enters a date of signature on DADS' Daily Attendance Record form that is before the date of the last day services are provided. DADS applies the error to the total number of units reimbursed after the signature date.

(2) The DAHS facility fails to sign DADS' Daily Attendance Record form and the signature can be verified on DADS' Daily Transportation Record form. DADS applies the error to the total number of units reimbursed on the unsigned form.

(3) The DAHS facility fails to list the client on DADS' Daily Attendance Record form, but the client was listed on DADS' Daily Transportation Record form. DADS applies the error to the total number of units reimbursed for the period the client was left off the attendance record form.

(4) The DAHS facility completes the total units of service column and leaves the time in and time out columns blank on DADS' Daily Attendance Record form, but the time in and time out can be verified on DADS' Daily Transportation Record form. DADS applies the error to the total number of units reimbursed in which the time in time out days were left blank.

(5) The DAHS facility leaves the days of service blank on DADS' Daily Attendance Record form, but the days of service can be verified elsewhere on the form or on DADS' Daily Transportation Record form. DADS applies the error to the total number of units reimbursed for the days left blank.

(6) The DAHS facility fails to enter a date of signature on DADS' Daily Attendance Record form to certify total number of units provided to the client. DADS applies the error to the total number of units reimbursed on the undated form.

(7) The DAHS facility corrects the date of signature on DADS' Daily Attendance Record form, but fails to initial the correction. DADS applies the error to the number of units reimbursed after the earliest signature date.

(8) The DAHS facility uses a signature stamp, but fails to initial the stamped signature. DADS applies the error to the total number of units reimbursed on the signature stamped form.

(9) The DAHS facility makes an illegible entry or illegible correction to any portion of record of time of DADS' Daily Attendance or Daily Transportation Record form. DADS applies the error to the total number of units reimbursed for the days in which entries are illegible.

(10) The DAHS facility completes DADS' Daily Attendance or Daily Transportation Record form in pencil. DADS applies the error to the total number of units reimbursed that were completed in pencil.

(11) The DAHS facility uses liquid paper or correction fluid to correct an entry in DADS' Daily Attendance or Daily Transportation Record form. DADS applies the error to the total number of units reimbursed that were corrected for the billing period.

(b) In the absence of acceptable secondary documentation, financial errors include the errors specified in paragraphs (1)-(3) of this subsection.

(1) The DAHS facility is reimbursed for services, but DADS' Daily Attendance and Daily Transportation Record form is missing for the period for which services are reimbursed. DADS applies the error to the total number of units reimbursed for the billing period.

(2) The DAHS facility is reimbursed for units that exceed the units recorded on DADS' Daily Attendance and Daily Transportation Record form. DADS applies the error to the total number of units reimbursed in excess of the units recorded.

(3) The DAHS facility is reimbursed for units of service and the client did not receive services or was Medicaid ineligible (not applicable to Title XX clients). DADS applies the error to the total number of units reimbursed for the days the client did not receive services or was Medicaid ineligible.

(c) Corrections of critical omissions or errors in DAHS facility documentation must be postmarked or date stamped as received by DADS within 14 days after the regional nurse mails DADS' Notification of Critical Omissions/Errors in Required Documentation form to the DAHS facility. If the DAHS facility fails to meet this time frame;

(1) the date of prior approval can be no earlier than the postmark or DADS-stamped date on the corrected documentation; or,

(2) DADS may refer the client to another DAHS facility of the client's choice.

(A) If there is space in another DAHS facility, the regional nurse notifies the caseworker by the next workday to give the client or client's family/representative the option to be referred to another DAHS facility.

(B) The caseworker will contact the client within three workdays after being notified by the regional nurse and refers the client to another DAHS facility, if the client or the client's family/representative prefers this option.

(d) An exception of 12% of the paid unit rate is the administrative portion applied to the unit of service.

 

§98.211 Billing and Payment

 

(a) The method of payment is a unit of authorized service and is defined as half a day. One unit of service constitutes three hours but less than six hours of covered services provided by the DAHS facility. Six hours or more of service constitutes two units of service. Time spent in approved transportation provided by the DAHS facility shall be counted in the unit of service.

(b) The DAHS facility is not entitled to payment if:

(1) the DAHS facility fails to submit prior approval forms or supporting documentation to the regional nurse within the required time frames for DAHS facility initiated referrals;

(2) the DAHS facility did not maintain the staff-client ratio for one or more days;

(3) the DAHS facility exceeded its license capacity; or

(4) the DAHS facility's monthly claims do not correspond to the DAHS facility's service authorizations and DADS' Daily Attendance/Daily Transportation Record form.

 

§98.212 Sanctions

 

(a) A DAHS facility may be sanctioned under §49.11(d) of this title (relating to Contracting Requirements) for failing to follow the terms of the DAHS facility contract, or failure to comply with program rules, policies, and procedures, or both.

(b) DADS can deny and recoup funds from a DAHS facility for the days it exceeded its licensed capacity. The amount denied or recouped is two units of service (regardless of the number of units actually provided) for every individual (client, applicant, private pay, etc.) that exceeded the DAHS facility license capacity.