THE GULF COAST CENTER
INDIVIDUALS WITH DEVELOPMENTAL DISABILITY SERVICES
(IDD)
PROVIDER NETWORK MANUAL
REVISED SPRING 2010
Table of Contents
Section
Page
1. Purpose …………………………………………………… 3
2. Manual Updates …………………………………………..
3
3. Audience ………………………………………………….
3
4. Limitation ………………………………………………… 3
5. Referral and Authorization Process ………………….…… 3
6. Covered Services …………………………………………
4
6.1 Service Definitions ………………………………....... 6
6.2 Service Requirements..…………………….…………
10
6.3 Service Outcomes (optional)..…..…………….……… 11
7. Provider Chart Documentation Requirements ……….…… 15
8. Provider Agency Documentation ………………………… 17
9. Claims and Billing ………………………………………... 17
10.Reporting Requirements ………………………………….. 18
11.Staff Training Requirements ……………………………… 19
12.Complaints ………………………………………………... 24
13.Contract Monitoring ………………………………………. 24
14.Sanctions, Appeals and Contract Termination ……………. 24
2
THE GULF COAST CENTER
PROVIDER NETWORK MANUAL FY 10
Section 1.
Purpose of this Manual
This manual was developed to assist providers in implementing the requirements specified for
The Gulf Coast Center’s (hereinafter “Authority”) IDD Services Open Enrollment Provider
Network. This manual focuses on the requirements for providing those service components
offered under General Revenue and Home and Community Based Services funded services per
applicable Texas Administrative Codes, the annual Department of Aging and Disability Services
Performance Contract requirements for IDD services (previously contracted under TDMHMR)1,
and Authority policy and procedure.
Section 2.
Manual Updates
From time to time this manual will be updated. Update notifications will include the information
pertaining to the pages that should be removed from the manual, the new replacement pages, and
an acknowledgement form that must be completed and returned to the Director of IDD Provider
services (identified below) within 20 calendar days after the date that you receive it. Please mail
acknowledgment forms to:
Barry Kusnerik
The Gulf Coast Center
7000 Ave B
Santa Fe, TX 77510
Section 3.
Audience
This manual was written for the use of those providers who are contracted under the Authority’s
MR IDD Services Open Enrollment Provider Network.
Section 4.
Limitation
This manual is an attempt to integrate applicable State of Texas rules and regulations, Authority
policy and procedures, and questions from service providers into a more “user friendly” format.
This manual does not replace, supercede, or override any applicable rules of the Texas
Administrative Code or other legislation. Questions regarding the content of this manual should
be directed to Barry Kusnerik at (409) 944-4449.
Section 5.
Referral and Authorization Process
a. Waiting List. The Gulf Coast Center will maintain a comprehensive waiting list for
all individuals awaiting services, to include Supported Employment, Day
Habilitation, Community Support Services, and Respite services….
1
The State of Texas reorganized its health and human services system. Due to the reorganization, the TDMHMR
system split into two newly formed state agencies September 1, 2004. The mental health system and services are now
under the Texas Department of State Health Services and the mental retardation system and services are under the Texas
Department of Aging and Disability Services. For purposes of this Manual any use of “TDMHMR” shall be inclusive of
the newly formed State Agency(ies), name changes and designated services.
3
b. Individuals advancing off the waiting list for general revenue funded services will
develop an individualized budget and purchase services of their choice as identified
in their Individual Plan of Care/Person Directed Plan.
c.
Referral Process. All referrals on Individuals will come from the Authority Liaison
following development of a person directed plan which will include Respite,
Employment, Day Habilitation and/or Community Support Services goals and
objectives for the Individual. The Authority Liaison will coordinate with the
Individual in selecting a provider from the list of contracted Providers and accessing
other State Rehabilitative (Department of Assistive and Rehabilitative Services –
DARS) services if pursuing employment. Individuals will document their choice and
are allowed to change Providers at their own discretion.
d.
Providers aware of individuals wishing to transfer/change providers after services
have already begun must notify the Authority Liaison of the desire to transfer to
another provider.
e.
Authorization of Services. The Service Coordinator/Authority Liaison will
authorize the type and amount of services needed to meet the Individual’s needs
identified in his/her person directed plan or support plan. This staff will work closely
with the chosen Provider and the Individual to finalize the actual services to be
authorized.
Section 6.
Covered Services
Services will be delivered based on those services that are identified and budgeted as determined
by the Individual’s IPC/PDP. Payment for hours delivered will be based on those services
previously authorized by service coordinators and on review of the plan and satisfaction of
individual and/or family of the services Current rates for services and recommended hours are
set forth below:
Community Support Services (contracted agency)
Funding Source: General Revenue

Service
Community Support
Hrly rate
$22.94/hr
Timeframes
as requested
Community Support Services (non-traditional provider only)
Funding Source: General Revenue

Service
Community Support
Hrly rate
$15.98/hr
Timeframes
as requested
Funding Source: HCS

Service
Supported Home Living
$25.67/hr
Hrly rate
as requested
Timeframes
Supported Employment Services
Funding Source General Revenue


Service
Hrly rate
Employment Assistance $ 25.39
Supported Employment $ 25.39
Description
Job search/development
Supports on the job
4
Funding Source HCS

Service
Supported Employment
Hrly rate
$28.75
Description
Supports on the job
Day Habilitation
Funding Source: General Revenue
Service
.
50 unit= min. 2 hrs
 Day Habilitation
$ 13.50
1 unit=5 hrs direct service
$ 27.00
Funding Source: HCS
Level of Need 1 Unit Rate
Service
.50 unit
 Day Habilitation
$11.01
75 unit
$16.52
1 unit
$22.03
.
Service
 Day Habilitation
Level of Need 5 Unit Rate
.50 unit
.75 unit
$12.62
$18.93
1 unit
$25.24
.
Service
 Day Habilitation
Level of Need 8 Unit Rate
.50 unit
.75 unit
$15.27
$22.91
1 unit
$30.55
.
Service
 Day Habilitation
Level of Need 6 Unit Rate
.50 unit
.75 unit
$20.59
$30.89
1 unit
$41.18
.
Behavioral Therapy
Funding Source: General Revenue

Service
Rate
Behavior Therapy
Description
$72.15/hr
as needed
Occupational Therapy
Funding Source: General Revenue

Service
Rate
Occupational Therapy
$68.97/hr
Description
as needed
Phyiscal Therapy
Funding Source: General Revenue

Service
Rate
Phyiscal Therapy
$73.25/hr
Description
as needed
Service
Rate
Speech/Language Therapy $69.78/hr
Description
as needed
Speech/Language Therapy
Funding Source: General Revenue

5
Respite (contracted agency)
Funding Source: General Revenue
Service
 Respite
o In-Home
o Facility-based
Rate Description
Rate
$13.97/hr up to 24 hrs per calendar day
$13.97/hr up to 10 hrs max per calendar day
Respite (non-traditional provider only)
Funding Source: General Revenue
Service
Rate
Description
 Respite
o Standard respite
$10.00/hr up to 24 hrs per calendar day
o Medical/behavioral need
$15.00/hr up to 24 hrs max per calendar day
o Intense Medical/behavioral need - determined on a case by case basis
Other Services
Funding Source: HCS only
Service
Rate
 Respite
o In-Home $15.28
o Facility-based $15.28

Foster Care/Companion Care



Psychology/Behavioral
Dietary
Nursing
o RN
o Specialized RN
o LVN
o Specialized LVN







6.1
Social Work services
Specialized Therapies
Audiology,
Occupational Therapy
Physical Therapy
Speech/Language Therapy
Description
hr up to 10 hrs max per calendar day
hr up to 10 hrs max per calendar day
Rate
LON 1 - $46.84
LON 5 - $50.46
LON 8 - $68.60
LON 6 - $94.00
$72.15
$48.07
$40.98
$47.13
$26.97
$31.02
$44.30/hr
up to $1,000.00 Dental
$45.52
$68.97
$73.25
$69.78
Service Definitions
a.
Community Living Services
1. Employment Assistance – ( General Revenue Only) service component assists
individuals to locate paid employment in the community.
6
(a) The employment assistance component assists an individual with the
participation of the LAR to identify:
1. his or her employment preferences;
2. his or her job skills;
3. his or her requirements for the work setting and work conditions; and
4. prospective employers that may offer employment opportunities
compatible with the individual’s identified preferences, skills, and
requirements.
(b) The employment assistance provider facilitates the individual’s employment
by contacting prospective employers and negotiating the individual’s employment.
(c) Employment assistance is reimbursed on an hourly unit basis.
(d) The employment assistance service component must be re-authorized by the
individual’s service planning team every 180 calendar days after the initiation of
the service component.
2. Supported employment - service component provides on-going individualized
supports needed by an individual to sustain paid work in an integrated work
setting.
(a) An individual receiving supported employment is:
1. compensated directly by the individual’s employer in accordance with
the Fair Labor Standards Act; and
2. employed in an integrated work setting by an employer that has no
more than one employee or 3.0% of its employees with disabilities
unless the individual’s IPC/PDP indicates otherwise or the employer
subsequently hires an additional employee with disabilities who is
receiving services from a provider other than the individual’s program
provider or who is not receiving services.
(b) Supported employment may only be provided when the service has been
denied or is otherwise unavailable to an individual through a program operated by
a state rehabilitation agency or the public school system.
(c) Supported employment is provided away from the individual’s place of
residence.
(d) Supported employment does not include payment for the supervisory
activities rendered as a normal part of the business setting.
(e) Supported employment does not include services provided to an individual
who does not require such services to continue employment.
3.
Day Habilitation - assists an individual to acquire, retain, or improve self-help,
socialization, and adaptive skills necessary to live successfully in the community
and participate in home and community life and does not include services that are
funded under §110 of the Rehabilitation Act of 1973 or §602(16) and (17) of the
Individuals with Disabilities Education Act.
(a) The day habilitation service component provides:
1. individualized activities consistent with achieving the outcomes
identified in the individual’s IPC/PDP;
2. activities necessary to reinforce therapeutic outcomes targeted by
waiver service components, school, or other support providers;
3. services in a group setting other than the individual’s home for
normally up to five days a week, six hours per day;
7
4.
personal assistance for individuals that cannot manage their personal
care needs during the day habilitation activity;
5. assistance with medications and the performance of tasks delegated by
a registered nurse in accordance with state law; and
6. transportation during the day habilitation activity necessary for the
individual’s participation in day habilitation activities.
(b) The day habilitation component may not be provided at the same time
supported employment is provided to an individual who has obtained
employment.
Respite – is provided for the planned or emergency short-term relief of the unpaid
caregiver of an individual.
(a) The respite service component provides individuals:
1. assistance with activities of daily living and functional living tasks;
2. assistance with planning and preparing meals;
3. transportation or assistance in securing transportation;
4. assistance with ambulation and mobility;
5. assistance with medications and performance of tasks delegated by a
Registered Nurse in accordance with state law;
6. habilitation and support that facilitate:
(i)
an individual’s inclusion in community activities, use of natural
supports and typical community services available to all people;
(ii) an individual’s social interaction and participation in leisure a
activities; and
(iii) development of socially valued behaviors and daily living and
independent living skills.
(b) Reimbursement for respite provided in a setting other than the individual’s
residence includes payment for room and board.
(c) Respite is provided on an hourly or daily unit basis.
(d) If for HCS services Respite may be provided in the individual’s residence
or, if certification principles stated in §419.578(o) of this title (relating to
Certification Principles: Service Delivery) are met, in other locations.
4.
5. Community Support/Supported Home Living - The community support service
component provides services and supports in an individual’s home and at other
community locations that are necessary to achieve outcomes identified in an
individual’s person-directed plan ( IPC/PDP).
(a) The community support service component provides habilitative or support
activities that:
1. provide or foster improvement of or facilitate an individual’s ability to
perform functional living skills and other activities of daily living;
2. assist an individual to develop competencies in maintaining his or her
home life;
3. foster improvement of or facilitate an individual’s ability and
opportunity to:
(i)
participate in typical community activities including activities
that lead to successful employment;
(ii) access and use of services and resources available to all citizens
in the individual’s community;
8
(iii) interact with members of the community;
(iv) access and use available non-TxHmL Program services or
supports for which the individual may be eligible; and
(v)
establish or maintain relationships with people, who are not
paid service providers, that expand or sustain the individual’s natural
support network.
(b) The community support service component provides assistance with
medications and the performance of tasks delegated by a registered nurse in
accordance with state law.
(c) The community support service component does not include payment for
room or board.
(d) The community support service component may not be provided at the same
time that the respite, day habilitation, or supported employment service
component is provided.
(e) The community support service component is reimbursed on an hourly
basis.
6. Foster Care/Companion Care this component provides:
(a) direct personal assistance with activities of daily living (grooming, eating,
bathing, dressing, and personal hygiene);
(b) assistance with meal planning and preparation;
(c) securing and providing transportation;
(d) assistance with housekeeping;
(e) assistance with ambulation and mobility;
(f) reinforcement of counseling and therapy activities;
(g) assistance with medications and the performance of tasks delegated by an RN;
(h) supervision of individuals’ safety and security;
(i) facilitating inclusion in community activities, use of natural supports, social
interaction, participation in leisure activities, and development of socially valued
behaviors; and
(j) habilitation, exclusive of day habilitation;
b.
Professional and Technical Support Services
1. Nursing services - component provides treatment and monitoring of health care
procedures as prescribed by a physician or medical practitioner or as required by
standards of professional practice or state law to be performed by licensed nurses.
(a) The nursing service component includes:
1. administration of medication;
2. monitoring an individual’s use of medications;
3. monitoring an individual’s health data and information;
4. assisting an individual or LAR to secure emergency medical services
for the individual;
5. making referrals for appropriate medical services;
6. performing health care procedures as ordered or prescribed by a
physician or medical practitioner or as required by standards of
professional practice or law to be performed by licensed nursing
personnel; and
7. delegating and monitoring tasks assigned to other service providers by
a registered nurse in accordance with state law.
(b) The nursing service component is reimbursed on an hourly unit basis.
9
2. Behavioral Support Service - component provides specialized interventions that
assist an individual to increase adaptive behaviors to replace or modify
maladaptive or socially unacceptable behaviors that prevent or interfere with the
individual’s inclusion in home and family life or community life. The component
is reimbursed on an hourly unit basis and includes:
(a) assessment and analysis of assessment findings of the behavior(s) to be
targeted necessary to design an appropriate behavioral support plan;
(b) development of an individualized behavioral support plan consistent with
the outcomes identified in the individual’s IPC/PDP;
(c) training of and consultation with the LAR, family members, or other
support providers and, as appropriate, with the individual in the
purpose/objectives, methods and documentation of the implementation of the
behavioral support plan or revisions of the plan;
(d) monitoring and evaluation of the success of the behavioral support plan
implementation; and
(e) modification, as necessary, of the behavioral support plan based on
documented outcomes of the plan’s implementation.
3. Specialized Therapies - service component provides assessment and treatment by
licensed occupational therapists, physical therapists, speech and language
pathologists, audiologists, and dietitians and includes training and consultation
with an individual’s LAR, family members or other support providers. Specialized
therapies are reimbursed on an hourly unit basis.
6.2
Service Requirements. Attachment A describes the requirements for services based
upon The Gulf Coast Center’s Performance Contract obligations under the Data Verification
Criteria used in State reviews.
a.
FOSTER CARE (HCS only)
1. Required activities:
(a)
direct personal assistance with activities of daily living (grooming, eating,
bathing, dressing, and personal hygiene);
(b)
assistance with meal planning and preparation;
(c)
securing and providing transportation;
(d)
assistance with housekeeping;
(e)
assistance with ambulation and mobility;
(f)
reinforcement of counseling and therapy activities;
(g)
assistance with medications and the performance of tasks delegated by an
RN;
(h)
supervision of individuals’ safety and security;
(i)
facilitating inclusion in community activities, use of natural supports, social
interaction, participation in leisure activities, and development of socially
valued behaviors; and
(j)
habilitation, exclusive of day habilitation;
10
b.
c.
NURSING
1. Registered nurse by the Board of Nurse Examiners for the State of Texas; or
2. Licensed as a vocational nurse by the Board of Vocational Nurse Examiners for
the State of Texas.
BEHAVIORAL SUPPORT
1. licensed as a psychologist by the Texas State Board of Examiners of Psychologists;
2. licensed as a psychological associate by the Texas State Board of Examiners of
Psychologists and working under the supervision of a licensed psychologist;
3. licensed as a psychological associate by the Texas State Board of Examiners of
Psychologists or certified as a DADS-certified psychologist in accordance with §415.161
of this title (relating to DADS -certified psychologists) and working in a public agency;
or
4. certified as a behavior analyst by the Behavior Analyst Certification Board, Inc.
d.
SPECIALIZED THERAPIES
1. The program provider must assure that a provider of specialized therapies is licensed by
the appropriate State of Texas licensing authority for the specific therapeutic service
provided by the provider.
6.3
Service Outcomes (Optional)(General Revenue Only). At the time of their Person
Directed Plan and Individual Plan of Care, individuals and/or their families may choose to
purchase outcomes for Employment and Community Support services. Outcomes for Supported
Employment and Community Development are optional and are determined by the individuals
purchasing those services and will be designated in their Person Directed Plan and Individual
Plan of Care.
a.
PROFILES. Service Coordinator/Liaison may authorize providers to complete a
profile as indicated in the IPC/PDP to help identify best possible options
regarding services or supports to be delivered.
Recommended hours and Time frames for Employment and Community Support
outcomes are listed in Table A (below).
Outcomes
Employment Profile
Community Profile
Employment Planning
Community Planning
Portfolio
Employment Placement
Community Placement
Employment Analysis
Community Analysis
Calendar
Employment Supports
Community Supports
Recommend
Hours
10-15 hours
3-5 hours
4-8 hours
20 - 25 hours
Suggested time
frame
4 weeks
(2weeks if
update)
2 weeks
Within 2 weeks
of plan
3months
10 hours
18 hours each
months
As needed
11
b.
SUPPORTED EMPLOYMENT OUTCOMES (Optional)
1. Supported Employment. Supported Employment services are directed toward
Individuals securing and maintaining work as part of the competitively employed
work force or otherwise employed in regular community jobs where most of their
co-workers are not persons with disabilities. Jobs are required to be at least nine
(9) hours per week unless otherwise indicated by the individual and his/her LAR
or specified in the individuals IPC/PDP or Support plan. All documentation for
payment must meet Data Verification criteria for Supported Employment services
and be provided to the Service Coordinator/Employment Liaison who will process
the information for payment.
2. Outcome Payment. Completion of one of the defined steps in the Supported
Employment process is assisting an Individual to become a viable member of the
workforce. The Provider receives payment for only authorized hours submitted
for services delivered in accordance with individuals IPC/PDP and/or upon
completed service product and upon satisfaction of those services. Documentation
from the Provider varies with the Outcomes and is shown below. Documentation
must be provided to the assigned Authority Liaison. Suggested steps or outcomes
for those wishing to obtain employment are:
(a)
Employment Profile. This outcome includes the development of a
document called the Employment Profile in which the Individual’s interests,
talents, and abilities are determined, potential jobs or job tasks are specified,
target employers or employer categories are identified, and the conditions
necessary for employment and environmental aspects relevant to successful
placement are detailed. The purpose of the Profile is to create a plan for the best
possible fit between the Individual and the needs of an employer. Jobs are not
required to be full time, but will depend on the individual’s needs and desires. The
development of the Profile should include documented face-to-face and telephone
meetings with the Individual in different environments and at different times.
Any others that the Individual identifies as important to the plan (family members,
friends, etc.) should be included in the meetings and discussions. The Individual
must participate fully in the discussions and the development of the initial plan for
supports needed. Provider also discusses with the Individual how the plan to
work might impact his/her benefits (such as Medicaid). Payment is contingent
upon receipt of the Employment Profile and Profile Log. Profiles must be
completed within 4 weeks of date of initial contact with family unless otherwise
indicated in the IPC/PDP.
(b)
Employment Planning meeting. This meeting will follow the completion
of the employment profile and its primary function is to identify those areas the
individual has expressed employment interests in while participating in the
employment profile. Payment is contingent upon receipt of the Employment Plan
meeting minutes and Employment Plan Log. Planning meeting must be scheduled
and held within 2 weeks from date of completion of the profile.
12
(c)
Placement. This Outcome includes securing a job(s) which matches the
tasks/jobs, preferences and conditions specified in the Employment Profile. The
number of contacts with family regarding status of placement will be determined
by family. Unless renegotiated with the Individual, all conditions must be met. A
job task analysis can be purchased/authorized which would indicate the amount of
supports that might be needed at the job site. This Outcome is considered met
when the Individual begins his/her third day of work on the job and reports
satisfaction with the job choice to his/her Service Coordinator. Payment is
contingent on receipt of documentation from the Provider which must include a
progress note describing the job duties, the hours, the pay, etc.; the job task
analysis; and the plan for job coaching and supports.
1. Portfolio. The portfolio is a visual/written description of the individual
that provides information on who they are and the contributions they
have to offer. Payment is contingent upon receipt of the Portfolio Log
and completed Portfolio. If purchased, portfolios must be completed
within 2 weeks from completion of the planning meeting. The
Individual or his/her LAR/Parent has the authority to waive the
requirement.
2. Support Services. The purpose of this phase is to transition the worker
to an independent level of employment. Payment is contingent on
receipt of documentation from the Provider which must include written
progress report showing hours worked, progress made and any
problems identified. The report must reflect all pertinent data
including dates and locations of support, as required by the Data
Verification Criteria. Provider must include a written plan for ongoing
support and Follow-Along services as authorized by PDP/IPC. If an
Individual loses employment a revised IPC/PDP can be held to address
authorizing additional funds based on availability of funds remaining
in their personal budget.
3. Independent Employment. Independent employment is achieved when the
individual no longer needs supports to maintain employment. If an individual
experiences employment problems, the initial provider will be contacted to assist
with resolution. Additional Support services can be authorized by revising the
IPC/PDP to address this as a need and that the individual has funds remaining in
their personal budget to pay for the supports.
c.
COMMUNITY DEVELOPMENT (Optional). Community development is
designed to link a person to their community by means of utilizing staff to
assist an individual to establish a connection/relationship to their specific
area of interest.
1. Community Development includes those activities that assist an individual in
participating in meaningful activities in the community or in the person’s home
that facilitate the implementation of his/her person directed plan. Community
services include the planning, development, and training or facilitation of specific
outcomes that a consumer desires, such as obtaining a camera, joining a health
club, increasing their circle of friends, volunteering in the community, attending
13
community colleges, joining civic organizations, joining a crafts class, joining a
bowling league etc…. Supports are those identified in the planning of community
life that are necessary for the consumer to participate in a desired community
activity or event, such as transportation, personal assistance, or safety assurances
such as accompanying someone to a special concert in their community.
(a)
Outcome Payment. Completion of one of the defined steps in the
community development process is assisting an Individual to become a viable
member of their community. The Provider receives payment for only authorized
hours submitted for services delivered in accordance with individuals IPC/PDP
and/or upon completed service product and upon satisfaction of those services.
Documentation from the Provider varies with the Outcome and is shown below.
Documentation must be provided to the assigned Authority Liaison.
1.
Community Profile. This Outcome includes the development of a
document called the Community Profile in which the Individual’s
interests are determined, potential community opportunities are
identified, and the conditions necessary for participation and
involvement relevant to successful placement are detailed. The
purpose of the Profile is to identify opportunities in the community
that reflect the interests of the Individual. Participation time is strictly
determined by the desires of the Individual. The development of the
Profile should include documented face-to-face and telephone
meetings with the Individual in different environments and at different
times. Any others that the Individual identifies as important to the
plan (family members, friends, etc.) should be included in the meetings
and discussions. The Individual must participate fully in the
discussions and the development of the initial plan for supports
needed. Payment of the Outcome is contingent upon receipt of the
Profile Log, Community Profile and a list of meeting attendees. List
must show date of meeting.
2.
Community Plan. These meetings follow the completion of the
community profile and its primary function is to identify and target
those areas the individual has expressed interests in participating in
through his/her profile. Payment is contingent upon receipt of the
Community Plan Meeting Minutes and community Plan Log
3.
Portfolio. The portfolio is a visual/written description of the individual
that provides information on who they are and the contributions they
have to offer. Payment is contingent upon receipt of the Portfolio Log
and completed Portfolio. The individual or his/her LAR/Parent has the
authority to waive the requirement of this outcome and Provider will
not receive reimbursement.
4.
Development/Placement. This Outcome is met when an appropriate
match in the community reflecting the preferences, conditions and
interests specified in the Community Profile has been identified.
Unless renegotiated with the Individual, all conditions must be met. A
community task analysis can be purchased/authorized which would
indicate the amount of supports that might be needed at the site.
Payment is contingent on receipt of documentation from the Provider
which must include the community involvement development log,
14
5.
6.
7.
Section 7.
Characteristics of Ideal Activities Checklist and the Community
Development Form.
Analysis. This is performed after the community activity has been
developed and will provide details of the activity as well as
information on the schedule, times and where the areas of support will
be coming. Payment is contingent upon receipt of the community
analysis log, community activity inventory log and community
support/training analysis.
Calendar. This is developed to provide individuals with a schedule of
events, activities, etc. that reflects how his/her days will be spent for
the month. The Calendar is developed based on information gathered
by the provider regarding community events, activities, etc… the
individual has identified as areas of interest and has expressed a desire
in the involvement of these activities. Payment is contingent upon
receipt and review of the quarterly Calendar.
Follow-along Services. The purpose of this phase is to transition the
individuals to become more independent within his/her community.
Payment is contingent on receipt of documentation from the Provider
which must include written progress report showing hours worked,
progress made and any problems identified. The report must show
dates and locations of support, indicating at least one monthly face-toface contact. If an Individual chooses to no longer participate in the
activity, a revised IPC/PDP can be held to address authorizing
additional funds based on availability of funds remaining in their
personal budget.
Provider Billing (see also Section 9 below) and Chart Documentation Requirements
a.
Provider must submit required billing documentation forms by the 7th calendar day of the
following month of which the Covered Services were provided.
b.
Direct Service Time: Direct service time must be completed on each document
submitted and appropriately reported on table included on each form and will
include the date, service code, start time, end time, travel time (If applicable) and
total time. Direct Service Time only will be denoted in the Start Time:End
Time and denoted in the Total Duration. Travel will be reported in a separate
column denoted as such.
Note: “Total Duration” for Day Habilitation, The Gulf Coast Center will pay for
services up to six hours per day. Start time may begin at individuals arrival time
(if day hab services/training are initiated at this time) or at the time scheduled day
hab begins in the facility for all individuals. For all other services, actual start
time:end time (hrs:minutes) must be reported in this field and that time should be
reported in the Total Duration column (ie 9:17 am – 10:45 am = 1 hr 28 min). The
rounding guidelines will be used to determine rate hours to be billed.
c.
Billing: Progress notes must be turned in at the time of Billing, if no Billing is
being submitted, Progress notes will still be required to validate service delivery
and will still be required to be submitted at the due date for Billing.
15
1. General Revenue – documentation addressing status on outcomes/action
steps will be completed on a bi-monthly basis via billing data sheets and
submitted bi-monthly.
2. Phone calls/contacts are billable only as described under Attachment A
DVCManual R041 – 2(d) and R042 2(f)
3. If no monthly contact is made in a month for whatever reason, the Authority
Liaison should be notified. A progress note must be written to address
explanation of why an individual was not seen for the month.
4. Providers may submit billing twice a month or monthly (30 day time frame).
Providers will be responsible for submitting payment requests for late
payments.
5. All required employment and community logs will be submitted with Billing
and Progress Notes, with completed direct service time tables included on
each form.
d.
Communication: There must be open communication between the Authority’s
Liaison, Providers, and with the Service Coordinators.
1. e. Progress Notes: Due to state requirements for the entry of service events into the States database
and in compliance with our performance contract with the Department of Aging and Disability
Services, providers must promptly submit all progress notes / billing data forms. Payment for
progress notes / billing data forms received on or before the 18 th of the month (for services delivered
from 1st thru the 15th ) will be issued on the 1st of the following month. NOTE: If the 18th or 7th falls
on a weekend, they are due on that previous Friday. Payment for progress notes / billing data forms
received on or before the 7th of the month (for services delivered from 15th thr the end of the month )
will be issued on the 15th of the following month For example, an individual receives respite on
February 11th, the provider must submit progress notes / billing data forms by Feb 18th in order to
obtain reimbursement on the 1st of the month.. For an individual that receives respite on February
25th, provider must submit progress notes / billing data forms by March 7th in order to obtain
reimbursement on the 15th of the month. Progress notes / billing data forms received between the 7th
and 13th day of the month , will be paid on the next payment schedule. Billing forms received
after this date and that are unable to be entered as a result of the State mandated deadline, will
not be reimbursable.
Days Service Delivered
Paperwork Due dates
1st thru 15th of month
18th of the same month
16th thru end of the month
No later than 7th of following month
Billing does not have to accompany progress notes.
1. All progress notes should end with writer’s full name, title and name of
company
2. Progress Notes are to be clear and clean documentation, reflecting a “face-toface contact” integrating the below guidelines:
 Can someone else read my writing, is it legible?
 How did I communicate with the individual regarding their training needs?
 Was my communication with them directly tied to the Support Plan/Action
Steps
 Does the note reflect and show purpose and intent?
 Does the note reflect progress on the action step? Have they shown
improvement since the last training? If not, did I why they did not
16









g.
Section 8.
improve, what were the problems? (i.e. problems with family, boss,
seizures, medication…)
How did I help them with these problems?
Can I tell from my note, how I intend to help them meet their training
objective or how we will work on this in the future?
Can I tell from my note if the individual is responding to the service?
Does the note reflect when and where the service took place, location?
Did I sign my title with my name?
Did the individual identified in the progress note sign the note also?
Did I date the note?
Written in black or blue ink only, no white out/correction ink
One line corrections with initials and date
Referred Individuals: Gulf Coast Center Individuals that have gone through
Department of Assistive and Rehabilitative Services – DARS and obtained
employment, should be identified to Liaison Workers.
Provider Agency Documentation
a.
Provider must maintain records necessary to verify services delivered and billed to
Authority.
b.
Provider must additionally maintain records including the following:
1. Names of all Individuals enrolled with Provider and the type of service(s)
authorized
2. Evidence of licensure, certification or accreditation, as appropriate.
(Department of Assistive and Rehabilitative Services for Supported
Employment (if applicable-not required), Department of Labor for Sheltered
Workshop)
3. Evidence of insurance coverage
4. Evidence of annual criminal history checks, Nurses Aide Registry and
Employee Misconduct Registry checks of staff
5. Evidence of successful completion of required staff training
6. Annual fire marshal/fire safety inspections
Section 9.
Claims and Billing
a.
Bills for Payment. Provider may choose to submit a billing invoice to Authority
either on a monthly or bi-monthly basis, however; ALL documentation must be
received no later than the 7th day of the following month in order to be paid on the
15th of that month., NOTE: If the 18th or 7th falls on a weekend, they are due on the
previous Friday Provider agrees that failure to submit claims within such time
period may, at Authority’s sole discretion, result in disallowance of the claims for
the purposes of payment. All claims will be considered final unless Provider
requests an adjustment in writing within sixty (60) days after receipt of payment
from Authority.
b.
Billing data sheets for all services shall report Location of Services, Type of
Service, Dates of Service, Total Duration of Services, Start Time and End Time,
17
c.
d.
Attendance status, and units billed. Total duration shall reflect accurate hours of
direct service delivery per day as indicated on The Gulf Coast Center Billing Data
Form (Attachment I).
Billing data sheets for Employment or Community supports must be accompanied
by specific service products as identified in the IPC/PDP. Provider shall report
status on current actions steps identified in the IPC/PDP.
Bills should be sent to: Gulf Coast Center
Attn: Gulf Coast Center Liaison
7000 Ave B
Santa Fe, TX 77510
Billing questions should be directed to Barry Kusnerik at (409) 944-4449.
e.
The Bill for Services should include all Individuals for whom payment is being
requested and show the total amount due Provider for the billing period.
Specific information is required on each Individual to process payment of the Bill:
 The name of the Individual
 Dates of services provided
 The number of units under each service being billed
 The amount due per Individual based on the services provided, less any other
payor reimbursement (such as Department of Assistive and Rehabilitative
Services funding)
f.
Supporting documentation (Progress notes, Employment Profiles, etc.) should
be sent directly to the Gulf Coast Center Liaison. Documentation requirements
for the various services are included in Section 7 of this manual and with the
service descriptions.
g.
Other payors. If the Individual has another payor for the service (such as
(Department of Assistive and Rehabilitative Services – DARS)), the other payor
must be billed and benefits exhausted prior to billing Authority for the services.
h.
Payments will typically be made to Provider for Authorized Services within 30
days of receipt of the Bill for Services. If supporting required documentation is
not submitted to the Liaison, payments to the Provider will not be processed, but
will be held pending receipt of all required documents. Billing forms and
supporting documentation received after 13th of the month, for all services
delivered in the preceding month, that are unable to be entered as a result of the
State mandated deadline, will not be reimbursable
Section 10.
a.
Reporting Requirements
Abuse, Neglect, Exploitation. Providers must report to the Department of
Family and Protective Services (at 800-647-7418) all allegations (which effects all
individuals being served by the Provider whether under this Network or not) of
abuse, neglect, and exploitation in compliance with federal and state law, rules,
and regulations, and Authority policies and procedures. Incident Reports
concerning only those individuals that are also Authority consumers receiving
18
services should be faxed to the Authority’s Rights Protection Officer within 24
hours. (Fax no. (281) 338-2460).
b.
:
Critical Incidents. Providers are required to fax an incident report with
information regarding the occurrence of any of the following critical incidents
within 24 hours to the Authority’s Rights Protection Officer at (281) 338-2460.
1. Deaths
2. Suicide attempts/threats with plan
3. Serious injury
4. Allegations of abuse, neglect, or exploitation
5. Allegations of homicide/attempted homicide/threat with a plan
6. Serious medication errors -- the incorrect or wrongful administration of a
medication (such as a mistake in dosage, route of administration or intended
consumer), a failure to prescribe or administer the correct drug, medication
omission, failure to observe the correct time for administration, or lack of
awareness of adverse effects of drug combinations which place the
Individual’s health at risk so that immediate medical intervention or enhanced
surveillance on behalf of the Individual is required.
7. Incidents of restraint or seclusion
The Service Coordinator for the Individual should also be notified.
Critical Incident Reporting forms must be completed monthly on those
critical incidents indicated on the page entitled “Types of Reportable Data”
(attachments)
Section 11.
a.
Staff Training Requirements
Training. The Provider and Provider staff are required to meet the training
requirements to work with Authority clients.
Provider may submit training policies, procedures and materials to verify that
training requirements are met. Authority Staff Development Director will review
submitted training materials upon request. Training may be provided by the
Provider or obtained from another entity as long as the training meets the required
job competencies, as determined by Authority. Questions regarding training
should be directed to the Authority’s Human Resources Dept at (409) 763-2373.
In addition, Authority staff will offer technical assistance and support to providers
on any area of service requested.
b.
Scheduling Training with Authority. The Authority will provide a calendar of
annual training opportunities for each fiscal year to the Provider. Provider may
register staff for classes by sending a fax listing the names of those who will
attend to Human Resources Department at (409) 763-5538 at least two weeks
prior to the scheduled class. Provider will be billed for any persons registered, but
who do not give 24 hour cancellation notice by fax.
c.
Training Costs. Provider may use Authority’s Training Center to meet the
required training for staff and will be billed per person per class as follows:
19
Required Trainings
CPR
First Aid
Personal Outcomes (on hold)
PMAB - Initial
PMAB - Refresher
PMAB Refresher (as approved by our master instructor)
Documentation (GCC Liaison staff) no charge 4 hours
$27.00
$27.00
no charge
$50.00
$37.50
$18.75
4 hours
4 hours
8 hours
6 hours
4 hours
2 hours
NOTE. Special Needs trainings
Self Administration of Medications Training. Staff that assist individuals, who
requires the supervision of self administration of medication, will be required to
participate in this training. This training is offered thru The Gulf Coast Center
Essential Learning on-line training program for an annual fee of 12.00.
Diabetes Training – Staff that provide supports to individuals with diabetes will
be required to review training packet and take test. This training packet will be
distributed as needed.
High Blood Pressure – Staff that provide supports to individuals with high
blood pressures will be required to review training packet and take test. This
training packet will be distributed as needed.
Hypothyroidism – Staff that provide supports to individuals with
hypothyroidism will be required to review training packet and take test. This
training packet will be distributed as needed.
Additional trainings may be developed for staff as deemed appropriate to meet
the specific needs of the individual being served.
Optional Trainings
Person-Directed-Planning
(Required) Study Manual/Self Paced Test
Infection Control /AIDS/HIV Disease
Intro to IDD
Normalization
Screening & Crisis
Client Rights/Confidentiality/Reporting Abuse and Neglect
Corporate Compliance
(Required) Service Related Trainings/Video Tapes
**Supported Employment/Community Development
Provider must complete The Gulf Coast Center Supported employment documentation
requirements and trainings or demonstrate awareness of supported employment thru
other trainings or written summary of personal knowledge acceptable to MRA
Video tapes are also available regarding there service areas
Provider will be sent an invoice monthly for all training provided with a copy of the training
record attached.
20
PROVIDER TRAINING REQUIREMENTS
Provider Agencies (traditional provider) – Direct services in Community Support, Day
Habilitation, Supported Employment, Respite
Provider will be not be subject to the general personnel rules, regulations, and policies which affect the
activities of Authority employees except required training; specifically CPR (every two years); First Aid
(every 3 years), and PMAB (Preventive Management of Aggressive Behavior) (annually) Corporate
Compliance and Client Rights (annually), Infection Control (annually), Self Administration of
Medication, (annually, if applicable), Introduction to IDD (one time training), Normalization and
Sensitivity (one time training) and Screening and Crisis Management (annually). Provider will be
allowed 60 days upon signing of this contract to show evidence of completion of these trainings or be
subject to withholding of payment and/or termination of contract.
Individual Providers (non-traditional provider) – Direct services in Community Support,
Day Habilitation, Supported Employment, Respite
Provider will not be subject to the general personnel rules, regulations, and policies which affect the
activities of Authority employees except required training; specifically PMAB (Preventive Management
of Aggressive Behavior) as needed for individuals with behavioral challeges (annually) Corporate
Compliance and Client Rights (annually), Infection Control
Provider will be allowed 60 days upon
signing of this contract to show evidence of completion of these trainings or be subject to withholding of
payment and/or termination of contract.
Individual providers serving more than two individuals will require provider to be compliant in all
trainings as that of traditional provider
Training Matrix
Group
All
Course title
Identifying,
Reporting, and
Preventing Abuse
and Neglect
All
Consumer Rights
and Confidentiality
All
Infection Control
Direct Contact
Limited
contact
Screening and
Consumer Crisis
Related Job Competencies
Identify acts and possible signs of abuse and
neglect.
Safeguard consumer and evidence.
Report abuse and neglect.
Prevent abuse and neglect.
Uphold consumer rights (including confidentiality
and HIV/AIDS).
Report rights violations.
Identify consumers whose rights have been
temporarily
restricted
Implement temporary restrictions
Follow hand washing procedures
Use standard precautions.
Perform infection control techniques appropriate to
job role
Refer or screen consumer for services as
appropriate to job role.
Use face to face or telephone interviewing
techniques.
Apply principles of crisis intervention.
Initial Training
Preservice
Refresher
Annual
Preservice
Annual
Preservice
Annual
Preservice
Annual
21
All
Accident
Prevention and
Emergency
Response
Direct Contact
Limited
contact
Techniques for
prevention and
management of
aggressive behavior
All
Policies and
Procedure
All
Mission and
Service delivery
system
Direct Contact
Limited
contact
Needs and
Perspectives of
Consumers and
Families
All
HIV/AIDS
Unlicensed
staff
People with
Developmental
Disabilities
All IDD
Person-Centered
Approach
Direct Contact
Observing and
Reporting
Direct Contact
Seizure
Intervention
Direct Contact
CPR
Follow safety guidelines.
Report accidents and hazards.
Carry out responsibilities in emergencies, including
fires, weather emergencies and work place violence
situations
Use verbal intervention techniques to prevent
aggression.
Protect self and others from aggressive behavior
using appropriate verbal or physical techniques
Preservice
As locally
determined
Preservice
Annual
Act in accordance with MHMRA policies,
procedures, and standards, including standards for
ethical and professional conduct.
Communicate about service delivery system.
Partner to create options responsive to consumers
needs and preferences
Promote mission and goals
Interact with families and consumers sensitive to
their needs, situations, and perspectives.
Identify service outcomes valued by consumers and
families.
Provide equal access to consumers with special
needs.
Interact and implement treatment based on
knowledge about how differences (cultural or
disability related) may influence perspectives and
needs.
Communicate accurately about HIV/AIDS.
Maintain confidentiality.
Practice HIV/AIDS prevention behaviors.
Use common definitions associated with priority
population.
Communicate facts about Individuals with
Developmental Disabilities
Attribute certain behaviors as related
Developmental Disabilities
Apply principles of normalization and personcentered approach in interactions and habilitation
planning and implementation.
Observe consumers for heath and behavioral status,
progress, medication side effects and interactions,
and seizures
Orally report events to appropriate people.
Document observation
Support safety and recovery of people experiencing
seizures
Within 60 days
As locally
determined
Within 60 days
As locally
determined
Within 60 days
As locally
determined
Within one year
As locally
determined
Within 60 days
As locally
determined
Within 60 days
As locally
determined
Within 60 days
As locally
determined
Within 60 days
Competency
checks
according to
locally
specified
schedule
Clear obstructed airways.
Perform rescue breathing.
Perform CPR. using technique appropriate to age
and physical characteristics of persons served
Within 60 days
Competency
checks
according to
locally
specified
schedule
22
Direct Contact
First Aid
Apply first aid decision-making procedure (include
activation of ERS).
Provide direct pressure.
Alleviate shock.
Alleviate heat exhaustion and heat stroke.
Identify signs of poisoning.
Contact and cooperate with EMS or Poison Control
Center
Perform roles in identifying and planning outcomes
with consumers and families.
Implement plans.
Evaluate effectiveness.
Coordinate and cooperate with other service
providers (including coordination of records).
Within 60 days
Competency
checks
according to
locally
specified
schedule
Direct Contact
Treatment/
Habilitation model
Within 60 days
Competency
checks
according to
locally
specified
schedule
Those who use
behavior
intervention
procedures
Behavior
Management
Restraint
Seclusion
Apply principles of least restrictiveness in
interventions and daily behavior building
interactions.
Apply behavior intervention procedures specific in
individuals.
Maintain consumer rights.
Follow restraint procedures.
Use mechanical restraints
Follow Seclusion procedures
(MH only)
Apply knowledge of basic pharmacology, policies
and procedures.
Supervise the self-administration of medication.
Document self-administration.
Prior to implementing
behavior management
When new
procedures
are introduced
Direct Contact
who supervise
selfadministration
of medication
Those who
serve
consumers
with physical
or sensory
disabilities
Those who
prepare menus
or food or
assist with
dining
All who
handle
materials
identified as
hazardous
Supervising the
Self-administration
of Medication
Before supervising selfadministration of medication
As locally
determined
Using Adaptive
Equipment
Assist with or use adaptive equipment specific to
the individual
Before serving individuals
using adaptive equipment
As locally
determined
Food Service Skills
Apply principles of nutrition in menu planning.
Support special diets.
Follow procedures to prevent contamination of
food.
Before preparing menus or
food
As locally
determined
Hazardous
Materials
Identify chemical and materials that are hazardous.
User proper techniques and protective equipment in
handling and disposal of hazardous materials
Prior to handling hazardous
materials
When
exposure to
hazardous
materials
changes
significantly
23
Section 12.
Complaints
a.
Complaints from Individuals
1. Provider must inform Individuals that they may file a complaint with the
Authority specific to services delivered regarding the Provider by calling
Barry Kusnerik at (409) 944-4449.
2. Individuals may also call the Authority’s Rights Protection Officer with
suspicions of right violations, abuse, neglect or exploitation at 888-839-3229
Monday – Friday 8:00 am to 5:00 pm.
3. Individuals may also call the Texas Department of Family and Protective
Services 1-800-647-7418 24 hours to report allegations of abuse and neglect.
b.
Complaints from Provider. The Authority desires a successful partnership with
Provider to best serve the Individuals. To this end, Authority encourages Provider
to call with concerns, problems and complaints regarding the Authority’s
operations and interactions with Provider. Complaints should be directed to the
Chief Operations Officer at (888) 839-3229. Every effort will be made to address
the issues involved.
Section 13.
Contract Monitoring
a.
The Authority’s Director of IDD Provider Services or his designee will conduct
reviews to include, but not limited to:
1. Special reviews based on complaints or other client related incidents
2. Verification of training, licensure, certification, insurance
3. Annual criminal history background checks, Nurses Aide Registry and
Employee Misconduct Registry completed on all direct service employees
(this is included in the TxHmL TAC 419.579 (q) (1)(2)(3)
4. Facility safety checks including but not limited to accessibility, cleanliness,
ADA compliance, Annual Fire Marshall/Fire and Safety reports, and etc.
b.
Reviews will be scheduled in advance with Providers whenever possible. The
Authority contact person for contract monitoring is:
Barry Kusnerik
The Gulf Coast Center
7000 Ave B
Santa Fe, TX 77510
Section 14.
a.
Sanctions, Appeals and Contract Termination
Authority shall take punitive recourse for actions that pose a hazard to Individuals
or potentially violate Services guidelines.
b.
Penalties/Sanctions. The failure of the Provider to perform any responsibility set
forth in this manual, the signed Provider Agreement, its exhibits or attachments,
or any law, regulation, rule or requirement incorporated by reference may result in
any one or more of the following to be imposed or taken by the Authority, subject
to notice as provided herein:
1. Submission of a Plan of Correction to the Authority;
2. Return funds to the Authority:
i.
For serving unauthorized persons with funds subject to the Provider
Agreement and
ii.
For using funds for unauthorized purposes
3. Withholding by the Authority, in whole or in part, any payments due and
owing to the Provider until the Provider has cured the breach to the
satisfaction of the Authority;
4. Legal action to protect or remove Individuals when the life, health, welfare, or
safety of one or more Individuals is endangered, or could be endangered or if
the Authority has a reasonable belief that the Provider has engaged in the
misuse of state or federal funds, fraud, or illegal acts;
5. If Authority is able to demonstrate a direct link between a sanction or penalty
imposed upon Authority by any State Agency due to Provider’s performance,
Provider will refund/reimburse/remit to Authority those portions of the
sanction/penalty assessed to Authority. Examples of such instances would be
documentation chart audits, CARE accuracy, failure to report accurate and
timely information/data, and etc.
6. Suspension of participation in the provider network and/or or withholding of
new referrals until performance deficiency or breach is cured to the
satisfaction of the Authority; and/or
7. Termination of Provider Agreement.
c.
Imposition of Penalties. The Authority’s Director of IDD Provider Services or
his/her designee shall commence the imposition of penalties as set out in this
section when the Director of IDD Provider Services is of the opinion a failure to
perform by the Provider has occurred. This procedure shall utilize the following
steps:
1. Prior to imposing any penalty, the Authority Director of IDD Provider Services
shall send the Provider a Proposal of Penalties by certified mail stating any
alleged breach(es) and the applicable penalty;
2. The Provider shall file any response with the Authority’s Legal Affairs
Director within ten (10) business days from the date the notice is received;
3. The Legal Affairs Director shall review the response, and if the Director
concludes that a breach has occurred, shall send out a “Notice of Penalties” by
certified mail fifteen (15) days from the date of receipt of the Provider’s
Response;
4. The “Notice of Penalties” shall be sent to the Provider, the Authority’s
Executive Director, and the Authority’s Chief Financial Officer. If a Notice of
Appeal is not filed by the Provider within fifteen (15) days from the date of
2
the “Notice of Penalties”, the appropriate action will be imposed by the
Authority’s Legal Affairs Director.
d.
Appeals. Any Provider receiving a “Notice of Penalties” may appeal the
imposition by filing a “Notice of Appeal” with the Authority’s Executive Director
within fifteen (15) days of the date of receipt of the “Notice of Penalties”. The
procedure should be as follows:
1. The Authority’s Executive Director will select three (3) persons to form a
resolution panel to hear the appeal within the time period specified. At least
one member of the panel must be an employee of another Provider;
2. The panel shall hold a conference within the time period specified by the
Authority’s Executive Director. Based upon information presented by the
Provider and Authority, the panel shall make recommendations concerning the
resolution of the alleged breach (es). The Authority’s Executive Director
serves as final authority in the resolution process and may accept or reject all
or part of the panel’s recommendations. Provider shall be notified of the
Authority’s Executive Director’s final determination in writing; and
3. The appeal of any penalty shall stay in the imposition of such action. If the
penalty is affirmed, the Provider shall remit any monetary amounts assessed in
the affirmed action to the Authority’s Chief Financial Officer. The Authority
may seek recovery of the amount in any court of competent jurisdiction.
4. Appeals will be subsequently reviewed by the Corporate Compliance
Committee (CCC) for administrative consistency and recommendations. The
CCC’s recommendation(s) have no bearing on Section 14.d but are for
internal use only.
e.
Contract Termination. If the contract/agreement is terminated, Provider is
expected to cooperate with the Authority in the transfer of Individuals to other
providers.
1. Immediate Termination. Authority may terminate the Provider Agreement
immediately if:
(a)
Authority does not receive the funding allocation to pay for designated
services under the Provider Agreement from the Texas Legislature or
the designated State Agency responsible for allocating funds to the
Authority for individuals with Developmental Disabilities
(b)
Authority has cause to believe that termination of the Agreement is in
the best interests of the health and safety of the persons with mental
disability served under the Agreement;
(c)
Provider has become ineligible to receive Authority funds;
(d)
Provider or its employees has its Texas license or certification
suspended or revoked;
(e)
in the case of Providers providing direct services to clients, failure to
disclose a criminal conviction;
(f)
if the Provider submits falsified documents or fraudulent billings, or if
the Provider makes false statements; or
3
2. Termination upon Default. Upon written Notice of Default of any of the
obligations to be performed under the terms of this Agreement, the defaulting
party will have fifteen (15) days in which to correct or cure the default to the
reasonable satisfaction of the non-defaulting party. If, at the end of such
fifteen (15) days cure period, such default remains uncorrected, then and in
such event, the non-defaulting party shall have the right to terminate this
Agreement upon an additional fifteen (15) day written Notice of Termination
to the defaulting party.
3. Termination by Mutual Consent. This Agreement may be terminated with
thirty (30) days written notice by the parties’ mutual consent or by the parties’
inability to agree to subsequent amendments to this Provider Manual or the
Provider Agreement.
4. Termination for Failure to Disclose Criminal Conviction. The Authority may
immediately terminate this Agreement at its sole discretion if it determines
that the Provider did not fully and accurately disclose the following
information concerning persons convicted of crimes:
a. The identity of any employee, officer, or other person directly or indirectly
involved in this Agreement who has been convicted of any criminal
offense related to any state or federally funded program; or
b. The identity of any employee, officer, or other person directly or indirectly
involved in this Agreement who is in direct contact with persons served
and who has been convicted of a crime including any sexual offense, drugrelated offense, homicide, theft, assault, battery, or any other crime
involving personal injury or threat to another person.
1) Should any person have a conviction described above, Provider will
immediately remove the individual from direct contact with persons
served.
2) If the Provider has a conviction described above, this Agreement may
be terminated immediately.
5. Effect Upon Notice of Termination. Upon notice of termination, Provider will
cooperate fully with Authority in the transfer of Individuals to other services.
Provider recognizes that during any notice period preceding the effective date
of termination, Authority, may at its sole discretion, deny authorization to
Individuals to receive Services.
6. Effect upon Termination. Upon termination, the rights of Authority and
Provider under this Agreement will terminate, except that termination will not
release the parties of their respective obligations with respect to:
a. Payments accrued for authorized Services by Provider prior to
termination;
4
b. Provider’s agreement not to seek compensation from Individuals for
Services prior to termination of this Agreement;
c. The continuation of Provider’s care for Individuals receiving Services
from Provider until continuation of the Individuals’ care can be arranged
by Authority. Authority will reimburse Provider for such care pursuant to
the terms of this Agreement; and
d. Requirements of this Agreement regarding confidentiality and record
retention will survive this Agreement.
7. Dispute Resolution. In the event a dispute arises between the parties
involving the provision or interpretation of any term or condition of this
Agreement, and both parties desire to attempt to resolve the dispute prior to
termination or expiration of the Agreement, or withholding payments, then the
parties may refer the issue to a dispute resolution panel composed of at least
three persons selected by the Authority’s Executive Director or his designee
and adhere to the following steps:
a. At least one member of the panel must be an employee or designee of the
Provider, at least one member must be an employee of the Authority and at
least one member must be an employee of another Network Provider or a
representative from the ARC of the Gulf Coast.
b. The panel shall hold a conference within the time period specified by the
Authority’s Executive Director or his designee.
c. The panel shall make written recommendations concerning the resolution
of the dispute based upon information presented by the Authority and
Provider.
d. The recommendation shall be submitted to the Provider within the
specified time frame.
e. The Authority’s Executive Director or his designee serves as the final
authority in the resolution process and may accept or reject all or part of
the panel’s recommendations.
f. Provider shall be notified of the Authority’s Executive Director or his
designee’s final determination in writing.
5
ATTACHMENT A
Community Support (R021)
1. Service Category: IDD Community Services
Services provided to assist an individual to participate in age-appropriate community activities
and services. The type, frequency and duration of Support Services are specified in the
individual’s Plan of Services and Supports. The MRA ensures that an array of Support
Services is available in the LSA. This service category includes:
Community Support - Individualized activities that are consistent with the individual’s persondirected plan and provided in the individual’s home and at community locations, (e.g., libraries
and stores). Supports include:
. habilitation and support activities that foster improvement of, or facilitate an individual’s
ability to perform functional living skills and other daily living activities;
. activities for the individual’s family that help preserve the family unit and prevent or limit
out-of-home placement of the individual;
. transportation for an individual between home and the individual’s community employment
site or day habilitation site; and
. transportation to facilitate the individual’s employment opportunities and participation in
community activities.
2. Required activities:
a) Face-to-face contact to assist, train, and support the individual’s participation in home or
age appropriate community activities available to and used by the rest of the community.
b) Face-to-face support services provided to the individual’s family member to preserve the
family unit/prevent or limit out-of-home placement.
c) Individualized, habilitation or support services (including transportation) identified in the
individual’s plan of services and supports (which is the plan in place at the time the
service was delivered).
d) The monthly contact is accomplished face-to-face with the individual or family member
unless the activity meets the criteria listed under Optional Activities #3. d.
e) Phone calls are not a covered activity.
3. Optional activities:
a) Crisis intervention.
b) Participation in service planning team meetings.
c) Providing transportation for an individual to/from home directly to the individual’s
community employment site or day habilitation/vocational training site and transportation
to facilitate the individual’s employment opportunities and participate in community
activities as specified in the plan of services and supports (e.g., Individual will receive
Supported Employment services once a week with transportation provided daily to the job
site).
d) Face-to-face contacts with a collateral who represents a community organization that is
identified in the individual’s plan as a setting where the individual would like to participate
6
in an activity. The contact must be focused on the interests of the specific individual
served as identified in that individual’s plan. Documentation should include reasons why
the individual served is not present during the contact. Any monitoring activity after the
individual is established with a community organization would not be an acceptable
activity. That may be part of service coordination monitoring.
e) Functional living skills assessment done face-to-face with the individual if the purpose of
the assessment is to focus on how best to approach a community living skill (e.g., using a
bus).
4. Prohibited activities:
a) Services provided to individuals residing outside their own home or family home or
receiving residential services.
b) Individuals in OBRA should not be opened to this service.
c) Phone calls under any condition.
d) Any activity that directly supports the individual but is not face-to-face with the individual
or family member of the individual (e.g., meal prep, shopping, etc.) and not consistent with
the exception noted in #3.d above.
e) Habilitation activities provided and reported as part of Day Habilitation.
f) Community Support may not be reported simultaneously with Hourly Respite.
g) Providing transportation for individuals from one day habilitation/supported employment
site to another or during the time Day Habilitation is being reported/provided.
h) Community Support may not be reported when the purpose of the service is to provide
planned or emergency relief of the unpaid caregiver (this is respite).
i) Community Support (including transportation) provided by someone who lives with the
individual.
j) Community Support provided simultaneously with Day Habilitation/Vocational Training
services.
k) Community Support may not be used to pay for tuition for a day camp.
5. Minimum frequency of service delivery:
Monthly
6. Mutually exclusive with any other services:
Family Living (R031), Residential Living (R032), and Contracted Specialized Residences
(R033)
7. Differentiation from other similar services:
N/A
8. Location specific (e.g., at home, at an office):
Own home, natural home or community, majority of the time spent in the activity occurs away
from the program site (meeting at and dispersing from a program site prior to and after
community activities is acceptable).
9. Limited to sub-population of priority population:
7
N/A
10. Reference document, law, rule, policy, etc.:
Current Performance Contract
11. Clarifications:
a) “Other Community Locations” referenced in the definition does not include MRA
locations.
b) Transportation reported under this service includes
i) Transportation of an individual to a Day Habilitation/Vocational Training site to begin
or end day habilitation services and
ii) Transportation of an individual to provide a Community Support service, Employment
Assistance or Supported Employment
c) Transportation reported under Community Support but in the absence of any other
support services (e.g., Supported Employment) is expected to be time limited
demonstrating a shift toward more natural supports to address transportation needs.
Transportation under Community Support services is intended to assist individuals in
obtaining or maintaining outcomes in the community. Other resources for transportation
should be explored first to justify the need for GR funded transportation. The need for GR
funded Community Support including transportation must be documented in the plan of
services and supports. The plan must demonstrate how transportation will assist the
individual in obtaining or maintaining his/her outcomes.
d) Collateral is defined as family member of the individual.
e) Community Support does not include payment for room or board and may not be provided
at the same time that Hourly Respite, Day Habilitation, Vocational Training or Supported
Employment services are provided.
f) For individuals attending public school, R021 services must be delivered outside the
individual’s public school day.
g) Community Support is provided to individuals living in their own home or family homes.
The services include provision of assistance, training and support necessary for the
individual to complete personal care, health maintenance, and independent living tasks;
participate in community activities, and develop, retain and improve community living
skills. Crisis intervention activities provided in the home setting are also captured in this
category.
h) Community Support can include habilitation activities that include, but are not limited to,
training in self help and independent living skills, implementation of programs developed
by a licensed therapist, and implementation of programs to develop appropriate social
behaviors.
i) Services must be provided to households that support the family’s effort to maintain the
individual in the home or to family members to prepare and support the family in
reintegrating an individual from an out-of-home living arrangement.
j) Community Support may not be reported when staff assistance is not needed by an
individual to achieve goals or outcomes, complete personal care, maintain health and
independent living skills, participate in community activities, or develop, retain, and
improve community living skills.
8
k) Volunteer work must be consistent with the Fair Labor Standards Act. Volunteering
should be in positions that were created and exist for “people without disabilities” as well.
Volunteering to determine if a person likes or is qualified for a job is not acceptable as an
R021 activity.
l) A day camp that meets the definition of day habilitation should be coded as Day
Habilitation (R053) and not Community Support. If an individual needs support to
participate in a summer camp, Community Support could be used, on an hourly basis, to
provide support for the person to be integrated into camp activities. Community Support
can not be used to pay for tuition to a day camp. Community Support can not be
provided during the same time a person is receiving Day Habilitation.
m) A foster family home is consistent with family home and therefore not considered
residential services.
9
Out-of-Home Respite (Required Service) (R022)
1. Service Category: IDD Community Services
Services provided to assist an individual to participate in age-appropriate community activities
and services. The type, frequency and duration of Support Services are specified in the
individual’s Plan of Services and Supports. The MRA ensures that an array of Support
Services is available in the LSA. This service category includes:
Respite - Planned or emergency short term relief services provided to the individual’s unpaid
caregiver when the caregiver is temporary unavailable to provide supports due to non-routine
circumstances. This service provides an individual with personal assistance in daily living
activities (e.g., grooming, eating, bathing, dressing and personal hygiene) and functional living
tasks. The service includes assistance with: planning and preparing meals; transportation or
assistance in securing transportation; assistance with ambulating and mobility; reinforcement
of behavioral support or specialized therapies activities; assistance with medications and the
performance of tasks delegated by an RN in accordance with state law; and supervision of
the individual’s safety and security. The service also includes habilitation activities, use of
natural supports and typical community services available to all people, social interaction and
participation in leisure activities, and assistance in developing socially valued behaviors and
daily living and functional living skills.
Note 1: Persons assigned to Residential Living Services or Contracted Specialized
Residences may not be reported in Respite.
Note 2: “Respite” is a Required service, but either In-Home or Out-of-Home Respite will
satisfy the requirement for providing the Required service. All members of the priority
population(s) are eligible for this service and this service must be provided with resources
other than In-Home and Family Support.
This service includes:
Out-of-Home Respite – Respite provided outside of the individual’s residence. This includes
Hourly Respite, grid code 3122, which has a maximum duration of 10 hours per encounter,
and Daily Respite, grid code 3132. Daily Respite is reported if the planned duration is either
overnight or greater than 10 hours. Client_Time reported for Daily Respite may be less than
10 hours per day. All Daily Respite encounters are converted to 24 hours upon processing of
the final encounter data file.
2. Required activities:
a) Relieve primary care providers of responsibilities on temporary basis for short period of
time.
b) Care and supervision of individuals outside of their residence (i.e., out of home).
c) Maximum duration is 30 consecutive days per episode.
d) The need for a Respite service must be documented on the Plan of Services and
Supports or Respite Plan (if no other R0 assignments) with an exception allowed in an
emergency situation with unplanned respite needs.
10
e) The plan must specifically denote the amount and payer of respite service (to distinguish
from IHFS funded respite).
f) Face-to-face contact with the individual to provide respite care.
3. Optional activities:
a) Transportation during the course of respite service.
b) Transportation from respite service to another service such as Day Habilitation.
4. Prohibited activities:
a) Continuous overnight placement for more than 30 consecutive days.
b) Respite Care provided to individuals who live independently.
c) Hourly Respite (3122) may not be reported for the same time period that Day Habilitation,
Vocational Training, Community Support, Supported Employment or Employment
Assistance is reported.
5. Minimum frequency of service delivery:
Open and close per service event. Note: this service may be left open if provided at least
once per calendar month.
6. Mutually exclusive with any other services:
a) Cannot use In-Home Family Support money to provide this service.
b) Residential Living (R032) or Contracted Specialized Residences (R033).
7. Differentiation from similar other services:
Respite Services through In-Home Family Support may be documented on the same plan as
respite covered by general revenue but should be reported separately to CARE through the In
Home Family Support Program.
8. Location specific (e.g., away from the family home or at a home designated for respite):
A variety of locations.
9. Limited to sub-population of priority population:
N/A
10. Reference document, law, rule, policy, etc.:
a) Current Performance Contract
b) §534.053(a)(4) Texas Health and Safety Code
11. Clarifications:
a) In all cases, the “plan” must address the amount and payer of respite services to
distinguish from IHFS funded respite, likely noted in the same plan starting in FY
2004.
b) Out-of-Home Respite provides care to and supervision of individuals out of their usual
residence. This service is intended to relieve family members or other primary care
11
providers of their responsibilities for providing care on a temporary basis for short periods
of time. It may be provided at a variety of locations, e.g., the home of a relative or a family
friend, a home specifically for respite, a location usually considered a Residential Service,
or a private facility, e.g., a hospital. Duration of this service may be for a part of one day
or for several consecutive days, but it is intended that it be temporary and brief.
Continuous overnight placement in a Respite situation for more than 30 consecutive days
usually requires assignment to a Residential Service. Appropriate standards for an out-ofhome
situation (e.g., Respite, Residential) will apply.
c) “Non-routine” is intended to allow for regularly scheduled respite services. Respite may be
provided regularly but is not intended to provide caregiver relief during routine caregiver
working hours (e.g., Day Care).
d) As the need for respite services, except in an emergency situation, should be documented
on the Plan of Services and Supports or Respite Plan (if no other R0 assignments) an
entry of “as needed” for the frequency, etc., does not really state what the individual is to
receive. The preferred or best practice would be to include the specifics for amount and
frequency in the plans. From the DVR perspective, it seems that allowing the plan to
describe the maximum number of hours is okay but in doing so the frequency, if not
addressed, could be interpreted a number of ways (e.g., per day, per week, etc.). Per #
11.a. above, the plan must also address amount and payer of respite services.
e) The Mental Retardation and Behavioral Health Outpatient Warehouse (MBOW) will
automatically substitute a value of “24” for the Client Time field on all records for Daily
Respite, grid code 3132, regardless of the value submitted on the record. This field will
not be verified in Data Verification activities at either the local or DADS levels and will be
scored “NA” for Daily Respite encounters.
f) MBOW will not convert the Start Time to 00:00 in an encounter for Daily Respite, grid
code 3132. Daily services do not require that edit. The Start Time field will not be verified
in Data Verification activities at either the local or DADS levels and will be scored “NA” for
Daily Respite encounters.
12
In-Home Respite (Required Service) (R023)
1. Service Category: IDD Community Services
Services provided to assist an individual to participate in age-appropriate community activities
and services. The type, frequency and duration of Support Services are specified in the
individual’s Plan of Services and Supports. The MRA ensures that an array of Support
Services is available in the LSA. This service category includes:
In-Home Respite - Planned or emergency short term relief services provided to the
individual’s unpaid caregiver when the caregiver is temporary unavailable to provide supports
due to non-routine circumstances. This service provides an individual with personal
assistance in daily living activities (e.g., grooming, eating, bathing, dressing and personal
hygiene) and functional living tasks. The service includes assistance with: planning and
preparing meals; transportation or assistance in securing transportation; assistance with
ambulating and mobility; reinforcement of behavioral support or specialized therapies
activities; assistance with medications and the performance of tasks delegated by an RN in
accordance with state law; and supervision of the individual’s safety and security. The
service also includes habilitation activities, use of natural supports and typical community
services available to all people, social interaction and participation in leisure activities, and
assistance in developing socially valued behaviors and daily living and functional living skills.
Note 1: Persons assigned to Residential Living Services or Contracted Specialized
Residences may not be reported in Respite.
Note 2: “Respite” is a Required service, but either In-Home or Out-of-Home Respite will
satisfy the requirement for providing the Required service. All members of the priority
population(s) are eligible for this service and this service must be provided with resources
other than In-Home and Family Support.
This service includes:
In-Home Respite – Respite based at the home of the individual. This includes Hourly
Respite, grid code 3123, which has a maximum duration of 10 hours per encounter, and
Daily Respite, grid code 3133. Daily Respite is reported if the planned duration is either
overnight or greater than 10 hours. Client_Time reported for Daily Respite may be less than
10 hours per day. All Daily Respite encounters are converted to 24 hours upon processing of
the final encounter data file.
2. Required activities:
a) Relieve primary care providers of responsibilities on temporary basis for a short period of
time.
b) Care and supervision of individuals at their residence (i.e., in home).
c) Maximum duration is 30 consecutive days per episode.
d) The need for a Respite service must be documented on the Plan of Services and
Supports or Respite Plan (if no other R0 assignments) with an exception allowed in an
emergency situation with unplanned respite needs.
13
e) The plan must specifically denote the amount and payer of respite service (to distinguish
from IHFS funded respite).
f) Face-to-face contact with the individual to provide respite care.
3. Optional activities:
a) Transportation during the course of respite service.
b) Transportation from respite service to another service such as Day Habilitation.
4. Prohibited activities:
a) Continuous overnight placement for more than 30 consecutive days.
b) Respite Care provided to individuals who live independently.
c) Hourly Respite (3123) may not be reported for the same time period that Day
Habilitation, Vocational Training, Community Support, Supported Employment or
Employment Assistance is reported.
5. Minimum frequency of service delivery:
Open and close per service event. Note: this service may be left open if provided at least
once per calendar month.
6. Mutually exclusive with any other services:
a) Cannot use In-Home Family Support money to provide this service.
b) Residential Living (R032) or Contracted Specialized Residences (R033).
7. Differentiation from similar other services:
Respite Services through In-Home Family Support may be documented on the same plan as
respite covered by general revenue but should be reported separately to CARE through the In
Home Family Support Program.
8. Location specific:
Based at the family home only
9. Limited to sub-population of priority population:
N/A
10. Reference document, law, rule, policy, etc.:
a) Current Performance Contract
b) §534.053(a) (4) Texas Health and Safety Code
11. Clarifications:
a) In all cases, the “plan” must address the amount and payer of respite services to
distinguish from IHFS funded respite likely noted in the same plan starting in FY
2004.
b) In-Home Respite provides care to and supervision of individuals based at their usual
residence. This service is intended to relieve family members or other primary care
14
providers of their responsibilities for providing care on a temporary basis for short periods
of time. Duration of this service may be for a part of one day or for several consecutive
days, but it is intended that it be temporary and brief. Continuous overnight placement in a
Respite situation for more than 30 consecutive days usually requires assignment to a
Residential Service. Appropriate standards for an out-of- home situation (e.g., Respite,
Residential) will apply.
c) “Non-routine” is intended to allow for regularly scheduled respite services. Respite may be
provided regularly but is not intended to provide caregiver relief during routine caregiver
working hours (e.g., Day Care).
d) As the need for respite services, except in an emergency situation, should be documented
on the Plan of Services and Supports or Respite Plan (if no other R0 assignments) an
entry of “as needed” for the frequency, etc., does not really state what the individual is to
receive. The preferred or best practice would be to include the specifics for amount and
frequency in the plans. From the DVR perspective, it seems that allowing the plan to
describe the maximum number of hours is okay but in doing so the frequency, if not
addressed, could be interpreted a number of ways (e.g., per day, per week, etc.).
e) The Mental Retardation and Behavioral Health Outpatient Warehouse (MBOW) will
automatically substitute a value of “24” for the Client Time field on all records for Daily
Respite, grid code 3133, regardless of the value submitted on the record. This field will
not be verified in Data Verification activities at either the local or DADS levels and will be
scored “NA” for Daily Respite encounters.
f) MBOW will not convert the Start Time to 00:00 in an encounter for Daily Respite, grid code
3133. Daily services do not require that edit. The Start Time field will not be verified in
Data Verification activities at either the local or DADS levels and will be scored “NA” for
Daily Respite encounters.
g) If the respite service is based at the consumer's home, it should be recorded as In-Home
Respite, even if the service involves travel to different locations.
15
Employment Assistance (R041)
1. Service Category: IDD Community Services
Services provided to assist an individual to participate in age-appropriate community activities
and services. The type, frequency and duration of Support Services are specified in the
individual’s Plan of Services and Supports. The MRA ensures that an array of Support
Services is available in the LSA. This service category includes:
Employment Assistance – Assistance to an individual in locating paid, individualized,
competitive employment in the community, including:
. helping the individual identify employment preferences, job skills, work requirements
and conditions; and identifying prospective employers offering employment compatible
with the individual’s identified preferences, skills and work requirements and
conditions.
2. Required activities:
a) Assistance in choosing and obtaining employment.
b) Services and supports are identified in the individual’s Plan of Services and Supports
(which is the plan in place at the time the service was delivered).
c) Services and supports provided longer than a 180-calendar day period should be justified
by the service planning team in the individual’s record.
d) Contacts are accomplished face-to-face with the individual or by phone contact
with the individual or collateral (i.e., prospective employer or LAR/family member
with whom they live) by supported employment staff to provide employment
assistance that identifies the individual’s skills, preferences, and requirements for
employment and on behalf of the individual to negotiate employment. Two of the
three monthly contacts in a three month period must be face to face with the
individual; the contact the remaining month may be either face to face or by
telephone with the individual or collateral.
3. Optional Activities:
Participation in service planning team meetings.
4. Prohibited Activities:
a) Employment Assistance provided when an individual is employed in the community unless
the plan of services and supports has identified outcomes for the individual to find
additional or more suitable employment.
b) Habilitation activities provided and reported as part of Employment Assistance are not
allowed (e.g., teaching/training to complete applications).
c) Providing transportation to an individual. This should be captured and reported under
Community Support – R021.
d) Staff travel time or time spent waiting to provide a service.
e) Face-to-face contact with an individual to provide Employment Assistance services
simultaneously with Day Habilitation services, Vocational Training services, Supported
16
Employment, Community Support or Respite.
f) Employment Assistance provided without an individual’s service planning team reauthorizing
the service after the expiration of the previous 180-day authorization.
g) Reviewing records or any other documentation regarding the individual.
5. Minimum frequency of service delivery:
Monthly
6. Mutually exclusive with any other services:
N/A
7. Differentiation from other similar services:
Day Habilitation (R053) is non-vocational and should lead to participation in the community in
any other interest area except employment.
8. Location specific (e.g., at home):
N/A
9. Limited to sub-population of priority population:
N/A
10. Reference document, law, rule, policy, etc.:
Current Performance Contract
11. Clarifications:
a) This service facilitates the individual’s employment by determining the individual’s
interests and needs around employment and contacting prospective employers on behalf
of the individual and negotiating the individual’s employment.
b) This service is provided no longer than 180 days from initial assignment unless justified by
the service planning team in the individual’s record. For data verification purposes,
assignment for more than 180 days from the date of the plan of services and supports
should be reviewed to analyze progress made toward choosing and securing employment
and to reassess the overall situation. Assignment longer than 180 days must be justified
in the individual’s record every 180 days that the assignment is open.
c) The intent for the 180-day review is for the employment assistance staff and the individual
to identify why the individual is not employed and determine what approach needs to be
taken. This activity is not Service Coordination review and authorization. Staff and
individual review of the overall situation will address:
1) how the type of job being secured was identified, and
2) how prospective employers were identified and approached.
d) For data verification purposes, the service planning team discussing and reauthorizing the
service will be minimally represented by the individual/LAR, MRA staff authorizing
services, and staff providing Employment Assistance Services.
e) Verification that the service is on the plan of services and supports will continue. If
the plan is older than 180 days, then evidence will be needed of continued
17
justification by the service planning team within 180 days prior to the selected
sample month. If the plan occurred within 180 days of the selected sample month,
no additional documentation will be necessary other than the plan. For example, if
the plan was done in 5/09 and the selected sample month is 12/09, the plan was not
done within 180 days of the selected sample month, so documentation justifying
continued need within 180 days after 5/09 and within 180 days prior to 12/09 must
be submitted for verification.
f) Any Employment Assistance services provided to the school age population must be
jointly developed in the individual’s transition plan, delivered in coordination with the
school district, and provided outside of the six-hour school day. Employment Assistance
services provided to a person who is home-schooled must be delivered outside of the
regular school day. The intent is to not use GR funds to provide something the school
district is obligated to provide.
g) Individuals in OBRA may not be open to R041.
h) Employment Assistance is directed toward individuals securing employment at a
community business as part of the competitively employed work force. The activities
provided are job development, which means the development of work relevant information
regarding the individual, employment planning and assisting the individual to secure
employment.
i) Collateral defined as prospective employer or LAR/family member with whom the
individual lives.
j) Employment Assistance is individualized and not delivered in a group setting.
k) Assisting the individual to complete and deliver an application as a component of
Employment Assistance in the absence of identifying the individual’s skills,
preferences, and requirements for employment is not an allowable Employment
Assistance activity. Service delivery documentation needs to support job
development and exploration, indicating the process and consideration given in
identifying a particular potential employer. Documentation must justify how
assistance with applications relates to that particular identified potential employer
as identified through the service planning process. Documentation must also
justify how job development activities relate to the individual’s skills, preferences
and requirements for employment as identified through the service planning
process.
l) If no other individualized Employment Assistance activity is evident in the sample month,
a service planning meeting to discuss continued need for the service is acceptable if the
staff that provide Employment Assistance services is in attendance. A meeting to discuss
discontinuation from services is not an acceptable activity.
m) Volunteering to determine if an individual likes or is qualified for a job is not acceptable as
an R041 activity.
n) Data Verification does not verify funding sources but verifies if GR funded services meet
the service definition.
18
Supported Employment (R042)
1. Service Category: IDD Community Services
Services provided to assist an individual to participate in age-appropriate community activities
and services. The type, frequency and duration of Support Services are specified in the
individual’s Plan of Services and Supports. The MRA ensures that an array of Support
Services is available in the LSA. This service category includes:
Supported Employment – Supported employment is provided to an individual who has paid,
individualized, competitive employment in the community (i.e., a setting that includes nondisabled workers) to help the individual sustain that employment. It includes individualized
support services consistent with the individual’s person-directed plan as well as supervision
and training.
2. Required activities:
a) Training, supports, or interventions related to sustaining the individual’s employment
provided directly to the individual by Supported Employment program provider staff or
contractors. Services and supports provided to maintain employment in regular
community jobs.
b) An integrated setting is defined as community jobs where no more than 1 employee or 3%
of coworkers have disabilities (unless the plan indicates otherwise or the employer
subsequently hires an additional employee with disabilities who is receiving services from
a provider other than the individual’s program provider).
c) Individual is compensated directly by employer.
d) Services and supports are provided by Supported Employment staff.
e) Services and supports are identified in the individual’s Plan of Services and Supports
(which is the plan in place at the time the service was delivered).
f) The monthly contact is accomplished face-to-face with the individual or by phone
call with the individual or collateral (i.e., supervisor/employer/coworker or
LAR/family member with whom they live). Two of the three monthly contacts in a
three month period must be face to face with the individual; the contact the
remaining month may be either face to face or by telephone with the individual or
collateral.
3. Optional Activities:
Participating in service planning team meetings to discuss continuing need for services. A
discharge staffing would not qualify as an R042 activity.
4. Prohibited Activities:
a) Individual is independently employed without services and supports.
b) Activities conducted prior to the individual’s employment such as employment interest
assessments or interviews conducted with the individual. Employment interest
assessments are captured under R041-Employment Assistance.
c) Community job development activities such as job searches or completing job
applications. These activities are captured and reported under R041-Employment
19
Assistance if consistent with conditions outlined under R041 #11k, otherwise captured
and reported under R043.
d) Supported Employment services provided by someone other than Supported Employment
program provider staff or contractors.
e) Activities provided to an individual who is eligible for supported employment through the
public school system, the Department of Assistive and Rehabilitative Services (DARS),
etc.
f) Staff time spent providing transportation to an individual between the individual’s home
and the employment site. This is reported under R021-Community Support.
g) Volunteer work performed by the individual to determine if they like or are qualified for a
job.
5. Minimum frequency of service delivery:
Monthly
6. Mutually exclusive with any other services:
N/A
7. Differentiation from other similar services:
Day Habilitation (R053) is non-vocational and should lead to participation in the community in
any other interest area except employment.
8. Location specific (e.g., at home):
N/A
9. Limited to sub-population of priority population:
N/A
10. Reference document, law, rule, policy, etc.:
Current Performance Contract
11. Clarifications:
a) Any Supported Employment services provided to the school age population must be
jointly developed in the individual’s transition plan, delivered in coordination with the
school district, and provided outside of the six-hour school day. Supported Employment
services provided to a person who is home-schooled must be delivered outside of the
regular school day. The intent is to not use GR funds to provide something the school
district is obligated to provide.
b) Individuals in OBRA may not be open in R042.
c) This service code may be used to count services provided to an individual who is selfemployed, provided services to that individual are clearly documented.
d) The data verification process verifies GR funded services only.
e) Supported Employment includes services and supports, including supervision and
training, essential to sustain paid work by an individual.
f) Supported Employment is, in most cases, provided away from the individual’s place of
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residence and does not include payment for the supervisory activities rendered as a
normal part of the business setting. If services are provided away from the place of
employment, documentation should describe why the services needed to be
provided away from the job site.
g) Supported Employment is not merely checking on an individual for whom no
problems or needs are evident in record documentation.
h) When an individual is successfully employed and no longer in need of provider furnished
Supported Employment services and/or supports, he/she should be classified as
“Independently Employed.” An indicator has been created in CARE to reflect this status
and the date on which it occurs. This CARE indicator allows the MRA to maintain
information on persons who have successfully completed Supported Employment
services. In the event that a person in the indicator needs Supported Employment
services because they are at risk of losing their job, or have lost that job, a priority should
be given in providing Supported Employment services to that individual in order to
maintain employment. If a new Supported Employment assignment is opened for such
individuals, an end date is given to the I.E. indicator. The MRA should use the I.E.
indicator again if the individual again becomes “Independently Employed.”
i) Supported Employment does not include transportation to or from the job site.
j) If while employed, an individual wishes to secure a different or an additional job, job
development in assisting the person to secure that employment is reported under R041 Employment Assistance.
k) Attendance in a group/job club does not count as Supported Employment.
l) Assisting an employed individual in completing and filing reports for Social Security (such
as wage reports) does not constitute R0 42.
m) Data Verification does not verify funding sources but verifies if GR funded services meet
the service definition.
n) A service planning meeting with the individual and Supported Employment staff to discuss
continued need is an acceptable activity but meeting primarily to discontinue the person
from Supported Employment is not allowed as the only evidence of the service.
o) Volunteer work to determine if an individual likes or is qualified for a job is not allowed.
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Day Habilitation (R053)
1. Service Category: IDD Community Services
Services provided to assist an individual to participate in age-appropriate community activities
and services. The type, frequency, and duration of Support Services are specified in the
individual’s Plan of Services and Supports. The MRA ensures that an array of Support
Services is available in the LSA. This service category includes:
Day Habilitation - Assistance with acquiring, retaining, or improving self help, socialization,
and adaptive skills necessary to live successfully in the community and to participate in home
and community life. Individualized activities are consistent with achieving the outcomes
identified in the individual’s person-directed plan and activities are designed to reinforce
therapeutic outcomes targeted by other service components, school or other support
providers. Day habilitation is normally furnished in a group setting other than the individual’s
residence for up to six (6) hours a day, five days per week on a regularly scheduled basis.
The service includes personal assistance for individuals who cannot manage their personal
care needs during the day habilitation activity as well as assistance with medications and the
performance of tasks delegated by a RN in accordance with state law.
2. Required activities:
a) Assistance, support, and training to acquire, retain, or improve adaptive skills.
b) Assistance, support, and training should lead to the participation in age-appropriate
community activities and the use of typical community services.
c) Specified in the individual’s Plan of Services and Supports (which is the plan in place at
the time the service was delivered).
d) Face-to-face contact with the individual to provide day habilitation activities.
3. Optional activities:
a) Transportation to other day habilitation sites/activities. Transportation of an individual
during the course of Day Habilitation services to provide day habilitation services is
included in the day habilitation service and daily rate. However, transportation to/from a
Day Habilitation site to begin/end day habilitation services is captured and reported under
Community Support-R021.
b) Classroom participation.
c) Face-to-face time spent in evaluations/assessments with a specific individual (with or
without their representatives present) related to the provision of day habilitation.
d) Participation in service planning team meetings.
4. Prohibited activities:
a) Vocational training (however, an individual may have a concurrent open assignment to
R041, R042, and/or R043, as appropriate).
b) Transportation unrelated to day habilitation activities.
c) Contacts other than face-to-face with the individual.
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d) Day Habilitation may not be provided to an individual at the same time as Supported
Employment, Respite, Community Support, Employment Assistance or Vocational Training.
e) An individual’s participation in day activities funded through other sources at no cost to the
program provider (e.g., DARS, public school system, Medicaid Rehabilitative Services for
Persons with Chronic Mental Illness, senior citizens’ centers, ECI programs, and volunteer
or other community based sources).
f) Phone calls or collateral contacts
g) May not be used for tuition to a camp
5. Minimum frequency of service delivery:
Monthly
6. Mutually exclusive with any other services:
N/A
7. Differentiation from other similar services:
Vocational Training (R043) is required to develop work behaviors and work skills; these
services are intended to lead to employment. Transportation to/from a Day Habilitation site to
begin/end day habilitation services is captured and reported under R021-Community Support.
8. Location specific (e.g., at home, at an office):
Away from home
9. Limited to sub-population of priority population:
N/A
10. Reference document, law, rule, policy, etc.:
Current Performance Contract
11. Clarifications:
a) Day Habilitation activities are consistent with achieving the outcomes identified in the
individual’s person-directed plan and activities designed to reinforce therapeutic outcomes
targeted by other service components, school or other support providers (e.g., reinforce
speech therapy, behavioral support interventions, etc.).
b) This service includes activities designed to assist in acquisition, retention, and/or
improvement in adaptive skills necessary for continued community living.
c) Included in this category are group activities that provide structured day services designed
to improve skills such as attending to tasks, purposeful manipulation of objects, using
leisure time appropriately, self-help skills, and other skills not included in a vocational
category. These structured day services should produce outcomes that are meaningful to
the individual and result in increased participation by the individual in the community.
d) This may provide an alternative for individuals not participating in Employment Assistance,
Supported Employment or Vocational Training.
e) For individuals attending public school, R053 services must be delivered outside the
individual’s public school day. The intent is to not use GR funds to provide something the
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school district is obligated to provide.
f) Day Habilitation may not be reported when an individual refuses to participate in a day
habilitation activity unless documentation supports the individual was offered alternative
activities throughout the day.
g) Time spent addressing outcomes to increase or retain vocational skills is not considered
Day Habilitation.
h) Time spent by an individual receiving other services that do not allow the individual to
participate in the day habilitation activity (e.g., doctor appointments, consultations with or
treatments by therapist, etc.) are not captured and reported under R053-Day Habilitation.
If during the Day Habilitation activity another service is provided to the individual that
prevents the individual’s participation in the Day Habilitation activity, the amount of time
the individual receives the other service must not be considered as time spent in the Day
Habilitation activity. The individual must be “logged out” and then “logged back in” for the
time spent involved in the other activity.
i) Transportation of an individual during the course of Day Habilitation services to provide
day habilitation services is included in the day habilitation service and daily rate.
Transportation during Day Habilitation activities is necessary for the individual’s
participation in the day habilitation activities and can include providing transportation to an
individual between day habilitation sites.
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Nursing (R054)
1. Service Category: IDD Community Services
Services provided to assist an individual to participate in age-appropriate community activities
and services. The type, frequency and duration of Support Services are specified in the
individual’s Plan of Services and Supports. The MRA ensures that an array of Support
Services is available in the LSA. This service category includes:
Nursing - Treatment and monitoring of health care procedures prescribed by physician or
medical practitioner or required by standards of professional practice or state law to be
performed by licensed nursing personnel.
2. Required activities:
a) Face-to-face or telephone contact with the individual to provide nursing care, health
condition monitoring/assessment, and/or medication administration and monitoring.
b) Face-to-face or telephone contact with a collateral (i.e., family member, other health care
providers or service providers regarding the health/medical condition of the individual
and/or any training related to their health/medical condition.
c) Provider’s scope of practice must be within that authorized by the licensing or certification
body.
d) Nursing is provided by a nurse who is currently:
i) Licensed as a registered nurse (RN) by the Board of Nurse Examiners of the State of
Texas; or
ii) Licensed as a vocational nurse (LVN) by the Board of Nurse Examiners of the State of
Texas.
e) Nursing services and supports are provided based on established and documented
medical needs as specified in the Plan of Services and Supports that is in place at the
time the service was delivered, with an exception allowed in a crisis situation with
unplanned nursing needs.
3. Optional activities:
a) Participation in service planning team meetings.
b) Face-to-face or telephone contact with a physician, physicians assistant, or advanced
practice nurse regarding the health/medical condition of the individual.
4. Prohibited Activities:
a) Delivery of or supervision of services or tasks not requiring the credentials of a licensed
nurse (e.g., supervision of an individual, providing personal care to an individual, or
transporting/accompanying an individual to a physician’s appointment).
b) Arranging medical appointments.
c) Providing transportation for an individual. This should be captured and reported under
Community Support – R021.
d) Travel time or time spent waiting to provide a nursing service.
e) Providing training on illness, injury, healthcare interventions, etc., applicable to the
general population (e.g., CPR, first aid, infection control, etc.)
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f) Developing and monitoring individual health care plans (i.e., review of documentation and
report writing) are considered administrative related activities and not captured and
reported as a Nursing service.
5. Minimum frequency of service delivery:
Monthly; open and close if not an ongoing service.
6. Mutually exclusive with any other services:
N/A
7. Differentiation from other similar services:
Nursing services are no longer captured and reported under the larger umbrella of
Specialized Therapies. Nursing services maintains a separate definition and unique service
grid code for encounter reporting.
8. Location specific (e.g., at home, in a clinic):
Any location
9. Limited to sub-population of priority population:
N/A
10. Reference document, law, rule, policy, etc.:
Current Performance Contract
11. Clarifications:
a) Documenting the provision of services and medication/treatment administration (e.g., such
as written narratives, Medication Administration Record, Assessment forms, etc.);
preparing treatments or medication for administration; controlling medications; reviewing
individual records; and reordering, refilling, or delivering medications is not captured and
reported under R054-Nursing.
b) Training of non-licensed personnel by a Registered Nurse in the performance, monitoring,
reporting, and documentation of prescribed health/medical interventions for a specific
individual (tasks which require delegation by an RN in accordance with the Board of
Nurse Examiners Rule – Delegation of tasks to unlicensed persons) is an allowable
activity.
c) Training of non-licensed personnel conducted by a licensed nurse (RN or LVN) in the
performance, monitoring, reporting, and documentation of health/medical interventions for
a specific individual (tasks which do not require delegation by an RN) is an allowable
activity.
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Specialized Therapies (R054)
1. Service Category: IDD Community Services
Services provided to assist an individual to participate in age-appropriate community activities
and services. The type, frequency and duration of Support Services are specified in the
individual’s Plan of Services and Supports. The MRA ensures that an array of Support
Services is available in the LSA. This service category includes:
Specialized Therapies - Assessment and treatment by licensed or certified professionals for:
social work services, counseling services, occupational therapy, physical therapy, speech and
language therapy, audiology services, dietary services, and behavioral health services other
than those provided by a local mental health authority pursuant to its contract with the
Department of State Health Services (DSHS); and training and consultation with family
members or other providers.
2. Required activities:
a) Specialized therapy as specified in the individual’s plan of services and supports (which is
the plan in place at the time the service was delivered).
b) Face-to-face contact with an individual to conduct assessments or provide therapy.
c) Face-to-face with a collateral (i.e., family member or other service provider) regarding the
therapy provided to the individual.
d) Training provided to direct service providers or family members responsible for
performing, monitoring, reporting and documenting a specific individual treatment plan for
the individual.
e) Face-to-face contact with individuals or their family members or other service providers
(excluding service coordinators and licensed/certified staff employed or contracted by the
program provider) necessary for the provision of a specific service to the individual and
outside the context of a service planning team meeting.
f) Provider of Specialized Therapies is licensed by the appropriate State of Texas licensing
authority for the specific therapeutic service provided by the provider.
g) The minimum monthly contact is accomplished face-to-face with the individual or collateral
(i.e., family member or service provider).
3. Optional activities:
Participation in service planning team meetings.
4. Prohibited Activities:
a) Developing and monitoring individualized treatment plans (i.e., review of documentation
and report writing), individualized menus, therapy schedules, etc., as these activities are
considered administrative related activities and not captured and reported as a
Specialized Therapy service.
b) Delivery of or supervision of services or tasks outside the scope of professional
certification/licensure (e.g., supervising an individual, providing personal care, or
scheduling appointments).
c) Providing transportation for an individual. This should be captured and reported under
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Community Support – R021.
d) Travel time or time spent waiting to provide services.
e) Providing training for other service providers related to general procedures or topics (e.g.,
training in the general principles of the specialized therapy, general care of adaptive aids
and equipment, etc.).
f) Contacts other than face-to-face. No phone calls are allowed
5. Minimum frequency of service delivery:
Monthly; open and close if not an ongoing service.
6. Mutually exclusive with any other services:
N/A
7. Differentiation from other similar services:
Specialized Therapy services have been redefined to exclude Nursing and Behavioral
Support Services. Service grid codes for encounter reporting are specific to the therapy
provided. Behavioral Health Services are no longer captured and reported under the larger
umbrella of Specialized Therapies. Behavioral Health Services maintains a separate
definition and unique service grid code for encounter reporting effective 09/01/06.
8. Location specific (e.g., at home, in an office):
Any location
9. Limited to sub-population of priority population:
N/A
10. Reference document, law, rule, policy, etc.:
Current Performance Contract
11. Clarifications:
a) Non-traditional therapies are not captured and reported under Specialized Therapies.
b) The purchase of adaptive equipment is not captured and reported under Specialized
Therapies.
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Behavioral Support (R055)
1) Service Category: IDD Community Services
Services provided to assist an individual to participate in age-appropriate community activities
and services. The type, frequency and duration of Support Services are specified in the
individual’s Plan of Services and Supports. The MRA ensures that an array of Support
Services is available in the LSA. This service category includes:
Behavioral Support - Specialized interventions by professionals with required credentials to
assist an individual to increase adaptive behaviors and to replace or modify maladaptive
behavior that prevent or interfere with the individual’s inclusion in home and family life or
community life. Support includes:
. assessing and analyzing assessment findings so that an appropriate behavior support
plan may be designed;
. developing an individualized behavior support plan consistent with the outcomes identified
in the individual’s Plan of Services and Supports;
. training and consulting with family members or other providers and, as appropriate, the
individual; and
. monitoring and evaluating the success of the behavioral support plan and modifying the
plan as necessary.
2) Required activities:
a) Specialized therapy assessment or intervention as specified in the individual’s Plan of
Services and Supports (which is the plan in place at the time the service was delivered)
with an exception allowed in a crisis situation with unplanned behavioral support needs;
b) Provider’s scope of practice must be within that authorized by the licensing or certification
body.
c) The provider of behavioral support must be:
i) Licensed as a licensed psychologist by the Texas State Board of Examiners of
Psychologists;
ii) Licensed as psychological associate by the Texas State Board of Examiners of
Psychologists;
iii) Certified as a behavior analyst by the Behavior Analyst Certification Board, Inc. .
iv) If not licensed or certified as described in i, ii, or iii above, the provider must be in
possession of the required educational credentials and under professional supervision
as required by the licensing or certification body for the credentials in i, ii or iii above.
The MRA must maintain documentation of the:
(1) applicable supervision requirements;
(2) provider’s qualifications; and
(3) supervision agreement; or
v) Certified as a DADS-certified psychologist in accordance with 40 TAC
§5.161.
d) Face-to-face, telemedicine, or telephone contact with individuals, their family members or
29
other service providers (direct service provider excluding service coordinators and
licensed/certified staff employed or contracted by the program provider) necessary for the
provision of a specific service to a specific individual outside the context of a service
planning team meeting. Such as:
i) Face-to-face contact with an individual to conduct assessment or provide specialized
interventions to increase adaptive behaviors, replace or modify maladaptive or socially
unacceptable behaviors.
ii) Training provided to direct service providers or family members responsible for
performing, monitoring, reporting and documenting a specific individual behavioral
support plan for a specific individual.
3) Optional activities:
a) Medication review and counseling as an adjunct to development or review of a behavioral
support plan.
b) Face-to-face or telephone contact with a physician (including a psychiatrist) regarding the
behavioral support provided to the individual. This physician may be an employee or
contract staff with the MRA or an external physician.
c) Participation in service planning team meetings.
4) Prohibited Activities:
a) Developing and monitoring individualized behavioral support plans (i.e., review of
documentation and report writing) are considered administrative related activities and not
captured and reported as a Behavioral Support service.
b) Delivery of or supervision of services or tasks outside the scope of the professional
certification/licensure (e.g., supervising an individual, providing personal care or
scheduling appointments).
c) Providing transportation for an individual. This should be captured and reported under
Community Support – R021.
d) Travel time or time spent waiting to provide services.
e) Providing training for other service providers related to general procedures or topics (e.g.,
training in the general principles of behavioral intervention or therapy).
5) Minimum frequency of service delivery:
Monthly; open and close if not an ongoing service.
6) Mutually exclusive with any other services:
N/A
7) Differentiation from other similar services:
As of 9-01-08, Behavioral Support services are no longer captured and reported under the
larger umbrella of R054. Behavioral Support services maintains a separate definition and
unique service grid code for encounter reporting. Counseling and psychotherapy not
provided in the context of development or review of a behavioral support plan should be
repor+ted as Specialized Therapy R054.
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8) Location specific (e.g., at home, in a clinic):
Any location
9) Limited to sub-population of priority population:
N/A
10) Reference document, law, rule, policy, etc.:
Current Performance Contract
11) Clarifications:
a) Behavioral Support Services are only delivered by those with the credentials noted in #2
c) above. This does not include Physicians, LPCs and Psychiatrists.
b) Counseling is an allowable service if performed by those with the credential noted under
#2 c) above. Goals and objectives for counseling should refer to a change in a behavior
that would prevent or interfere with the individual’s inclusion in home or family life, or life in
the community.
c) Implementation of Behavior Plans developed by those qualified (see credentials #2 c) is
captured under R021-Community Support Services.
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