Revision 23-1, Effective Nov. 13, 2023

A.1 Assistive Technology for People who are Blind or Visually Impaired

Revision 23-1, Effective Nov. 13, 2023

Evaluating Assistive Technology

Qualifications

Assistive technology evaluators must:

• have earned a degree from an accredited college or university with a specialization in computer science, education, rehabilitation, or a related field, with one year of work experience in the education or rehabilitation of people who have visual or other disabilities; or 
  • have earned a high school diploma or passed a General Educational Development (GED) test, with four years of progressively responsible work experience in the education or rehabilitation of people who have visual or other disabilities; and
• be knowledgeable about computers and assistive technology, the applications of technology, and the methods of evaluating technology for people who are blind or visually impaired;
• possess the ability to simulate computer and technological environments, similar to the situations that a person may encounter on the job or in school;
• able to conduct objective evaluations; and
• able to make objective recommendations.

Staff-to-Person Ratio

Assistive technology evaluations must be conducted one-on-one, with one evaluator assigned for each person.

Service Delivery

Assistive technology evaluations determine the most effective assistive technology for meeting the person’s independent living goals.

Assistive technology evaluations give people who are blind access to:

• the services of a knowledgeable assistive technology evaluator; and
• the latest assistive equipment.

Minimum Assessment Requirements

To meet the minimum requirements, the person must have:

• a typing speed of at least 30 words per minute (WPM), if the independent living goal is related to the purchase of computer software such as ZoomText, Window-Eyes or JAWS; and
• a braille reading speed of 50 WPM in Grade 2 (uncontracted braille) using braille devices, when braille is the preferred reading format, if the independent living goal is related to the purchase of a braille display or braille note taker.

These minimum assessment requirements are evaluated on a case-by-case basis. For example, these requirements may be waived for people with secondary disabilities that limit the use of one or both hands and for people who have sustained a traumatic brain injury. The evaluator should discuss these circumstances with the person’s service provider as appropriate.

Evaluation Period for Assistive Technology

The length of time required to complete an assistive technology evaluation is based on the person’s circumstances. Therefore, there are no set time requirement for each evaluation. It is recommended that the evaluator plan for about 2.5 hours.

Conducting the Evaluation

The evaluator must:

• remain impartial and objective throughout the evaluation process;
• not express personal opinions, make other comments, or take other actions that may be mistaken for bias or promoting one product over another during the evaluation;
• show the person only the products that will assist them in meeting their independent living goals;
• conduct the evaluation, including the evaluator's interview with the person, in a confidential manner; and
• not grant any other person permission to observe the evaluation, unless:
  • the person expressly agrees to allow the other person to be present; and
  • the observer agrees not to ask questions, make suggestions, or otherwise comment during the evaluation process.

Evaluation Components

Assistive technology evaluations include the following three components:

• A private interview is held with the person to discuss their background and to review information developed by the service provider.
• The person’s ability (or potential ability) to use assistive technology equipment and to benefit from the service provider's recommendations is assessed and observed.
• A closing interview is held to summarize the results of the evaluation process and is documented in the evaluation report.

Interview Process–Evaluation of Video Magnification Systems

The evaluator asks the following questions during evaluation interviews for video magnification systems including closed circuit televisions or CCTVs:

• Is color identification critical to the person’s independent living goal?
• What specific tasks will the person be completing with a video magnification system. For example, reading-only, or reading and writing?
• Is the person able to read in an efficient manner using magnification of a video system? What level of magnification is required to read using the video magnification system?
• Does the person use a computer at home?

Interview Process–Evaluation of Scanners

During evaluation interviews for scanners, the evaluator should determine:

• if the person has significant eye fatigue;
• if the person has video magnification that is too large to be productive;
• if the person feels nauseous when using the video magnification system;
• what the nature of the person’s degenerative eye condition is;
• if the person is fully aware of other resources, such as:
  • the Texas State Library; and
  • reader services such as oral reading or related services for people who are blind; and
• what the person’s computer needs are for using braille or speech-related features and any tasks that they will perform using a scanner, including:
  • entering scanned documents into a computer (Has the person brought samples of documents to be scanned or can he or she describe the documents?); and
  • manipulating scanned documents on a computer.

Interview Process–Evaluation of Computer Applications

The following areas are addressed during evaluation interviews for screen magnification devices, refreshable braille display devices, and screen reader systems:

• If the person is using a computer to meet his or her independent living goals, the evaluator notes:
  • the kind of computer the person is using;
  • the software the person is using; and
  • the access equipment the person is using.
• The evaluator discusses as many aspects of the person’s independent living goal as possible, takes notes, and rechecks the person’s file for discrepancies. If possible, the evaluator uses information documented in the file to elicit additional details about the person’s independent living tasks.
• The evaluator documents the person’s skill level, including:
  • typing speed;
  • accuracy; and
  • keyboard familiarity.
• The evaluator notes the person’s previous computer experience, including:
  • the type of computer used;
  • the type of software used;
  • where and when the person got the experience; and
  • whether the experience was acquired before the loss of vision.
• The evaluator asks whether the person has experience with:
  • computer access equipment;
  • video magnification systems, including CCTVs;
  • computer braille devices;
  • refreshable braille display devices; or
  • synthesized speech devices.

Post-Evaluation Discussion

When the interview and product evaluations have been completed, the assistive technology evaluator:

1. discusses with the person the evaluator's equipment recommendations and the consequences of the recommendations; and
2. answers any questions the person has about the recommendations and the evaluation process.

The service provider also reminds the person that:

• the purpose of the evaluation is to help the evaluator make recommendations; and
• the only decision the person’s evaluator can make is whether to purchase or not purchase assistive technology equipment.

Documenting the Assessment

Documentation of the assessment should contain the following:

• Information about any specific evaluation requirements for the type of assistive technology evaluated.
• Minimum assessment requirements addressed, such as typing speed or braille reading speed, or the reason for waiving the requirement.
• A list of the products that were evaluated with the person.
• Any previous experience the person has with assistive technology.
• The final recommendation and an explanation how the assistive technology will help the person in meeting his or her independent living goals.

Providing Training on Assistive Technology

Training is provided to prepare a person to use assistive technology effectively to meet their independent living goals. Training may be provided at a facility, on-site at a person’s home, or in a community resource center. Facility-based trainers or on-site trainers can provide group training.

Qualifications

Assistive technology trainers must:

• have a high school diploma or GED;
• be knowledgeable about computers and assistive technology that is designed for people who are blind or visually impaired;
• be familiar with computer and assistive technology applications for people who have visual disabilities or other disabilities;
• be familiar with appropriate instructional methods for people who have visual disabilities or other disabilities and participate in required training as developed including confidence builder training or its equivalent;
• able to vary training to meet the specific needs of each person; and
• demonstrate proficiency in assistive technology training on specific assistive equipment, per HHSC standards and any periodic proficiency tests required by HHSC.

Staff-to-Person Ratio

For conducting group training on assistive technology, the staff-to-person ratio may not exceed one staff member to three people (1:3).

Scope of Services

Assistive technology trainers provide the following services:

1. Baseline assessment
2. Training that includes:
   • basic computer hardware and software, including keyboarding for approved facilities only, introduction to computers, introduction to application software, use of the Internet, and printing and faxing using computers that are equipped with assistive software and designed for users who have low-vision or are blind;
   • advanced computer software, including advanced skills training in computer hardware and software applications; and
   • assistive technology, including training in specific assistive technology products
3. Post-training assessment

Baseline Assessment

The assistive technology trainer administers a basic skills test to each person who is referred for assistive technology training. Use the baseline assessment to determine the level of training required for each person.

A.2 Assistive Technology for People with Significant Disabilities

Revision 23-1, Effective Nov. 13, 2023

Assistive technology refers to mechanical aids that substitute for or enhance physical or mental functions that are impaired. Assistive technology can be any item—whether homemade, purchased off the shelf, modified, or commercially available that is used to help a person perform a task of daily living. The Individuals with Disabilities Education Act, as amended, defines assistive technology device. See 34 CFR, Section 300.5, Assistive technology device.

Using assistive technology can increase a person’s level of independence by:

• improving the quality of life;
• increasing productivity;
• expanding educational options;
• increasing opportunities for success;
• reducing the need for support services; and
• increasing participation in activities.

Assistive technology helps persons with disabilities become independent. It improves self-esteem and quality of life.

Assistive Technology Services

Assistive technology services help a person with a disability select, acquire, or use an assistive technology device.

The services can include:

• assessing the person’s need for assistive technology;
• training the person to use the assistive technology;
• training the family or supervisor to use the assistive technology for reinforcement and backup; and
• fitting, adapting, maintaining, and repairing the assistive technology, as needed.

Examples of Assistive Technology

Assistive technology includes low, mid, and high-tech devices or equipment.

Low-tech Assistive Technology

Low-tech assistive technology refers to devices or equipment that does not require much training, that is relatively inexpensive, and that does not have complex or mechanical features.

Examples

Handheld magnifiers, large print text, canes or walkers, color coding, automatic lights, and specialized pen or pencil grips.

Mid-tech Assistive Technology

Mid-tech assistive technology refers to devices or equipment that may have complex features, may be electronic or battery-operated, or may require training to use. Mid-tech devices and equipment are also more expensive than the low-tech devices and equipment.

Examples

Talking spell-checkers, manual wheelchairs, electronic organizers, closed-caption televisions, amplifiers, text pagers, larger computer monitors, books on tape, remote controls for the user’s environment, and an alternate mouse or keyboard for a computer.

High-tech Assistive Technology

High-tech assistive technology refers to the most complex devices or equipment. High-tech items have digital or electronic components, may be computerized, will likely require training and effort to learn to use, and cost more than low- and mid-tech items.

Examples

Power wheelchairs or scooters, prosthetic devices, digital hearing aids, computers with specialized software such as voice recognition or magnification software, electronic aids to daily living, voice-activated telephones, and communication devices with voices.

Assistive Technology Can Reduce Barriers

Using assistive technology reduces barriers and increases independence. It allows a person with disabilities to perform essential functions. Many people know what type of assistive technology device is needed to accomplish a task. If a person does not know, talking with them and trying available low-tech items may help figure out what will work best. Other times, get a formal assistive technology evaluation to assess the person’s circumstances and abilities and to determine what assistive technology device or equipment is needed. Finally, talking with someone who has been through a similar experience may help you figure out which assistive technology device to use.

One Size Does Not Fit All

People with the same disability do not always have the same functionality. An assistive technology that works for one person may not work for another. It is best to work with rehabilitation professional to get an assessment before buying a high-tech item. Many low or mid-tech items can be purchased off-the-shelf from a vendor of durable medical equipment.

Resources for Obtaining Information on Assistive Technology

To get advice before purchasing assistive technology, contact an unbiased resource, such as the Assistive and Instructional Technology Lab at the University of Texas Austin. Many vendors can offer professional advice, as well. However, use caution and consider whether a less-expensive product will meet a person’s needs.

Revision 23-1, Effective Nov. 13, 2023

Cognitive Rehabilitation Therapy

Vendor Qualifications

A cognitive rehabilitation therapist provides cognitive rehabilitation therapy.

Cognitive rehabilitation therapy focuses on the development of the cognitive skills such as the ability to perceive, recognize, conceive, judge, imagine and reason, that are lost or altered as a result of neurological damage. The aim of treatment is to enhance functional competence in real-world situations.

The therapy includes:

• direct retraining;
• use of compensatory strategies; or
• use of cognitive tools.

The therapist must be licensed as one of the following:

• A psychologist licensed by the State Board of Examiners of Psychologists
• A psychiatrist licensed by the State Board of Medical Examiners
• An occupational therapist licensed by the Executive Council of Physical Therapy and Occupational Therapy Examiners
• A speech and language pathologist certified by the State Committee of Examiners for Speech and Language Pathologists and Audiologists

Required Procedures

The required procedures are as follows:

• Evaluation and recommendation by a psychologist or psychiatrist
• Approved treatment plan limited to achieving independent living (IL) goals with specific intervention which is ordinarily no more than 12 sessions

Problem-centered Counseling

Vendor Qualifications and Required Procedures

A licensed marriage and family therapist (LMFT) provides goal-oriented or problem-centered counseling services.

An LMFT must be licensed by the Texas State Board of Examiners of Marriage and Family Therapists.

The required procedures are as follows:

• Evaluation and prescription by a psychiatrist or psychologist
• Approved treatment plan limited to achieving IL goals with specific intervention which is ordinarily no more than 12 sessions

A licensed professional counselor provides goal-oriented or problem-centered counseling services. The counselor must be licensed by the Texas State Board of Examiners of Professional Counselors.

The required procedures are as follows:

• Evaluation and prescription by a psychiatrist or psychologist
• Approved treatment plan limited to achieving IL goals with specific intervention which is ordinarily no more than 12 sessions

A psychiatric-mental health advanced practice nurse provides evaluation, goal-oriented or problem-centered counseling services or medication management. The nurse must be licensed by the Texas Board of Nursing.

A psychologist provides or supervises the provision of psychological services. When a person under the supervision of the licensed psychologist provides services, the licensed psychologist must sign all reports. The psychologist must be licensed by the Texas State Board of Examiners of Psychologists or licensed to practice in the state where the service is rendered, unless exempt.

A licensed clinical social worker provides goal-oriented or problem-centered counseling services. The social worker must be licensed by the Texas State Board of Social Work Examiners.

The required procedures are as follows:

• Evaluation and prescription by a psychiatrist or psychologist
• Approved treatment plan limited to achieving IL goals with specific intervention which is ordinarily no more than 12 sessions

Note: Community-based behavioral health and developmental disability services centers and some state agencies are exempt from the licensing act.

Mental Health Wellness and Recovery Action Planning

Vendor Qualifications

Wellness and Recovery Action Planning (WRAP) facilitators

The WRAP program is for adults with a severe mental health disability. The program's primary goal is to help people identify and learn to use wellness tools such as coping strategies and resources, when they experience triggers or early warning signs that their mental health is worsening or when things are breaking down.

WRAP facilitators must:

• be well grounded and actively committed to his or her own recovery;
• not be a family member of the person who receives peer support services;
• have completed a 40-hour WRAP facilitator training provided by a qualified, current Advance Level WRAP facilitator recognized by the Copeland Center; and
• have completed the Mental Health Recovery: WRAP Facilitator Certification from the Copeland Center. The prerequisites for the WRAP facilitator certification can be met by taking the Mental Health Recovery Correspondence Course.

Required Procedures

Provided only to adults who have a severe mental illness.

To be eligible, a person must meet the following criteria:

• Be at least 18 years old.
• Have a mental illness such as schizophrenia, major depression, manic-depressive disorder (bipolar), or other severely disabling mental disorder that meets the diagnostic criteria specified in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). Substance abuse disorders and developmental disorders are excluded, unless they co-occur with another diagnosable severe mental illness.
• Have functional impairments resulting from the mental illness that substantially interfere with or limit two or more major life activities.
• Require crisis resolution and long-term support and treatment to manage the mental illness.

The primary deliverable for the session for the participant is a comprehensive action plan to help manage his or her own illness.

WRAP services can be delivered either individually or in a group setting. In a group setting, the ratio between WRAP facilitators and the group cannot be greater than one WRAP facilitator to eight people.

Facilitators must follow the Copeland Center's WRAP values and ethics, process, and concepts.

Facilitators must use the evidence-based model recognized by the Substance Abuse and Mental Health Services Administration.

Facilitators follow the WRAP Facilitator's Training Manual and use the PowerPoint presentation slides and CD.

Revision 23-1, Effective Nov. 13, 2023

C.1 Hearing Aid Devices and Services

Revision 23-1, Effective Nov. 13, 2023

C.1.1 Hearing Aids

Revision 23-1, Effective Nov. 13, 2023

C.1.1.1 Qualifications

Revision 23-1, Effective Nov. 13, 2023

Audiologist – Provides audiological examinations, may dispense hearing aids, and may provide basic audiometric assessments. Must be licensed by the State Board of Examiners for Speech-Language Pathology and Audiology. To dispense hearing aids, the audiologist must also be licensed by the State Committee of Examiners in the Fitting and Dispensing of Hearing Instruments.

Hearing aid specialist – Dispenses hearing aids, may provide basic audiometric assessments and may provide hearing aid evaluations. Must be licensed by the State Committee of Examiners in the Fitting and Dispensing of Hearing Instruments.

C.1.1.2 Required Procedures

Revision 23-1, Effective Nov. 13, 2023

Hearing aids are designed to be:

• monaural (involving one ear); or
• binaural (involving both ears).

Hearing aid models may be described as:

• in-the-ear (ITE);
• behind-the-ear (BTE); or
• complete-in-canal (CIC).

Hearing aids may only be purchased based with the medical recommendation of a physician or audiologist.

Once the purchase of a hearing aid has been recommended by the physician or audiologist, evaluation services may be purchased to determine which hearing aid model is most appropriate based on the person’s needs and informed choice.

Evaluation services may be purchased from a physician, audiologist, or licensed hearing aid fitter and dispenser.

Evaluation services should always include:

• a complete hearing aid evaluation;
• identification of the most appropriate hearing aid by manufacturer and model; and
• identification of recommended accessories (if needed).

Ear mold impressions are generally required. Contact the vendor to determine if this service will be completed at the time of the hearing aid evaluation or later. For example, after the vendor has submitted a written report and received approval for the purchase.

Schedule and purchase the initial fitting as soon as it is verified that the dispenser has the correct product.

C.1.2 Cochlear Implant Components

Revision 23-1, Effective Nov. 13, 2023

Cochlear implants may be authorized when they are expected to improve the person’s ability to participate in activities in the home and community per the person’s planned independence goals. Document the expected outcomes, such as an improved ability to understand spoken communication or respond to environmental cues clearly. Place the documentation in the case file as part of the assessing and planning process.

In addition, before planning to provide the person with cochlear implant services, ensure that they have:

• good general health, as evaluated by a general history and physical examination;
• no serious medical problems that would preclude surgery or participation in the aural rehabilitation program;
• a significant-to-profound hearing loss in both ears and is unable to effectively use a hearing aid in the implanted ear; and
• been evaluated by an otologic surgeon who is active in cochlear implant surgery.

The evaluation report completed by the otologic surgeon must:

• include diagnosis;
• include recommendations for treatment;
• include a prognosis; and
• ensure that:
  • consultation with a licensed medical provider has occurred;
  • an effective aural rehabilitation program following surgery is available; and
  • the person, through counseling and guidance:
    • understands the prescribed cochlear implant program and is willing and able to complete it;
    • is aware of the potential side effects from receiving a cochlear implant;
    • is aware of the availability of communication enhancements that are like the cochlear implant, such as tactile stimulation instruments, but elects to receive the cochlear implant to stimulate hearing; and
    • has expressed realistic expectations that the implant:
      • may be enhanced by a hearing aid in the better ear or the use of other assistive listening devices; and
      • can create the perception of sound but will not restore normal hearing.

C.1.3 Hearing Aid Repair

Revision 23-1, Effective Nov. 13, 2023

The costs for repairing a hearing aid, including the costs for labor, shipping and handling, should not exceed the cost of buying a new hearing aid.

Reprogramming hearing aids is allowable, especially if necessary to allow the person to make use of other training being provided.

C.1.4 FM System

Revision 23-1, Effective Nov. 13, 2023

Purchase a frequency modulation (FM) system directly from a manufacturer or an audiologist.

The required procedures are as follows:

• Do not pay a fitting and dispensing fee when purchasing an FM system through an audiologist.
• When more training is needed for an FM system, and if the necessary training is not available from a comparable benefit, negotiate payment for the time to train the person to use an FM system.

C.2 Home Modifications

Revision 23-1, Effective Nov. 13, 2023

Qualified vendors may purchase an assessment from a licensed occupational therapist, physical therapist, or professional engineer specializing in assistive technology.

Rehabilitation engineering services are used when the home modifications include design or modification of a product such as complex wheelchair ramps, ceiling track lifts, stair lifts and environmental controls. Only licensed professional engineers may provide rehabilitation engineering services. Other services not requiring design or modification of a product may be provided by an assistive technology professional or other specialist.

Adaptive equipment may require installation, but usually does not result in permanent structural changes. Household equipment may be specially designed, selected, or altered to enable the person to perform independently in the home despite his or her functional limitations.

Modifications are limited to equipment that can be removed from the residence without permanent damage to the property should the individual move, fail to cooperate in achieving the planned objective, and so on.

For purchases over $1,000, the service provider must develop policies and procedures that include an approval process, internal controls, and an oversight process.

The required process and documentation include the following:

• A full assessment of the person’s needs, followed by consideration of accommodation alternatives, including the need for individual training or education regarding the use of rehabilitation technology. Assessment services identify options that will allow the person to function as independently as possible.
• A written agreement from the property owner, before equipment such as a ramp or grab bars is attached (for example, bolted or nailed) to the property.
• When the person receiving the service, or their spouse, owns the home to be modified the service provider must purchase a lien examination from either a title insurance company or other source such as a law office. If there is a lien, notify the lien holder of the proposed modification and request that the lien holder expressly disclaim in writing any interest in the equipment installed in the residence. If the lien holder will not sign the disclaimer, the service provider must have a policy that includes the decision-making process for continuing with the plan for modification when the lienholder will not sign a disclaimer. Rental properties do not require the purchase of a lien examination.
• All documentation related to the home modification must be kept in the person’s case file.

Devices and durable medical equipment that are not attached to the property are not considered home modifications. Examples of items which may not be attached to the property include threshold ramps, modular ramps, tub lifts, and some wi-fi enabled smart devices. The service provider utilizes funds from the other purchased services budget category rather than the home modification budget category. The written agreement from the property owner and lien search are not required when an item is not attached to the property.

C.3 Prosthetics

Revision 23-1, Effective Nov. 13, 2023

C.3.1 Qualifications

Revision 23-1, Effective Nov. 13, 2023

Prosthetist and Orthotist – Fabricates and supplies prostheses and orthotics. Must be licensed by the State Board of Orthotics and Prosthetics.

Pedorthist – Fabricates and supplies below-the-ankle orthotics. Must be certified by the Board for the Certification in Pedorthics.

Occupational therapist – Must be licensed by the Executive Council of Physical Therapy and Occupational Therapy Examiners to practice in the state where services are rendered.

Physical therapist – Must be licensed by the Executive Council of Physical Therapy and Occupational Therapy Examiners to practice in the state where services are rendered.

Oculist – Must have board certification from the National Examining Board of Ocularists.

C.3.2 Required Procedures

Revision 23-1, Effective Nov. 13, 2023

Ocular prosthesis should be provided by an ocularist that is a member of the American Society of Ocularists. Members of this organization adhere to the society’s standard operating procedures for the fitting and fabrication of custom-made ophthalmic prosthetics. To find a list of ocularists in Texas, see the American Society of Ocularists website.

Before agreeing to purchase any ocular prosthesis, the service provider must have verification from an ophthalmologist that treatment has been completed and the person is ready to be fitted for a prosthesis. Additionally, the service provider must get a written estimate from the ocularist detailing the expenses to be incurred in the process of fitting and fabricating the artificial eye.

For other prosthetics, based on the medical practitioner’s prescription, the orthotist or prosthetist recommends the design of a device that best meets the person’s needs.

For orthoses, a physician's examination is required before the purchase of an initial orthosis or if the person is having difficulty using the current orthosis.

Orthoses include:

• corsets;
• orthopedic shoes;
• braces;
• splints; and
• artificial muscles.

For prostheses, an orthopedist's or physiatrist's examination is required before the purchase of the first prosthesis. If the person has difficulty using his or her current prosthesis, an orthopedist's or physiatrist's evaluation is required before planning the purchase of a second prosthesis.

All vendors of orthoses and prostheses must:

• be currently licensed by the Texas Board of Orthotics and Prosthetics;
• perform all measurements, fittings, alignments, and final checkouts for purchased devices;
• fabricate or directly supervise the fabrication of these devices; and
• provide final delivery and instructions for use.

Consider purchasing more technologically advanced devices or components only if required by the person’s unique independent living or medical needs.

If the cost is $12,500 or more, prior approval by the HHSC Independent Living Program manager is required.

The vendor should agree to replace, without cost to the service provider or the person, defective parts and materials within 90 days of the person receiving the completed orthosis or prosthesis.

The following are not covered by—and do not create exclusions to—the vendor’s warranty:

• straps, evidence that the device has been altered by anyone other than the vendor; or
• changes in the person’s condition that affect the use of the device.

The vendor honors the manufacturer warranties and pays all costs associated with warranty replacements.

The person pays all costs associated with extended warranties.

Repair the current orthosis or prosthesis unless the repair cost is more than 60 percent of the replacement cost.

Arrange training in the use of above-knee prosthesis to people who:

• have not worn one before;
• will have a different type of prosthesis than before; or
• have not worn one for a prolonged period.

A prosthetist may provide training in the use of a below knee prosthesis. If the prosthetist recommends more training, arrange for it from a qualified physical or occupational therapist.

A qualified physical or occupational therapist may provide training in the use of an upper extremity prosthesis.

C.4 Vehicle Modification Individual Service

Revision 23-1, Effective Nov. 13, 2023

Service providers and installers must adhere to health and safety standards that can be found at the Texas A&M Transportation Institute (TTI) website. Service providers must get prior approval by the HHSC Independent Living Program manager or designee for vehicle modifications that the cost $5,000 or more. Oversight, planning and inspection is subject to review by and must be coordinated with TTI or similar entity by contract with the service provider or Independent Living Center.

Modifying a person’s vehicle may be necessary when all other options for transportation have been explored and exhausted and the person cannot meet the planned goals for independence without the adaptive equipment. Procedures for evaluating the person’s ability to operate or travel safely as a passenger in a modified vehicle must be developed before agreeing to provide a modification service. These procedures must be guided by the TTI requirements and ILS requirements outlined in these standards related to vehicle modification and detailed in the person’s ILP. Individuals must be fully informed of the evaluation process, and those interactions should be clearly documented in case management software, before the person is instructed to purchase a vehicle. Some vehicles cannot be modified and maintain their structural integrity. Therefore, safety standards must be strictly followed. Vehicle modifications range in cost from less than $1,000, for simple hand controls, to many thousands of dollars for van conversions with complex steering controls.

Deciding that vehicle modification is reasonable and necessary requires careful consideration of many factors, including:

• available transportation alternatives;
• person’s financial ability to purchase vehicle, insurance and maintenance;
• effect of vehicle selection on the cost of modification;
• cost of the modification; and
• complexity of the modification.

Carefully guide the person through the entire process, including making an informed choice.

To guide the person:

• provide them with information about:
  • vehicle selection;
  • vehicle modification rebate programs; and
  • the need to visually inspect any used vehicle before agreeing to pay for modifications;
• obtain the person’s written commitment to maintain the vehicle and the installed modifications and ensure that the person has the resources to do so;
• counsel the person on the ultimate cost of replacing the vehicle and modifications and let them know they should plan to drive the vehicle for the life of the adaptive equipment, which averages seven to 10 years; and
• ensure and document that the person has the financial resources to:
  • make vehicle and insurance payments; and
  • maintain the vehicle and adaptive equipment.

C.4.1 Overview of Vehicle Modification Equipment

Revision 23-1, Effective Nov. 13, 2023

This appendix applies to contracted vehicle modification equipment (VME) purchased by ILS service providers. Contracted VME items purchased for customers by ILS includes, but is not limited to:

• lowered floor conversions;
• mobility aid hoists;
• mechanical and electronic primary control systems (i.e., hand controls);
• reduced effort powered steering;
• access battery systems;
• seating systems;
• driver and passenger restraint systems.

A complete list of vehicle modifications accepted for purchase can be found at the TWC/TTI website.

C.4.2 Limitations on Vehicle Modification Services

Revision 23-1, Effective Nov. 13, 2023

Do not sponsor vehicle modification or purchase equipment available from the vehicle manufacturer or dealer for:

• a vehicle that is not owned by the person or one of their immediate family members, such as a spouse or parent;
• a vehicle without a current Texas state vehicle inspection;
• parts not impacting the person driving the modified vehicle such as stereo, air conditioning or windshield wipers; or
• items of a cosmetic nature.

Carefully weigh the specific vehicle modification against:

• the person’s functional abilities; and
• intended use of the vehicle.

C.4.3 Service Provider Requirements

Revision 23-1, Effective Nov. 13, 2023

The ILS service provider is required to coordinate with Texas A&M Transportation Institute (TTI) to ensure that the vehicle modification proposed to be purchased is an accepted vehicle for lowered floor conversions, or an acceptable product. The coordination includes getting a pricing review from TTI by submitting the driving evaluation, service estimate from the vehicle modification vendor and the person’s medical reports. Upon completion of an installation of a vehicle modification, the ILS service provider is required to coordinate with TTI to purchase an inspection when the cost is $9,000 or higher and the person is the driver. The service provider will provide or coordinate an inspection of the vehicle modification when the cost is less than $9,000 or when the person receiving the service is not the driver and the modification is over $9,000. Any inspection, by service provider or TTI, will occur before delivery of the vehicle to the person.

The ILS service provider’s sub-contracted vendors must meet the following requirements:

• be an authorized dealer of the VME being provided or serviced;
• have a National Mobility Equipment Dealers Association (NMEDA) certified technician on staff for the VME being installed and purchased; and
• have an American Welding Society (AWS) certified welder to perform any welding that may be necessary during VME installation.

C.4.4 Evaluating the Driver

Revision 23-1, Effective Nov. 13, 2023

Once written recommendation or a prescription is obtained from a licensed practitioner for a driver’s evaluation, evaluate the person’s ability to drive using the services of a certified driving rehabilitation specialist. This evaluation also includes recommendations for the assistive equipment that are necessary for a person to drive a vehicle. This evaluation is provided to the vehicle modification vendor for their cost estimate as well as to TTI for their pricing review.

The person must complete a driver evaluation and training with the appropriate equipment, if the person has:

• never driven;
• never driven with adaptive equipment;
• progressive disabilities; or
• significant changes in his or her condition.

The person should have a valid driver's license with appropriate restrictions before a beginning a vehicle modification. It is required that the ILS service provider get a front and back copy of the person’s current and valid Texas Driver’s License with restrictions.

If a valid Texas Driver’s License with appropriate restrictions has not been obtained, the ILS service provider can purchase additional driving training from a certified driving rehabilitation specialist who will be able to arrange for the person to take the driving test in the modified vehicle.

If the person currently drives a modified vehicle, this may be verified by getting a front and back copy of the valid Texas Driver’s license with appropriate restrictions listed.

C.4.5 Evaluating Used Vehicles

Revision 23-1, Effective Nov. 13, 2023

An ASE certified mechanic must evaluate the used vehicle before it is modified to ensure the sound mechanical condition of all major components when:

• the cost of the modification is $1,000 or more; and
• the vehicle has more than 50,000 miles or is more than four years old.

The service provider pays for the cost of the evaluation and obtains a detailed report from the mechanic.

C.4.5.1 Evaluating Used Vehicles for Lowered Floor Conversions

Revision 23-1, Effective Nov. 13, 2023

Consult the TTI website for acceptable vehicles for lowered floor conversions.

Due to manufacturer requirements for lowered floor vehicle conversions, they will only be completed on vehicles that:

• have fewer than 30,000 miles;
• pass a mechanic’s inspection; and
• show no evidence of the vehicle ever having been in a wreck or damaged from flooding or other disasters.

The service provider pays for the cost of the evaluation and obtains a detailed report from the mechanic.

C.4.6 Obtaining the Modification Proposal

Revision 23-1, Effective Nov. 13, 2023

The service provider and the person will select a vehicle modification vendor. The service provider gives the person a list of approved vehicle modification vendors in the person’s geographic area.

At no cost to the service provider or person, the vehicle modification vendor prepares a proposal for the modification. The vehicle modification vendor should be provided with a copy of the completed driver’s evaluation in order to estimate the cost of exact equipment necessary for the person’s modification. If the person currently drives an adapted vehicle and a driving evaluation was not required, the vehicle modification vendor may determine assistive equipment needs based on the existing vehicle modification being used by the person.

After the proposal is received, decide with the person which modifications are reasonable and necessary for achieving the planned goal.

C.4.7 Reviewing the Modification Plan Before the Vehicle Is Purchased

Revision 23-1, Effective Nov. 13, 2023

Before the person purchases a vehicle, the service provider should have processes in place for internal management to review a plan for modifications that cost more than $1,000. If the vehicle modification requires HHSC prior approval, this approval should be obtained before the person purchases a vehicle.

Review the information gathered to get a TTI pricing review and determine if the:

• vendor’s quoted cost of the modification equipment is reasonable;
• modification prescribed by the service provider appears to meet the person’s needs; and
• specifications for equipment meet the standards and are on the TTI approved products list or have received TTI approval in writing.

Before issuing the authorization to modify, verify that the vehicle purchased is the same vehicle described in the quote and in the modification plan.

For modifications costing $1,000 or more, review a copy of:

• the certificate of title; or
• the tax collector's receipt for the Texas title application, registration, and motor vehicle tax.

The person or an immediate family member such as the i person’s spouse or parent must own the vehicle.

If there is a lien on the vehicle, get the lien holder’s expressed disclaimer of any interest in the installed equipment in writing.

If the lien holder agrees and later reclaims the vehicle for any reason, the service provider may:

• remove the installed equipment; and
• repay the lien holder for any vehicle damage caused by the installation of equipment.

Procedures, including contacting a legal resource for advice, must be developed by the service provider when a lien holder will not sign the disclaimer.

C.4.8 Insuring the Vehicle

Revision 23-1, Effective Nov. 13, 2023

When providing vehicle modification services, the person must get, at his or her expense, insurance that covers the replacement cost of the sponsored modifications. Encourage the person to carry comprehensive coverage on the vehicle. The service provider must have a policy for proceeding with modifications for vehicles that do not have comprehensive coverage.

Obtain and file a copy of:

• the paid front and back of the insurance policy; or
• verification from the insurance company that the person is eligible for insurance when the modification is completed.

C.4.9 Purchasing Equipment and Modification Repairs

Revision 23-1, Effective Nov. 13, 2023

The service provider may fund repairs to adaptive equipment and vehicle modifications.

The service provider may also fund repairs to adapted vehicles, when warranted.

Consider and document in the individual case file that:

• the vehicle is:
  • owned by the person or a family member; and
  • the person’s primary means of transportation;
• vehicle repair is a best-value decision to meet the person’s transportation needs meaning, the decision is based on the:
  • vehicle's overall condition and ongoing repairs are not expected; and
  • fact that repair costs do not exceed the vehicle's fair market value;
• there are no comparable services and benefits available to meet this person’s transportation needs, such as public bus service; and
• the person has a plan for meeting transportation expenses after case closure.

To fund equipment repairs:

• get a price quote from an adaptive equipment specialist or certified mechanic;
• ensure the safety of the modification such as the provision of tie downs; and
• inspect the work before delivery to the person or payment for completion.

Do not reclaim equipment that is broken, outdated, or no longer under warranty.

All modifications must meet the standards required by TTI and will be subject to pricing review or inspection as required in the TTI or service provider memorandum of understanding.

C.5 Wheelchairs and Scooters

Revision 23-1, Effective Nov. 13, 2023

C.5.1 Required Procedures

Revision 23-1, Effective Nov. 13, 2023

When the service provider determines that the assistive device has no salvage value, the service provider may decide to relinquish ownership. The service provider must develop and follow policies and procedures that address relinquishing ownership of the assistive device.

Written recommendations are required for:

• the initial purchase of medical assistive devices and supplies; and
• replacement items when the medical condition is progressive.

If required to get a written recommendation or prescription, place the written recommendation or prescription for the assistive device in the individual case file. This should be obtained from:

• a physician;
• a physician assistant;
• an advanced practice nurse;
• a dentist; or
• an optometrist.

When the written recommendation or prescription does not describe the item, get a letter of specification from an appropriate, certified paramedical specialist such as a physical or occupational therapist, orthotist or prosthetist.

Replacement wheelchairs require that the service provider gets an estimate of the cost for refurbishing the original chair from the local vendor of wheelchair repair services.

Consider whether repair or replacement is the more cost-effective course.

When a replacement chair that differs in size and other features from the chair previously prescribed and currently in use by the person, request that the person be reevaluated by a physiatrist or physical or occupational therapist.

Service providers generally do not purchase non-folding competition sports chairs intended primarily for sports-related activities.

When a person requests a non-folding chair that appears appropriate for their needs:

• ensure that the person can use the non-folding chair as effectively as a folding chair in all activities related to completing the independence goal, for example, when:
  • driving; and
  • loading and unloading the chair into an automobile;
• observe or ask a physiatrist or physical therapist to evaluate the person’s ability to drive using a non-folding chair and load and unload the chair into an automobile; and
• ensure that purchasing a non-folding chair will not result in additional expense, such as modifying a van or home to accommodate the new chair.

Lightweight chairs – Purchase a lightweight chair when appropriate for the person’s needs.

Do not purchase:

• more than one set of front casters including, 5" hard or 8" pneumatic;
• more than one set of arm rests including desk type or sloped; or
• sports-related options including spoke guards and anti-tip front casters.

Wet weather guards are not considered sports-related items.

Wheelchair accessories – Except for power units and controllers or seating and positioning systems, replacement parts can be purchased as needed.

Revision 23-1, Effective Nov. 13, 2023 

Overview

Diabetes self-management education services are used to:

• assess the person’s ability to independently manage his or her diabetes at home;
• assess the person’s ability to independently manage his or her diabetes in the workplace;
• prepare a person to make informed choices about his or her diabetes; and
• help the person develop the confidence and skills to implement his or her choices.

Qualifications

Diabetes self-management education services are provided by a vendor who instructs and counsels the individual and family through individual and/or group skills training.

Education and Experience Requirement

A vendor is a health professional, who:

• is licensed or registered, as required by his or her profession;
• has completed basic academic requirements for his or her field;
• has practiced for at least one year; and
• has one year of diabetes education experience.

A vendor must be a registered nurse (RN), registered dietician (RD), or certified diabetes educator (CDE). For RNs and RDs, the service provider keeps a copy of the active license on file. For a CDE, the service provider keeps a copy of the current certification from the National Certification Board for Diabetes Education (NCBDE) or the American Association of Diabetes Educators (AADE) on file.

Through academic preparation, continuing education, or on-the-job training, the vendor will have developed:

• a knowledge and understanding of diabetes and its management, including the nutritional and pharmaceutical aspects of care;
• a knowledge and understanding of basic educational and behavioral science;
• a knowledge of evidence-based nutritional, pharmaceutical, and therapeutic care of the person with diabetes;
• the additional skills necessary to work in a thorough and efficient manner, such as planning, organizing, communicating, cooperating, delegating, and working without direct supervision; and
• a knowledge of visual impairment and blindness.

A vendor (CDE, RN or RD) must have at least one year of paid experience providing diabetes education. RNs and RDs must have completed 15 hours of continuing education units (CEUs) on diabetes from an accredited agency within the 12 months immediately preceding the application date. A CDE must have completed 10 hours of CEUs on diabetes from an accredited agency within the 12 months immediately preceding the application date. The CEUs must be from an agency approved by the service provider's licensing or certifying body.

A diabetes vendor is determined to be qualified if the vendor holds a contract in good standing with the Texas Workforce Commission’s vocational rehabilitation program.

The service provider must verify the education and experience requirements and make that verification available to HHSC at any time and in any format requested.

Training Requirement

The vendor must attend required training as developed that may include training about visual impairment or blindness.

If travel is necessary in order to attend the required training, the vendor is responsible for paying all travel costs including transportation, food, and lodging.

Technical Skills Requirement

A vendor must:

• be able to assess a person’s educational needs and clinical status;
• have public speaking skills;
• offer interactive teaching techniques for people;
• be able to communicate technical medical information at a level appropriate for the learner;
• be able to create a positive and accepting learning environment;
• be able to relate positively to all people;
• believe in the capabilities and independence of people with disabilities;
• have good verbal and written communication skills;
• have basic computer skills, including word processing; and
• have a private email address, which will not be given to non-approved staff members.

The potential vendor must be able to demonstrate knowledge about diabetes and behavioral change as well as demonstrate skill in the use of the adaptive techniques that are available to people who are blind or visually impaired.

Scope of Services

Up to 15 hours of individual diabetes self-management education services are considered standard. The 15 hours include the initial assessment, skills training, and post training assessment.

Diabetes self-management education services include:

• an initial assessment that is generally up to two hours;
• skills training on diabetes self-management that is generally up to 12 hours; and
• a post training assessment which is generally up to one hour.

Individual skills training on diabetes self-management is divided into short, two-hour blocks segments, to reduce travel costs and ensure that the person maintains the physical and intellectual stamina needed to benefit from the skills training.

Reimbursement

HHSC only reimburses providers for its vendor’s time spent teaching people about diabetes.

Vendors are not reimbursed for:

• travel time;
• planning time;
• office interaction time; or
• time spent completing and submitting the required paperwork.

Assessing Diabetes Self-Management Education Services

The vendor ensures that the individualized education plan, which includes the initial assessment, instructional and skills training methods and teaching materials, is appropriate for each person, based on the person’s:

• age;
• type of diabetes (type I or II) and duration;
• cultural influences; and
• learning abilities.

The initial assessment for each person must include their: 

• relevant medical history;
• cultural influences;
• health beliefs and attitudes;
• diabetes knowledge;
• self-management skills and behaviors;
• readiness to learn;
• cognitive ability;
• physical limitations;
• level of family support;
• financial status;
• employment issues related to diabetes, if any; and
• current or potential need for adapted diabetes devices, including talking monitors for blood sugar or blood pressure, syringe magnifiers, and count-a-dose aids.

As part of the initial assessment, the vendor recommends the specific skills training that the person may need.

The training may include information on:

• the pathophysiology of diabetes (an overview);
• nutrition;
• exercise and activity;
• blood glucose monitoring and use of the monitoring results;
• diabetes-related complications;
• management of sick days;
• medical treatment;
• medication;
• foot, skin, and dental care;
• preconception care, pregnancy, and gestational diabetes;
• insulin;
• use of the health care system;
• community resources;
• stress and psychosocial adjustment;
• goal setting;
• employment issues or barriers to employment, as related to diabetes; and
• adaptive diabetes self-management equipment and tools.

If an initial assessment was conducted within the last 12 months and there has been no significant change in the person’s medical status such as no new medications prescribed, no new complications reported, and the vendor believes that there is adequate information to begin skills training, then training may begin immediately based on that evaluation.

If it has been more than 12 months since the previous assessment, or if there has been a significant change in the person’s medical status, another initial assessment must be conducted to evaluate the person’s current medical status and educational needs.

Training and Assessment Tool Kit

It is highly recommended that the service provider have a tool kit of adaptive equipment to demonstrate during assessment and training.

The items suggested for the tool kit are as follows:

• Blood glucose meter
• Count-a-dose
• Magniguide
• Meal Measure
• Insulin pen or other injectable for demonstration purposes
• Talking blood pressure monitor

It is also recommended that the disposable supplies needed to demonstrate the adaptive equipment such as test strips, syringes and insulin, be made a part of the training tool kit.

Skills Training for Diabetes Self-Management

The number of skills training hours recommended for individual diabetes self-management is based on:

• the initial assessment; and
• the topics covered that are related to the person’s independent living goals.

Skills training on diabetes self-management must include:

• goals for behavioral change; and
• participation in healthy lifestyle changes.

A copy of the current diabetes education materials is provided to the person in their preferred medium such as large print and CD.

Other education materials, resources, and referrals are documented on the required forms.

Diabetes self-management education is primarily intended to:

• provide knowledge and skills training; and
• help the person identify barriers, solve problems, and develop coping skills to achieve effective self-care and behavior change.

The initial assessment and subsequent skills training on diabetes self-management is based on the seven self-care behaviors identified by the American Association of Diabetes Educators (AADE).

The AADE’s seven self-care behaviors known as AADE7 are:

• healthy eating;
• being active;
• monitoring;
• taking medications;
• healthy coping;
• problem solving; and
• reducing risk.

Confidentiality of Information

To protect the integrity and dignity of each person, the service provider must keep their information confidential, as required by the Health Insurance Portability and Accountability Act (HIPAA), as applicable. The service provider must have policy and procedures in place that facilitate access to confidential records.

The vendor must develop and use physical safeguards for confidential records and ensure that the records are available to authorized staff members only.

Post-Training Assessment

Post-training follow-up assessments are conducted by the vendor at least one month or 30 calendar days after the skills training is completed.

As part of the post-training assessment, the vendor:

1. reviews the skills training provided; and
2. reinforces the behavioral changes.

If a post-training assessment is provided before one month or 30 calendar days after the skills training is completed, the vendor must secure approval from the referring service provider.

Documentation

The service provider's initial assessment, skills training, equipment follow-up assessment, and other findings for each person are documented using forms developed and provided by the service provider.

Exceptions

When speaking by phone or in person to the independent living service provider about differences in service delivery, including changes in a service authorization or no-show request, the service provider's call or in-person discussion should be documented in an email between all parties.

Revision 23-1, Effective Nov. 13, 2023

Overview

Independent living skills training is designed to accommodate for the person’s vision loss in daily living activities.

Qualifications

Vendors providing independent living skills training must have earned a bachelor's degree from an accredited college or university in rehabilitation, education, psychology, sociology or a related field and:

• have one year of work experience in rehabilitation teaching, rehabilitation, or education of people with disabilities, or have two years of work experience in general education or a related field; or
• have been included on the list of independent living skills trainers who previously held contracts with the Department of Assistive and Rehabilitative Services to provide this service.

Scope of Services

Independent living skills vendors provide the following services in the person’s home or local community, at the discretion of the person. The vendor may provide one or more of the following services, as authorized by the service provider.

The needs assessment is for people who are blind and is completed with the person to identify the barriers that prevent him or her from functioning independently. This process is completed face-to-face with the person by vendor staff or a subcontractor and should occur after the person is determined eligible for services. The service provider uses the needs assessment to develop the ILP.

Independent living skills training is training in techniques that enable a person to perform the skills of daily living in alternative ways.

These skills are divided into the following categories:

• Personal management—including grooming, eating, maintaining health, staying safe, identifying and coordinating clothing, and managing medication
• Home management—including sewing, cleaning clothing, keeping house, preparing meals safely in the kitchen, planning for grocery shopping, and performing minor home repair
• Communication—including telling and managing time, using the telephone, managing money, writing, organizing, and using adaptive devices
• Information access and technology—including using magnifiers, video magnification systems including closed circuit televisions and other low-vision devices, as well as adapting computers and other types of technology for the person’s use

Service Provider Responsibilities

The service provider:

• sends referrals to the vendor;
• determines the person’s eligibility for independent living services;
• refers eligible people to the vendor for the needs assessment if this service is subcontracted;
• develops the ILP with the person and enters it into the Independent Living Electronic Data Reporting System;
• authorizes independent living skills training hours;
• manages case records;
• reviews documentation of services provided by the vendor;
• authorizes the purchase of recommended equipment and services;
• documents the purchase of equipment and services in the person’s ILP; and
• arranges for or provides more complex services, including braille instruction, orientation and mobility training within the person’s community, and diabetes education.

Vendor Responsibilities

The vendor:

• conducts a needs assessment, if sub-contracted by the service provider;
• provides services as directed by the service provider and as described under Scope of Services, above;
• submits the appropriate documentation for each type of service to the service provider for review and approval;
• provides training in basic independent living skills, as described in the needs assessment and ILP;
• periodically assesses the person’s progress toward goals and timelines with the service provider;
• submits appropriate recommendations for purchasing products and services for the person to the service provider; and
• provides the service provider with a written report of each contact that includes details of the assessment, or the service provided and the outcome.

Needs Assessment

The vendor must contact a person who is referred for a needs assessment within 30 calendar days of the referral.

The vendor must document the needs assessment on the form provided by the service provider. The recommendations section of the form must contain a summary of the independent living skills training and services that the vendor has identified for inclusion in the ILP.

Independent Living Skills Training

After the service provider has developed the ILP, the vendor provides monthly training services as authorized by the service provider. The services are documented monthly using a progress report developed by the service provider.

The monthly report must:

• detail the services provided to the person;
• document the outcome of each service; and
• include any recommendations for changes to the ILP.

Revision 23-1, Effective Nov. 13, 2023 

Overview

An interpreter conveys messages between people without contributing to the dialogue.

Use interpreter services to facilitate communication in the independent living process. Qualified personnel provide interpreter services and include the use of sign language and oral interpretation for people who are deaf or hard of hearing and tactile interpretation for people who are deafblind.

Maintaining Confidentiality

The service provider informs the interpreter and person that information provided is maintained in confidence.

Using Certified Interpreters

The service provider uses certified interpreters when possible.

Refer to the Texas Health and Human Services Commission (HHSC) Office of Deaf and Hard of Hearing (DHHS) Resources page for a list of certified interpreters.

A certified interpreter holds at least one of the following current certificates of competency from one of the following organizations:

• Registry of Interpreters for the Deaf (RID)
  • Interpreter Certificate
  • Transliteration Certificate
  • Reverse Skills Certificate
  • Comprehensive Skills Certificate
  • Master Comprehensive Skills Certificate
  • Legal Skills Certificate
• Board for Evaluation of Interpreters, HHSC Office for Deaf and Hard of Hearing Services (DHHS):
  • Level I
  • Level II
  • Level III Certificate
  • Level IV Certificate
  • Level V Certificate:
    • Basic
    • Advanced
    • Master

Find more information on the DHHS page Situations and Recommended Interpreter Certification Levels.

Using Noncertified Interpreters

Use a noncertified interpreter who is otherwise competent to interpret when a certified interpreter is not available. In these cases, get the person’s written approval before hiring the interpreter.

Do not use a noncertified interpreter in the following settings:

• Medical
• Legal
• Psychiatric

Purchasing Interpreter Services

Make every effort to plan service delivery per the regular day rates. The service provider will need to establish a contract with a local interpreter service.

Translator Services

Provide translator services for the person:

• in the native language of the person, if their ability to speak English is limited; and
• in the mode of communication that the person uses.

The service provider must maintain a list of translators by name, address, phone number, and language spoken and must update the list at least annually.

The service provider informs the translator and person that information provided will be maintained in confidence.

Guidelines for Translator Services

When the person has a limited ability to speak English, make every effort to locate a translator who:

• can effectively communicate in the person's native language;
• is impartial;
• maintains the confidentiality of the person’s information; and
• is acceptable to the person. 

Get help to identify translators from organizations such as high schools, colleges, universities, the local chamber of commerce, churches, or private translator services, where representatives of the person’s ethnic group may be found.

Use a speakerphone to communicate with the translator when it is not practical for the translator to be present.

When the service provider sponsors a training program or other group services, ensure that the person who has a limited ability to speak English receives adequate help from:

• the translator;
• an individual volunteer;
• a community organization; or
• other resources. 

Revision 23-1, Effective Nov. 13, 2023

Function of Orientation and Mobility Vendors

Orientation and Mobility (O&M) vendors offer complex, interrelated services designed to promote independent travel skills for people who are blind or visually impaired.

O&M training prepares people to travel independently with competence and confidence. Orientation is the process of using the available senses to establish one's position and relationship within the environment. Mobility is the ability to travel in the environment with the help of an established tool including white canes, dog guide, and electronic travel aids.

Qualifications and Requirements

The O&M service provider must ensure that each person approved to provide O&M services to independent living people meets one of the following requirements:

• The vendor is certified by either the Academy for Certification of Vision Rehabilitation and Education Professionals (ACVREP) or the National Blindness Professional Certification Board (NBPCB).
• The vendor is not certified at the start of the contract, but he or she:
  • has a degree in O&M from an accredited college or university with an established O&M training curriculum and will be certified by ACVREP or NBPCB within one year of the contract date; or
  • has at least two years of full-time work experience teaching O&M skills for an entity that the service provider recognizes, such as a rehabilitation center, Veterans Affairs (VA) hospital, or educational system; and 
  • has three professional references indicating the person's ability to teach O&M skills to blind or visually impaired people; and
  • will be certified by ACVREP or NBPCB within one year of the contract date.

To continue contracting for independent living services, all O&M vendors under the contract must maintain ACVREP or NBPCB certification.

Training

In addition to meeting the education, training, and experience requirements described above, all prospective O&M vendors must participate in required training developed by HHSC. Each vendor is responsible for all costs related to attending the training.

Internship Requirements

O&M vendors who use interns to serve people receiving ILS services must:

• observe a minimum of 12 lessons during the internship;
• document the observations; and
• make the observations available for monitoring review by the service provider who may request them in any format for HHSC monitoring.

O&M interns must:

• attend confidence builders training or its equivalent (interns are responsible for all training-related expenses);
• be supervised by a certified O&M vendor for the duration of the internship;
• be observed by the certified O&M vendor for a minimum of 12 lessons during the internship;
• follow all standards for O&M services in this document; and
• sign and forward reports to the supervising O&M vendor for his or her approval.

Scope of Services

Orientation and Mobility (O&M) services include:

• an initial assessment of any of the person’s O&M skills including strengths, challenges and existing competency levels;
• a review of the assessment results and training recommendations with the person; and
• O&M skills training as agreed upon by the person, the service provider and the O&M vendor.

Vendor Objectivity

The O&M vendor must remain impartial and objective.

Referral Information

Before contacting the person, the O&M vendor receives referral information from the service provider.

Initial Assessment

Assessments may be conducted using the person’s functional vision, which is an opportunity for them to recognize that their vision may not meet all their travel needs.

The initial assessment includes an evaluation of the person’s O&M skills in multiple situations, which may include:

• the person’s home and immediate surrounding area;
• public areas, such as a church, park or college campus;
• commercial areas, such as a bank, store or mall;
• transit systems, such as paratransit or taxis, if available;
• local buses and similar public transportation, if available;
• rural areas, if applicable;
• residential areas are those with light vehicle and foot traffic and some stop signs;
• small business areas are those with heavier traffic and simple traffic lights;
• downtown areas are those with heavy vehicle and foot traffic and complex traffic lights;
• commercial transportation systems, such as buses, trains, and airplanes, if applicable; and
• travel using low-vision devices, if applicable.

Post-Assessment Discussion

Following the initial assessment, the O&M vendor reviews the results with the person and answers any questions that he or she may have about the recommended training. A meeting with the person, service provider, and O&M vendor is strongly recommended, so that all parties can agree on the overall O&M training plan.

Documenting the Initial Assessment

Initial assessment reports must be documented and submitted to the service provider per the service provider’s requirements.

The assessment report includes the:

• O&M vendor's observations and comments;
• The person’s current skill level and recommendations for O&M skills training in each of the areas included in the initial assessment;
• number of recommended training hours for each area;
• the person’s goals for O&M training;
• total number of recommended training hours;
• anticipated period listing beginning and ending dates for recommended training;
• person’s signature on their acceptance or rejection of the training recommendations;
• height of the rigid cane that is most appropriate for the person using the measurement between the person’s chin and nose when standing up; and
• description of all the travel aids that the person uses or would benefit from using.

Training Authorization

After submitting an assessment report, the O&M vendor must contact the service provider to discuss the initial assessment and get authorization to provide training services.

The topics covered during the discussion include:

• the vendor's recommendations for training (if any), including recommendations on the:
  • O&M skills needed;
  • proposed completion date of the training; and
  • number of training hours authorized by the person’s service provider;
• anticipated delays in services, if any;
• special considerations or extended dates for direct training, if any;
• the person’s readiness to begin nonvisual O&M skills training; and
• the person’s understanding of O&M skills training and its potential benefits.

Monthly Progress Reports

After receiving authorization to provide training services, the O&M vendor must document each person’s monthly training progress.

Monthly progress reports must be submitted within 30 days of the end of each calendar month until the person’s O&M services are completed or services are no longer recommended by the person’s service provider.

Each person’s monthly progress report must include:

• the number of training hours provided in each training area; and
• a detailed narrative of each skill area addressed during the reporting period and the training location for each lesson.

Training locations include:

• home, both indoors and outdoors;
• public areas including bank, church and doctor's office;
• commercial areas such as grocery store and mall;
• transit systems including public transportation, paratransit and taxi,
• rural areas;
• residential areas such as light traffic and stop signs;
• small business areas are those with heavier traffic and simple traffic lights;
• downtown areas are those with heavy traffic and complex lights;
• commercial travel including trains and planes;
• a detailed explanation of anticipated training for the upcoming month;
• an explanation of deviations from assessment recommendations, if any; and
• a detailed narrative of cumulative progress, if training is complete.

Expectations of Training

It is expected that O&M training services for independent living people be conducted using nonvisual (blindfold) techniques and a rigid (nonfolding) cane. All exceptions must be discussed with the service provider before training services begin and must be fully documented in the O&M vendor’s required reports.

O&M vendors will discuss the benefits of nonvisual training with each person. Role modeling and peer support for nonvisual training are encouraged.

Travel Aids

The service provider provides one rigid, long, white cane for each person for O&M assessment and training, to be distributed by the O&M vendor. The O&M vendor conveys to the service provider the appropriate length for the person using the person’s height and other information.

If a person has a dog guide, they are assessed by the O&M vendor to ensure that they have proficient cane skills. O&M training can occur with either a cane or a dog guide.

The O&M vendor must include observations and recommendations of cane skills in the initial assessment. Recommended hours for training must include the person’s travel needs, regardless of the mobility tool (dog or cane). Additional hours are not requested for training with a dog guide.

In addition, O&M vendors give information about cane purchasing to each person.  People are responsible for acquiring all replacement canes, cane tips and back-up canes.

O&M vendors may recommend other travel aids or other items to the person’s service provider. But, the decision to purchase more items rests solely with the service provider.

O&M vendors are not reimbursed for items provided to a person by the service provider.

Providing Services

The O&M training may not exceed the extent of services such as type of training and total number of hours authorized by the person’s service provider.

O&M vendors cannot provide more than six hours of training on any given day, even if multiple people are served in that day. Lessons are approximately two hours long. Without prior authorization from a service provider, a person must not receive more than four hours of O&M instruction on any given day.

Consistent and frequent scheduling is recommended to maximize learning.

For people receiving independent living services, the service provider authorizes two to three hours for the initial assessment. The vendor’s initial assessment report should determine if training is necessary, the total number of hours needed to complete the training, and a breakdown of how the hours will be completed including number, length and frequency of training sessions. 

The service provider will review the initial assessment report and determine if the vendor’s recommendations align with:

• the person’s goals
• the complexity of the environment the person will be navigating such as distance, number of obstacles, amount of traffic, if public transit is involved, and the person’s current familiarity with the area
• the person’s stamina and ability to walk, focus, and learn for the recommended length of a session which is based on conversations with the person and understanding of their disabilities
• prior O&M completed under similar circumstances

Transporting people does not count toward training time. O&M vendors are not reimbursed for time spent in the car, even when a person is present.

The O&M vendor must notify the service provider within 24 hours about all:

• no-shows, cancellations, or rescheduled appointments;
• issues, concerns, or circumstances that might impact or delay planned services; and
• issues that might delay the completion of services.

O&M vendors must get written approval from the service provider before deviating from any of these standards during training, even when based on a person’s needs.

If Services Are Interrupted

If training cannot be completed as planned or if services are postponed indefinitely because of unexpected circumstances, the O&M vendor must notify the service provider within 24 hours. The service provider will then document the postponed services. 

Revision 23-1, Effective Nov.13, 2023 

Qualifications

On occasion, certain medical professionals are needed to direct or support the provision of medical services.

The credentials required and the functions performed may include the following:

• Advanced practice nurse licensed by the Texas Board of Nursing provides medical evaluation and/or treatment. 
• Certified registered nurse anesthetist (CRNA) certified by the American Association of Nurse Anesthetists administers anesthesia. 
• Chiropractor licensed by the Texas Board of Chiropractic Examiners provides manipulative treatment of the spine and functional capacity assessments. 
• Licensed surgical assistant licensed by the Texas Medical Board provides assistant surgeon services. 
• Physician provides medical examinations or treatment. Exception: A podiatrist licensed in the state where services are rendered may provide medical or surgical services limited to foot conditions.
• M.D. (doctor of medicine) or D.O. (doctor of osteopathy) licensed by the Texas State Board of Medical Examiners to practice in the state where services are rendered.
• Physician assistant licensed by the Texas Physician Assistant Board provides medical examinations, medication management or treatment. 
• Podiatrist (doctor of podiatric medicine or DPM) licensed by the Podiatric Medical Examiners Board provides medical examinations and treatment for foot conditions. 
• Registered nurse first assistant licensed by the Texas Board of Nursing provides assistant surgeon services. 
• Specialist physician performs examinations, treatment or surgery. The physician must be certified by an American Medical Specialty Board or the American Osteopathy Specialty Board, or has the training and experience to be eligible for examination by a specialty board.
• Physician providing surgery must be board certified or eligible for examination by a specialty board in the area of the physician's surgical specialty.
• Speech and language pathologist certified as a speech-language pathologist by the State Board of Examiners for Speech-Language Pathology and Audiology provides, with the concurrence of a physician, speech and hearing therapy after surgery or trauma affecting speech. 
• Speech trainer certified as a speech-language pathologist by the State Board of Examiners for Speech-Language Pathology and Audiology provides speech training in both expressive (speech language production) and receptive (lip and speech reading) language. May also evaluate and provide training in the us of speech augmentation devices. 

Outpatient Services

Outpatient services may include:

• physician visits;
• physical or occupational therapy;
• speech, language, or hearing therapy; or
• nursing care, as provided by home health or outpatient clinics.

Provide outpatient services only when prescribed by a physician and only if they are likely, within a reasonable period, to correct or modify substantially a stable or slowly progressive physical or mental impairment that constitutes a substantial impediment to independence.

If the service provider requests an extension of treatment beyond his or her initial recommendation, assess the person’s potential for continued progress. Your assessment may involve reviewing notes on progress of the treatment or contacting the physician or service provider.

If continuing treatment is appropriate:

1. clearly document in the case file how continued services are expected to contribute to achieving the independence goal;
2. approve up to a total of 30 visits or therapy sessions; and
3. obtain approval from HHSC to extend treatment beyond 30 visits or therapy sessions.

Physical Therapy

Purchase physical therapy (PT) when required to increase:

• coordination;
• strength; or
• range of motion.

A physician recommends, and later reviews, the provision of PT. A licensed physical therapist provides the service.

Prescription Drugs and Medical Supplies

Provide prescription drugs and medical supplies, as needed, when a person cannot buy or get them from comparable sources.

When a person is discharged from a medical rehabilitation facility or hospital that has an in-house pharmacy, pay for a 30-day take-home supply of the prescription drugs and medical supplies that the person received while in the facility or hospital.

If prescription drugs and supplies are needed beyond the 30 days, arrange to purchase them from a pharmacy in the person’s home area. Buy from the least-expensive available source. When specialized prescription drugs or supplies are not readily available from a local source, buy them from the hospital pharmacy.

Prescription drugs and medical supplies shall not be purchased on an on-going basis. Typically, the services should not extend more than 120 days.

Speech Therapy and Speech Training

Speech therapy provides treatment for disorders of:

• speech;
• language;
• voice;
• communication; and
• auditory processing.

A physician recommends, and later reviews, the provision of speech therapy. A licensed speech-language pathologist provides these services.

The speech-language pathologist may also provide:

• speech training in both expressive (speech and language production) and receptive (lip or speech reading) systems; and
• evaluation and training in the use of speech augmentation devices.

A physician's recommendation and review are not required for speech training.

Oxygen and CPAP Machines

Oxygen concentrators or portable oxygen tanks may be provided as medically necessary. A prescription or order from a physician is required. The service provider may not pay for more than a 30-day supply of portable oxygen. After the 30-day supply runs out, the person will be responsible for all future oxygen refills. The service provider must assess the person’s ability to pay for ongoing portable oxygen tank refills.  If a person is unable to afford portable oxygen refills the purchase of an oxygen concentrator may be the best option. 

CPAP machines are an allowable expense with a prescription or order from a physician. A sleep study conducted within the past 12 months is required unless replacing an existing CPAP.  If the person is receiving a new CPAP and has not had a sleep study within the past 12 months, the service provider may purchase one. A sleep study must be performed under the supervision of a licensed physician.  Before purchasing the CPAP machine or sleep study, the service provider must assess the person’s ability to pay for replacement masks, filters, tubing, and other ongoing maintenance for the CPAP. The ILS Program will purchase a one-time 90-day supply of CPAP supplies such as mask, filters and tubing. The on-going purchase of CPAP supplies is not covered by the ILS program.

Other Durable Medical Goods and Services

Required Procedures

After an initial prescription is received, get the specifications for the prescription, that is, the type, size and special features needed, by arranging for the person to be evaluated by:

• a physiatrist;
• a physical or occupational therapist; or
• another qualified service provider.

Definitions

The following are definitions for different types of durable medical equipment.

Power wheelchairs: A power wheelchair is battery-operated. It has a base with four wheels and adjustable seat with armrests. It also has a controller called a joystick or touch pad attached to one armrest that allows the rider to control the movement of the chair. The chair can be disassembled for transport and usually comes with an on-board battery charger. The braking system is either automatic or electric. Powered wheelchairs can be customized with advanced technology and with several options, including the width and depth of seat size, seat-to-floor height, footrests and leg rests.

Manual wheelchairs: A standard manual wheelchair may have a cross-brace frame that folds easily for transport or storage, or may be nonfolding, with a rigid frame. The chair may have built-in or removable, optional armrests or footrests for ease of transfer, a mid- to high-level back, and push handles to allow another person to propel the chair. The seat sizes may be customized for the user. The standard tire used for the rear wheels on most wheelchairs is a pneumatic tire, with a standard size of 24 inches. Pneumatic tires have wheel locks, sometimes called brakes, which can be applied by pushing a lever located on the sides, allowing the user to control the speed or come to complete stop.

Scooters: A scooter is a power-operated vehicle that has a seat on a long platform, moves on either three or four wheels, is controlled by a steering handle, and can be independently driven by a user. It has rear drive, uses a 24-volt system and an electronic or dynamic braking system, has high-to-low speed settings, and has tires designed for indoor and outdoor use.

Power units and controllers: A power unit and controller is a computer peripheral or general control device that has a hand-held stick that pivots about one end and transmits its angle in two or three dimensions to a computer, or to a touch pad that serves the same purpose. A power unit and controller is used to propel, brake, steer, negotiate, and maneuver a powered wheelchair or scooter around obstacles.

Seating or positioning systems: A wheelchair seating system is designed for the person to:

• provide postural support, enabling the person to sit when they do not have sufficient strength or control to do so unaided;
• provide correction to encourage normal postural development and to reduce the tendency to develop orthopedic deformities;
• enhance functionality, enabling the person to perform everyday tasks in the home or social setting where person would not otherwise be able to perform those tasks;
• manage the distribution of pressure to reduce the risk of tissue damage from inappropriate loads being applied to the skin; and
• accommodate established orthopedic deformities.

The actual components and complexity of any wheelchair seating system depend on the problems that the system addresses. This definition includes parts such as cushions, as well as the complete system.

Patient lifts: Patient lifts are assistive devices used to help caregivers transfer a person safely back and forth from a bed to a chair when the person cannot transfer without help. Lifts fall into four broad categories: mobile lifts, sit-to-stand lifts, ceiling lifts and wall-mounted lifts. The lifts can be operated hydraulically or electronically.

The definition of patient lifts does not include:

• lifts that require structural modification of a building; or
• lift chair recliners, sometimes referred to as easy chairs, with seats that raise an occupant to a standing position.

Hospital beds: A hospital bed consists of special features such as a modified catch-spring assembly and bed ends with casters and manually operated foot-end cranks or an electric motor. These features permit independent adjustment of the elevation of the head and knee sections. The bed can accommodate a standard trapeze bar when attached to the head end and other accessories. The bed should be equipped to accommodate side rails. This definition does not include special or customized mattresses.

Fabricated good: A fabricated good is a device constructed to meet a specific need.

Functional unit: A functional unit is the fully constructed or fabricated durable medical equipment that can be immediately used by the person for whom it was specified. For example, a wheelchair would include the frame, seating system, controls, batteries, or other parts necessary to make it immediately usable by the person.

Manufacturer's suggested retail price (MSRP): The MSRP is the published price that a manufacturer of a product suggests that retailers charge for the product.

Other medical goods and supplies: Other medical goods and supplies are all the medical goods and supplies not defined as durable medical equipment.

Contractor-provided specification: A contractor-provided specification is a written detailed description of the exact product to be provided, including the cost of the product and the date that the product will be delivered.

Revision 23-1 Effective Nov. 13, 2023 

Vendor Qualifications

A vendor must meet the following qualifications:

• Hold a bachelor's degree in education or a related field.
• Have a working knowledge of the following:
  • The medical, psychological, social, and independent living issues faced by people who are deafblind, are visually impaired or hard of hearing, or are otherwise disabled
  • Assessment techniques and tools
  • American Sign Language, augmentative communication, manual signs, and other communication systems
  • Knowledge of agencies, people, and facilities that serve those who are deafblind, with or without other disabilities, and serve the culture and adaptive needs of people who are deafblind
• Can do the following:
  • Adapt teaching methods to the needs of people who are elderly and either deafblind or deafblind and multiply disabled
  • Help people adapt or modify common items in the home to make the items accessible
  • Assess, formulate, organize, and implement an individualized program of instruction with people 
  • Teach people to read and write all aspects of uncontracted braille
  • Communicate using American Sign Language, including using tactile sign language
  • Teach assistive technology, as needed, to enable a person who is deafblind to access independent living skills
  • Deliver, install, and setup adaptive aids or devices

Vendor Authorization

Services must not begin until the service provider has been notified of approval.

Deafblind Services Vendor Responsibilities

The deafblind services vendor:

1. completes an assessment of needs;
2. submits the right documentation for each type of service to the service provider for review and approval;
3. submits proper recommendations to the service provider for purchasing products and services for each person; 
4. trains people who are deafblind to use adaptive equipment, including visual alarms and vibrating alerting systems; and
5. provides a written report of each contact to the service provider including details of the assessment or service provided and the outcome.

Initial Contact

The deafblind services vendor must make the initial contact with a person who is referred for deafblind services training within 15 working days of the referral.

Revision 23-1, Effective Nov.13, 2023 

Eyeglasses and Contact Lenses

Required Qualifications

An ophthalmologist must be licensed by the Texas Medical Board.

An optometrist must be licensed by the Texas Optometry Board.

Purchasing Procedures

Eyeglasses and contact lenses may only be purchased for a person who is significantly visually impaired with best correction. Eyeglasses and contacts lenses that restore vision to better than 20/70 are not purchased with funds from this contract. Once a recommendation and a prescription from a licensed optometrist or ophthalmologist has been received, purchase lenses and frames per the following procedures:

• Single vision, bifocal, and trifocal glasses or contact lenses may be purchased using available funds.
• Lenses may have tint and be impact-resistant, if prescribed.
• Frames must be the least expensive serviceable type available. The person may supplement the additional cost for frames, if the cost of the person’s choice exceeds the minimum cost for a functional frame.
• Compare the cost of contact lenses with the cost of glasses before purchasing contact lenses, to determine the most cost-effective way to meet the required need for the person. 

Low Vision Services

Low vision services may be provided to eligible people whose visual acuity cannot be improved by conventional prescription eyeglasses. Low vision evaluations should be provided by an optometrist or ophthalmologist who has received specialized low vision training.

Optical Low Vision Devices

Optical low vision devices are complex optical aids designed by a specialist for a specific person, based on the person’s functional vision and optical prescription.

Examples of optical low vision devices include highly sophisticated bioptic, telemicroscopic, and reversed telescopic optical systems, as well as other single or compound optic systems.

Non-Optical Low Vision Devices

People with low vision may benefit from low-tech adaptations, such as modifications in lighting or the use of contrasting colors, including using a place mat that contrasts in color with the plate, as well as non-optical low vision devices.

Non-optical low vision devices include the following:

• Readily available independent living aids such as 20/20 pens and bold line paper
• Video magnification devices, including closed circuit television (CCTV)
• Non-prescription optical devices, such as hand-held magnifiers and telescopes

A technology evaluation or a low vision specialist recommendation is required for technology purchases of $2,500 or more such as, some video magnification systems (CCTV) and stand-alone scanners.

To purchase a non-optical low vision device:

1. get the price for each item; and
2. consider the needs for accessibility, training and installation;
3. document the specific information about the item, such as the:
   • manufacturer;
   • model number or version; and
   • monitor size; and
4. purchase as needed.

Revision 23-1, Effective Nov. 13, 2023 

The following information give further technical guidance about implementation of the ILS Standards for Service Providers. These items apply to ILS Purchased Services contracts.

The technical guidance includes recommendations for written policies or procedures. Additionally, a written policy is required when the standards call for a “written policy,” “written documentation,” “procedure” or “plan.” “Policy” defines what the service provider’s plan or guiding principle is, relating to the required standards. “Procedures” are the process or steps the applicant takes to ensure the policy is carried out. Procedures should answer the questions of who, where and how a policy will be implemented. Policies and procedures are the service provider’s guiding principles and implementation process and should not restate a standard. Policy submissions that reflect a restatement of standards will not be accepted. Service provider may also need to develop additional policies to guide the delivery of services, even when not required by the standards.

1. Service provider will make available an organizational chart of the entire service provider organization. This chart will include:
   • all job positions including filled, vacant and proposed;
   • clearly identified personnel who will be assigned to the ILS program and meet staff requirements in the ILS standards;
   • positions that will be responsible for making eligibility determinations and service delivery for the ILS program; and
   • positions that will have administrative or supervisory responsibility over the ILS program. 
2. Service provider will inform HHSC of all changes in staff allocated to the ILS program within 10 business days of the change including termination, hiring and promotion.
3. Service provider will provide HHSC staff with the qualifications of staff assigned to the ILS program, together with how the proposed staffing arrangement:
   • maximizes efficiency and effectiveness of the delivery and provision of IL services; and
   • how staff will provide services specifically for people who are:
     • blind or visually impaired;
     • deaf or hard of hearing; or
     • deaf and blind.
4. Service provider will check the licensing authority website for any staff who hold a professional license to determine if there are any restrictions to the license. If staff transport people in either a service provider owned vehicle or private vehicle, annual driver license checks should be obtained.  
5. Service provider must have a written safety policy that includes procedures for people served and employees in emergency situations, such as severe weather or fire.
6. Service provider will develop a policy with the proposed method of service delivery to all areas of the counties that the service provider serves. This policy will include the following:
   • how access to services will be provided in both rural and urban areas;
   • an estimate of the greatest distance a person would travel to access services;
   • the frequency of availability of services to be provided for the person; 
   • how services will be provided by staff in areas near (within 10 miles) and not immediately adjacent (greater than 10 miles) to the service provider’s physical location;
   • how the organization intends to provide services directly to people by service provider staff or a subcontractor; and
   • a plan to address the unique needs of people with significant disabilities and those who are blind.
7. Service provider must have a written policy and procedure about a person’s participation in the cost of services, as well as the collection of their participation funds. This policy should be shared with the person at the time of application and before purchases are made. The policy must include the following:
   • discuss the person’s participation process during the application process;
   • discuss the person’s cost participation process before being determined eligible;
   • a person’s participation agreement as developed by the service provider that will be signed by the person and service provider representative;
   • A person’s participation will be collected before delivery of goods or services; and
   • the timeline for the person to receive goods or services after a person’s participation has been collected.
8. Service provider must have a written policy and procedure to ensure that staff will enter timely documentation. At a minimum, the policy will include:
   • ILS DRS entry of services the requested services at the time of application, update services at the time the plan is written, and provide entry updates throughout the services phase of the case;  
   • entry of all case documentation including phase dates, case notes, requested services and service records, in the ILS Data Reporting System (DRS) and the CIL's case management system by the 5th business day of each month, as required in Chapter 10: Reporting and Quality Assurance; and
   • entry of all case documentation in the ILS DRS before the case is closed. Service records must be entered, including the paid date, and verified as accurate before the case is closed in the ILS DRS. The process should include who in the organization will review service records before case closure.

9. Service provider will develop a written in-house training policy and procedure for ensuring each employee is trained on the following:

   • confidentiality;
   • data use agreement;
   • case management techniques and expectations;
   • ILS purchased services and outsource process;
   • case documentation requirements; and
   • HIPAA.

   The policy must also include:

   • documentation that each staff has participated in the training at least annually;
   • outline or curriculum of specific topics covered in the training;
   • other internal training available to direct service delivery staff; and
   • external training opportunities available to direct service delivery staff.
10. Service providers who own, lease or use dedicated space where people receive or plan for ILS services are considered to have a physical location. Service providers must provide documentation of compliance with the Americans with Disabilities Act to HHSC upon application and within 30 days of relocation. Service Provider will have policies and procedures to describe the following:
    • building is accessible to all people;
    • services are accessible to all people;
    • universal staff accessibility;
    • communication is accessible to all people;
    • information related to services and providers is available and accessible to all people; and
    • a paper copy of the completed ADA Checklist for Existing Facilities kept on hand for the location.
11. Service provider must have an incident reporting system in place. A form for staff reporting of incidents must be developed and, at a minimum, include the date, time and place of incident, nature of the incident, names of HHSC ILS people, witnesses or others involved, the name of person making the report, a description of incident, and actions taken and planned by the provider as a result of the incident. The service provider must report incidents involving HHSC Purchased Services people to their HHSC compliance specialists and keep records per the records retention policy.   
12. Service provider will inform their staff and people requesting services that the HHSC Office of Ombudsman and Office of Inspector General (OIG) are available to report complaints or concerns about the provision of IL services.
13. Service provider will ensure that a minimum of 25 percent of funds are expended in each purchased service category on a quarterly basis. In the event a category is underutilized, the service provider will document lack of requested services in that category or the amount of funds reserved to be expended in the purchased service category before requesting movement of funds from one purchased service category to another.
14. Service provider will ensure that HHSC prior approved purchases are initiated within 60 days of prior approval notification.
15. Service provider will demonstrate that a written policy and procedure is in place that, at a minimum, includes the following:
    • The service provider’s method for separating ILS Purchased Services funds from other funding streams, including accounting systems, financial documentation and software, and that allocations are tracked.
    • ILS Purchased Services contract funds are used only to serve people with an ILP in the ILS Purchased Services program or for the explicit exceptions in the ILS Standards for Providers Chapter 5 for people who have not completed an ILP. 
    • The service provider has procedures to track and manage funds appropriately, including submission of prior approval packets based on availability of funds.
    • There are implemented checks and balances for all types of expenditures.
16. Service provider will have a bookkeeper, accountant or chief financial officer available to submit and communicate with HHSC staff about monthly RARs, quarterly advances, budget revisions and other financial reporting documents. This bookkeeper, accountant or chief financial officer will not serve in the role of executive director or interim executive director.
17. Service provider will implement an intake and referral process for ensuring that services are not duplicated with comparable benefits such as health insurance and local, state and federal resources. The intake process should include asking people the names of other agencies where they receive services for the service provider to complete coordination of services with that entity(ies).
18. Service provider accepts referrals from all community organizations on behalf of people. The service provider contacts the referred person to verify interest in services and get any information necessary to complete the initial contact.
19. Service provider will develop and maintain a community resources list annually to be shared with staff and people, as appropriate.
20. Service provider will ensure that staff attend a minimum of nine HHSC trainings or webinars, specific to the implementation of the ILS Purchased Services contract and ILS Standards for Providers, each fiscal year. The service provider is responsible for ensuring all staff receive the information from HHSC trainings or webinars. If all staff are not available to attend the HHSC trainings or webinars, the service provider should have staff in attendance provide the training information to those who were not in attendance.
21. Service provider will collaborate and partner with community and state organizations including Texas Workforce Commission  Older Individuals Who Are Blind program, Deaf and Hard of Hearing Center, Lighthouse for the Blind, Texas Workforce Commission Rehabilitation Services, Hadley School for the Blind, and American Foundation for the Blind, to help with developing staff’s skills and to increase availability of services for blind or visually impaired, deaf or hard of hearing, and people who are deafblind.
22. Service provider ensures staff in direct service delivery positions attend trainings such as in-services, workshops, online trainings and seminars that address serving people who are blind or visually impaired, deaf or hard or hearing or deafblind.
23. Service provider will have a written quality assurance program for review of program activities that evaluate compliance with the Independent Living Services rules and the Independent Living Services Standards. At a minimum, this will include the following and all areas listed in Chapter 10: Reporting and Quality Assurance.
    • Review a minimum of 10 percent of all people’s case files each fiscal year. The case reviews will be conducted by staff members not directly involved in the delivery of services under this contract.
    • Create and retain an ILS outsource specific case review form used to document all case reviews.
    • A process for managing and monitoring the performance of vendors and subcontractors that includes the quality of goods or services provided.
24. Service provider will enter person’s success stories into the ILS DRS on a monthly basis, by the fifth day after the end of the previous month. These person’s success stories should include examples of people served with different disabilities, including those who are deaf or hard of hearing and blind or visually impaired.
25. Service provider will obtain an annual financial audit conducted by an independent auditor in compliance with Generally Accepted Auditing Standards (GAAS), as published by the American Institute of Certified Public Accountants.
26. Service provider must follow ILS Standards Chapter 6: Purchased Goods and Services, and ILS Standards Appendices. This is to provide purchased goods and services that are within the scope of the program and that best fit the person’s needs while observing efficient budgeting practices and standards.
27. Service provider must adopt and implement procurement policies that address: 
    • conflict of interest situations; 
    • planning for procurement needs; 
    • separation of duties; 
    • criteria and situations for obtaining bids or proposals; 
    • purchasing of supplies and equipment; 
    • contracts for goods or services; and 
    • maintenance of procurement records.
28. Service provider will document coordination of purchases with any comparable benefit, resource or service available before expending funds from the contract in compliance with the Uniform Grant Guidance.
29. Service provider will have a written policy and procedure detailing how confirmation of delivery and installation of equipment is completed. At a minimum, the policy and procedure should include:
    • The service provider staff or position who will confirm that installed equipment is working and that the person was trained on the use of the equipment issued.
    • The requirement for the service provider to get an itemized delivery ticket signed by the person for each item delivered and installed.
    • The requirement for the service provider to confirm delivery and installation with the person before payment of a vendor’s invoice.
    • Information detailing who will repair or replace damaged or faulty equipment when a warranty is applicable and when the warranty or service agreement has expired.
    • The service provider policy for including information about warranties, service repair and return of equipment in disrepair or good condition in purchase agreements with vendor.
30. Service provider must refer to and follow guidance provided in Chapter 5, Service Delivery Process, and Section 5.9, Waiting List. This includes having a written policy that is consistent with Section 5.9: Waiting List. The policy should include a method of contact with people and a time frame to follow up about continued need for the requested services that are on the ILP. These contacts with people must be documented in the ILS DRS to show when a person is moved to the waiting list due to lack of funding, as well as the projected date for follow-up contact to inform the person of funding availability.
31. Service provider will establish a code of conduct for staff who perform home visits and will provide training on the code of conduct to staff assigned to the ILS Purchased Services contract.
32. Service provider will monitor, through performance evaluations, direct observations and other allowable methods, allowable interactions of IL staff with people. Internal monitoring should be performed at minimum on an annual basis, per service provider personnel policies.
33. Service provider will report on all community outreach and education specific to the ILS Purchased Services contract annually. The community outreach should include specific contacts in underserved or unserved areas of their ILS Purchased services contract area and underutilized categories of purchased services.
34. Service provider must utilize the communication preference of people with all types of disabilities including people who are deaf and hard of hearing, either by subcontractor or direct service provider.
35. Service provider will utilize certified or qualified ASL interpreters and collaborate with the Deaf and Hard of Hearing Access Specialist to get information about hiring appropriate interpreters.