Revision 18-3

 

 

Division 1 General Provisions

 

§19.2701 Purpose

The purpose of this subchapter is to:

(1) describe the requirements of a nursing facility related to preadmission screening and resident review (PASRR), which is a federal requirement in Code of Federal Regulations, Title 42, Part 483, Subpart C to ensure that:

(A) an individual seeking admission to a nursing facility or a resident of a nursing facility receives a PASRR Level I screening (PL1) to identify whether the individual or resident is suspected of having mental illness (MI), an intellectual disability (ID), or a developmental disability (DD); and
(B) an individual or resident suspected of having MI, ID, or DD receives a PASRR Level II evaluation (PE) to confirm MI, ID, or DD and, if confirmed, to evaluate whether the individual or resident needs nursing facility care and specialized services;

(2) describe the requirements of a nursing facility related to a designated resident who receives services planning and transition planning; and

(3) describe the requirements of a nursing facility related to nursing facility specialized services.

 

§19.2703 Definitions

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

(1) Alternate placement assistance — Assistance provided to a resident to locate and secure services chosen by the resident or LAR that meet the resident's basic needs in a setting other than a nursing facility. Assistance includes the identification of specific services and supports available through alternate resources for which the resident may be eligible and an explanation of the possible benefits and consequences of selecting a setting other than a nursing facility.
(2) Coma — A state of unconsciousness characterized by the inability to respond to sensory stimuli as documented by a physician.
(3) Comprehensive care plan — A plan, defined in §19.101 of this chapter (relating to Definitions), that includes, for a designated resident, nursing facility specialized services and nursing facility PASRR support activities.
(4) Convalescent care — A type of care provided after an individual's release from an acute care hospital that is part of a medically prescribed period of recovery.
(5) CMWC —Customized manual wheelchair A wheelchair that consists of a manual mobility base and customized seating system and is adapted and fabricated to meet the individualized needs of a designated resident.
(6) DADS — Department of Aging and Disability Services or HHSC, as its successor agency. For purposes of the PASRR process, HHSC is the state authority for intellectual and developmental disabilities.
(7) DD — Developmental disability. A disability that meets the criteria described in the definition of "persons with related conditions" in Code of Federal Regulations (CFR) Title 42, §435.1010.
(8) Delirium — A serious disturbance in an individual's mental abilities that results in a decreased awareness of the individual's environment and confused thinking.
(9) Designated resident — A Medicaid recipient with ID or DD who is 21 years of age or older and who is a resident.
(10) DME— Durable Medical Equipment  The following items, including any accessories and adaptations needed to operate or access the item:

(A) a gait trainer;
(B) a standing board;
(C) a special needs car seat or travel restraint;
(D) a specialized or treated pressure-reducing support surface mattress;
(E) a positioning wedge;
(F) a prosthetic devise; and
(G) an orthotic device.

(11) DSHS — Department of State Health Services. For purposes of the PASRR process, DSHS is the state mental health authority.
(12) Emergency protective services — Services that are furnished by the Department of Family and Protective Services to an elderly or disabled individual who has been determined to be in a state of abuse, neglect, or exploitation.
(13) Exempted hospital discharge — A category of nursing facility admission that occurs when a physician has certified that an individual who is being discharged from a hospital is likely to require less than 30 days of nursing facility services for the condition for which the individual was hospitalized.
(14) Expedited admission — A category of nursing facility admission that occurs when an individual meets the criteria for one of the following categories: convalescent care, terminal illness, severe physical illness, delirium, emergency protective services, respite, or coma.
(15) HHSC Health and Human Services Commission or its designee.
(16) ID — Intellectual disability. Mental retardation, as described in CFR Title 42, §483.102(b)(3)(i).
(17) IDT — Interdisciplinary team. A team consisting of:

(A) a resident with MI, ID, or DD;
(B) the resident's LAR, if any;
(C) a registered nurse from the nursing facility with responsibility for the resident;
(D) a representative of a LIDDA or LMHA, or if the resident has MI and DD or MI and ID, a representative of the LIDDA and LMHA; and
(E) other persons, as follows:

(i) a concerned person whose inclusion is requested by the resident or LAR;
(ii) a person specified by the resident or LAR, nursing facility, or LIDDA or LMHA, as applicable, who is professionally qualified or certified or licensed with special training and experience in the diagnosis, management, needs and treatment of people with MI, ID, or DD; and
(iii) a representative of the appropriate school district if the resident is school age and inclusion of the district representative is requested by the resident or LAR.

(18) Individual — A person seeking admission to a nursing facility.
(19) ISP — Individual service plan. A service plan developed by the service planning team for a designated resident in accordance with §17.502(2) of this title (relating to Service Planning Team (SPT) Responsibilities for a Designated Resident).
(20) LAR — Legally authorized representative. A person authorized by law to act on behalf of an individual or resident with regard to a matter described by this subchapter, and who may be the parent of a minor child, the legal guardian, or the surrogate decision maker.
(21) LIDDA — Local intellectual and developmental disabilities authority. An entity designated by the executive commissioner of HHSC, in accordance with Texas Health and Safety Code §533A.035.
(22) LIDDA specialized services — Support services, other than nursing facility services, that are identified through the PE or resident review and may be provided to a resident who has ID or DD. LIDDA specialized services are:

(A) service coordination, which includes alternate placement assistance;
(B) employment assistance;
(C) supported employment;
(D) day habilitation;
(E) independent living skills training; and
(F) behavioral support.

(23) LMHA — Local mental health authority. An entity designated by the executive commissioner of HHSC, in accordance with Texas Health and Safety Code §533.035. For the purposes of this subchapter, LMHA includes an entity designated by the DSHS as the entity to perform PASRR functions.
(24) LMHA specialized services — Support services, other than nursing facility services, that are identified through the PE or resident review and may be provided to a resident who has MI. LMHA specialized services are defined in Title 25, Texas Administrative Code (TAC), Chapter 412, Subchapter I (relating to MH Case Management), including alternate placement, and 25 TAC Chapter 416, Subchapter A (relating to Mental Health Rehabilitative Services).
(25) LTC Online Portal — Long Term Care Online Portal. A web-based application used by Medicaid providers to submit forms, screenings, evaluations, and the long term services and supports Medicaid identification section of the MDS assessment.
(26) MDS assessment — Minimum data set assessment. A standardized collection of demographic and clinical information that describes a resident's overall condition, which a nursing facility in Texas is required to submit for a resident of the facility.
(27) MI — Mental illness. Serious mental illness, as defined in 42 CFR §483.102(b)(1).
(28) Nursing facility — A Medicaid-certified facility that is licensed in accordance with Texas Health and Safety Code, Chapter 242.
(29) Nursing facility PASRR support activities — Actions a nursing facility takes in coordination with a LIDDA or LMHA to facilitate the successful provision of LIDDA specialized services or LMHA specialized services, including:

(A) arranging transportation for a designated resident to participate in a LIDDA specialized service or a LMHA specialized service outside the nursing facility;
(B) sending a resident to a scheduled LIDDA specialized service or a LMHA specialized service with food and medications required by the resident; and
(C) including in the comprehensive care plan an agreement to avoid, when possible, scheduling nursing facility services at times that conflict with LIDDA specialized services or LMHA specialized services.

(30) Nursing facility specialized services — Support services, other than nursing facility services, that are identified through the PE and may be provided to a designated resident. Nursing facility specialized services are:

(A) therapy services;
(B) CMWC; and
(C) DME.

(31) PASRR — Preadmission screening and resident review.
(32) PASRR determination — A decision made by DADS, DSHS, or their designee regarding an individual's need for nursing facility specialized services, LIDDA specialized services, and LMHA specialized services, based on information in the PE; and, in accordance with Subchapter Y of this chapter (relating to Medical Necessity Determinations), whether the individual requires the level of care provided in a nursing facility. A report documenting the determination is sent to the individual and LAR.
(33) PE — PASRR Level II evaluation. A face-to-face evaluation of an individual suspected of having MI, ID, or DD performed by a LIDDA or an LMHA to determine if the individual has MI, ID, or DD, and if so to:

(A) assess the individual's need for care in a nursing facility;
(B) assess the individual's need for nursing facility specialized services, LIDDA specialized services and LMHA specialized services; and
(C) identify alternate placement options.

(34) PL1 — PASRR Level I screening. The process of screening an individual to identify whether the individual is suspected of having MI, ID, or DD.
(35) Pre-admission — A category of nursing facility admission from a community setting that is not an expedited admission or an exempted hospital discharge.
(36) Referring entity — The entity that refers an individual to a nursing facility, such as a hospital, attending physician, LAR or other personal representative selected by the individual, a family member of the individual, or a representative from an emergency placement source, such as law enforcement.
(37) Resident — An individual who resides in a nursing facility and receives services provided by professional nursing personnel of the facility.
(38) Resident review — A face-to-face evaluation of a resident performed by a LIDDA or LMHA:

(A) for a resident with MI, ID, or DD who experienced a significant change in status, to:

(i) assess the resident's need for continued care in a nursing facility;
(ii) assess the resident's need for nursing facility specialized services, LIDDA specialized services and LMHA specialized services; and
(iii) identify alternate placement options; and

(B) for a resident suspected of having MI, ID, or DD, to determine whether the resident has MI, ID, or DD and, if so:

(i) assess the resident's need for continued care in a nursing facility;
(ii) assess the resident's need for nursing facility specialized services, LIDDA specialized services, and LMHA specialized services; and
(iii) identify alternate placement options.

(39) Respite — Services provided on a short-term basis to an individual because of the absence of or the need for relief by the individual's unpaid caregiver for a period not to exceed 14 days.
(40) Service coordination — As defined in §2.553 of this title (relating to Definitions), assistance in accessing medical, social, educational, and other appropriate services and supports that will help an individual achieve a quality of life and community participation acceptable to the person and LAR on the individual's behalf.
(41) Service coordinator — An employee of a LIDDA who provides service coordination.
(42) Severe physical illness — An illness resulting in ventilator dependence or diagnosis such as chronic obstructive pulmonary disease, Parkinson's disease, Huntington's disease, amyotrophic lateral sclerosis, or congestive heart failure, that results in a level of impairment so severe that the individual could not be expected to benefit from nursing facility specialized services, LIDDA specialized services or LMHA specialized services.
(43) SPT — Service planning team. A team that develops, reviews, and revises the ISP for a designated resident.

(A) The SPT always includes:

(i) the designated resident;
(ii) the designated resident's LAR, if any;
(iii) the service coordinator;
(iv) nursing facility staff familiar with the designated resident's needs;
(v) persons providing nursing facility specialized services and LIDDA specialized services for the designated resident;
(vi) a representative from a community provider, if one has been selected; and
(vii) a representative from the LMHA, if the designated resident has MI.

(B) Other participants on the SPT may include:

(i) a concerned person whose inclusion is requested by the designated resident or the LAR; and
(ii) at the discretion of the LIDDA, a person who is directly involved in the delivery of services to people with ID or DD.

(44) Surrogate decision maker — An actively involved family member of a resident who has been identified by an IDT in accordance with Texas Health and Safety Code §313.004 and who is available and willing to consent on behalf of the resident.
(45) Terminal illness — A medical prognosis that an individual's life expectancy is six months or less if the illness runs its normal course, which is documented by a physician's certification in the individual's medical record maintained by a nursing facility.
(46) Therapy services — Assessment and treatment to help a designated resident learn, keep, or improve skills and functioning of daily living affected by a disabling condition. Therapy services are referred to as habilitative therapy services. Therapy services are limited to:

(A) physical therapy;
(B) occupational therapy; and
(C) speech therapy.

(47) Transition plan — A plan developed by the SPT that describes the activities, timetable, responsibilities, services, and supports involved in assisting a designated resident to transition from the nursing facility to the community.

 

Division 2 Nursing Facility Responsibilities

 

§19.2704 Nursing Facility Responsibilities Related to PASRR

(a) If an individual seeks admission to a nursing facility, the nursing facility:

(1) must coordinate with the referring entity to ensure the referring entity conducts a PL1; and
(2) may provide assistance in completing the PL1, if the referring entity is a family member, LAR, other personal representative selected by the individual, or a representative from an emergency placement source and requests assistance in completing the PL1.

(b) A nursing facility must not admit an individual who has not had a PL1 conducted before the individual is admitted to the facility.
(c) If an individual's PL1 indicates the individual is not suspected of having MI, ID, or DD, a nursing facility must enter the PL1 from the referring entity into the LTC Online Portal. The nursing facility may admit the individual into the facility through the routine admission process.
(d) For an individual whose PL1 indicates the individual is suspected of having MI, ID, or DD, a nursing facility:

(1) must enter the PL1 into the LTC Online Portal if the individual's admission category is:

(A) expedited admission; or
(B) exempted hospital discharge; and

(2) must not enter the PL1 into the LTC Online Portal if the individual's admission category is pre-admission.

(e) Except as provided by subsection (f) of this section, a nursing facility must not admit an individual whose PL1 indicates a suspicion of MI, ID, or DD without a complete PE and PASRR determination.
(f) A nursing facility may admit an individual whose PL1 indicates a suspicion of MI, ID, or DD without a complete PE and PASRR determination only if the individual:

(1) is admitted as an expedited admission;
(2) is admitted as an exempted hospital discharge; or
(3) has not had an interruption in continuous nursing facility residence other than for acute care lasting fewer than 30 days and is returning to the same nursing facility.

(g) A nursing facility must check the LTC Online Portal daily for messages related to admissions and directives related to the PASRR process.
(h) Within seven calendar days after the LIDDA or LMHA has entered a PE or resident review into the LTC Online Portal for an individual or resident who has MI, ID, or DD, a nursing facility must:

(1) review the recommended list of nursing facility specialized services, LIDDA specialized services, and LMHA specialized services; and
(2) certify in the LTC Online Portal whether the individual's or resident's needs can be met in the nursing facility.

(i) After an individual or resident who is determined to have MI, ID, or DD from a PE or resident review has been admitted to a nursing facility, the facility must:

(1) contact the LIDDA or LMHA within two calendar days after the individual's admission or, for a resident, within two calendar days after the LTC Online Portal generated an automated notification to the LIDDA or LMHA, to schedule an IDT meeting to discuss nursing facility specialized services, LIDDA specialized services, and LMHA specialized services;
(2) convene the IDT meeting within 14 calendar days after admission or, for a resident review, within 14 calendar days after the LTC Online Portal generated an automated notification to the LIDDA or LMHA;
(3) participate in the IDT meeting to:

(A) identify which of the nursing facility specialized services, LIDDA specialized services, and LMHA specialized services recommended for the resident that the resident, or LAR on the resident's behalf, wants to receive; and
(B) determine whether the resident is best served in a facility or community setting.

(4) provide staff from the LIDDA and LMHA access to the resident and the resident's clinical facility records upon request from the LIDDA or LMHA;
(5) enter into the LTC Online Portal within 3 business days after the IDT meeting for a resident:

(A) the date of the IDT meeting;
(B) the name of the persons who participated in the IDT meeting;
(C) the nursing facility specialized services, LIDDA specialized services, and LMHA specialized services that were agreed to in the IDT meeting; and
(D) the determination of whether the resident is best served in a facility or community setting;

(6) include in the comprehensive care plan:

(A) the nursing facility specialized services agreed to by the resident or LAR; and
(B) the nursing facility PASRR support activities;

(7) submit a complete and accurate request for nursing facility specialized services in the LTC Online Portal within 20 business days after the date of the IDT meeting;
(8) start providing a therapy service within 3 business days after receiving approval from HHSC in the LTC Online Portal;
(9) order DME or CMWC in accordance with §19.2754(e) of this subchapter;
(10) provide on-going therapy services as approved by HHSC; and
(11) for a designated resident, annually document in the LTC Online Portal all nursing facility specialized services, LIDDA specialized services, and LMHA specialized services being provided to the designated resident.

 

§19.2705 Nursing Facility Responsibilities Related to the Fair Hearing Process

An individual or the individual's LAR or responsible party who is not in agreement with a PASRR determination that the individual does or does not require a nursing facility level of care may request a fair hearing to appeal the determination in accordance with 1 TAC Chapter 357, Subchapter A (relating to Uniform Fair Hearing Rules).

(1) If the hearing officer finds that the individual requires a nursing facility level of care, a nursing facility may admit the individual immediately. The individual must meet other eligibility requirements for the facility to receive payment for services provided to the individual.
(2) If the hearing officer finds that the individual does not require a nursing facility level of care, the nursing facility must not admit the individual.

 

§19.2706 Nursing Facility Responsibilities Related to a Designated Resident

(a) A nursing facility employee, nursing facility contractor, or nursing facility specialized services provider must report to the LIDDA the identity of any designated resident who expresses an interest in transitioning to the community.
(b) For a designated resident, a nursing facility must designate staff and necessary contractors to be members of the resident's SPT.
(c) A nursing facility must ensure its staff and contractors who are members of a designated resident's SPT:

(1) attend and participate in the designated resident's SPT meetings as scheduled and convened by the service coordinator;
(2) contribute to the development of the designated resident's ISP; and
(3) assist the SPT by:

(A) monitoring all nursing facility specialized services, LIDDA specialized services and LMHA specialized services, if applicable, provided to the designated resident to ensure the designated resident's needs are being met;
(B) making timely referrals, service changes, and amendments to the ISP as needed;
(C) ensuring that the designated resident's ISP, including nursing facility specialized services, nursing facility PASRR support activities, and LIDDA specialized services, is coordinated with the nursing facility's comprehensive care plan;
(D) if the designated resident has expressed interest in community living;

(i)developing a transition plan for the designated resident to live in the community; and
(ii)identifying the action the SPT will take to address concerns and remove barriers to the designated resident living in the community; and

(E) reviewing and discussing the information included in the ISP and transition plan with key nursing facility staff who work with the resident.

(d) A nursing facility must allow a service coordinator access to:

(1) a designated resident on a monthly basis, or more frequently if needed; and
(2) the designated resident's clinical facility records.

 

§19.2707 Transition Activities Related to Designated Residents

(a) A nursing facility must participate in implementing the transition plan developed by an SPT for a designated resident.
(b) A nursing facility must document in the comprehensive care plan for a designated resident any nursing facility responsibilities to support the implementation of the resident's transition plan.

 

§19.2708 Educational and Informational Activities for Residents

A nursing facility must:

(1) allow access to residents by the State Ombudsman, a certified ombudsman, an ombudsman intern, and representatives of the protection and advocacy system in the state for individuals with mental illness or individuals with intellectual or developmental disabilities to educate and inform them of their rights and options related to PASRR;
(2) allow access to designated residents to support educational activities about community living options arranged by the LIDDA; and
(3) provide a designated resident with adequate notice and assistance to be prepared for and participate in scheduled community visits.

 

§19.2709 Incident and Complaint Reporting

In addition to reporting incidents and complaints, including abuse and neglect, to DADS as required by §19.602 of this chapter (relating to Incidents of Abuse and Neglect Reportable to the (DADS) and Law Enforcement Agencies by Facilities) and §19.2006 of this chapter (relating to Reporting Incidents and Complaints), a nursing facility must report the information by making a telephone report immediately after learning of the incident or complaint:

(1) to the service coordinator, if it involves a designated resident; and
(2) to the LMHA representative, if it involves a designated resident with MI receiving LMHA specialized services.

 

Division 3 Nursing Facility Specialized Services for Designated Residents

 

§19.2750 Nursing Facility Specialized Services for Designated Residents

(a) A nursing facility must request authorization from HHSC to provide a nursing facility specialized service to a designated resident if the service is agreed to by the designated resident’s IDT in accordance with §19.2704 of this subchapter (relating to Nursing Facility Responsibilities Related to PASRR) or the designated resident’s SPT in accordance with §17.502(2) of this title (relating to Service Planning Team (SPT) Responsibilities for a Designated Resident.
(b) Before providing a nursing facility specialized service, a nursing facility must request and receive authorization from HHSC through the LTC Online Portal to provide the service.

 

§19.2751 Requesting Authorization to Provide Therapy Services

(a) Before requesting authorization to provide a therapy service to a designated resident, a nursing facility must ensure that:

(1) the therapy service is required by the designated resident’s comprehensive care plan;
(2) the designated resident has a diagnosis relevant to the need for the therapy service;
(3) the therapy service is ordered by the designated resident’s attending physician; and
(4) a therapy provider who meets the qualifications in §19.2752 of this division (relating to Qualifications of a Provider of Therapy Services) completes an assessment within 30 days before the nursing facility request for authorization to provide the therapy service.

(b) After a nursing facility submits a request for authorization to provide a therapy service to a designated resident:

(1) the nursing facility receives a written approval or denial of its request through the LTC Online Portal; and
(2) HHSC notifies the designated resident or the designated resident’s LAR that the request has been approved or denied.

(c) If HHSC denies a request for authorization to provide therapy services to a designated resident, the designated resident may request a fair hearing in accordance with 1 TAC Chapter 357, Subchapter A (relating to Uniform Fair Hearing Rules) to appeal the denial.

 

§19.2752 Qualifications of a Provider of Therapy Services

A nursing facility must ensure that therapy services are provided to a designated resident by:

(1) a person who:

(A) is a speech-language pathologist licensed by the Texas Department of Licensing and Regulation; or
(B) meets the educational requirements and has accumulated, or is in the process of accumulating, the supervised professional experience required to be licensed as a speech-language pathologist;

(2) an occupational therapist licensed by the Texas Board of Occupational Therapy Examiners;
(3) an occupational therapy assistance licensed by the Texas Board of Ocupational Therapy Examiners;
(4) a physical therapist licensed by the Texas Board of Physical Therapy Examiners; or
(5) a physical therapy assistant licensed by the Texas Board of Physical Therapy Examiners.

 

§19.2753 Payment for Therapy Services

(a) HHSC pays a nursing facility for therapy services provided to a designated resident based on fees determined in accordance with 1 TAC §355.313 (relating to Reimbursement Methodology for Rehabilitative and Specialized Services).
(b) A therapy session is one hour of therapy provided to one resident.
(c) An assessment is reimbursed at the same rate as a therapy session.
(d) An occupational therapist or physical therapist may assess a designated resident at any time to evaluate the needs of the designated resident for a therapy service, but HHSC does not pay for an assessment of a designated resident conducted within 180 days after the previous assessment of the designated resident.
(e) A nursing facility must submit a complete and accurate claim for a therapy service within 12 months after the last day of an authorization from HHSC to provide the service.

 

§19.2754 Requesting Authorization to Provide Durable Medical Equipment and Customized Manual Wheelchairs

(a) To request authorization to provide DME or a CMWC to a designated resident, a nursing facility must ensure that a physical therapist or occupational therapist licensed in Texas assesses the designated resident for the DME or CMWC. If, based on the assessment, the physical or occupational therapist recommends DME or a CMWC, the nursing facility must request authorization to provide the DME or CMWC through the LTC Online Portal. The assessment required by this subsection must be completed within 30 days before the nursing facility requests authorization through the LTC Online Portal.
(b) The request for authorization to provide DME or CMWC made through the LTC Online Portal must include:

(1) the assessment of the designated resident described in subsection (a) of this section;
(2) a statement signed by the designated resident’s attending physician that the DME or CMWC is medically necessary; and
(3) detailed specifications of the DME or CMWC from a DME supplier.

(c) The documentation of the physical or occupational therapy assessment required by subsection (a) of this section must include:

(1) a diagnosis of the designated resident relevant to the need for DME or a CMWC;
(2) the specific DME or CMWC, including any adaptations recommended for the designated resident; and
(3) a description of how the DME or CMWC will meet the specific needs of the designated resident.

(d) After a nursing facility submits a request for authorization to provide DME or a CMWC to a designated resident:

(1) the nursing facility receives a written approval or denial of its request through the LTC Online Portal; and
(2) HHSC notifies the designated resident or the designated resident’s LAR that the request has been approved or denied.

(e) If HHSC approves a request to provide DME or a CMWC to a designated resident, the nursing facility must order the DME or CMWC from a DME supplier within 5 business days after receiving notification of the approval through the LTC Online Portal.
(f) If HHSC denies a request to provide DME or a CMWC to a designated resident, the designated resident may request a fair hearing in accordance with 1 TAC Chapter 357, Subchapter A (relating to Uniform Fair Hearing Rules), to appeal the denial.

 

§19.2755 Payment for Durable Medical Equipment and Customized Manual Wheelchairs

(a) A nursing facility must fully explore and use other sources to pay for DME or a CMWC before requesting payment from HHSC. If another funding source is available, HHSC pays no more than the remaining balance after other sources have paid.
(b) HHSC pays a nursing facility for an assessment for DME or a CMWC for a designated resident based on fees determined in accordance with 1 TAC §355.313 (relating to Reimbursement Methodology for Rehabilitative and Specialized Services).

(1) HHSC pays for DME or CMWC assessment at the same rate as a therapy session.
(2) An occupational therapist or physical therapist may assess a designated resident at any time to evaluate the needs of the designated resident for DME or a CMWC, but HHSC does not pay for an assessment of a designated resident conducted within 180 days after the previous assessment of the designated resident.

(c) A complete and accurate claim for DME or a CMWC must be received by HHSC within 12 months after the day the DME or CMWC is purchased.
(d) A nursing facility must not submit a claim for payment for DME or a CMWC to HHSC before:

(1) an occupational therapist or physical therapist licensed in Texas verified that the DME or CMWC meets the original specifications and the needs of the designated resident; and
(2) the nursing facility documents the verification in the LTC Online Portal.

(e) If HHSC denies a request for payment for DME or a CMWC because a nursing facility did not obtain authorization before purchasing the DME or CMWC or did not submit necessary documentation to HHSC, the facility may not charge the designated resident or family for the DME or CMWC.

 

§19.2756 Administrative Requirements for Durable Medical Equipment and Customized Manual Wheelchairs

(a) A nursing facility must ensure that only the designated resident to whom DME or a CMWC belongs uses the DME or CMWC. A nursing facility must identify the DME or CMWC as the personal property of the designated resident.
(b) If the designated resident who was provided DME or a CMWC is discharged from a nursing facility, the designated resident retains the DME or CMWC.
(c) If a designated resident who was provided DME or a CMWC dies, the DME or CMWC becomes property of the designated resident’s estate. As part of the estate, the DME or CMWC is subject to Medicaid Estate Recovery Program requirements in 1 TAC Chapter 373 (relating to Medicaid Estate Recovery Program).
(d) If DME or a CMWC is donated or sold to a nursing facility by a designated resident or the personal representative of a designated resident’s estate, the transaction must be documented in accordance with §19.416 of this chapter (relating Personal Property).
(e) A modification, adjustment, or repair to DME or CMWC required within the first six months after delivery of the DME or CMWC is the responsibility of the DME supplier. More than six months after delivery of DME or a CMWC, a nursing facility must maintain and repair all medically necessary equipment for a designated resident, including DME or a CMWC obtained under this division, as required by §19.2601(b)(8)(C) of this chapter (relating to Vendor Payment (Items and Services Included).
(f) A nursing facility must submit a request to replace DME or a CMWC of a designated resident in the same manner as a request for authorization to provide DME or a CMWC to a designated resident. HHSC does not approve a request to replace a CMWC made within five years after a CMWC was purchased for the designated resident, unless the request includes:

(1) an order from the designated resident’s attending physician; and
(2) an assessment by an occupational therapist or physical therapist licensed in Texas, with documentation explaining why the designated resident’s current CMWC no longer meets the designated resident’s needs.