Day Activity and Health Services Provider Manual Section 5000€¦ · Effective: October 30, 2013...

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 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


• Form 2059, Summary of Client's Need for Service; • Form 2067, Case Information; • Form 2101, Authorization 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 • the licensed nurse determines an individual needs to be reassessed.

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








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

• case manager, • applicant himself, • applicant's physician, or • applicant's family.

Item 5210, Referrals, describes the process to obtain prior approval for an individual referred through the case manager. Item 5310, Facility Response to Facility-Initiated Referrals, describes the process for facility-initiated referrals.

If services must be started immediately or if the individual requests immediate services, the case manager-initiated referral may be converted into a facility referral by either the case manager or provider if the provider has a contract with DADS at the time the referral is changed from case manager-initiated to facility initiated.

5130 Case Manager Service Planning Process


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

• Form H1200 EZ, Application for Assistance - Aged and Disabled; and • Form 2059, Summary of Individual'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 DADS 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 individual receives other community care services.

The DADS case manager determines the number of units of service the individual needs per week according to

• the individual’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 case manager cannot authorize more than 10 units of DAHS per week.

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

The maximum number of units in the calendar month cannot exceed 46, provided within 23 possible calendar days. If the individual is scheduled to attend the facility on certain days of the

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/



week, and the individual is unable to attend on one of those days, the individual can make up the authorized units of service on a subsequent day.

If the individual is authorized to receive two units (six hours or more) of DAHS, The individual is entitled to receive up to 10 hours of service during the day. Before referring the individual for DAHS, the case manager

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

The case manager refers the individual by sending the facility a referral packet consisting of Form 2110, Community Care Intake, Form 2059, and Form 2101.

5140 Freedom of Choice


The individual is guaranteed freedom of choice among the DAHS facilities that serve the area, regardless of any relationship to a provider.

40 TAC §98.202(a)(3), concerning Program Overview, states that a DAHS facility must serve eligible individuals, unless a facility is at licensed capacity.

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

5150 Interest Lists


It is against Medicaid regulations for DADS to maintain a waiting list for any Title XIX service. DAHS providers should notify DADS case management staff as license capacity is reached for any day. The DAHS facility certifying officer notifies DADS operations that capacity has been reached.

If a provider’s facility reaches its licensed capacity, the DADS case manager will refer an individual to another facility if the individual is willing to attend. If there are no other facilities or the individual is not willing to attend another facility, the DADS case manager explains to the individual that the service is not currently available in his area, but may make a referral to the facility originally selected by the individual. The case manager will pursue other appropriate service options dependent on the individual’s eligibility status and needs.


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



A facility operating at capacity may maintain a facility interest list for Title XIX and private-pay individuals. If a facility maintains a waiting list, the procedures in Appendix III, Interest List Procedures, must be followed.

5200 Prior Approval Process for Case 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 case manager.

5210 Referrals


Case Manager-Initiated Referrals

The DADS case manager will send Form 2101, Authorization for Community Care Services, to the DAHS facility. Once the DAHS facility receives Form 2101 from the case manager, the DAHS facility must send a referral packet to the DADS regional nurse within 14 days after the receipt of Form 2101 from the case manager. The referral packet includes the following: 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 DAHS provider cannot obtain the physician’s orders within 14 calendar days, the provider must send Form 2067, Case Information, 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 referral.

The case manager must

• evaluate the cause of the delay, and • take whatever action is necessary to ensures e that the individual receives services at the

earliest possible date.


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



This may necessitate making a new referral to a different facility. In this event, the case 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 case manager evaluates each situation on a case-by-case basis. In the event of disagreement with the case manager’s action, the case manager’s supervisor may be contacted. The frequent submittal of Forms 2067 Case Information, about facility delays in service initiation to the DADS case manager may also be brought to the contract specialist’s attention.

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 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 by the receiving facility; 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.

Initial DAHS Individuals

The provider’s nurse must ensure that the medical diagnosis listed in the health assessment is 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 licensed 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 update 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 DADS 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 date 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 ISP must be reviewed to ensure all appropriate information reflected on the physician’s orders 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 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.

The licensed nurse 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.

5212.3 Initial and Ongoing DAHS Individual Service Plan

A provider must ensure the ISP includes 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.

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 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.

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 ISP must be clearly linked to internal documentation maintained by the DAHS 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.

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.

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 physician’s orders within 14 days, a 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 - On or before the date services are initiated, verbal or written.

Conditions such as cerebral palsy, organic brain syndrome and Alzheimer’s disease, are considered qualifying medical diagnoses for DAHS. Mental health issues and intellectual and developmental disabilities are not considered qualifying medical diagnosis, but may be present if the individual’s need for licensed nursing care is related to a coexisting qualifying medical



diagnosis. A diagnosis of alcoholism by itself is considered a mental condition and does not make someone eligible for DAHS.

Physicians 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 include the date of issue and expiration. Physicians 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://public.tmb.state.tx.us/HCP_Search/searchinput.aspx or contact the Verification DADS of the Texas Medical Board at 800-248-4062 or fax 512-305-7051. Also, a directory exists of Texas licensed physicians that includes a list of MDs (doctors of medicine) and DOs (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.

If the physician does not want a copy of the health assessment document, the physician's refusal 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

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

• 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. The 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, the 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 Case Manager Referral


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

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 the provider. If this date is not feasible, the regional nurse negotiates the beginning date of coverage on Item 4 of Form 2101 with the provider and DADS case manager according to the individual’s needs and the individual’s unique circumstances.






The DADS regional nurse determines if a condition qualifies as an acute medical condition. The DADS regional nurse may contact the individual’s physician to discuss the individual’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 the provider about approval or denial of routine cases. The DADS regional nurse approves prior approval if the:

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

The regional nurse sends:

• copies of Form 2101 to the provider and 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 case manager sends the individual a written notification.

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 a provider’s facility through the facility-initiated process.

5310 Facility Response to Facility-Initiated Referrals


A 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.

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 case manager. See Section 5820, Individual Transfers, for more information about transfer procedures.





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. A provider must document the reason for the immediate placement on Form 2067, Case Information, to the case manager.

The licensed nurse:

• records the physician's orders on Form 3055, Physician’s Orders (DAHS); • gathers 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 Form 2101 from the case manager is received.

5311 Facility That Does Not Have a Contract with DADS


If the facility does not have a contract with DADS when it admits a Medicaid recipient pending eligibility determination for DAHS, the case 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 DADS, the case manager gives the individual the option to attend a different facility with a current DADS contract. If the individual chooses to stay in the current facility, the case manager denies the services.

If the facility continued to provide services to the individual, the effective date for reimbursement of services to the individual is the date the facility notifies the case manager that it has a DADS contract. The facility may notify the case manager by telephone or through Form










2067, Case Information, that it has a contract with DADS.. This notification serves as a second referral to the case manager.

5320 Case Manager Response to Facility-Initiated Referral


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

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

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

If the applicant is financially eligible, the case manager sends

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

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

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

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

The case manager notifies the individual of his eligibility or ineligibility within 10 days of the decision, using Form 2065.

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

5321 Payment for Services Following Change of Individual’s Status


If a provider admits a Medicaid individual 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 individual either dies, moves to another facility, or decides he no






longer wants to receive services before the case manager has an opportunity to conduct the assessment, a provider can be reimbursed for services provided to the individual if

• the provider documented on attendance or transportation records that services to the individual were provided,

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

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

5330 Regional Nurse Prior Approval on Facility-Initiated Referral


Upon receipt of Form 2101 from the case 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.

The DADS regional nurse follows the policy in §98.204(d) when prior approval forms or additional documentation is not 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 • DADS stamp-in date.

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

5400 Critical Omissions


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

5410 Critical Omissions or Errors in Required Documentation





Policy guidance regarding the documentation of the Individual Health Assessment or Plan of Care, Physician Orders or critical errors or omissions is found at: 40 TAC §98.204, DAHS Facility-Initiated Referrals

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 to the facility along with the rejected prior approval packet.

5411 Corrections of Critical Omissions or Errors


Rule: 40 TAC §98.210, Administrative Errors and Corrections, contains information on processes for corrections of critical omissions or errors in facility documentation.

To expedite the processing, a 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


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

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 individual should be referred to another facility.












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

5600 Case Manager Follow-up


The DADS case manager monitors the individual 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 individual's condition.

5610 Return of Form 2101


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

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. The provider should return Form 2101 as soon as possible after receiving it from the case manager or DADS regional nurse. To comply with contract 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, • provider’s signature, and • date of provider’s signature.

5700 Facility Responsibilities


A 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 the facility while the individual is at the DAHS facility. A provider should use the case 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 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.

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 (not 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 individual and his family.

If an individual has been determined to need a low or salt-free diet (as evidenced by the individual's diagnosis or physician's orders), the individual must be served a meal meeting the dietary requirements ordered by the physician. If a provider is adhering to the physician's orders to provide a salt-restricted meal to the individual, but the individual says he does not want the salt-free diet, then the provider is meeting the dietary requirement as ordered by the physician. The individual can, however, choose whether to comply with the salt restricted diet or not.

If meals are not prepared at the facility, the DADS of State 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 Department of State Health Services at P. O. Box 149347, Austin, Texas 78714-9347, 512-834-6670.

5740 Transportation


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

Rules 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 records are included in §98.209(b), concerning Record Maintenance. A facility that provides transportation or has a subcontract with a private or public transportation entity must use Form 3682, Day Activity and Health Services Daily Transportation Record.

The provider must:

• coordinate the use of other transportation resources within the community; • make every effort to have families transport individuals; • manage upkeep and operation of facility vehicles, including liability insurance. Vehicles used

by the 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 individuals being transported.



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

If alternative transportation options are not available, the provider is ultimately responsible for providing the transportation to the individual. Refer to §98.202(a)(3) in Item 5140, Freedom of Choice, which indicates that a provider may not refuse to serve eligible individuals.

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

5750 Other Supportive Services


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

Rule: 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 individuals in program activities. Program activities include games, crafts, field trips, and any other activities that require the use of material or supplies.

A 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, a 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.

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

• trips or special events, or • cultural enrichment.

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

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



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

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

A 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.

Examples:

• 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 individual. Items for the individual's personal use are the individual's responsibility.

5760 Notifications


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

If a DAHS individual is diagnosed with active Tuberculosis (TB), the facility must immediately inform the individual’s physician of the condition. In order for the individual to remain at the facility, the individual’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 individual’s family to keep the individual at home. If the physician reports in writing that the TB is not infectious, the individual 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 Services (DSHS) office, or ask for the TB Elimination Division at 512-533-3000.

5761 Change in Ownership


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

5770 Individual Rights and Responsibilities





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

40 TAC Chapter 49, Contracting For Community Care Services.

5771 Complaints


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.

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 30 calendar days of receipt of the complaint.

5800 Reporting Significant Changes

Revision 02-5; Effective Upon Receipt The 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 individual's plan of care:

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

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

• reviews the individual's plan of care, • 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 case manager must approve significant changes in the plan of care which may affect eligibility or units of service.


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




Case Manager Review and Approval

If the case manager . . . Then he . . . agrees with the provider’s request for a plan of care change,

updates Form 2101 to reflect the changes.

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

sends the provider a Form 2067 stating the rationale for not changing the plan of care. If the provider still wants a change in the individual plan of care, the provider requests a review by the case manager's supervisor to resolve the difference in opinion.

If services are denied or reduced, the case manager follows individual notification procedures.

5810 Individuals Who Fail to Comply with Service Delivery Provisions


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

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

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

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

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

5820 Individual Transfers




An individual who wants to transfer to a new contracted facility must make the request to his DADS case manager. The case manager will coordinate with the losing facility, and provide the new facility with an effective date of the transfer, within 14 days after the individual’s written or oral request. The provider will not be reimbursed for services provided to an individual who is transferring from another contracted DAHS facility before the effective date established by the case manager.

Within 14 days of the individual's written or oral request to transfer to a new facility, the case 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 an 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 case manager coordinate individual 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 owned by operated under the same DAHS contract contractor.

New physician’s orders are required for individuals who transfer to a new DAHS facility operatedowned by a different DAHS contractor.

5821 Health Assessment 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. A provider must conduct the health assessment and individual service plan according to Section 5211, Health Assessment, and Section 5212, Individual Service Plan.

5830 Moves to Un-Contracted Facilities


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

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




The case manager

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

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

If the individual chooses to receive services from the un-contracted facility, the individual is

o informed that DADS 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 DADS cannot pay for services at the new facility because the facility does not have a contract with DADS; and

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

5840 Suspension of Services


Rule: 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 case manager coordinates closure and the termination date with the provider to allow time for individual notification of the right to appeal.

The case manager investigates the reported loss of Medicaid eligibility. If he verifies that the individual is indeed losing eligibility, the case manager

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

5900 Prior Approval Renewal Process


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

5910 Renewal of Prior Approval by the Case Manager





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

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

If the case manager does not renew the prior approval before the individual’s current prior approval expires, the 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 case manager will still

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

number of units change.

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

Procedures to Renew Prior Approval

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

verbally notifies the individual 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 individual Form 2065 to notify him of the change in the service plan; and

• sends the DAHS facility an updated and signed Form 2101 to notify the provider of the change. The effective date of the increase in units is seven days from the date Form 2101 is mailed to the 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 effective date of the decrease.

is reassessed or redetermined ineligible for services,

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

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


5911 Renewal of Prior Approval by the Case Manager for Short-Term Individuals


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

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

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

5920 Termination of Services


If the case manager determines the individual is no longer eligible for DAHS, he

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

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




Day Activity and Health Services Provider Manual Section 5000€¦ · Effective: October 30, 2013...

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