BOARD MEMBERS John M. Bradley - Texas

[Pages:41]COMMISSIONER James R. Hine

August 27, 2003

BOARD MEMBERS

John M. Bradley Chair, Dallas

Jerry Kane Vice Chair, Corpus Christi

Abigail Rios Barrera, M.D. San Antonio

John A. Cuellar Dallas

Manson B. Johnson Houston

Terry Durkin Wilkinson Midland

To: Subject:

Primary Home Care (PHC) Providers

Long Term Care (LTC) Information Letter No. 03-13 Revisions to Chapter 47, Primary Home Care (PHC), Effective September 1, 2003

Effective September 1, 2003, the Texas Department of Human Services (DHS) will adopt revisions to the provider agency rules for the Primary Home Care (PHC) program. The new rules:

? change the name of 1929(b) services (or frail elderly) to community attendant (CA) services;

? add a definition for `Primary Home Care Program' and clarify the three types of services under the PHC program;

? remove the requirement for a provider agency nurse assessor or supervisor; ? add a definition of `practitioner' and use this more accurate term in place of

`physician'; ? remove the physician's orders from the PHC Program for primary home care and

community attendant (formerly frail elderly or 1929(b) services); ? add a practitioner's statement of medical need to establish a client's need for

services based on a medical diagnosis(es), and requirements regarding this medical need determination for personal care services in a non-medical program; ? change provider agency licensing requirements to only allow services in the PHC Program to be delivered under the Personal Assistance Services (PAS) category of license; ? expand the requirements for retroactive payment procedures; and ? correct several cross-references to other sections of the Texas Administrative Code.

Provider agencies will have a 30-day period to implement the new rules.

DHS has identified those provider agencies that do not currently have the PAS category of licensure for their PHC contract. These provider agencies will be contacted individually to ensure compliance with the new rule on required licensure category.

John H. Winters Human Services Complex ? 701 West 51st Street ? P.O. Box 149030 ? Austin, TX 78714-9030 ? (512) 438-3011 Call your local DHS office for assistance.

LTC Information Letter No. 03-13 August 27, 2003 Page 2

A manual revision containing the rule changes will be completed and made available in the near future.

REVISED INSTRUCTIONS

The instructions for the following forms have been revised to reflect the rule changes:

? Form 3040, Attendant Orientation/Supervisory Visit ? Form 3050-A, Health Assessment/Individual Service Plan

Provider agencies must ensure they follow the attached instructions carefully to ensure proper completion of these forms. Forms 3040 and 3050-A will be revised no later than October 1, 2003.

REVISED FORMS

The following forms have been revised to reflect the changes to the rules:

? Form 3070, DAHS/PHC Notification of Critical Omissions/Errors in Required Documentation

? Form 3070-A, Primary Home Care Notification of Critical Omissions/Errors in Required Documentation

Copies of the revised forms and the instructions are attached to this Information Letter.

The revision to Form 3070 and Instructions:

? changes the form name from `DAHS/PHC Notification of Critical Omissions/Errors in Required Documentation' to `Day Activity and Health Services Notice of Critical Omissions; and

? revises the purpose of the form for use only with the Day Activity and Health Services (DAHS) Program.

The revision to Form 3070-A and Instructions:

? changes the form name from `Primary Home Care Notification of Critical Omissions/Errors in Required Documentation' to `Primary Home Care Notice of Critical Omissions;

? adds space for the provider agency's name and vendor number; ? changes the references from R.N. supervisor to supervisor; ? replaces references to Form 3055-A with Form 3052; and ? revises the critical omissions to reflect the changes to the critical omissions

effective September 1, 2003.

LTC Information Letter No. 03-13 August 27, 2003 Page 3

NEW FORMS

Form 3052, Primary Home Care Practitioner's Statement of Medical Need, is a new form. Form 3052 is used by the provider agency to obtain a statement from the client's practitioner that the client has a need for PHC services based on medical diagnosis(es). Until automation changes can occur to remove the requirements for a diagnosis code entry, provider agencies must collect the diagnosis from the practitioner.

Provider agencies should begin using the new and revised Forms for all actions processed on or after September 1, 2003. Provider agencies should continue to use the previous versions of any necessary forms for all actions already in process before September 1, 2003. Provider agencies will be allowed a 30-day grace period to print supplies of Form 3052 and use supplies of Form 3055-A. DHS staff has been instructed to accept either version of a form if it is signed between September 1, 2003 and September 30, 2003.

The new and revised forms and instructions will be available as soon as possible in the electronic version of the Community Care Provider Forms Manual (CCPFM). The CCPFM may be accessed at

HIPAA REQUIREMENTS

Provider agencies are required to continue compliance with the federal Health Insurance Portability and Accountability Act of 1996 (HIPAA). Please reference Long Term Care (LTC) Information Letters 02-33 and 03-05, located at for HIPPA requirements

An electronic version of this letter and the revised PHC rules can be accessed at: .

Please contact your contract manager if you have any questions. Contract managers should contact Sarah Hambrick at (512) 438-2578 if they have any questions.

Sincerely,

Signature on file

Becky Beechinor Assistant Deputy Commissioner Long Term Care Services

BB:ck

Attachments

Subchapter A, General Provisions and Services

?47.1901. Definitions ?47.1902. Required Services ?47.1903. Staffing Requirements ?47.1904. Training Requirements

Subchapter B, Service Requirements

?47.2901. Referrals to Provider Agencies ?47.2902. Assessment, Service Plan, and Requesting Prior Approval ?47.2903. Provider Agency Requirements after Verbal Referral for Primary Home Care or Community Attendant Services ?47.2904. Critical Omissions/Errors for Primary Home Care or Community Attendant Services ?47.2905. Initiation of Service ?47.2908. Monitoring Medicaid Eligibility for Primary Home Care ?47.2909. Medical Need Determination ?47.2910. Service Breaks ?47.2911. Orientation of Attendants ?47.2912. Service Plan Changes ?47.2913. Prior Approval Renewal for Community Attendant Services ?47.2914. Suspension of Services

Subchapter C, Claims Payment

?47.3906. Claims Payment Reviews and Audits ?47.3907. Missing Records ?47.3908. Retroactive Payment Procedures

Subchapter D, Provider Contracts

?47.4902. Primary Home Care Provider Qualifications ?47.4903. Provisional Contracts ?47.4904. Current Contractors ?47.4905. Option To Contract for Family Care Services

Subchapter E, Support Documents

?47.5902. Reimbursement Methodology for Primary Home Care

Subchapter F, Sanctions

?47.6902. Sanctions

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Subchapter A, General Provisions and Services

?47.1901. Definitions. The following words and terms have the following meanings when used in this chapter, unless the context clearly indicates otherwise:

(1) Abuse--Willful infliction of injury, unreasonable confinement, intimidation, or cruel punishment with resulting physical harm, pain, or mental anguish; or willful deprivation by a caretaker or oneself of goods or services that are necessary to avoid physical harm, mental anguish, or mental illness.

(2) Adult--A person 18 or older, or an emancipated minor. (3) Aged or elderly person--A person 65 or older. (4) Assignee--A legal entity that assumes the responsibilities and duties of a current primary home care contract through a legal assignment of contract from another legal entity. (5) Assignor--A legal entity that assigns its primary home care contract to another legal entity through an assignment of contract. (6) Attendant--A provider agency employee who provides the authorized tasks to the client. (7) Client--A person who is determined by the department to be eligible for services. (8) Community attendant (CA) services--A service under the Primary Home Care program providing in-home attendant services to eligible clients. Clients receiving CA services must have a medical need for specific tasks. CA services are provided under Title XIX of the federal Social Security Act (relating to Grants to States for Medical Assistance Programs), at 42 U.S.C. ?1396t (relating to Home and community care for functionally disabled elderly individuals). (9) Controlling interest--an owner who is a sole proprietor, a partner owning 5.0% or more of the partnership, or a corporate stockholder owning 5.0% or more of the outstanding stock of the contracted provider, or a member of the board of directors. (10) Days--Any reference to days means calendar days, unless otherwise specified in the text. Calendar days include weekends and holidays. (11) Department--The Texas Department of Human Services. (12) Emancipated minor--A person under 18 years of age who has the power and capacity of an adult. This includes a minor who has had the disabilities of minority removed by a court of law or a minor who, with or without parental consent, has been married. (13) Exploitation--The illegal or improper act or process of a caretaker or others using an adult's resources for monetary or personal benefit, profit, or gain. (14) Family care (FC) services--A service under the Primary Home Care Program providing in-home attendant services to eligible adults. FC services are provided under Title XX of the federal Social Security Act (relating to Block Grants to States for Social Services), at 42 U.S.C. ?1397 et seq. (15) Income eligible--An adult who is neither a Supplemental Security Income (SSI) or Temporary Assistance for Needy Families (TANF) client, but who has income that is equal to or less than the eligibility level established by the department. (16) Institution--A nursing home, personal care home, intermediate care facility for the mentally retarded (ICF-MR), or state hospital. (17) Medicaid eligible--An individual who is eligible for Medicaid as an SSI or TANF client, or who is eligible for medical assistance only while living in the community. (18) Neglect--Failure to provide for oneself the goods or services that are necessary to avoid physical harm, mental anguish, or mental illness; or the failure of a caretaker to provide these goods or services. (19) Person with a disability--A person who, because of physical, mental, or developmental impairment, is limited in his capacity to adequately perform one or more essential activities of daily living. Activities of daily living include but are not limited to:

(A) personal and health care;

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(B) mobility; (C) communication; and (D) money management. (20) Practitioner--A physician currently licensed in Texas, Louisiana, Arkansas, Oklahoma, or New Mexico; a physician assistant currently licensed in Texas; or a registered nurse approved by the Texas State Board of Nurse Examiners to practice as an advanced practice nurse. (21) Practitioner's statement--A document signed by a practitioner that includes a client's diagnosis, current medications, and a statement that the client has a current medical need for assistance with personal care tasks and other activities of daily living. (22) Primary Home Care Program--A Texas Department of Human Services attendant care services program. Community attendant (CA), primary home care (PHC), and family care (FC) are the three types of services available under the Primary Home Care Program. (23) Primary home care (PHC) services--A service under the Primary Home Care Program providing in-home attendant services to eligible clients. Clients receiving PHC services must have a medical need for specific tasks. PHC services are provided under Title XIX of the federal Social Security Act, at 42 U.S.C. ?1396a et seq. (relating to State plans for medical assistance). (24) Prior approval--A decision made by the department regional nurse/caseworker, before services begin and before payment can be made, that the applicant or client meets the department criteria for the requested service. (25) Provider agency--A home and community support services agency that has a contract with the department to provide services under the Primary Home Care Program. (26) Provisional contract--A time-limited contract. (27) Special attendant--A provider agency employee who can substitute for another attendant. (28) Supervisor--A provider agency employee who: (A) coordinates the delivery of services in the client's service plan; (B) supervises attendants; and (C) complies with ?97.404 of this title (relating to Standards Specific to Agencies Licensed to Provide Personal Assistance Services). (29) Unit of service--One hour of authorized service delivered to a prior-approved client.

?47.1902. Required Services. A provider agency must provide services that include but are not limited to:

(1) Personal care. These services include assistance with activities related to the care of the client's physical health. These activities include:

(A) bathing; (B) dressing; (C) preparing meals; (D) feeding; (E) exercising; (F) grooming; (G) caring for routine hair and skin needs; (H) taking self-administered medication; (I) toileting; and (J) transferring/ambulating. (2) Home management. These services include assistance with housekeeping activities that support the client's health and safety. These activities include: (A) changing bed linens; (B) housecleaning; (C) laundering;

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(D) shopping; (E) storing purchased items; and (F) washing dishes; (3) Escort. Accompanying the client on trips to obtain medical diagnosis or treatment or both. This service does not include the direct transportation of the client by the attendant.

?47.1903. Staffing Requirements. (a) A supervisor must supervise attendants. The provider agency must not knowingly send

attendants who have symptoms of communicable disease to a client's home. (b) Attendants must: (1) be at least 18; (2) be neither legal nor foster parents of minor children who receive the service; and (3) not be spouses of clients (not applicable to family care). (c) The two types of attendants are as follows: (1) Regular attendants. Each regular attendant must receive a general orientation as

described in ?47.2911 of this chapter (relating to Orientation of Attendants), before or at the time services begin.

(2) Special attendants. Special attendants may be used to initiate services, prevent a break in service, or provide ongoing services. Although special attendants are required to receive the general orientation specified in paragraph (1) of this subsection, they do not have to receive it in the client's home as long as they meet the following requirements.

(A) The special attendant must meet the requirements in subsection (b) of this section.

(B) The special attendant must either: (i) meet the requirements described in ?97.701 of this title (relating to Home

Health Aides); or (ii) meet the following requirements: (I) have six continuous months of experience in delivering personal care tasks

in family care or primary home care; and (II) have demonstrated competency in providing personal care tasks to the

satisfaction of the supervisor.

?47.1904. Training Requirements. Before assuming responsibilities, all supervisors must receive training in the policies and procedures of the Primary Home Care Program, and family care services, if the provider agency delivers this service.

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Subchapter B, Service Requirements

?47.2901. Referrals to Provider Agencies. (a) Unless a client needs a verbal referral for services, provider agencies receive written

referrals based on the following priorities: (1) client's choice; and (2) rotation of eligible providers.

(b) The client's or provider agency's choice of attendants is not limited unless: (1) the caseworker has specified that a particular attendant should not be employed by

the provider agency; or (2) the supervisor, caseworker, or regional nurse has determined that the attendant is not

providing adequate care. (c) The provider agency must refer an individual who is eligible for Medicaid or who is potentially eligible for Medicaid to the Texas Department of Human Services within seven days of the date the provider agency develops the client's service plan.

?47.2902. Assessment, Service Plan, and Requesting Prior Approval. (a) Provider agencies must obtain, from the regional nurse, prior approval of medical need

for applicants and renewal of prior approval for certain clients. (1) Except as indicated in paragraph (2) of this subsection, only initial prior approval of

medical need by the department regional nurse is required for applicants who have a medical condition causing functional impairment in personal care.

(2) Annual renewal of prior approval by the department regional nurse is required for clients who are eligible under the provisions of the Social Security Act, ?1929(b). (b) When a provider agency receives a referral from a caseworker, the supervisor must make every effort to request prior approval for the client within 14 days of the authorization for community care services referral date. (c) If the provider agency cannot request prior approval within 14 days, the provider agency must notify the caseworker about the reason for delay. This notification must be sent on the case information form within 14 days of the referral date. (d) The supervisor must conduct an initial on-site assessment for all referrals using the client assessment form. (e) If the supervisor cannot conduct the assessment within 14 days of the referral date, the provider agency must notify the caseworker about the reason for delay. The notification must be sent on the case information form, within the 14-day period. (f) Using the service plan form, the supervisor must develop a service plan for the client. The service plan must be agreed upon and signed by the client/client's family and agency. The service plan must include:

(1) the client assessment; (2) tasks and hours; (3) the attendant service schedule; and (4) frequency of supervisory visits. (g) After the supervisor conducts the assessment, he must obtain the practitioner's statement described in ?47.2909 of this chapter (relating to Medical Need Determination). If the provider agency cannot obtain the practitioner's statement within 14 days of the referral date, the provider agency must notify the caseworker about the reason for delay by sending the case information form within the 14-day period. The case information form must include the date of the assessment and must be dated after the assessment date.

?47.2903. Provider Agency Requirements after Verbal Referral for Primary Home Care or

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