Day Activity and Health Services Provider Manual Section 5000 … · 2014-08-07 · Department of Aging and Disability Services Day Activity and Health Services Provider Manual Revision:

Department of Aging and Disability Services Day Activity and Health Services Provider Manual Revision: 13-1 Effective: October 30, 2013

Section 5000

Service Requirements

5100 Overview

Revision 13-1; Effective October 30, 2013

This section describes the interaction between the Department of Aging and Disability Services (DADS)DADS and facility staff. This material is presented in a normal and chronological sequence of events, following the individual from initial application for services through service delivery and suspension/ or termination of services.

5110 Enrollment Forms Needed


• Form 2059, Summary of Client's Need for Service; • Form 2067, Case Information; • Form 2101, ApprovalAuthorization for Community Care Services; • Form 2110, Community Care Intake; • Form 3049, DAHS Health Assessment; • Form 3050, DAHS Individual Service Plan; • Form 3055, Physician's Orders (DAHS); and • Form 3070, Day Activity and Health Services Notification of Critical Omissions.

Note: no edits performed on Subsections 5120 through 5210.

5211 Health Assessment

A DAHS facility nurse must complete the health assessment for each referral. The DAHS facility nurse completes the health assessment using Form 3049, Day Activity and Health Services Health Assessment and send Form 3049 with Form 3055, Physician’s Order for Day Activity and Health Services to the individual’s physician to request physician’s orders. The health assessment may be conducted at either the facility or the individual's home.

Health assessments must be conducted when:

• applicants need initial prior approval; • individuals transfer from one facility to another; or

http://www.dads.state.tx.us/forms/2059








• the licensed nurse determines an individual needs to be reassessed.

The health assessment must be signed by the applicant/individual or responsible party each time it is completed or revised by the facility.

The health assessment identifies specific conditions that may impact an individual’s functioning. For example, Form 3049 may indicate an individual has residual paralysis from a stroke. The identification of residual paralysis on the assessment could translate to a number of tasks the individual needs assistance with that would be documented on Form 3050.

The medical diagnosis listed in the health assessment form must be the same as the diagnosis listed on the physician’s orders. Assessment of functional and physical status must reflect symptoms the individual experienced within 30 days of the date the assessment is completed. When the signed physician’s order is obtained by the facility nurse, it may be necessary to update the individual plan of care based on new information such as medications and diagnosis listed on the physician’s orders.

The licensed nurse must make a determination to conduct a new assessment based on a determination the current assessment is no longer accurate and does not reflect the individual’s current conditions or symptoms. 5211.1 Health Assessment

Health assessment due dates:

For case manager initiated referrals - Within 14 calendar days after the referral date (Form 2101, Item 1) or the date the provider received the Form 2101 as indicated by date stamp; whichever is later.

If the DAHS provider cannot complete the health assessment within 14 calendar days after the referral date, a Form 2067, Case Information, must be sent to the DADS case manager explaining why and a copy kept in the individual's case record.

For facility-initiated referrals - On or before the date services are initiated. 5212 Individual Service Plan (ISP)

The Form 3050, DAHS Individual Service Plan is completed at the same time as Form 3049 DAHS Health Assessment is completed by the facility nurse. Once Form 3055, Physician’s Orders for DAHS, is signed and returned by the physician, the ISP will need to be reviewed to ensure all appropriate information reflected on the physician’s order is included on the ISP (e.g. medications, treatments, frequency of treatments).

A new ISP is completed for individuals:

• who need initial prior approval; • who transfer from one facility to another; • when the licensed nurse determines an individual needs a new service plan developed; or

• multiple plan updates have resulted in the individual’s plan being difficult to follow and a brand new ISP is needed to ensure the current treatment, monitoring and interventions can be identified clearly.

Updates to existing ISPs are needed when:

• changes to the individual’s treatment, monitoring and intervention occur; or • nursing service needs have changed based on new or supplemental physician’s orders.

The ISP must include documentation of

• treatments, monitoring and intervention ordered by the physician, including the indicated frequency; and

• all medications, whether taken at the DAHS facility or at the individual’s home, must be documented to include dosage, route and frequency.

All treatments, skilled care and medications indicated on the ISP must match the physician’s order or supplemental orders. If the physician’s order is updated, the ISP is updated to clearly indicate the date when treatments, medications or skilled services were revised or added.

Information received from the case manager may convey problems that the individual is experiencing at home that may need to be addressed by DAHS staff. For example, the individual may not have adequate bathroom facilities at home causing a need for personal care at the DAHS facility. All personal care and health teaching provided at the DAHS facility must be reflected on the ISP including the schedule and frequency of the tasks provided.

The ISP form is the appropriate document where DAHS facility staff must actively update and enter changes in the individual’s service plan to reflect the individual’s current status. Documentation regarding the frequency of treatment, monitoring, or interventions must be clearly linked to internal documentation maintained by the DAHS facility so DADS monitoring staff can determine the type of assistance currently provided by the DAHS staff. Updates regarding changes to the individual’s service plan must be documented as changes occur and must include the effective date of the change. Additional information regarding updates may be entered in the “Additional Information/Notes” section of the Individual Service Plan, Form 3050. A new ISP must be completed if numerous changes and subsequent documentation result in unreadable documentation. An external party (such as a contract monitor, utilization review monitor or auditor) should be able to determine the treatments, monitoring and interventions, personal care tasks and health teaching being provided; and the frequency of each service component within the service plan.

5120 Referrals to Facility

Revision 00-1; Effective April 1, 2000

An applicant may be referred to a DAHS facility by the

• caseworkercase manager, • applicant himself,

• applicant's physician, or • applicant's family.

Item 5210, Facility Response to Caseworker ReferralReferrals, describes the process you follow to obtain prior approval for a clientan individual referred through the caseworkercase manager. Item 5310, Facility Response to Facility-Initiated Referrals, describes the process you follow for facility-initiated referrals.

If services must be started immediately or if the clientindividual requests immediate services, the caseworkercase manager-initiated referral may be turnedconverted into a facility referral by either the caseworkercase manager or facilityprovider if the facilityprovider has a contract with DHS whenDADS at the time the referral is changed. from case manager-initiated to facility initiated.

5130 CaseworkerCase Manager Service Planning Process


In a face-to-face interview with the clientindividual, preferably at the client'sindividual's home. As an alternative, the caseworkercase manager can conduct the interview by telephone. The DADS case manager completes

• Forms 1203 or 1203-E,Form H1200 EZ, Application for Assistance (- Aged and Disabled);; and • Form 2059, Summary of Client'sIndividual's Need for Service. • Form 2059-W, Summary of Individual's Need for Service Worksheet • Form 2060, Needs Assessment Questionnaire and Task/Hour Guide • Form 2307, Rights and Responsibilities

The caseworkerDADS case manager determines whether the applicant meets the day activity and health services (DAHS) financial eligibility criteria and has unmet needs that can be met through DAHS. To avoid duplication of services, unmet need must be considered when the clientindividual receives other CCADcommunity care services.

The caseworkerDADS case manager determines the number of units of service the clientindividual needs per week according to

• the client'sindividual’s preference, and • unmet need.

Units of service are designated on Form 2101, Authorization for Community Care Services, as follows:

• one unit equals more than three hours but less than six hours (or half day); and • two units equal more than six hours (or one full day) up to 10 hours.

The caseworkercase manager cannot authorize more than 10 units of DAHS per week.

http://www.dads.state.tx.us/handbooks/dahs/5000/5000.htm#sec5210



http://www.dads.state.tx.us/forms/H1200-EZ/


http://www.dads.state.tx.us/forms/2059-W/

http://www.dads.state.tx.us/forms/2060/



A clientAn individual who needs less than three hours of service per week is not eligible for DAHS.

You may provide services to the client up to the maximum number of units in the calendar month. The maximum number of units in the calendar month cannot exceed 23 two-unit 46, provided within 23 possible calendar days per month. The maximum number of units in the calendar month is figured using the number of operating days (Monday through Friday) in the calendar month.

. If the clientindividual is scheduled to attend the facility on certain days of the week, and the clientindividual is unable to attend on one of those days, the clientindividual can make up this day the authorized units of service on a subsequent day.

If the clientindividual is authorized to receive two units (six hours or more) of DAHS, you cannot stop providing services (take the client home) after the client receives the six hours. Because the facility must be open 10 hours a day, you must allow clientsThe individual is entitled to receive up to 10 hours of service if they have been determined by the caseworker to need two units (six hours or more) of care by the DAHS facility. during the day. Before referring the client to youindividual for DAHS, the caseworkercase manager

• verifies Medicaid eligibility for the month in which financial eligibility is determined, or • certifies the applicant eligible for Title XX DAHS.

The caseworkercase manager refers the client to youindividual by sending youthe facility a referral packet consisting of Form 2110, Community Care Intake, Form 2059, and Form 2101.

5140 Freedom of Choice


The client maintainsindividual is guaranteed freedom of choice among the DAHS facilities that serve the client's area based on federal requirements for services which are funded under Medicaid. If the applicant/client meets all DAHS eligibility requirements, he has freedom of choice in choosing a DAHS facilityarea, regardless of any relationship to thea provider.

§98.202(a)(3) — A Day Activity and Health Services (DAHS) facility40 TAC §98.202(a)(3), concerning Program Overview, states that a DAHS facility must serve eligible clientsindividuals, unless a facility is at licensed capacity.

If, after completing the health assessment, the facilityprovider determines the facility cannot meet the needs of the clientindividual, the facilityprovider may request a joint staffing via Form 2067 to the caseworkercase manager to determine why the facilityprovider cannot meet the needs of the clientindividual. Written referrals for services are based on priorities included in §98.203(a) — Written Referrals for Services.


http://info.sos.state.tx.us/pls/pub/readtac$ext.TacPage?sl=R&app=9&p_dir=&p_rloc=&p_tloc=&p_ploc=&pg=1&p_tac=&ti=40&pt=1&ch=98&rl=202



§98.203 — Written Referrals for Services

(a)

Day activity and health services (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.

5150 WaitingInterest Lists


It is against Medicaid regulations for DHSDADS to maintain a waiting list for any Title XIX service. YouDAHS providers should notify DHSDADS case management staff as you approachlicense capacity is reached for any day. The DAHS facility certifying officer notifies supervisors, workers, and nurses of the situation.DADS operations that capacity has been reached.

If youra provider’s facility reaches its licensed capacity, the caseworkerDADS case manager will refer a clientan individual to another facility if the clientindividual is willing to attend. If there are no other facilities or the clientindividual is not willing to attend another facility, the workerDADS case manager explains to the clientindividual that the service is not currently available in his area. The worker informs the client that he will , but may make a referral to the facility originally selected by the clientindividual. The worker shouldcase manager will pursue other appropriate service options dependingdependent on the client'sindividual’s eligibility status and needs.

If you areA facility operating at capacity you may maintain your own waitinga facility interest list for Title XIX and private-pay clients. If the client is willing to wait for a slot to become available, follow theindividuals. If a facility maintains a waiting list, the procedures in Appendix III, WaitingInterest List Procedures., must be followed.

5200 Prior Approval Process for CaseworkerCase Manager Referrals

Revision 00-2; Effective November 1, 2000

This section explains how to request prior approval for an applicant after receipt of the referral packet from the caseworkercase manager.

5210 Referrals Facility Response to Caseworker Referral


Case Manager-Initiated Referrals

The DADS case manager will send Form 2101, Authorization

Standard 1c. Timely Request for Prior Approval

(See Form 2310, Compliance Monitoring Guide on Day Activity and Health Community Care Services (, to the DAHS) Facilities, for standards.)

§98.203 —

(b)

When a facility. Once the DAHS facility receives Form 2101 from the case manager, the DAHS facility must send a referral frompacket to the caseworker, the facilityDADS regional nurse must make every effort to request prior approval for the client within 14 days after the receipt of the Form 2101 from the case manager. The referral date on the Texas Department of Human Services' (DHS's) authorization for community care services form.packet includes the following: (c)

Form 2059, Summary of Individual's Need for Service. Form 2059-W, Summary of Individual's Need for Service Worksheet Form 2101, Authorization for Community Care Services; Form 2110, Community Care Intake; Form 3049, DAHS Health Assessment; Form 3050, DAHS Individual Service Plan; and Form 3055, DAHS Physician’s Orders Rule: 40 TAC §98.203(g) — Written Referrals for Services. If the facility DAHS provider cannot request prior approvalobtain the physician’s orders within 14 calendar days, the facilityprovider must notify the caseworker about the reason for delay. This notification must be sent on DHS'ssend Form 2067, Case Information form, to the case manager explaining why and a copy kept in the individual’s case record.

40 TAC §98.203 (b) and (c), provides the applicable policy when services are not started within 14 days of the referral date..


http://www.dads.state.tx.us/forms/2059-W/



The caseworkercase manager must

• evaluate the cause of the delay, and • take whatever action is necessary to ensureensures e that the clientindividual receives services

at the earliest possible date.

This may necessitate making a new referral to a different facility. In this event, the caseworkercase manager verbally notifies the original agency and DADS regional nurse and confirms in writing (using Form 2067) that the original referral is being withdrawn.

The caseworkercase manager evaluates each situation on a case-by-case basis. IfIn the caseworker has a patternevent of transferring clients to other agencies and you disagreedisagreement with the caseworker'scase manager’s action, you can contact the caseworker'scase manager’s supervisor. On the other hand, if you frequently submit may be contacted. The frequent submittal of Forms 2067 Case Information, about facility delays in service initiation to the caseworker, this willDADS case manager may also be brought to the contract manager'sspecialist’s attention.

A timely Form 2067, Case Information, must be in the client's case record for Standard 1c, Timely Request for Prior Approval, to be met. The DAHS facility may meet Standard 1c if the missing Form 2067 is found and given to DHS within three workdays after DHS staff leave the review site. Refer to Item 7333, Missing Documents, for more information.

Also see Section 5820, Client Transfers, for information on transfers that occur between DAHS facilities that are initiated by the individual.

Facility-initiated referrals –

The DAHS provider must submit a prior approval packet to the DADS regional nurse within 30 calendar days after the date of the initial physician’s order, verbal or written. The prior approval packet consists of the following:

Form 2101, Authorization of Community Care Services; Form 2110, Community Care Intake; Form 3049, DAHS Health Assessment; Form 3050, DAHS Individual Services Plan; and Form 3055, DAHS Physician’s Orders.

See 40 TAC §98,204(c)-(d), concerning DAHS Facility-Initiated Referrals.

5211 Health Assessment


A DAHS facility nurse must complete the health assessment for each referral. A DAHS facility licensed nurse must complete the health assessment for each referral. The assessment may be



conducted by an RN or LVN, dependent upon the individual’s presenting health conditions. The DAHS facility nurse completes the health assessment using Form 3049, DAHS Health Assessment, and sends Form 3049 with Form 3055, Physician’s Orders (DAHS), to the individual’s physician to request physician’s orders. The health assessment may be conducted at either the facility or the individual's home.

Health assessments must be conducted when:

• individuals need initial prior approval; • individuals transfer from oneby the receiving facility to another; or • the licensed nurse determines an ongoing individual needs to be reassessed.

The health assessment must be signed by the individual or responsible party each time it is completed or revised by the facility nurse.

The health assessment identifies specific conditions that may impact an individual’s functioning. For example, Form 3049 may indicate an individual has residual paralysis from a stroke. The identification of residual paralysis on the assessment could translate to a number of tasks the individual needs assistance with that would be documented on Form 3050, DAHS Individual Service Plan.

TheInitial DAHS Individuals

The provider’s nurse must ensure that the medical diagnosis listed in the health assessment must beis the same as the diagnosis listed on the physician’s orders. The assessment of functional and physical status must reflect symptoms the individual experienced within 30 days of the date the assessment is completed. When the signed physician’s orders are obtained by the facilitylicensed nurse, it may be necessary to update the health assessment with additional information, such as medications and diagnosis.

Ongoing DAHS Individuals

The facility nurse must makeupdate the health assessment when the nurse makes a determination to conduct a new assessment based on concerns the current assessment is no longer accurate and does not reflect the individual’s current conditions/ or symptoms.

Health Assessment Due Dates

For caseworkerDADS case manager initiated referrals, the due date is within 14 calendar days after the referral date on Form 2101, Authorization for Community Care Services, Item 1, or the dateddate the facility received Form 2101, as indicated by the date stamp, whichever is later.

If the DAHS facility nurse cannot complete the health assessment within 14 calendar days after the referral date, Form 2067, Case Information, must be sent to the case manager explaining why and a copy kept in the individual's case record.






For facility initiated referrals, the due date is on or before the date services are initiated.

5212 Individual Service Plan (ISP)

Revision 13-1; Effective October 30, 2013 5212.1 Initial DAHS Individual Service Plan (ISP)

Form 3050, DAHS Individual Service Plan, is completed at the same time Form 3049, DAHS Health Assessment, is completed by the facility nurse. Once Form 3055, Physician’s Orders (DAHS) is signed and returned by the physician, the individual service planISP must be reviewed to ensure all appropriate information reflected on the physician’s orders is included on the individual service planISP (e.g., medications, treatments, frequency of treatments).

A new individual service plan ISP is completed for individuals:

• who need initial prior approval;

• who transfer from one facility to another;

• when the licensed nurse determines an individual needs a new service plan developed; or

• who transfer by the receiving facility;

5212.2 Updates to DAHS Individual Service Plan.

Updates to existing ISPs are needed when:

• changes to the individual’s treatment, monitoring and intervention occur;

• nursing service needs have changed based on new or supplemental physician’s orders;

• updates regarding changes to the individual’s service plan must be documented as changes occur. Additional information regarding updates may be entered in the “Additional Information/Notes” section of Form 3050;

• when the licensed nurse determines an individual needs a new service plan developed; or

• when multiple plan updates have resulted in the individual’s plan becoming difficult to follow and a brand new individual service plan is needed to ensure the current treatment, monitoring and interventions can be identified clearly. An external party, when reading the paln, should be able to identify the treatments, monitoring and interventions, personal care tasks and health teaching provided to the individual receiving DAHS, as well as the frequency or schedule.

Updates to existing individual service plans are needed when:




• The licensed nursechanges to the individual’s treatment, monitoring and intervention occur; or

• nursing service needs have changed based on new or supplemental physician’s orders.

• The individual service plan must include documentation of treatments, monitoring and intervention ordered by the physician, including the indicated frequency, and all medications, whether taken at the DAHS facility or at the individual’s home, must be documented to include dosage, route and frequency.

All treatments, skilled care and medications indicated on the individual service plan must match the physician’s orders or supplemental orders. If the physician’s orders are updated, the individual service plan is updated to clearly indicate the date when treatments, medications or skilled services were revised or added.

Information received from the case manager may convey problems that the individual is experiencing at home that may need to be addressed by DAHS staff. For example, the individual may not have adequate bathroom facilities at home causing a need for personal care at the DAHS facility. All personal care and health teaching provided at the DAHS facility must be reflected on the individual plan of care, including the schedule and frequency of the tasks provided.

Form 3050 is the appropriate document where DAHS facility staff must actively update and enter changes in the individual’s plan of care to reflect the individual’s current needs.

Updates regarding changes to the individual’s service plan must be documented as changes occur. Additional information regarding updates may be entered in the “Additional Information/Notes” section of Form 3050. Facility nurses must indicate dates associated with any changes (deletions or additions) to treatments, monitoring or interventions, such as medications or skilled care provided at the DAHS facility.

A new individual service plan must be completed if numerous changes subsequent

5212.3 Initial and Ongoing DAHS Individual Service Plan

A provider must ensure the ISP includes documentation result in illegible service plan. An external party should be able to determine the of treatments, monitoring and interventions,intervention ordered by the physician, including the indicated frequency, and all medications, whether taken at the DAHS facility or at the individual’s home, must be documented to include dosage, route and frequency.

A provider must ensure that all treatments, skilled care and medications indicated on the ISP match the physician’s orders or supplemental orders. If the physician’s orders are updated, the ISP is updated to clearly indicate the date when treatments, medications or skilled services were revised or added.

Information received from the case manager may convey problems that the individual is experiencing at home that may need to be addressed by DAHS staff. For example, the individual

may not have adequate bathroom facilities at home causing a need for personal care tasks at the DAHS facility. All personal care and health teaching provided toat the individual receiving DAHS, as well as facility must be reflected on the ISP, including the schedule and frequency or scheduleof the tasks provided.

Form 3050 is the appropriate document where DAHS facility staff must actively update and enter changes in the individual’s plan of care to reflect the individual’s current needs.

Documentation regarding the frequency of treatment/, monitoring/ or interventions outlined in the Individual Service PlanISP must be clearly linked to internal documentation maintained by the DAHsDAHS facility so that DADS monitoring staff can determine the type of assistance currently provided by the DAHS staff.

5213 Physician's Orders

Revision 13-1; Effective October 30, 2013 5213.1 Initial Physician’s Orders for Enrollment of Individual into DAHS

A new Form 3055 is needed upon initial request for DAHS.

After the facility nurse has conducted the health assessment and completed both Form 3050, DAHS Individual Service Plan, and Form 3055, Physician’s Orders (DAHS), these forms are sent to the DADS regional nurse for approval of eligibility for DAHS. Physician’s orders are required for individuals receiving DAHS under Title XIX and Title XX.

5213.2 Supplemental Physician’s Orders

As a best practice, Form 3055, should be completed by the physician or physician's nurse whenever possible; however, the DAHS facility nurse may complete Form 3055 and obtain the physician's signature.

A new Form 3055 is needed upon initial request for DAHS. The current physician’s orders and any supplemental orders on file must be accurately reflected in the individual’s service plan. Supplemental orders pertaining to additional diagnosis or treatments submitted later on separate documents must be kept together with the current Form 3055 to accurately reflect the individual’s complete record of medical diagnosis, treatments, monitoring and interventions.

Written physican orders on Form 3055 are due to the DADS regional nurse within 14 calendar days after the referral date on Form 2101, Authorization for Community Care Sevices, Item 1. For caseworker initiated referrals, the physician’s due date is within 14 calendar days after the referral date on Form 2101.

5213.3 Physician’s Orders



Case manager initiated referrals - Within 14 calendars days after the referral date (Form 2101 item 1).

If the DAHS facility cannot obtain the physician’s orders within 14 calendar days, Form 2067,a Form 2067, Case Information, must be sent to the case manager explaining why, and a copy kept in the individual’sindividual's case record.

For facility initiated referrals, the physician’s due date is on - On or before the date services are initiated (oral, verbal or written)..

The DAHS nurse assesses conditionsConditions such as cerebral palsy, organic brain syndrome and Alzheimer’s disease, which are considered qualifying medical diagnoses for DAHS. Mental health issues and intellectual and developmental disabilities are not considered qualifying medical conditionsdiagnosis, but may be present if the individual’s need for licensed nursing care is related to a coexisting medical condition. Alcoholismqualifying medical diagnosis. A diagnosis of alcoholism by itself is considered a mental condition and the diagnosis by itself does not make someone eligible for DAHS.

The Medical Practice Act and related rules require that physicians practicing from across the state lines into Texas have a special purpose license in order to treat individuals in Texas. Nurses in Texas, therefore, may accept orders only from those physicians who are legally authorized to practice in the state.

For temporaryPhysicians from bordering states who have their practice within 50 miles from the Texas state line who provide care to DAHS individuals are considered in-state providers.

Temporary permits, must enterinclude the date of issue and expiration. For physiciansPhysicians assigned to military medical facilities, must use the military number assigned.

To verify if a physician is licensed to practice in the state of Texas, check online at http://reg.tmb.state.tx.us/OnLineVerif/Phys_NoticeVerif.asphttp://public.tmb.state.tx.us/HCP_Search/searchinput.aspx or contact the Verification DepartmentDADS of the Texas Medical Board at 800-248-4062 or fax 512-463-9416305-7051. Also, a directory exists of Texas licensed physicians whichthat includes a list of MDs (doctors of medicine) and DDsDOs (doctors of osteopathy) licensed to practice in Texas through the Texas Medical Board.

This directory may be purchased at:

Texas Medical Board P.O. Box 2018, Mail Code 251 Austin, TX 78768-2018

The physician cannot be the facility owner nor have a significant or contractual relationship with the facility.

http://public.tmb.state.tx.us/HCP_Search/searchinput.aspx

http://public.tmb.state.tx.us/HCP_Search/searchinput.aspx

If the physician does not want a copy of the health assessment, document, the physician's requestrefusal of a copy must be in writing.

The DAHS facility may accept faxed physician's orders from the physician. When a fax machine is used, it is not necessary for the prescribing physician to sign the order at a later date. as long as the faxed copy is signed.

Expenses incurred to complete the physician's order are not allowable costs in the DAHS program. Offers of or requests for payment for completing orders will be referred for Medicaid fraud investigation.

A physician can bill an individual who is not covered by Medicaid for completion of physician's orders. Exception: If a physician has accepted Medicaid payments for the diagnosis and treatment of the individual's illness that makes him eligible for DAHS, then he cannot bill the individual for completion of physician's orders.

Physicians who are graduates of medical school and meet all the requirements for licensure, but are waiting for final approval of licensure by the Board of Medical Examiners, are issued temporary licenses. This allows the physician to practice until a license number is obtained. The temporary license has an issue and expiration date. In this situation, indicate on Form 3055:

• "temporary license," and • the expiration date of the license.

The DAHS facility can only accept a physician's order dated on or before the expiration date of the temporary license.

The physician's order must be signed, dated, and include MD or DO credentials. Physician signature stamps are acceptable.

Physician’s Stamped Signature

If . . . Then . . . the signature stamp is a facsimile of the physician's signature,

neither initials nor signature are needed. YouThe provider must have documentation from the physician approving the signature stamp. The authorization must

• be signed by the physician, and • include a copy of the stamped signature that will be used.

the signature stamp is typewritten or block-printed,

the stamped orders must also be initialed or signed by the physician. Initials are accepted if initials are the physician's usual signature. If initials are used, youthe provider must type or print the physician's name above or below the signature line.

If the physician fails to date Form 3055 or if the signature date is illegible, the facility stamp-in date will be considered the date of the physician's orders. The date stamp must include the day, month, year, and the name of the facility. An abbreviated name or initials are acceptable.

5220 Regional Nurse Prior Approval for CaseworkerCase Manager Referral

When the DADS regional nurse receives the required forms from youthe DAHS facility, he reviews Forms 2059, 3049, 3050, and 3055 to determine if the clientindividual meets the DAHS medical eligibility criteria found in Section 3200, Medical Criteria.

The regional nurse must keep the envelope that the prior approval material was mailed in. If more than one prior approval packet was included in the envelope, the regional nurse or his designee (such as clerical staff) must indicate on the outside of the envelope the names of the prior approval packets that were included in the envelope.

For case manager initial cases, the DADS regional nurse establishes the beginning date of coverage on Item 4 of Form 2101 as the date Form 2101 is expected to be mailed to youthe provider. If this date is not feasible, the regional nurse negotiates the beginning date of coverage on Item 4 of Form 2101 with youthe provider and the caseworker,DADS case manager according to the client'sindividual’s needs and the client'sindividual’s unique circumstances.

The DADS regional nurse determines whatif a condition qualifies as an acute medical condition is. The DADS regional nurse may contact the client'sindividual’s physician to discuss the client'sindividual’s condition and the approximate length of time needed for full recovery.

Within seven days of the receipt of the prior approval request, the regional nurse uses Form 2101 to notify youthe provider about approval or denial of routine cases. The DADS regional nurse grantsapproves prior approval if the:

• clientindividual meets the medical eligibility criteria specified, and • documentation from youthe provider that contains no critical omissions or errors.

CopiesThe regional nurse sends:

• copies of Form 2101 are sent to youthe provider and the caseworker. DADS case manager when granting prior approval.

• copies of Form 2101 in denial of prior approval in an initial case to the provider and the case manager.

If services are denied, the client receivescase manager sends the individual a written notification from the caseworker. In denial of an initial case, copies of Form 2101 are also sent to you and the caseworker..

5300 Prior Approval Process for Facility-Initiated Referrals






Revision 02-5; Effective Upon Receipt

This section explains how to request prior approval for an applicant who enters youra provider’s facility through the facility -initiated process.

5310 Facility Response to Facility-Initiated Referrals


YouA provider may immediately admit any Medicaid individual pending eligibility determination for DAHS if the DAHS facility has a contract with DADS and the DAHS facility is willing to risk loss of revenue if the applicant is determined not to be eligible.

§98.204 — Facility-Initiated Referrals.

(a)

The applicant may be admitted to a day activity and health services 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.

Rule: 40 TAC §98.204, Facility-Initiated Referrals.

An applicant is someone who is not currently receiving DAHS services at a contracted facility. A facility-initiated referral must not be made on current DAHS individuals.

Example: An individual who is attending Facility A moves to Facility B and wants to attend there. Facility B cannot make a facility-initiated referral because the person is already a DAHS individual. Additionally, Facility B will not be reimbursed for services provided before the transfer date established by the caseworkercase manager. See Section 5820, ClientIndividual Transfers, for more information about transfer procedures.

(b)

When a facility initiates a referral:

(1)





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

§98.204(b) —

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

(c)

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

If the facility fails to receive Form 2101, Authorization for Community Care Services, within 30 days from the date of the physician's orders, the facility may submit the prior approval packet without Form 2101.

For Item (3), the date of the verbal notification is the date of the request for Community Care for Aged and Disabled services. YouA provider must document the reason for the immediate placement on Form 2067, Case Information, to the caseworkercase manager.

The licensed nurse:

• records the physician's orders on Form 3055, Physician’s Orders (DAHS); and • completesgathers the completed Form 3049, DAHS Health Assessment completed by a

licensed nurse; and





• completes Form 3050, DAHS Individual Service Plan.

Refer to the following items to obtain additional information on completing these forms:

• Section 5211, Health Assessment • Section 5212, Individual Service Plan; and • Section 5213, Physician's Orders.

Submit the following forms to the regional nurse to obtain prior approval for the facility-initiated referral:

• Form 3049; • Form 3050; and • Form 3055.

The regional nurse holds Form 3049, Form 3050, and Form 3055 until he receives Form 2101 from the caseworkercase manager is received.

5311 Facility That Does Not Have a Contract with DHSDADS


If the facility does not have a contract with DHSDADS when it admits a Medicaid clientrecipient pending eligibility determination for DAHS, the caseworkercase manager proceeds to determine eligibility for DAHS. If the DAHS applicant is determined eligible for DAHS and the facility still does not have a contract with DHSDADS, the caseworkercase manager gives the clientindividual the option to attend a different facility with a current DHSDADS contract. If the clientindividual chooses to stay in the current facility, the caseworkercase manager denies the services.

If the facility continued to provide services to the clientindividual, the effective date for reimbursement of services to the clientindividual is the date the facility notifies the caseworkercase manager that it has a DHSDADS contract. The facility may notify the caseworkercase manager by telephone or through Form 2067, Case Information, that it has a contract with DHS.DADS.. This notification serves as a second referral to the caseworkercase manager.

5320 Caseworker Case Manager Response to Facility-Initiated Referral


When you contacta provider contacts the DHS caseworkercase manager on a facility-initiated referral, the caseworkercase manager schedules an appointment with the applicant within 14 days of the date the caseworkercase manager or intake unit received verbal notification from the facility to obtain an application for CCAD services.






The caseworkercase manager determines if the applicant is Medicaid eligible, is not receiving another CCAD service which may duplicate DAHS, and is not a DAHS clientindividual at another facility.

If the clientindividual is interested in applying for other CCAD services, the caseworkercase manager assesses the applicant's functional need using Form 2060, ClientIndividual Needs Assessment Questionnaire and Task/Hour Guide. Form 2060 is not required for DAHS-only clientsindividuals.

If the applicant is financially eligible, the caseworkercase manager sends

• the original Form 2101 to the regional nurse, and • a copy to youthe provider.

The caseworkercase manager indicates in the comment section of Form 2101 that this is a facility-initiated referral.

If the applicant is not financially eligible, the caseworkercase manager must

• notify youthe provider by telephone of the applicant's denial, and • follow up the telephone call in writing using Form 2067.

The caseworkercase manager notifies the clientindividual of his eligibility/ or ineligibility within 10 days of the decision, using Form 2065.

Because the applicant is not financially eligible, youa provider cannot get reimbursed for services. The caseworkercase manager sends the regional nurse a copy of Form 2065.

5321 Payment for Services for Facility-Initiated Clients Who Have Either Died, Moved to Another Facility, or No Longer Receive ServicesFollowing Change of Individual’s Status


If you admita provider admits a Medicaid clientindividual through the facility-initiated referral process and follow all facility-initiated procedures (conduct health assessment/ or plan of care, obtain physician's orders, etc.) and the clientindividual either dies, moves to another facility, or decides he no longer wants to receive services before the caseworkercase manager has an opportunity to conduct the assessment, youa provider can be reimbursed for services provided to the clientindividual if

• youthe provider documented on attendance/ or transportation records that services to the clientindividual were provided,

• the caseworkercase manager verifies the clientindividual was Medicaid eligible when services were provided and received no other community care services which duplicate DAHS, and





• the regional nurse determines the clientindividual meets criteria for DAHS.

5330 Regional Nurse Prior Approval on Facility-Initiated Referral


Upon receipt of Form 2101 from the caseworkercase manager for verbal prior approval, the regional nurse uses procedures in Item 5220 to determine prior approval for a facility-initiated referral.

The regional nurse establishes the beginning date of coverage on Item 4 of Form 2101 for a facility-initiated referral using the date of the physician orders.

§98.204(d) — IfThe DADS regional nurse follows the facility fails to submitpolicy in §98.204(d) when prior approval forms or additional documentation within required time frames, or if the additional documentation is not adequate, the regional nurse cancels the facility-initiated prior approval and the facility is not reimbursed for services.submitted.

If the prior approval material is incomplete or is not received within required time frames, the regional nurse establishes the beginning date of coverage on Item 4 of Form 2101 using the earliest of the following dates:

• postage meter date (if not cancelled by the U.S. Post Office), • U.S. Post Office date, or • DHSDADS stamp-in date.

If the regional nurse needs more information after receiving the facility's request for verbal prior approval, he may contact the client'sindividual's physician or the caseworkercase manager.

5400 Critical Omissions


If the required documentation contains errors and/or omissions, the regional nurse returns the documentation to the facility for corrections.

5410 Critical Omissions/ or Errors in Required Documentation


§98.204(e) — If DADS ClientPolicy guidance regarding the documentation of the Individual Health Assessment/ or Plan of Care form or Physician's Order for Day Activity and Health Services form is missing,, Physician Orders or if any of the critical errors or omissions or errors stated in paragraphs




(1)-(9) of this subsection have occurred in the required documentation, the facility cannot obtain prior approval. is found at: 40 TAC §98.204, DAHS Facility-Initiated Referrals

(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 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 or osteopath 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 or osteopath 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 facility's stamped date is missing from DADS Physician's Order for Day Activity and Health Services form.

(9)

The 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.

An MD (Medical Doctor) or DO (Doctor of Osteopathy) must sign Form 3055, Physicians Orders (DAHS).

On Item 5 of the previous list, if the physician's license number is illegible, it is considered a missing license number.

If a critical omission or error is identified, the regional nurse

• completes Form 3070, Day Activity and Health Services Notification of Critical Omissions; and

• sends it to youthe facility along with the rejected prior approval packet.

5411 Corrections of Critical Omissions/ or Errors


§98.210(c) — Rule: 40 TAC §98.210, Administrative Errors and Corrections, contains information on processes for corrections of critical omissions or errors in 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 facility. If the 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 facility of the client's choice.

(A)

If there is space in another 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 facility.

(B)

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




To expedite the processing, youa provider may:

• return a copy of Form 3070, Day Activity and Health Services Notification of Critical Omissions, with the corrected packet; or

• note "corrected packet" at the top of either Form 3049, DAHS Health Assessment, Form 3050, DAHS Individual Service Plan, Form 3055, Physician’s Orders (DAHS), or Form 2067, Case Information.

5500 Initiation of Services


YouA provider must initiate services to a clientan individual within seven days from the beginning date of coverage. This does not apply to the facility-initiated referrals in which the clientindividual is already receiving services.

§98.205 —

Standard 2a. Timely Service Initiation

(See Form 2310, Compliance Monitoring Guide on Day Activity and Health Services (DAHS) Facilities, for standards.)

(a)

The facility must initiate services within seven days of the beginning date of coverage in Item 4 of the Texas Department of Human Services' (DHS's) Authorization for Community Care Services.

Standard 2b. Delayed Service Initation


(b)

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

The caseworker must








Service initiation policy for the DAHS facility is included in 40 TAC §98.205 (a) and (b) concerning Initiation of Services. The DADS case manager must:

• evaluate the situation, and • decide whether the clientindividual should be referred to another facility.

The caseworkerDADS case manager may use expedited procedures to refer the clientindividual to another facility, if appropriate.

A timely Form 2067, Case Information, must be in the client's case record for Standard 2b, Delayed Service Initiation, to be met. The DAHS facility may meet Standard 2b if the missing Form 2067 is found and given to DHS within three workdays after DHS staff leave the review site. Refer to Item 7333, Missing Documentation, for more information.

5600 CaseworkerCase Manager Follow-up


The caseworkerDADS case manager monitors the clientindividual when services are initiated and periodically thereafter to:

• ensure the continued adequacy of the plan of care and the quality of service delivery, and • observe the client'sindividual's condition.

5610 Return of Form 20592101


For initial referrals, youa provider must return Form 2101 to the caseworkercase manager within 14 days from the date of coverage of Form 2101.

Standard 2c. Return of Authorization Form


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

Rule: 40 TAC §98.205(c), concerning Initiation of Services.




This does not apply to facility-initiated referrals because services usually start before the coverage date on Form 2101. ReturnThe provider should return Form 2101 as soon as possible after you receivereceiving it from the caseworkercase manager or DHSDADS regional nurse. To comply with Standard 2c, Return of Authorization Form, entercontract monitoring standards the provider enters the following information on Form 2101, Authorization for Community Care Services — Service Authorization System (SAS):

• days of the schedule for services, • service initiation date, • total units or hours authorized, • yourprovider’s signature, and • date of yourprovider’s signature.

The DAHS facility may meet Standard 1c if the missing Form 2067 is found and given to DHS within three workdays after DHS leaves the review site. Refer to Item 7333, Missing Documentation, for more information.

5700 Facility Responsibilities


YouA provider must operate the program to promote active participation of individuals in a variety of ways. Services must be designed to address the physical, mental, medical, and social needs of individuals through the provision of rehabilitative/ or restorative nursing and social services which improve or maintain a person's level of functioning.

The specific needs of the individual must be addressed by yourthe facility while the individual is at the DAHS facility. YouA provider should use the caseworker'scase manager's Form 2101, Authorization for Community Care Services, Form 3049, DAHS Health Assessment; Form 3050, DAHS Individual Service Plan, and Form 3055, Physician's Orders, to determine what services the individual needs.

Required services listed in Section 1400, Required Services, are described below in more detail.

5710 Nursing Services


Nursing services include an individual’s assessment, assistance with prescribed medications, counseling concerning health needs, and supervision of personal care services.

§98.62(d)(2)(E) — The facility nurse is responsible for entering, dating, and signing monthly progress notes on medical care provided.






Facility Nurse responsibilities are described in: 40 TAC §98.62(d)(2)(E), concerning Program Requirements.

The monthly progress notes must be signed and dated by the licensed nurse documenting the medical notes. If the facility nurse is an LVN, the monthly notes do not have to be resigned by the RN consultant.

It is expected that individuals bring their own medical supplies to the facility. The facility, however, must be prepared to supply these items if an individual forgets his supplies or an unexpected need arises. The cost of these emergency supplies should be reported on the cost report.

New supplemental physician's orders written on a script pad (not to be confused with Form 3055, Physician's Orders (DAHS)) are required for:

• new treatments, • changes in medicine being administered at the facility, or • other procedures being provided by the appropriate licensed nurse which require a

physician's order.

New physician's orders are not required when the individual’s medical diagnosis changes.

5720 Physical Rehabilitative Services


Physical rehabilitative services include restorative nursing and group and individual exercises, including range of motion exercises.

5730 Nutrition/ and Food Services


Nutrition/ and food services include

• one hot noon meal a day, • a mid-morning and mid-afternoon snack, • preparation of foods required for special diets, and • dietary counseling and nutrition education for the clientindividual and his family.

If a clientan individual has been determined to need a low or salt-free diet (as evidenced by the client'sindividual's diagnosis and/or physician's orders), the clientindividual must be served a meal meeting the dietary requirements ordered by the physician. If you area provider is adhering to the physician's orders to provide a salt-restricted meal to the clientindividual, but the individual says he does not want the salt-free diet, then you arethe provider is meeting the dietary




requirement as ordered by the physician. The clientindividual can, however, choose whether to comply with the salt restricted diet or not.

If meals are not prepared at the facility, the Texas DepartmentDADS of Health'sState Health Services food service sanitation rules specify that hot meals cannot be in transit for more than one hour from the time the food is taken from the stove/ or microwave until it is delivered to the DAHS facility. Cooked foods should be 140°F when placed in containers for transport to the facility. Cold foods should be enclosed and isolated from hot foods to maintain appropriate temperature.

For additional information on food service sanitation, contact the Texas Department of State Health Services at 1100 West 49th StreetP. O. Box 149347, Austin, Texas 78756-3199, (78714-9347, 512) -834-66356670.

5740 Transportation


Transportation includes transportation to and from the facility and to and from a facility approved to provide therapies if the clientindividual requires specialized services on days of attendance at the DAHS facility.

§98.206(5)(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.

§98.209(b) — Attendance records. The facility must use DHS forms to maintain a daily recordRules on vehicle maintenance by the DAHS facility is located in 40 TAC §98.206(5)(D), concerning Program Requirements.

The rule on maintenance of attendance and transportation to and from therecords are included in §98.209(b), concerning Record Maintenance. A facility, including the time each client began receiving services and the time he left the facility's care. If transportation is provided by the facility, driver's transportation records must be used. Arrival and departure times must be documented for clients not using facility-provided transportation.

Facilities that provideprovides transportation and/or havehas a subcontract with a private/ or public transportation entity must use DHS's transportation records formForm 3682, Day Activity and Health Services Daily Transportation Record.

YouThe provider must:

• coordinate the use of other transportation resources within the community; • make every effort to have families transport clientsindividuals;



http://dadsview.dads.state.tx.us/forms/3682/

• manage upkeep and operation of facility vehicles, including liability insurance. Vehicles used by yourthe facility must be maintained in a condition to meet the vehicle inspection requirements of the Texas Department of Public Safety; and

• have sufficient staff to ensure the safety of clientsindividuals being transported.

If none of the above alternative transportation options are not available, you arethe provider is ultimately responsible for providing the transportation to the clientindividual. Refer to §98.202(a)(3) in Item 5140, Freedom of Choice, which indicates that youa provider may not refuse to serve eligible clientsindividuals.

Transportation for DAHS Medicaid clientsindividuals is available in every county through the Medical Transportation Program. When providing medical transportation to a DAHS clientindividual, the clientindividual must not be picked up or dropped off at the DAHS facility. The clientindividual must be picked up and dropped off at his home.

5750 Other Supportive Services


Activities offered at yourthe facility must be meaningful, fun, therapeutic, and educational, etc.

§98.42(d)(3)(E) — The activities director is responsible for signing and dating monthly progress notes about social and related support services activities provided.

YouRule: 40 TAC §98.62 (d) (3) (A-E), concerning Program Requirements, includes the responsibilities for the DAHS activities director.

A provider must have a supply of materials adequate for the participation of all clientsindividuals in program activities. Program activities include games, crafts, field trips, and any other activities that require the use of material or supplies.

YouA provider must offer at least three different scheduled activities daily. These activities must be chosen from the following categories:

• exercises, • games, • educational/ or reality orientation, and • crafts.

On a weekly basis, youa provider must offer at least two different activities from each category. See Appendix III, Examples of Day Activity and Health Services Activities, for examples of activities that can be provided under each category.

YouA provider must offer at least one of the following activities monthly:



http://www.dads.state.tx.us/handbooks/dahs/appendix/III/index.htm

• trips/ or special events, or • cultural enrichment.

When you take a clientprovider takes an individual on a field trip, such as to the movies, zoo, etc., youthe provider are responsible for paying admission charges to ensure that all clientsindividuals have access to these activities. The cost for admission may be claimed on yourthe provider’s cost report.

ClientsIndividuals must be accompanied by DAHS staff anytime they are on field trips or any other type of community activity outside of the facility.

Activities must be documented on the activities calendar. The activities calendar must contain specific listings of activities within each category.

YouA provider may schedule field trips on Saturday as special events, as long as the field trips are documented on the activities calendar. Refer to Section 1400, Required Services, for information on Saturday operations.

ExampleExamples:

• Exercise Category — parachute, ball toss, kick ball, cookie walk, wheel chair. • Crafts Category — sewing, leather craft, woodwork, beading, painting, life journal. • Games Category — bingo, dominoes, cards, chess, ring toss, role play (drama).

Craft items must be provided without charge to the clientindividual. Items for the client'sindividual's personal use are the client'sindividual's responsibility.

5760 Notifications


Standard 3b. Notification of Client's Illness/Injury at Facility

§98.208 —

(a)

If a client becomes ill or injured at the 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 facility until the physician has released the client. Examples of communicable disease are lice and scabies.

Note: Only (a) applies to Standard 3b.

(c)


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

Standard 3b, Notification of Client's Illness/Injury at Facility, is met if the case record shows that the client's relative or other responsible person was contacted on the same day the client became ill or injured at the facility.

Rule: 40 TAC §98.208 (a) to (c), Notifications.

If a DAHS clientindividual is diagnosed with active Tuberculosis (TB,), the facility must immediately inform the client'sindividual’s physician of the condition. In order for the clientindividual to remain at the facility, the client'sindividual’s physician must provide the facility a written statement that the tuberculosis is not infectious. Until the physician's statement is received by the facility, arrangements should be made with the client'sindividual’s family to keep the clientindividual at home. If the physician reports in writing that the TB is not infectious, the clientindividual may return to the facility.

To prevent the transmission of pulmonary TB in the infectious phase, isolation in a private room with ventilation to the outside is necessary according to the Centers for Disease Control and Prevention. Since Licensing Standards for Adult Day Care Facilities do not require facilities to provide this type of isolation room, DAHS facilities cannot be expected to provide the proper isolation to prevent the transmission of TB.

For more information regarding TB, contact the TB specialist at the local Texas Department of State Health (TDHServices (DSHS) office, or ask for the TB Elimination Division, TDH, at (512) 458-7447 in Austin-533-3000.

5761 Change in Ownership


§98.208 —

(d)

The facility must verbally notify DHS by the next DHS workday and in writing within seven days of verbal notification of the following changes in facility operations:

(3)

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

Change of ownership policy is included in 40 TAC §98.208(d), concerning Notifications.



5770 Client Individual Rights and Responsibilities


§49.13 —

(a)

The provider agency must provide each client with the following information before or at the time services begin:

(1)

a general orientation about tasks to be provided;

(2)

consumer rights and responsibilities;

(3)

client conduct requirements;

Standard 2d. Initial Notification of Complaint Procedures


(4)

procedures to file a complaint, including the name and/or title and telephone number of the person to call to lodge a verbal complaint; and

Note: Only (4) relates to Standard 2d.

(5)

provider agency responsibilities in providing services.

Standard 3a. Annual Notification of Complaint Procedures


(b)

Subsection (a)(2)-(5) of this section must be provided both verbally and in a written format each year. A copy of these materials will be maintained by the provider agency. An interpreter or written material in alternative formats will be made available to clients upon request.

(c)

The Texas Department of Human Services (DHS) must receive a copy of any changes before the provider agency amends its policies affecting the items specified in this section. In addition, each client must receive written notification of the change before it becomes effective.

Rule: 40 TAC §98.61(c) and (d) – General Requirements, rights.

40 TAC Chapter 49, Contracting For Community Care Services.

5771 Complaints


Standard 2d. Initial Notification of Complaint Procedures


§49.13(a) — The provider agency must provide each client with the following information before or at the time services begin:

(4)

procedures to file a complaint, including the name and/or title and telephone number of the person to call to lodge a verbal complaint.

Standard 3a. §49.13(b) in 40 TAC Chapter 49, Contracting For Community Care Services.

Section 2100 also specifies that procedures must be provided both verbally and in a written format each year.

Program Standard 4c and 4e. The provider agency maintains a log of complaints and makes the review of complaints accessible to the contract manager. The provider agency also maintains documentation that it investigated and resolved all complaints within five workdays of receipt of the complaint, including the client's initials on client-initiated complaints or witness's signature when the client refuses to sign; and submits the complaint findings to DHS within 30 days of receipt of the


http://info.sos.state.tx.us/pls/pub/readtac$ext.ViewTAC?tac_view=4&ti=40&pt=1&ch=49

http://info.sos.state.tx.us/pls/pub/readtac$ext.ViewTAC?tac_view=4&ti=40&pt=1&ch=49


complaint. (See Form 2310, Compliance Monitoring Guide on Day Activity and Health Services (DAHS) Facilities, for standards.)30 calendar days of receipt of the complaint.

§49.14 — Complaint Procedures. The provider agency must investigate and document all complaints as follows:

(1)

date stamp all written complaints received;

(2)

document verbal complaints;

(3)

maintain a log of the client complaints. The log of complaints must be accessible to the department's contract manager;

(4)

investigate and resolve all complaints, problems, or deficiencies and noncompliance with policies, procedures, and standards, which are reported by the client or the Texas Department of Human Services (DHS) staff, within the five workdays from the receipt of the report unless a different time frame is found in the service-specific manual. The documented complaint and resolution must be maintained by the provider agency and a copy submitted to DHS within 30 days of the receipt of the report; and

(5)

obtain the client's initials when a client-initiated complaint is resolved or obtain a witness's signature when the client refuses to sign.

5800 Reporting Significant Changes


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

You must notify the caseworkerThe reporting of significant changes in DAHS are listed in 40 TAC§98.208(b), concerning Notifications.

A provider must notify the case manager of any of the following circumstances that may require a change in the client'sindividual's plan of care:

• client'sindividual's health deteriorates or improves, • clientindividual no longer needs services, • clientindividual is discharged from the hospital, • clientindividual experiences problems with family relationships, • client'sindividual's housing changes (clientindividual moves), • clientindividual is referred for skilled home health services, or • client'sindividual's household composition changes.

Within 14 days of receipt of Form 2067, the caseworkercase manager

• reviews the client'sindividual's plan of care, and • responds to the written request. , • contacts the individual to confirm he is in agreement with proposed change, and • reviews the request for change which may affect eligibility or units of service.

The caseworkercase manager must approve significant changes in the plan of care which may affect eligibility or units of service.

Case Manager Review and Approval

If the caseworkercase manager . . .

Then he . . .

agrees with yourthe provider’s request for a plan of care change,

updates Form 2101 to reflect the changes.

determines that a change to the client'sindividual's plan of care is not necessary,

sends youthe provider a Form 2067 stating the rationale for not changing the plan of care. If youthe provider still wantwants a change in the clientindividual plan of care, you requestthe provider requests a review by the caseworker'scase manager's supervisor to resolve the difference in opinion.

If services are denied or reduced, the caseworkercase manager follows clientindividual notification procedures.

5810 Clients Individuals Who Fail to Comply with Service Delivery Provisions





YouA provider must document all incidents involving problems with a clientan individual being disruptive, refusing to leave the facility after 10 hours, and/or family members who do not pick the clientindividual up after 10 hours. YouA provider may request a joint staffing via Form 2067 to the caseworkercase manager regarding these problems. The caseworkercase manager contacts the clientindividual, family members, and the regional nurse (if appropriate) to attempt to resolve the problems in a way that is satisfactory to the clientindividual and the facility. If the client/individual or family member does not resolve the problems, the caseworkercase manager may terminate services.

In cases where a client/an individual or family member refuses to leave or pick up the clientindividual at the facility after 10 hours, there are other options that can be considered:

• the client/individual or family may be left with no choice but for the facility to transport the clientindividual home at the regular departure time along with other clientsindividuals; or

• the facility can initiate a private pay rate with the client/individual or family members for the additional time the clientindividual is in the facility after 10 hours.

However, before you implementa provider implements a procedure which may involve a cost to the client/individual or family member, youthe provider must inform the client/individual or family member verbally and in writing of the new procedure, and add the changes to the client'sindividual's Rights and Responsibilities. A written copy of the changes must be given to the clientindividual to initial and date and must be filed in the client's casefolder.individual's case record. A copy of the changes must also be given to the clientindividual.

5820 Client Individual Transfers


A clientAn individual who wants to transfer to a new contracted facility must make the request to his caseworker.DADS case manager. The caseworkercase manager will coordinate with the losing facility, and provide the new facility with an effective date of the transfer, no later than 10 workdayswithin 14 days after the client'sindividual’s written/ or oral request. YouThe provider will not be reimbursed for services provided to a clientan individual who is transferring from another contracted DAHS facility before the effective date established by the caseworker.case manager.

Within 1014 days of the client'sindividual's written/ or oral request to transfer to a new facility, the caseworkercase manager:

• updates Form 2101, Authorization for Community Care Services, by entering: o the new vendor number; o the effective date of the transfer; and o a statement in the comments section that this is a clientan individual transfer.

• sends the new facility the updated Form 2101; and • sends the old (losing) facility a Form 2101 terminating services.



It is critical that the caseworkercase manager coordinate clientindividual transfers from one DAHS facility to another to ensure that no duplication of services or gaps in dates of coverage exist.

New physician’s orders are not required for individuals who transfer to a new DAHS facility operated under the same DAHS contract. New physician’s orders are required for individuals who transfer to a new DAHS facility operated by a different DAHS contractor.

5821 Comprehensive Health Assessment/Individual Service Plan before Transfer


On or before the date an individual transfers to a new facility, the new facility must conduct a health assessment and an individual service plan. YouA provider must conduct the health assessment and individual service plan according to Section 5211, Health Assessment, and Section 5212, Individual Service Plan.

You do not have to obtain physician's orders for an ongoing DAHS individual. See Section 5213, Physician's Orders, for additional information.

5830 Moves to UncontractedUn-Contracted Facilities


If a clientan individual wants to relocate to a facility that does not have a current DAHS contract:

1. the caseworkercase manager contacts the clientindividual within 14 days of receipt of request from the client/individual or facility to determine why the clientindividual wants to change facilities.

The caseworkercase manager

o explains to the clientindividual that the facility does not have a contract with DHSDADS and DHSDADS cannot pay for services for the requesting facility, and

o gives the clientindividual the option of continuing to receive services from the current facility or having DHSDADS services terminated.

If the clientindividual chooses to receive services from the uncontractedun-contracted facility, the clientindividual is

o informed that DHSDADS cannot reimburse for his services at the facility, and o given a 12-day notice of termination of services.

The reason for denial on Form 2101 should be Code 77, voluntary withdrawal. The comments section of the denial notice (Form 2065) should state that DHSDADS cannot




pay for services at the new facility because the facility does not have a contract with DHSDADS; and

2. the regional nurse submits Form 2101 to terminate services for the current DAHS provider.

5840 Suspension of Services


§98.207 —

(a)

The 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 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 Texas Department of Human Services (DHS) denies the client's Medicaid/Title XX eligibility;

(7)

DHS enforces sanctions against the facility by terminating the contract;

(8)

the client threatens the health and safety of himself or others;

(9)

the client is absent from the facility for 15 consecutive days;

(10)

the client becomes ineligible for Medicaid. Each month the facility must verify that a client has a current DHS Medical Care Identification Card.

(b)

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

The caseworkerRule: 40 TAC §98.207, Suspension of Day Activity and Health Services.

The case manager confirms the reason for the suspension and takes appropriate action. If the suspension results in case closure or termination of DAHS, the caseworkercase manager coordinates closure and the termination date with youthe provider to allow time for clientindividual notification of the right to appeal.

For Item #10 the caseworkerThe case manager investigates the reported loss of Medicaid eligibility. If he verifies that the clientindividual is indeed losing eligibility, the caseworkercase manager

• terminates DAHS effective the last date of Medicaid coverage, and • seeks other available services for which the clientindividual may be eligible.

5900 Prior Approval Renewal Process


After the regional nurse gives initial prior approval for DAHS, the authorization is transferred to the caseworkercase manager. The caseworkercase manager renews ongoing DAHS services for these clientsindividuals according to Subsection 5910, Renewal of Prior Approval by the CaseworkerCase Manager.

5910 Renewal of Prior Approval by the CaseworkerCase Manager


The caseworkercase manager will send youthe DAHS facility Form 2101 when he reassesses the case if




• services are terminated, or • the number of units change.

If the caseworkercase manager does not renew the prior approval before the client'sindividual’s current prior approval expires, youthe DAHS facility will automatically receive a Form 3051-C extending the coverage period for an additional year.

Although the coverage period is open-ended, the caseworkercase manager will still

• conduct the functional reassessment of the clientindividual, and • send youthe provider a signed Form 2101 confirming continued clientindividual eligibility if

the number of units change.

The caseworkercase manager uses the following procedures to renew prior approval.

Procedures to Renew Prior Approval

If the client individual. . . Then the caseworkercase manager . . . is reassessed/ or redetermined eligible for services and there are no changes to the service plan,

verbally notifies the clientindividual that services will continue at the same level.

is reassessed/ or redetermined eligible for services and there are changes to the service plan (units),

sends the clientindividual Form 2065 to notify him of the change in the service plan; and

• sends youthe DAHS facility an updated and signed Form 2101 to notify youthe provider of the change. The effective date of the increase in units is seven days from the date Form 2101 is mailed to youthe provider. The effective date for a decrease is 12 days from the date Form 2101 is completed and mailed. Form 2065-A is completed and mailed within 12 days prior of the same day as Form 3051-Beffective date of the decrease.

is reassessed/ or redetermined ineligible for services,

• sends the clientindividual Form 2065 to notify him of the termination; and

• sends youthe provider an updated and signed Form 2101 to notify youthe provider of the termination.

5911 Renewal of Prior Approval by the CaseworkerCase Manager for Short-Term ClientsIndividuals


The caseworkercase manager will verbally contact the clientindividual before the short-term coverage period ends to determine the client'sindividual's need for continued services. Unless the caseworkercase manager terminates the prior approval before the client'sindividual's short-term prior approval period expires, youthe provider will automatically receive a Form 2101 extending the coverage period for an additional year.

The caseworkercase manager uses procedures in Subsection 5910, Renewal of Prior Approval by the Caseworkercase manager, to renew prior approval if the renewal is done within the required timeframes.

You doA provider does not have to renew physician's orders or obtain prior approval from the regional nurse for short-term clientsindividuals.

5920 Termination of Services


If the caseworkercase manager determines the clientindividual is no longer eligible for DAHS, he

• sends Form 2065, Notification of Community Care Services, to the clientindividual to terminate services; and

• updates Form 2101 and sends to youthe provider to terminate services.


