26 Tex. Admin. Code § 303.102

Current through Reg. 49, No. 24; June 14, 2024

Section 303.102 - Definitions

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

(1) Actively involved person--An individual who has significant, ongoing, and supportive involvement with a designated resident, as determined by the SPT based on the individual's:

(A) observed interactions with the designated resident;

(B) availability to the designated resident for assistance or support when needed; and

(C) knowledge of, sensitivity to, and advocacy for the designated resident's needs, preferences, values, and beliefs.

(2) Acute care hospital--A health care facility in which an individual receives short-term treatment for a severe physical injury or episode of physical illness, an urgent medical condition, or recovery from surgery and:

(A) may include a long-term acute care hospital, an emergency room within an acute care hospital, or an inpatient rehabilitation hospital; and

(B) does not include a stand-alone psychiatric hospital or a psychiatric hospital within an acute care hospital.

(3) Alternate placement assistance--Assistance provided to a resident to locate and secure services chosen by the resident or LAR that meets the resident's needs in a setting other than a NF. Alternate placement assistance includes transition planning, pre-move site review, and post-move monitoring.

(4) APRN--Advance practice registered nurse. An individual licensed to practice professional nursing as an advance practice registered nurse in accordance with Texas Occupations Code Chapter 301.

(5) Audio-only--An interactive, two-way audio communication that uses only sound and that meets the privacy requirements of the Health Insurance Portability and Accountability Act. Audio-only includes the use of telephonic communication. Audio-only does not include audio-visual or in-person communication.

(6) Audio-visual--An interactive, two-way audio and video communication that conforms to privacy requirements under the Health Insurance Portability and Accountability Act. Audio-visual does not include audio-only or in-person communication.

(7) Behavioral support--An IHSS that:

(A) is assistance provided for a designated resident to increase adaptive behaviors and to replace or modify maladaptive behaviors that prevent or interfere with the designated resident's interpersonal relationships across all service and social settings;

(B) is delivered in the NF or in a community setting; and

(C) consists of:

(i) assessing the behaviors to be targeted in an appropriate behavior support plan and analyzing those assessment findings;

(ii) developing an individualized behavior support plan that reduces or eliminates the target behaviors, assisting the designated resident in achieving the outcomes identified in the HSP;

(iii) training and consulting with the LAR, family members, NF staff, other support providers, and the designated resident about the purpose, objectives, and methods of the behavior support plan;

(iv) implementing the behavior support plan or revisions to the behavior support plan and documenting service delivery in accordance with the IDD Habilitative Specialized Services Billing Guidelines;

(v) monitoring and evaluating the success of the behavior support plan implementation;

(vi) revising the behavior support plan as necessary; and

(vii) participating in SPT and IDT meetings.

(8) Business day--Any day except Saturday, Sunday, or a national or state holiday listed in Texas Government Code § 662.003(a) or (b).

(9) Calendar day--Any day, including weekends and holidays.

(10) CMWC--Customized manual wheelchair. In accordance with § 554.2703(5) of this title (relating to Definitions) and consistent with the requirements of Texas Human Resources Code § 32.0425, a wheelchair that consists of a manual mobility base and customized seating system and is adapted and fabricated to meet the individualized needs of a designated resident.

(11) Collateral contact--A person who is knowledgeable about the individual seeking admission to a NF or the resident, such as family members, previous providers or caregivers, and who may support or corroborate information provided by the individual or resident.

(12) Coma--A state of unconsciousness characterized by the inability to respond to sensory stimuli as documented by a physician.

(13) Convalescent care--A type of care provided after an individual's release from an acute care hospital that is part of a medically prescribed period of recovery.

(14) Day habilitation--An IHSS that:

(A) is assistance provided for a designated resident to acquire, retain, or improve self-help, socialization, and adaptive skills necessary to successfully and actively participate in all service and social settings;

(B) is delivered in a setting other than the designated resident's NF;

(C) does not include services provided under the Day Activity and Health Services program;

(D) includes expanded interactions, skills training activities, and programs of greater intensity or frequency beyond those a NF is required to provide by 42 Code of Federal Regulations (CFR) §483.24; and

(E) consists of:

(i) individualized activities consistent with achieving the outcomes identified in a designated resident's HSP to attain, learn, maintain, or improve skills;

(ii) activities necessary to reinforce therapeutic outcomes targeted by other support providers and other specialized services;

(iii) services in a group setting at a location other than a designated resident's NF for up to five days per week, six hours per day, on a regularly scheduled basis;

(iv) personal assistance for a designated resident who cannot manage personal care needs during the day habilitation activity;

(v) transportation between the NF and the day habilitation site, as well as during the day habilitation activity necessary for a designated resident's participation in day habilitation activities; and

(vi) participating in SPT and IDT meetings.

(15) DD--Developmental disability. A disability that meets the criteria described in the definition of "persons with related conditions" in 42 CFR § 435.1010.

(16) Delirium--A serious disturbance in an individual's mental abilities that results in a decreased awareness of the individual's environment and confused thinking.

(17) Designated resident--An individual:

(A) whose PE or resident review is positive for ID or DD;

(B) who is 21 years of age or older;

(C) who is a Medicaid recipient; and

(D) who is a resident or has transitioned to the community from a NF within the previous 365 days.

(18) DME--Durable medical equipment. The items described in § 554.2703(10) of this title.

(19) Emergency protective services--Services furnished by the Department of Family and Protective Services to an elderly or disabled individual who has been determined to be in a state of abuse, neglect, or exploitation.

(20) Employment assistance--An IHSS that:

(A) is assistance provided for a designated resident who requires intensive help locating competitive employment in the community; and

(B) consists of:

(i) identifying a designated resident's employment preferences, job skills, and requirements for a work setting and work conditions;

(ii) locating prospective employers offering employment compatible with a designated resident's identified preferences, skills, and requirements;

(iii) contacting prospective employers on a designated resident's behalf and negotiating the designated resident's employment;

(iv) transporting a designated resident between the NF and the site where employment assistance services are provided and as necessary to help the designated resident locate competitive employment in the community; and

(v) participating in SPT and IDT meetings.

(21) Essential supports--Those supports identified in a transition plan that are critical to a designated resident's health and safety and that are directly related to a designated resident's successful transition to living in the community from residing in a NF.

(22) Exempted hospital discharge--A category of NF admission that occurs when a physician has certified that an individual who is being discharged from an acute care hospital is likely to require less than 30 days of NF services for the condition for which the individual was hospitalized.

(23) Expedited admission--A category of NF admission that occurs when an individual meets the criteria for one of the following categories: convalescent care, terminal illness, severe physical illness, delirium, emergency protective services, respite, or coma.

(24) Extenuating circumstances--Circumstances beyond the LIDDA's, LMHA's or LBHA's control that prevents meeting in person. A disaster declared by the governor is excluded from this definition.

(25) Habilitation coordination--Assistance for a designated resident residing in a NF to access appropriate specialized services necessary to achieve a quality of life and level of community participation acceptable to the designated resident and LAR on the designated resident's behalf.

(26) Habilitation coordinator--An employee of a LIDDA who provides habilitation coordination.

(27) HHSC--The Texas Health and Human Services Commission.

(28) HHSC instructor-led training--Training delivered by an HHSC employee.

(29) HSP--Habilitation service plan. A plan developed by the SPT while a designated resident is residing in a NF that:

(A) is individualized and developed through a person-centered approach;

(B) identifies the designated resident's:

(i) strengths;

(ii) preferences;

(iii) desired outcomes; and

(iv) psychiatric, behavioral, nutritional management, and support needs as described in the NF comprehensive care plan or MDS assessment; and

(C) identifies the specialized services that will accomplish the desired outcomes of the designated resident, or the LAR's on behalf of the designated resident, including amount, frequency, and duration of each service.

(30) ID--Intellectual disability, as defined in 42 CFR § 483.102(b)(3)(i).

(31) IDD--Intellectual and developmental disability.

(32) IDT--Interdisciplinary team. A team consisting of:

(A) a resident with MI, ID, or DD;

(B) the resident's LAR, if any;

(C) an RN from the NF with responsibility for the resident;

(D) a representative of:

(i) the LIDDA, if the resident has ID or DD;

(ii) the LMHA or LBHA, if the resident has MI; or

(iii) the LIDDA and the LMHA or LBHA, if the resident has MI and DD, or MI and ID; and

(E) others as follows:

(i) a concerned person whose inclusion is requested by the resident or LAR;

(ii) an individual specified by the resident, LAR, NF, LIDDA, LMHA, or LBHA, as applicable, who is professionally qualified, certified, or licensed with special training and experience in the diagnosis, management, needs, and treatment of people with MI, ID, or DD; and

(iii) a representative of the appropriate school district if the resident is school age and inclusion of the district representative is requested by the resident or LAR.

(33) IHSS--IDD habilitative specialized services. IHSS are:

(A) behavioral support;

(B) day habilitation;

(C) employment assistance;

(D) independent living skills training; and

(E) supported employment.

(34) ILST--Independent living skills training. An IHSS that:

(A) is assistance provided for a designated resident that is consistent with the designated resident's HSP;

(B) is provided in the designated resident's NF or in a community setting;

(C) includes expanded interactions, skills training activities, and programs of greater intensity or frequency beyond those a NF is required to provide by 42 CFR § 483.24; and

(D) consists of:

(i) habilitation and support activities that foster improvement of or facilitate a designated resident's ability to attain, learn, maintain, or improve functional living skills and other daily living activities;

(ii) activities that help preserve the designated resident's bond with family members;

(iii) activities that foster inclusion in community activities generally attended by people without disabilities;

(iv) transportation to facilitate a designated resident's employment opportunities and participation in community activities, and between the designated resident's NF and a community setting; and

(v) participating in SPT and IDT meetings.

(35) Implementation plan--A plan for each IHSS on the designated resident's plan of care that includes:

(A) a list of the designated resident's outcomes identified in the HSP that will be addressed using IHSS;

(B) specific objectives to address the outcomes required by subparagraph (A) of this paragraph that are:

(i) observable, measurable, and outcome-oriented; and

(ii) derived from assessments;

(C) a target date for completion of each objective;

(D) the frequency, amount, and duration of IHSS needed to complete each objective; and

(E) the signature and date of the designated resident, LAR, and service provider agency.

(36) In-person (or in person)--Within the physical presence of another person. In-person or in person does not include audio-visual or audio-only communication.

(37) LAR--Legally authorized representative. An individual authorized by law to act on behalf of an individual seeking admission to a NF or resident with regard to a matter described by this chapter, and who may be the parent of a minor child, the legal guardian, or the surrogate decision maker.

(38) LBHA--Local behavioral health authority. An entity designated by the executive commissioner of HHSC, in accordance with Texas Health and Safety Code § 533.0356.

(39) LCSW--Licensed clinical social worker. An individual who is licensed as a licensed clinical social worker in accordance with Texas Occupations Code Chapter 505.

(40) Licensed psychologist--An individual who is licensed as a psychologist in accordance with Texas Occupations Code Chapter 501.

(41) LIDDA--Local intellectual and developmental disability authority. An entity designated by the executive commissioner of HHSC, in accordance with Texas Health and Safety Code § 533A.035.

(42) LMFT--Licensed marriage and family therapist. An individual who is licensed as a marriage and family therapist in accordance with Texas Occupations Code Chapter 502.

(43) LMHA--Local mental health authority. An entity designated by the executive commissioner of HHSC, in accordance with Texas Health and Safety Code § 533.035.

(44) LPC--Licensed professional counselor. An individual who is licensed as a professional counselor in accordance with Texas Occupations Code Chapter 503.

(45) LTC online portal--Long term care online portal. A web-based application used by Medicaid providers to submit forms, screenings, evaluations, and other information.

(46) MCO service coordinator--Managed care organization service coordinator. The staff person assigned by a resident's Medicaid managed care organization to ensure access to and coordination of needed services.

(47) MDS assessment--Minimum data set assessment. A standardized collection of demographic and clinical information that describes a resident's overall condition, which a licensed NF in Texas is required to submit for a resident admitted into the facility.

(48) MI--Mental illness. Serious mental illness, as defined in 42 CFR § 483.102(b)(1).

(49) MI quarterly meeting--A quarterly meeting that is convened by the LMHA or LBHA for a resident with MI to develop, review, or revise the PCRP and the transition plan, if the resident is transitioning to the community.

(50) MI specialized services--Specialized services for a resident with MI, if eligible, as described in the Texas Resilience and Recovery Utilization Management Guidelines, including:

(A) crisis intervention services;

(B) day programs for acute needs;

(C) medication training and support services;

(D) psychiatric diagnostic interview examination;

(E) psychosocial rehabilitation services;

(F) routine case management; and

(G) skills training and development.

(51) NF--Nursing facility. A Medicaid-certified facility that is licensed in accordance with the Texas Health and Safety Code Chapter 242.

(52) NF comprehensive care plan--A comprehensive care plan, defined in § 554.2703(3) of this title.

(53) NF PASRR support activities--Actions a NF takes in coordination with a LIDDA, LMHA, or LBHA to facilitate the successful provision of an IHSS or MI specialized service, including:

(A) arranging transportation for a NF resident to participate in an IHSS or a MI specialized service outside the facility;

(B) sending a resident to a scheduled IHSS or MI specialized service with food and medications required by the resident; and

(C) stating in the NF comprehensive care plan an agreement to avoid, when possible, scheduling NF services at times that conflict with IHSS or MI specialized services.

(54) NF specialized services--The following specialized services available to a resident with ID or DD:

(A) therapy services;

(B) CMWC; and

(C) DME.

(55) PA--Physician assistant. An individual who is licensed as a physician assistant in accordance with Texas Occupations Code Chapter 204.

(56) PASRR--Preadmission screening and resident review. A federal requirement in 42 CFR Part 483, Subpart C that requires states to prescreen all individuals seeking admission to a Medicaid-certified NF for ID, DD, and MI.

(57) PCRP--Person-centered recovery plan. For a resident with MI, the PCRP identifies the services and supports that are needed to:

(A) meet the needs of the resident with MI;

(B) achieve the desired outcomes; and

(C) maximize the ability for the resident with MI to live successfully in the most integrated setting possible.

(58) PE--PASRR level II evaluation. An evaluation as described in § 303.302(a)(2) of this chapter (relating to LIDDA, LMHA, and LBHA Responsibilities Related to the PASRR Process):

(A) of an individual seeking admission to a NF who is suspected of having MI, ID, or DD; and

(B) performed by a LIDDA, LMHA, or LBHA to determine if the individual has MI, ID, or DD and, if so, to:

(i) assess the individual's need for care in a NF;

(ii) assess the individual's need for specialized services; and

(iii) identify alternate placement options.

(59) Physician--An individual who is licensed to practice medicine in accordance with Texas Occupations Code Chapter 155.

(60) PL1--PASRR level I screening. The process of screening an individual seeking admission to a NF to identify whether the individual is suspected of having MI, ID, or DD.

(61) Plan of care--A written plan that includes:

(A) the IHSS required by the NF baseline care plan or NF comprehensive care plan;

(B) the frequency, amount, and duration of each IHSS to be provided for the designated resident during a plan year; and

(C) the services and supports to be provided for the designated resident through resources other than PASRR.

(62) Preadmission process--A category of NF admission:

(A) from a community setting, such as a private home, an assisted living facility, a group home, a psychiatric hospital, or jail, but not an acute care hospital or another NF; and

(B) that is not an expedited admission or an exempted hospital discharge.

(63) QIDP--Qualified intellectual disability professional. An individual who meets the qualifications described in 42 CFR § 483.430(a).

(64) QMHP-CS--Qualified mental health professional-community services. An individual who meets the qualifications of a QMHP-CS as defined in § 301.303 of this title (relating to Definitions).

(65) Referring entity--The entity that refers an individual to a NF, such as a hospital, attending physician, LAR or other personal representative selected by the individual, a family member of the individual, or a representative from an emergency placement source, such as law enforcement.

(66) Relocation specialist--An employee or contractor of an MCO who provides outreach and relocation activities to individuals in NFs who express a desire to transition to the community.

(67) Resident--An individual who resides in a NF.

(68) Resident review--An evaluation of a resident performed by a LIDDA, LMHA, or LBHA as described in § 303.302(a)(2) of this chapter (relating to LIDDA, LMHA, and LBHA Responsibilities Related to the PASRR Process):

(A) for a resident whose PE is positive for MI, ID, or DD who experienced a significant change in condition, to:

(i) assess the resident's need for continued care in a NF;

(ii) assess the resident's need for specialized services; and

(iii) identify alternate placement options; and

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

(i) assess the resident's need for continued care in a NF;

(ii) assess the resident's need for specialized services; and

(iii) identify alternate placement options.

(69) Resident with MI--An individual:

(A) who is a resident of a NF;

(B) whose PE or resident review is positive for MI;

(C) who is at least 18 years of age; and

(D) who is a Medicaid recipient.

(70) Respite--Services provided on a short-term basis to an individual because of the absence of or the need for relief by the individual's unpaid caregiver for a period not to exceed 14 days.

(71) RN--Registered nurse. An individual licensed to practice professional nursing as a registered nurse in accordance with Texas Occupations Code Chapter 301.

(72) Service coordination--Assistance in accessing medical, social, educational, and other appropriate services and supports, including alternate placement assistance, that will help an individual to achieve a quality of life and community participation acceptable to the individual and LAR on the individual's behalf.

(73) Service coordinator--An employee of a LIDDA who provides service coordination.

(74) Service provider agency--An entity that has a contract with HHSC to provide IHSS for a designated resident.

(75) Severe physical illness--An illness resulting in ventilator dependence or a diagnosis, such as chronic obstructive pulmonary disease, Parkinson's disease, Huntington's disease, amyotrophic lateral sclerosis, or congestive heart failure, that results in a level of impairment so severe that the individual could not be expected to benefit from specialized services.

(76) Significant change in condition--Consistent with § 554.801(2)(C)(ii) of this title (relating to Resident Assessment), when a resident experiences a major decline or improvement in the resident's status that:

(A) will not normally resolve itself without further intervention by NF staff or by implementing standard disease-related clinical interventions;

(B) has an impact on more than one area of the resident's health status; and

(C) requires review or revision of the NF comprehensive care plan, or both.

(77) Specialized services--The following support services, other than NF services, that are identified through the PE or resident review and may be provided to a resident who has a PE or resident review that is positive for MI, ID, or DD:

(A) NF specialized services;

(B) IHSS; and

(C) MI specialized services.

(78) SPT--Service planning team. A team convened by a LIDDA staff person that develops, reviews, and revises the HSP and the transition plan for a designated resident. The team must include:

(A) the designated resident;

(B) the designated resident's LAR, if any;

(C) the habilitation coordinator for discussions and service planning related to specialized services or the service coordinator for discussions related to transition planning if the designated resident is transitioning to the community;

(D) the MCO service coordinator, if the designated resident does not object;

(E) the person who develops a permanency plan using the HHSC Permanency Planning Instrument for Children Under 22 Years of Age form and performs other permanency planning activities for a designated resident under 22 years of age, if the designated resident is at least 21 years of age but younger than 22 years of age;

(F) while the designated resident is in a NF:

(i) a NF staff person familiar with the designated resident's needs; and

(ii) an individual providing a specialized service for the designated resident or a representative of a provider agency that is providing specialized services for the designated resident;

(G) if the designated resident is transitioning to the community:

(i) a representative from the community program provider, if one has been selected; and

(ii) a relocation specialist;

(H) a representative from the LMHA or LBHA, if the designated resident's PE is positive for MI;

(I) a concerned person whose inclusion is requested by the designated resident or the LAR; and

(J) at the discretion of the LIDDA, an individual who is directly involved in the delivery of services for people with ID or DD.

(79) Supported employment--An IHSS that:

(A) is assistance provided for a designated resident:

(i) who requires intensive, ongoing support to be self-employed, work from the designated resident's residence, or work in an integrated community setting at which people without disabilities are employed; and

(ii) to sustain competitive employment in an integrated community setting; and

(B) consists of:

(i) making employment adaptations, supervising, and providing training related to the designated resident's assessed needs;

(ii) transporting the designated resident between the NF and the site where the supported employment services are provided and as necessary to support the designated resident to be self-employed, work from the designated resident's residence, or work in an integrated community setting; and

(iii) participating in SPT and IDT meetings.

(80) Surrogate decision maker--An actively involved family member of a resident who has been identified by an IDT in accordance with Texas Health and Safety Code § 313.004 and who is available and willing to consent to medical treatment on behalf of the resident.

(81) Terminal illness--A medical prognosis that an individual's life expectancy is six months or less if the illness runs its normal course and that is documented by a physician's certification in the individual's medical record maintained by a NF.

(82) Therapy services--In accordance with § 554.2703(46) of this title, assessment and treatment to help a designated resident learn, keep, or improve skills and functioning of daily living affected by a disabling condition. Therapy services are referred to as habilitative therapy services. Therapy services are limited to:

(A) physical therapy;

(B) occupational therapy; and

(C) speech therapy.

(83) Transition plan--A plan developed by the SPT or MI quarterly meeting attendees that describes the activities, timetable, responsibilities, services, and essential supports involved in assisting a designated resident or resident with MI to transition from residing in a NF to living in the community.

(84) Uniform assessment--The HHSC-approved uniform assessment tool for adult mental health services.

26 Tex. Admin. Code § 303.102

Adopted by Texas Register, Volume 44, Number 26, June 28, 2019, TexReg 3269, eff. 7/7/2019; Amended by Texas Register, Volume 46, Number 35, August 27, 2021, TexReg 5427, eff. 9/1/2021; Amended by Texas Register, Volume 49, Number 15, April 12, 2024, TexReg 2290, eff. 4/15/2024