Day Activity and Health Services Provider Manual

1000, Day Activity and Health Services Program Overview

Revision 14-2, Effective November 7, 2014

1100 Introduction

Revision 14-2; Effective November 7, 2014

Rule: 40 Texas Administrative Code (TAC), Chapter 98, Subchapter H, Day Activity and Health Services (DAHS) Contractual Requirements

Definition: 40 TAC, §98.2

Day Activity and Health Services (DAHS) facilities provide services to individuals residing in the community to prevent premature or unnecessarily prolonged placement in institutions. Services are designed to address the physical, mental, medical, and social needs of individuals through the provision of
rehabilitative/restorative nursing and social services which improve or maintain a person's level of functioning. The individual is able to remain in a family environment, thereby allowing the family a measure of normalcy for their daily activities.

The facility must be open during its published hours of operation to:

  • respond to inquiries from family members or Texas Department of Aging and Disability Services (DADS) staff concerning the individual, new referrals, etc.; and
  • provide services to any individual who wishes to be at the facility during that time.

1200 Legal Basis

Revision 14-2; Effective November 7, 2014

The standards for DAHS were developed to comply with the intent and requirements of:

  • Title 6 of the Human Resources Code, Chapters 102 and 103;
  • 45 Code of Federal Regulations (CFR) Part 96, Title XX of the Social Security Act; and
  • 42 CFR 440.130(d), Title XIX of the Social Security Act.

The laws and regulations provide for the care, treatment, health, safety, and welfare of individuals in DAHS facilities.

1300 General Requirements for Participation

Revision 14-2; Effective November 7, 2014

Provider enrollment is the method of contracting for DAHS. A legal entity may apply to receive a contract if the legal entity meets the requirements specified below.

1310 Licensure Requirement

Revision 14-2; Effective November 7, 2014

A provider must submit a copy of its renewed license to the provider’s regional contract manager within 10 days of receipt from the Regulatory Services Licensing Section. Not submitting a current license is a basis for automatic vendor hold on the provider’s contract.

1320 Delinquency in Payment of Franchise Tax

Revision 14-2; Effective November 7, 2014

State law prohibits the awarding of a contract or the granting of a license or permit by the state or a state agency to any corporation that is delinquent in its payment of franchise tax. A provider may obtain a Certificate of Good Standing by contacting:

Tax Assistance Section
Telephone Bank Operations
Toll Free 1-800-252-5555
Austin: 512-463-4600

1330 Denial of Contracts

Revision 14-2; Effective November 7, 2014

40 TAC §49.702, Application Denial Period

1400 Required Services

Revision 14-2; Effective November 7, 2014

40 TAC §98.202, Program Overview, §98.61, General Requirements, and §98.206, Program Requirements

1500 Excluded Services

Revision 14-2; Effective November 7, 2014

Since podiatry services and eye exams are not covered under the DAHS program, and the facility does not have to provide transportation to non-therapy services, it may be appropriate for the podiatrist or eye doctor to come into the facility.

1600 Licensing Information

Revision 14-2; Effective November 7, 2014

For information about licensing, applicants may:

  • call 1-800-458-9858;
  • fax a request to 1-877-438-5827; or
  • write to:

    Texas Department of Aging and Disability Services
    Regulatory Services Licensing Section – Mail Code E-349
    P.O. Box 149030
    Austin TX 78714-9030

2000, Contracting

Revision 14-2, Effective November 7, 2014

2100 Contracting Requirements

Revision 14-2; Effective November 7, 2014

Rule: 40 Texas Administrative Code (TAC) §98.202(a)(5), Program Overview

If this is the first time a provider has contracted with the Texas Department of Aging and Disability Services (DADS) to provide Day Activity and Health Services (DAHS), the provider must receive service-specific training before any referrals from DADS can be made. If the provider currently has a contract with DADS (for the same service in another region) and has already received orientation, the provider does not have to repeat the service-specific orientation or training again. Documentation indicating orientation has previously been received must be presented to the regional contract manager.

Failure to have adequate staff available to provide services upon receipt of training may lead to contract termination.

The provider maintains a log of complaints and makes review of complaints accessible to the contract manager. The provider must have documentation that it investigated and resolved all complaints within five workdays of receipt of a complaint, including the individual's initials on the individual-initiated complaint or witness's signature when the individual refuses to sign; and submit the complaint findings to DADS within 30 days of receipt of the complaint.

Facilities:

  • must comply with Executive Order 11246, titled "Equal Employment Opportunity," as amended by Executive Order 11375 and supplemented in Department of Labor regulations at 41 CFR part 60;
  • must comply with applicable provisions of the Clean Air Act (42 U.S.C. 7401 et seq.) and the Federal Water Pollution Control Act, as amended (33 U.S.C. 1251 et seq.) if funding under this contract exceeds $100,000;
  • must comply with §231.006, Texas Family Code, which stipulates that the individual or business entity named in the contract, bid, or application, certifies it is not ineligible to receive the specified grant, loan, or payment and acknowledges that the contract may be terminated and payment may be withheld if this certification is inaccurate;
  • are responsible for their behavior, as well as the behavior of their staff and subcontractors to ensure a violence-free contractual relationship. Any remarks, gestures, or actions toward DADS employees, volunteers, and/or individuals who carry an implied threat of any kind, even if intended to be in jest, will be taken seriously and may lead to corrective action, up to and including revocation of the contract; and
  • must comply with advanced directives requirements. See Appendix V, Advance Directives.

2200 Advertising and Solicitation of Individuals

Revision 14-2; Effective November 7, 2014

Resource: Information Letter No. 2011-31, Complaints Regarding Solicitation

2300 General Contracting Requirements

Revision 14-2; Effective November 7, 2014

Provider enrollment is the method of contracting for DAHS services. A legal entity may apply to receive a contract if the legal entity meets the requirements specified in 40 TAC Chapter 49, Subchapter C, Requirements of a Contractor.

DADS does not limit contracting to a particular type of ownership.

A contract assignment must be made for the following reasons (not inclusive):

  • one entity assigns its contract with DADS to another entity,
  • the legal entity changes ownership, or
  • the tax status of the legal entity changes.

2310 Enrollment

Revision 14-2; Effective November 7, 2014

Community Services Contracts in DADS state office enrolls providers in the DAHS program. To have a provider’s enrollment-related questions answered, call 512-438-3550, or write to:

Texas Department of Aging and Disability Services
Community Services Contracts, Mail Code W-357
P.O. Box 149030
Austin Texas 78714-9030

2320 Effective Date of Contract

Revision 14-2; Effective November 7, 2014

Rule: 40 TAC §49.209 (h), Standard Contract

2330 Compliance with the Americans with Disabilities Act of 1990

Revision 14-2; Effective November 7, 2014

Because the Americans with Disabilities Act of 1990 (ADA) requires both private and public facilities to be accessible without discrimination, DADS can refuse to contract with a facility that has been licensed but does not meet ADA requirements, even if there are other facilities in the area who do meet ADA requirements.

2340 Participation in the Child and Adult Care Food Program (CACFP)

Revision 14-2; Effective November 7, 2014

To be eligible to participate in the CACFP, an applicant must be a:

  • public institution;
  • private, nonprofit, tax-exempt organization; or
  • proprietary (privately owned, for profit) organization with 25% or more of the participants enrolled at the facility receiving Title XIX and Title XX benefits and attend CACFP Adult Day Care Program Management Training. At least one training session is offered quarterly. To verify participation or application to participate in the CACFP, a provider must submit one of the following documents with its DAHS enrollment application or within 120 days of the effective date of the provider’s contract. Failure to provide this information within 120 days of the effective date of its contract may result in termination of the provider’s contract.

Submit one of the following, depending on a provider’s situation:

  • Department of Agriculture, Form 1653, Child and Adult Care Food Program Agreement Between Sponsoring Organization and Adult Day Care Center; or
  • a copy of the confirmation of the training letter from the Special Nutrition Program (SNP), if the provider is unable to attend a CACFP Adult Day Care training session because it is full. The letter must include:
    • the date that the provider contacted SNP to schedule training; and
    • the date of the training for which the provider is scheduled; or
    • a letter to the Community Care Section in state office stating the date that the provider submitted its CACFP application, if the provider submitted its CACFP application but the application will not be processed by the 120-day deadline.

Mail the above information to the following address:

Texas Department of Aging and Disability Services
Community Care Section
P.O. Box 149030, Mail Code W-521
Austin Texas 78761-9030

For information regarding participation in CACFP or for a copy of the program handbook, the provider may call 877-TEX-MEAL or email squaremeals@TexasAgriculture.gov.

2400 Contract Assignment

Revision 14-2; Effective November 7, 2014

Reference: Form 3254, Community Services Contract (Provider Agreement), Section IV, which states:

  1. Department and contractor mutually agree:
    1. That this contract shall not be transferred or assigned without the prior written consent of the department; ...

DADS mails a contract assignment application to the assignor within seven days after receipt of written notification to DADS of the intent to assign a contract.

An example of a contract assignment agreement is found in Appendix I, Assignment of Contracts.

2500 Subcontracts

Revision 14-2; Effective November 7, 2014

Rule: 40 TAC §49.308, Subcontracts

2510 Transportation

Revision 14-2; Effective November 7, 2014

A written subcontract is required if the provider has no means of providing required transportation and transportation is provided by a public or private transportation entity. A subcontract is not needed, however, if a public transportation entity provides the service as a part of its usual service to the general public. For example, a provider buys passes for its individuals to ride on a city paratransit service.

A provider may not limit the number of individuals it will transport. Any transportation limits for individuals who use wheelchairs violates a person's rights under the Americans with Disabilities Act (ADA) of 1990 and §504 of the Rehabilitation Act of 1973. On an individual-by-individual basis, however, a provider may refuse transportation services to an individual who is disabled if the provider obtains prior approval from the contract manager.

ADA regulations do not stipulate a mileage radius limit. Additionally, ADA regulations do not establish a maximum time frame for an individual to be in transit when transported to and from the individual's home.

A provider must contact the contract manager to demonstrate that providing services to the disabled individual would cause an undue financial burden or substantially alter the nature of the services of the provider.

2520 Meals

Revision 14-2; Effective November 7, 2014

A provider is not required to obtain approval from the Community Care section if:

  • the provider contracts for the preparation and delivery of meals with a management company; and
  • the Child and Adult Care Food Program has already approved the provider’s subcontract with the management company.

2600 Method of Payment

Revision 14-2; Effective November 7, 2014

A provider may choose to participate in the Attendant Compensation Rate Enhancement option and receive enhanced rates. The Attendant Compensation Rate Enhancement option was introduced to create incentives for increased wages and benefits for community care attendants. The participant and non-participant rates are included on the reimbursement charts. The Health and Human Services Commission (HHSC) Rate Analysis Department is responsible for annually enrolling providers in the Attendant Compensation Rate Enhancement option. The open enrollment period is July 1 through July 31, unless specified by HHSC.

A provider may obtain further information on the Attendant Compensation Rate Enhancement option by contacting:

Texas Health and Human Services Commission
Rate Analysis
Mail Code H-4005
1100 West 49th Street
Austin TX 78756-3101

Telephone numbers can be found at https://pfd.hhs.texas.gov/long-term-services-supports/contact-list. The statewide unit rates are determined by HHSC. Unit rates are based on data obtained from the cost report submitted to HHSC by each individual service contractor.

To find information about HHSC's methodology for setting a reimbursement rate, establishing allowable and unallowable costs, and establishing cost-report requirements, see Appendix II-A, Reimbursement Methodology for DAHS, and Appendix II-B, Cost Determination Process.

The facility may claim reimbursement for one unit of service if three hours, but less than six hours, of service are provided.

3000, Eligibility Requirements

Revision 14-2, Effective November 7, 2014

 

3100 Service Criteria

Revision 14-2; Effective November 7, 2014

 

Only providers that have Title XX contracts may accept applicants/individuals who meet social services block grant income eligibility guidelines and resource limits. Each region makes this decision based on funding available.

The provider must serve individuals determined eligible by the Texas Department of Aging and Disability Services (DADS). See Section 5140, Freedom of Choice. However, licensing standards for adult day care facilities define an adult as a person 18 years of age or older and therefore prohibit facilities from serving persons under age 18.

3200 Medical Criteria

Revision 14-2; Effective November 7, 2014

 

Mental illness, substance abuse, and intellectual developmental disabilities are not considered medical diagnoses.

3300 Duplication in Service

Revision 14-2; Effective November 7, 2014

 

 

3310 Adult Foster Care

 

Revision 14-2; Effective November 7, 2014

 

An adult foster care individual may receive up to 10 units of Day Activity and Health Services (DAHS) per week. Because foster care providers are reimbursed for providing personal care services and supervision only, a person receiving foster care or special services to persons with disabilities 24-hour attendant care may receive up to 10 units of DAHS per week to benefit from the services provided by the DAHS program.

A person receiving adult foster care services can attend a DAHS center operated by the adult foster care provider in whose home the individual lives if the:

  • individual is eligible for DAHS and the case manager authorizes the service;
  • individual has freedom of choice in the facility he attends; and
  • adult foster care provider is in compliance with adult foster care minimum standards.

3320 Residential Care

Revision 14-2; Effective November 7, 2014

 

An individual living in residential care (RC) may receive a maximum of one unit per day of DAHS only if the services provided by the DAHS facility are medical services which cannot be provided by the RC facility. RC providers are reimbursed for providing personal care service, 24-hour supervision, social and recreational activities, room and board, etc. Because RC facilities do not provide medical services, the number of units authorized to an RC individual should be limited to the time needed by the DAHS facility to provide the medical services. One unit (three-six hours) per day should be sufficient to meet the individual's medical needs. However, if the individual resides in a personal care facility that does not have a contract with DADS, the individual may receive up to two units of DAHS per day. A licensed personal care facility that does not have a DADS contract is not required to provide social and recreational activities.

3330 Client-Managed Attendant Services

Revision 14-2; Effective November 7, 2014

 

An individual enrolled with the Client-Managed Attendant Services (CMAS) program may receive up to 10 units of DAHS per week.

3340 Waiver Programs

Revision 14-2; Effective November 7, 2014

 

Individuals in the following waiver programs can access DAHS if they meet the DAHS eligibility criteria:

  • Home and Community-Based Services (HCS);
  • Home and Community-Based Services — Omnibus Budget Reconciliation Act (OBRA) (HCS-O); and
  • Medically Dependent Children Program (MDCP).

3350 Community Living Assistance and Support Services

Revision 14-2; Effective November 7, 2014

 

An individual in the Community Living Assistance and Support Services (CLASS) program may receive both CLASS waiver services and other community care services at the same time.

3360 Intermediate Care Facility for Individuals with an Intellectual or Developmental Disability

Revision 14-2; Effective November 7, 2014

 

DADS policy prohibits providing community care services to individuals who live in an institution. An institution is defined as, among other places, an intermediate care facility for individuals with an intellectual or developmental disability (ICF-IDD).

 

4000, Staffing

Revision 14-2, Effective November 7, 2014

 

4100 Staff Qualifications

Revision 14-2; Effective November 7, 2014

 

Rule: 40 Texas Administrative Code (TAC) §98.62, Program Requirements

This section provides additional guidelines for staff qualifications and requirements. It supplements but does not substitute or replace any qualifications or requirements in the adult day care and adult day health care licensing standards.

4110 Director

Revision 14-2; Effective November 7, 2014

 

A provider must have a director who is responsible for the overall management of the day activity and health services program.

A licensed vocational nurse (LVN) may qualify to serve as a director only if he meets the qualifications for director. An LVN without a degree does not qualify.

To qualify for director, the director must have worked for the required time with people in a human service or medically related program. The definitions in the adult day care and adult day health care licensing standards provide guidelines for determining a person's qualifications to be a facility director. Each applicant must be considered individually.

4120 Activities Director

Revision 14-2; Effective November 7, 2014

 

A provider must have an activities director who is responsible for planning and directing the daily program of activities. The activities director must meet qualifications listed in §98.62(a)(3), Program Requirements, concerning staff qualifications.

4130 Nurse

Revision 14-2; Effective November 7, 2014

 

A provider must have a nurse who is responsible for assessing the individual's initial and continued medical needs, developing an individual's plan of care, etc.

The nurse may also fulfill the functions of the director if he meets the qualifications for director.

4140 RN Consultant

Revision 14-2; Effective November 7, 2014

 

If the facility nurse is an LVN, the provider must have an RN consultant four hours per week. The RN consultant can serve as a substitute for the LVN.

4200 Staff Requirements

Revision 14-2; Effective November 7, 2014

 

Rule: 40 TAC §98.206, Program Requirements

The intent of the facility staffing requirement is to ensure that a responsible professional is at the facility when individuals are present. The nurse uses professional judgment to determine where he needs to be to meet the needs of the individuals (such as accompanying individuals on outings or staying at the facility).

Because the provider must have services available for at least 10 hours each day (see Section 1400, Required Services), a professional staff person must remain at the facility when individuals are present. A professional staff person is the:

  • facility nurse;
  • facility director; or
  • activities director.

Any time an individual is at the facility, the nurse, the director, or the activities director must be on site, although the individual may be supervised by an attendant.

4210 Director

Revision 14-2; Effective November 7, 2014

 

The director must perform duties relating to the provision of Day Activity and Health Services (DAHS) for at least 40 hours per week. A director who has a full-time job outside the DAHS facility from 8:00 a.m. to 5:00 p.m., Monday through Friday, does not fulfill the requirement that the director performs duties relating to the provisions of DAHS for at least 40 hours per week. A director who has a full-time job outside the DAHS facility cannot be responsible for the overall management of the facility. The DAHS facility must have services available at least 10 hours each day, five days per week (Monday through Friday). More than one part-time director may fulfill the 40-hour/week requirement.

4220 Activities Director

Revision 14-2; Effective November 7, 2014

 

The activities director must perform the duties related to the provision of DAHS for at least eight hours per day.

4230 Nurse

Revision 14-2; Effective November 7, 2014

 

The nurse must be present at the facility at least eight hours a day when one or more individuals are present to provide health care expertise, both ongoing and in case of emergency.

The facility nurse may leave the premises during a lunch break if the facility director or activities director is at the facility.

4240 RN Consultant

Revision 14-2; Effective November 7, 2014

 

The staff or RN consultant must provide four hours of consultation per week when individuals are present in the facility.

4250 Attendants

Revision 14-2; Effective November 7, 2014

 

At least one attendant or other direct service staff must be present at the facility when one individual is present.

4260 Registered Dietitian/Consultant

Revision 14-2; Effective November 7, 2014

 

Although the dietitian may provide individual nutritional consultation to individuals, the dietitian's main task is to:

  • plan or review menus; and
  • develop special diets for individuals that were ordered by their physician.

4270 Housekeeper

Revision 14-2; Effective November 7, 2014

40 TAC §98.62(a)(6)(A), Program Requirements

4280 Driver

Revision 14-2; Effective November 7, 2014

 

40 TAC §98.62(a)(6)(B) and §98.62(a)(4)(A), Program Requirements

4290 Volunteers

Revision 14-2; Effective November 7, 2014

 

 

4291 Under 18 Years of Age

Revision 14-2; Effective November 7, 2014

 

Summer youth students under 18 years of age may volunteer their services. However, they cannot serve as substitutes for regular staff. The volunteers may:

  • help with group activities (educational, social, recreational, etc.); and
  • assist with administrative tasks.

Volunteers may not assist and/or provide any personal care tasks. These volunteers may not be included in the staff-individual ratio because they do not meet staff qualifications.

4292 18 Years of Age or Older

Revision 14-2; Effective November 7, 2014

 

Volunteers must be able to perform duties prescribed. They must also receive the training required of direct delivery staff. These volunteers may be included in the staff-individual ratio. Note: An individual cannot perform any duties related to the delivery of DAHS services.

4300 Staff-Individual Ratios

Revision 14-2; Effective November 7, 2014

 

Rule: 40 TAC §98.62(b), Staffing Ratio

To safeguard the health and safety of individuals, a certain number of direct service staff must be present at the facility at all times. The number of staff required is determined by the number of individuals present each day, but must be at least one care giver to every eight individuals served.

Direct service staff include the director, licensed nurse, activity director and attendants.

A provider must maintain the required staff-individual ratio at the facility at all times. For staffing purposes, any individuals receiving DAHS, including DADS individuals and/or private-pay individuals, are included in the ratio.

Although the staff-individual ratio does not apply when individuals are in transit, the provider must assure the individual's health and/or safety outside the facility. When the provider takes the individual on activities outside the facility, such as zoos, movies, malls, etc., the provider must maintain the required staff-individual ratio at the destination.

4400 Criminal History Checks

Revision 14-2; Effective November 7, 2014

 

House Bill 1510 requires that persons convicted of certain crimes may not be employed in most facilities and agencies providing care to the aged and disabled. Therefore, criminal history checks on certain employees must be performed prior to an offer of employment except in emergency situations.

The law requiring criminal history checks provides protection of confidentiality, which prevents a provider or DADS from sharing the results of a criminal history check with anyone. Information obtained as a result of a criminal history check may not be shared with anyone except the employee affected and DADS.

If a provider receives inquiries from an individual, individual's family, potential employer or other interested parties, explain the following:

  • that the provider is required by law to conduct criminal history checks on all attendants;
  • that the provider is complying with the law; and
  • that the provider is being monitored for compliance with the law.

A provider must not share the reason for termination of the attendant with an individual or an individual's family if the termination is the result of a criminal history check. If the attendant shares the information with an individual, the provider may not confirm the reason for termination.

Procedures for conducting criminal history checks may be found in Appendix VII, Criminal History Check of Employees in Certain Agencies/Facilities Serving the Elderly or Persons with Disabilities.

4410 HIV/AIDS in the Workplace

Revision 14-2; Effective November 7, 2014

 

DADS guidelines are based on the Texas Department of State Health Services Model Education Program. The guidelines are found in Appendix IV, HIV/AIDS in the Workplace.

4420 Occupational Exposure to Bloodborne Pathogens

Revision 14-2; Effective November 7, 2014

 

Occupational Safety and Health Administration (OSHA) standards require that employers make available the Hepatitis B vaccine and vaccination series to all employees who have occupational exposure. Resources can be found at the Texas Department of State Health Services website for Bloodborne Pathogen Resources.

If a provider offers the vaccine, the full cost of vaccination expenses incurred may be reported on the cost report. The cost to provide vaccinations is currently included in the reimbursement rate.

4430 Training

Revision 14-2; Effective November 7, 2014

 

Rules for initial and ongoing training can be found in 40 TAC §98.62, Program Requirements.

 

5000, Service Requirements

Revision 18-2, Effective December 4, 2018

 

5100 Overview

Revision 14-2; Effective November 7, 2014

 

This section describes the interaction between the Texas Department of Aging and Disability Services (DADS) and facility staff. This material is presented in a normal and chronological sequence of events, following the individual from initial application for services through service delivery and suspension or termination of services.

 

5110 Enrollment Forms

Revision 15-4; Effective October 14, 2015

  • Form 2059, Summary of Client's Need for Service;
  • Form 2067, Case Information;
  • Form 2101, Authorization for Community Care Services;
  • Form 2110, Community Care Intake;
  • Form 3050, DAHS Health Assessment/Individual Service Plan;
  • Form 3055, Physician's Orders (DAHS); and
  • Form 3070, Day Activity and Health Services Notification of Critical Omissions.

5120 Referrals to Facility

Revision 14-2; Effective November 7, 2014

 

An applicant may be referred to a Day Activity and Health Services (DAHS) facility by the:

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

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

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

5130 Case Manager Service Planning Process

Revision 15-4; Effective October 14, 2015

 

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

  • Form H1200-EZ, Application for Assistance - Aged and Disabled;
  • Form 2059, Summary of Client's Need for Service;
  • Form 2059-W, Summary of Individual's Need for Services Worksheet; and
  • Form 2307, Rights and Responsibilities.

The DADS case manager determines whether the applicant meets the DAHS financial eligibility criteria and has unmet needs that can be met through DAHS. To avoid duplication of services, unmet need must be considered when the individual receives other community care services.

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

  • the individual’s preference; and
  • unmet need.

Units of service are designated on Form 2101, Authorization for Community Care Services, as follows:

  • one unit equals more than three hours but less than six hours (or half day); and
  • two units equal more than six hours (or one full day) up to 10 hours.

The case manager cannot authorize more than 10 units of DAHS per week.

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

The maximum number of units in the calendar month cannot exceed 46, provided within 23 possible calendar days.

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

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

Before referring the individual for DAHS, the case manager:

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

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

5140 Freedom of Choice

Revision 14-2; Effective November 7, 2014

 

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

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

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

5150 Interest Lists

Revision 14-2; Effective November 7, 2014

 

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

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

A facility operating at capacity may maintain a facility interest list for Title XIX and private-pay individuals.

5200 Prior Approval Process for Case Manager Referrals

Revision 14-2; Effective November 7, 2014

 

This section explains how to request prior approval for an applicant after receipt of the referral packet from the case manager.

5210 Referrals

Revision 15-4; Effective October 14, 2015

Case Manager-Initiated Referrals

The DADS case manager will send Form 2101, Authorization for Community Care Services, to the DAHS facility.

Once the DAHS facility receives Form 2101 from the case manager, the DAHS facility must send a referral packet to the DADS regional nurse within 14 days after the receipt of Form 2101 from the case manager. The referral packet includes the following:

Form 2059, Summary of Client's Need for Service;
Form 2059-W, Summary of Individual's Need for Services Worksheet; and
Form 2101, Authorization for Community Care Services;
Form 2110, Community Care Intake;
Form 3050, DAHS Health Assessment/Individual Service Plan; and
Form 3055, Physician’s Orders (DAHS).

Rule: 40 TAC §98.203(g), Written Referrals for Services

If the DAHS provider cannot obtain the physician’s orders within 14 calendar days, the provider must send Form 2067, Case Information, to the case manager explaining why and a copy is kept in the individual’s case record.

40 TAC §98.203 (b) and (c), provides the applicable policy when services are not started within 14 days of referral.

The case manager must:

  • evaluate the cause of the delay; and
  • take whatever action is necessary to ensure that the individual receives services at the earliest possible date.

This may necessitate making a new referral to a different facility. In this event, the case manager verbally notifies the original agency and DADS regional nurse and confirms in writing (using Form 2067) that the original referral is being withdrawn.

The case manager evaluates each situation on a case-by-case basis. In the event of a disagreement with the case manager’s action, the case manager’s supervisor may be contacted. The frequent submittal of Form 2067 about facility delays in service initiation to the DADS case manager may also be brought to the contract specialist’s attention.

Also see Section 5820, Individual Transfers, for information on transfers that occur between DAHS facilities that are initiated by the individual.

Facility-initiated Referrals

The DAHS provider must submit a prior approval packet to the DADS regional nurse within 30 calendar days after the date of the initial physician’s order, verbal or written. The prior approval packet consists of the following:

Form 2101, Authorization for Community Care Services;
Form 2110, Community Care Intake;
Form 3050, DAHS Health Assessment/Individual Service Plan;
Form 3055, Physician's Orders (DAHS);

See 40 TAC §98,204(c)-(d), DAHS Facility-Initiated Referrals.

5211 Health Assessment

Revision 15-4; Effective October 14, 2015

 

A DAHS facility licensed nurse must complete the health assessment for each referral. The assessment may be conducted by an RN or LVN, dependent upon the individual’s presenting health conditions. The DAHS facility nurse completes the health assessment using Form 3050, DAHS Health Assessment/Individual Service Plan, Sections II and Section III. The health assessment may be conducted at either the facility or the individual's home.

Health assessments must be conducted when:

  • individuals need initial prior approval;
  • individuals transfer by the receiving facility; or
  • the licensed nurse determines an ongoing individual needs to be reassessed.

The individual or responsible party must sign the health assessment each time the facility nurse has completed or revised the form.

The health assessment identifies specific conditions that may affect an individual’s functioning. For example, Form 3050, Sections II and III, may indicate an individual has residual paralysis from a stroke. The identification of residual paralysis on the assessment could translate to a number of tasks the individual needs assistance and documented on Form 3050, Section IV.

Initial DAHS Individuals

The assessment of functional and physical status must reflect symptoms the individual experienced within 30 days of the date the assessment is completed.

Ongoing DAHS Individuals

The facility nurse must update the health assessment when the nurse makes a determination to conduct a new assessment based on concerns the current assessment is no longer accurate and does not reflect the individual’s current conditions or symptoms.

Health Assessment Due Dates

For DADS case manager initiated referrals, the due date is within 14 calendar days after the referral date on Form 2101, Authorization for Community Care Services, Item 1, or the date the facility received Form 2101, as indicated by the date stamp, whichever is later.

If the DAHS facility nurse cannot complete the health assessment within 14 calendar days after the referral date, Form 2067, Case Information, must be sent to the case manager explaining why and a copy kept in the individual's case record.

For facility initiated referrals, the due date is on or before the date services are initiated.

5212 Individual Service Plan (ISP)

Revision 14-2; Effective November 7, 2014

 

 

5212.1 Initial DAHS ISP

Revision 15-4; Effective October 14, 2015

 

Form 3050, DAHS Health Assessment/Individual Service Plan, Section IV, is completed at the same time Form 3050, Section II and Section III are completed by the facility nurse.

A new ISP is completed for individuals:

  • who need initial prior approval; or
  • who transfer by the receiving facility.

Updates to existing individual service plans are needed when:

  • changes to the individual’s treatment, monitoring and intervention occur; or
  • nursing service needs have changed based on new or supplemental physician’s orders.

5212.2 Updates to DAHS ISP

Revision 15-4; Effective October 14, 2015

 

Updates to existing individual service plans (ISPs) are needed when:

 

  • changes to the individual’s treatment, monitoring and intervention occur;
  • nursing service needs have changed based on new or supplemental physician’s orders;
  • updates regarding changes to the individual’s service plan must be documented as changes occur. Additional information regarding updates may be entered in the “Additional Information/Notes” section of Form 3050, DAHS Health Assessment/Individual Service Plan;
  • when the licensed nurse determines an individual needs a new service plan developed; or
  • when multiple plan updates have resulted in the individual’s plan becoming difficult to follow and a brand new ISP is needed to ensure the current treatment, monitoring and interventions can be identified clearly. An external party, when reading the plan, should be able to identify the treatments, monitoring and interventions, personal care tasks and health teaching provided to the individual receiving DAHS, as well as the frequency or schedule.

The licensed nurse must indicate dates associated with any changes (deletions or additions) to treatments, monitoring or interventions, such as medications or skilled care provided at the DAHS facility.

5212.3 Initial and Ongoing DAHS ISP

Revision 15-4; Effective October 14, 2015

 

A provider must ensure the individual service plan (ISP) documentation of treatments, monitoring and intervention ordered by the physician, including the indicated frequency, and all medications, whether taken at the DAHS facility or at the individual’s home, must be documented to include dosage, route and frequency.

A provider must ensure that all treatments, skilled care and medications indicated on the ISP match the physician’s orders or supplemental orders. If the physician’s orders are updated, the ISP is updated to clearly indicate the date when treatments, medications or skilled services were revised or added.

Information received from the case manager may convey problems that the individual is experiencing at home that may need to be addressed by DAHS staff. For example, the individual may not have adequate bathroom facilities at home causing a need for personal care at the DAHS facility. All personal care and health teaching provided at the DAHS facility must be reflected on the ISP, including the schedule and frequency of the tasks provided.

Form Form 3050, DAHS Health Assessment/Individual Service Plan, and Form 3055, Physician's Orders (DAHS), are the appropriate documents where DAHS facility staff must actively update and enter changes in medications and treatments, and any subsequent changes in the individual’s plan of care to reflect the individual’s current needs.

Documentation regarding the frequency of treatment, monitoring or interventions outlined in the ISP must be clearly linked to internal documentation maintained by the DAHS facility so that DADS monitoring staff can determine the type of assistance currently provided by the DAHS staff.

5213 Physician's Orders

Revision 14-2; Effective November 7, 2014

 

 

5213.1 Initial Physician’s Orders for Enrollment of Individual into DAHS

Revision 15-4; Effective October 14, 2015

 

A new Form 3055, Physician’s Orders (DAHS), is needed upon initial request for DAHS.

After the facility nurse has conducted the health assessment and completed both Form 3050, DAHS Health Assessment/Individual Service Plan, Form 3055, Physician’s Orders, and Form 3055, these forms are sent to the DADS regional nurse for approval of eligibility for DAHS. Physician’s orders are required for individuals receiving DAHS under Title XIX and Title XX.

5213.2 Supplemental Physician’s Orders

Revision 14-2; Effective November 7, 2014

 

As a best practice, Form 3055, Physician’s Orders (DAHS), should be completed by the physician or physician's nurse whenever possible; however, the DAHS facility nurse may complete Form 3055 and obtain the physician's signature.

The current physician’s orders and any supplemental orders on file must be accurately reflected in the individual’s service plan. Supplemental orders pertaining to additional diagnosis or treatments submitted later on separate documents must be kept together with the current Form 3055 to accurately reflect the individual’s complete record of medical diagnosis, treatments, monitoring and interventions.

5213.3 Physician’s Orders and Signature

Revision 15-4; Effective October 14, 2015

 

Case manager initiated referrals ─ Within 14 calendars days after the referral date (Form 2101, Authorization for Community Care Services, Item 1). If the DAHS facility cannot obtain physician’s orders within 14 days, Form 2067, Case Information, must be sent to the case manager explaining why, and a copy kept in the individual's case record.

For facility initiated referrals ─ On or before the date services are initiated, verbally or written.

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

Physicians from bordering states who have their practice within 50 miles from the Texas state line who provide care to DAHS individuals are considered in-state providers.

Temporary permits must include the date of issue and expiration. Physicians assigned to military medical facilities must use the military number assigned.

To verify if a physician is licensed to practice in the state of Texas, check online at http://public.tmb.state.tx.us/HCP_Search/searchinput.aspx or contact the Verification Department of the Texas Medical Board at 800-248-4062 or fax 512-305-7051. Also, a directory exists of Texas licensed physicians that includes a list of MDs (doctors of medicine) and DOs (doctors of osteopathy) licensed to practice in Texas through the Texas Medical Board.

This directory may be purchased at:

Texas Medical Board
P.O. Box 2018, Mail Code 251
Austin TX 78768-2018

The physician cannot be the facility owner nor have a significant or contractual relationship with the facility.

The DAHS facility may accept faxed physician's orders from the physician. When a fax machine is used, it is not necessary for the prescribing physician to sign the order at a later date as long as the faxed copy is signed.

Expenses incurred to complete the physician's order are not allowable costs in the DAHS program. Offers of or requests for payment for completing orders will be referred for Medicaid fraud investigation.

A physician can bill an individual who is not covered by Medicaid for completion of physician's orders. Exception: If a physician has accepted Medicaid payments for the diagnosis and treatment of the individual's illness that makes him eligible for DAHS, then he cannot bill the individual for completion of physician's orders.

Physicians who are graduates of medical school and meet all the requirements for licensure, but are waiting for final approval of licensure by the Board of Medical Examiners, are issued temporary licenses. This allows the physician to practice until a license number is obtained. The temporary license has an issue and expiration date. In this situation, indicate on Form 3055, Physician’s Orders (DAHS):

  • "temporary license;" and
  • the expiration date of the license.

The DAHS facility can only accept a physician's order dated on or before the expiration date of the temporary license.

The physician's order must be signed, dated and include MD or DO credentials. Physician signature stamps are acceptable.

Physician’s Stamped Signature

If . . . Then . . .

the signature stamp is a facsimile of the physician's signature,

neither initials nor signature are needed. The provider must have documentation from the physician approving the signature stamp. The authorization must:

  • be signed by the physician; and
  • include a copy of the stamped signature that will be used.

the signature stamp is typewritten or block-printed,

the stamped orders must also be initialed or signed by the physician. Initials are accepted if initials are the physician's usual signature. If initials are used, the provider must type or print the physician's name above or below the signature line.

If the physician fails to date Form 3055 or if the signature date is illegible, the facility stamp-in date will be considered the date of the physician's orders. The date stamp must include the day, month, year and the name of the facility. An abbreviated name or initials are acceptable.

5220 Regional Nurse Prior Approval for Case Manager Referral

Revision 15-4; Effective October 14, 2015

 

When the DADS regional nurse receives the required forms from the DAHS facility, he reviews Form 2059, Summary of Client’s Need for Service, Form 3050, DAHS Health Assessment/Individual Service Plan, and Form 3055, Physician’s Orders (DAHS), to determine if the individual meets the DAHS medical eligibility criteria found in Section 3200, Medical Criteria.

For case manager initial cases, the DADS regional nurse establishes the beginning date of coverage on Item 4 of Form 2101, Authorization for Community Care Services, as the date Form 2101 is expected to be mailed to the provider. If this date is not feasible, the regional nurse negotiates the beginning date of coverage on Item 4 of Form 2101 with the provider and DADS case manager according to the individual’s needs and the individual’s unique circumstances.

The DADS regional nurse determines if a condition qualifies as a chronic medical condition. The DADS regional nurse may contact the individual’s physician to discuss the individual’s condition and the approximate length of time needed for full recovery.

Within seven days of the receipt of the prior approval request, the regional nurse uses Form 2101 to notify the provider about approval or denial of routine cases. The DADS regional nurse approves prior approval if the:

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

The regional nurse sends:

  • copies of Form 2101 to the provider and DADS case manager when granting prior approval; and
  • copies of Form 2101 in denial of prior approval in an initial case to the provider and the case manager.

If services are denied, the case manager sends the individual a written notification.

5300 Prior Approval Process for Facility-Initiated Referrals

Revision 14-2; Effective November 7, 2014

 

This section explains how to request prior approval for an applicant who enters a provider’s facility through the facility-initiated process.

5310 Facility Response to Facility-Initiated Referrals

Revision 15-4; Effective October 14, 2015

 

A provider may immediately admit any Medicaid individual pending eligibility determination for DAHS if the DAHS facility has a contract with DADS and the DAHS facility is willing to risk loss of revenue if the applicant is determined not to be eligible.

Rule: 40 TAC §98.204, DAHS Facility-Initiated Referrals

An applicant is someone who is not currently receiving DAHS services at a contracted facility. A facility-initiated referral must not be made on current DAHS individuals.

Example: An individual who is attending Facility A moves to Facility B and wants to attend there. Facility B cannot make a facility-initiated referral because the person is already a DAHS individual. Additionally, Facility B will not be reimbursed for services provided before the transfer date established by the case manager. See Section 5820, Individual Transfers, for more information about transfer procedures.

If the facility fails to receive Form 2101, Authorization for Community Care Services, within 30 days from the date of the physician's orders, the facility may submit the prior approval packet without Form 2101.

For Item (3), the date of the verbal notification is the date of the request for Community Care for Aged and Disabled services. A provider must document the reason for the immediate placement on Form 2067, Case Information, to the case manager.

The licensed nurse:

  • records the physician's orders on Form 3055, Physician’s Orders (DAHS); and
  • completes completes Form 3050, Health Assessment/Individual Service Plan.

Refer to the following items to obtain additional information on completing these forms:

Submit the following forms to the regional nurse to obtain prior approval for the facility-initiated referral:

  • Form 3050; and
  • Form 3055.

The regional nurse holds Form 3050 and Form 3055 until Form 2101 from the case manager is received.

5311 Facility That Does Not Have a Contract with DADS

Revision 14-2; Effective November 7, 2014

 

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

If the facility continued to provide services to the individual, the effective date for reimbursement of services to the individual is the date the facility notifies the case manager that it has a DADS contract. The facility may notify the case manager by telephone or through Form 2067, Case Information, that it has a contract with DADS. This notification serves as a second referral to the case manager.

5320 Case Manager Response to Facility-Initiated Referral

Revision 14-2; Effective November 7, 2014

 

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

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

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

If the applicant is financially eligible, the case manager sends:

  • the original Form 2101, Authorization for Community Care Services, to the regional nurse; and
  • a copy to the provider.

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

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

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

The case manager notifies the individual of his eligibility or ineligibility within 10 days of the decision, using Form 2065-A, Notification of Community Care Services.

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

5321 Payment for Services Following Change of Individual’s Status

Revision 14-2; Effective November 7, 2014

 

If a provider admits a Medicaid individual through the facility-initiated referral process and follows all facility-initiated procedures (conducts a health assessment or plan of care, obtains physician's orders, etc.) and the individual either dies, moves to another facility, or decides he no longer wants to receive services before the case manager has an opportunity to conduct the assessment, a provider can be reimbursed for services provided to the individual if:

  • the provider documented on attendance or transportation records that services to the individual were provided;
  • the case manager verifies the individual was Medicaid eligible when services were provided and received no other community care services which duplicate DAHS; and
  • the regional nurse determines the individual meets criteria for DAHS.

5330 Regional Nurse Prior Approval on Facility-Initiated Referral

Revision 14-2; Effective November 7, 2014

 

Upon receipt of Form 2101, Authorization for Community Care Services, from the case manager for verbal prior approval, the regional nurse uses procedures in Section 5220, Regional Nurse Prior Approval for Case Manager Referral, to determine prior approval for a facility-initiated referral.

The regional nurse establishes the beginning date of coverage on Item 4 of Form 2101 for a facility-initiated referral using the date of the physician orders./p>

The DADS regional nurse follows the policy in 40 TAC §98.204(d), DAHS Facility-Initiated Referrals, when prior approval forms or additional documentation is not is submitted.

If the prior approval material is incomplete or is not received within required time frames, the regional nurse establishes the beginning date of coverage on Item 4 of Form 2101 using the earliest of the following dates:

  • postage meter date (if not cancelled by the U.S. Postal Service);
  • U.S. Postal Service date; or
  • DADS stamp-in date.

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

5400 Critical Omissions

Revision 14-2; Effective November 7, 2014

 

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

5410 Critical Omissions or Errors in Required Documentation

Revision 14-2; Effective November 7, 2014

 

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

An MD (Medical Doctor) or DO (Doctor of Osteopathy) must sign Form 3055, Physicians Orders (DAHS).

On Item 5 of the previous list, if the physician's license number is illegible, it is considered a missing license number.

If a critical omission or error is identified, the regional nurse:

  • completes Form 3070, Day Activity and Health Services Notification of Critical Omissions; and
  • sends to the facility along with the rejected prior approval packet.

5411 Corrections of Critical Omissions or Errors

Revision 15-4; Effective October 14, 2015

 

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

To expedite the processing, a provider may:

  • return a copy of Form 3070, Day Activity and Health Services Notification of Critical Omissions, with the corrected packet; or
  • note "corrected packet" at the top of either Form 3050, DAHS Health Assessment/Individual Service Plan, Form 3055, Physician’s Orders (DAHS), or Form 2067, Case Information.

5500 Initiation of Services

Revision 14-2; Effective November 7, 2014

 

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

Service initiation policy for the DAHS facility is included in 40 TAC §98.205 (a) and (b), Initiation of Services.

The DADS case manager must:

  • evaluate the situation; and
  • decide whether the individual should be referred to another facility.

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

5600 Case Manager Follow-up

Revision 14-2; Effective November 7, 2014

 

The DADS case manager monitors the individual when services are initiated and periodically thereafter to:

  • ensure the continued adequacy of the plan of care and the quality of service delivery; and
  • observe the individual's condition.

5610 Return of Form 2101

Revision 14-2; Effective November 7, 2014

 

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

Rule: 40 TAC §98.205(c), Initiation of Services

This does not apply to facility-initiated referrals because services usually start before the coverage date on Form 2101. The provider should return Form 2101 as soon as possible after receiving it from the case manager or DADS regional nurse. To comply with contract monitoring standards, the provider enters the following information on Form 2101:

  • days of the schedule for services;
  • service initiation date;
  • total units or hours authorized;
  • provider’s signature; and
  • date of provider’s signature.

5700 Facility Responsibilities

Revision 15-4; Effective October 14, 2015

 

A provider must operate the program to promote active participation of individuals in a variety of ways. Services must be designed to address the physical, mental, medical and social needs of individuals through the provision of rehabilitative or restorative nursing and social services which improve or maintain a person's level of functioning.

The specific needs of the individual must be addressed by the facility while the individual is at the DAHS facility. A provider should use the case manager's Form 2101, Authorization for Community Care Services, Form 3050, DAHS Health Assessment/Individual Service Plan; and Form 3055, Physician's Orders (DAHS), to determine what services the individual needs.

Required services listed in Section 1400, Required Services, are described in more detail.

5710 Nursing Services

Revision 14-2; Effective November 7, 2014

 

Nursing services include an individual’s assessment, assistance with prescribed medications, counseling concerning health needs and supervision of personal care services.

Facility nurse responsibilities are described in 40 TAC §98.62(d)(2)(E), Program Requirements.

The monthly progress notes must be signed and dated by the licensed nurse documenting the medical notes. If the facility nurse is an LVN, the monthly notes do not have to be resigned by the RN consultant.

It is expected that individuals bring their own medical supplies to the facility. The facility, however, must be prepared to supply these items if an individual forgets his supplies or an unexpected need arises. The cost of these emergency supplies should be reported on the cost report.

New supplemental physician's orders (not Form 3055, Physician's Orders (DAHS)) are required for:

  • new treatments;
  • changes in medicine being administered at the facility; or
  • other procedures being provided by the appropriate licensed nurse which require a physician's order.

New physician's orders are not required when the individual’s medical diagnosis changes.

5720 Physical Rehabilitative Services

Revision 14-2; Effective November 7, 2014

 

Physical rehabilitative services include restorative nursing and group and individual exercises, including range of motion exercises.

5730 Nutrition and Food Services

Revision 14-2; Effective November 7, 2014

 

Nutrition and food services include:

  • one hot noon meal a day;
  • a mid-morning and mid-afternoon snack;
  • preparation of foods required for special diets; and
  • dietary counseling and nutrition education for the individual and his family.

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

If meals are not prepared at the facility, the Texas Department of State Health Services food service sanitation rules specify that hot meals cannot be in transit for more than one hour from the time the food is taken from the stove or microwave until it is delivered to the DAHS facility. Cooked foods should be 140°F when placed in containers for transport to the facility. Cold foods should be enclosed and isolated from hot foods to maintain appropriate temperature.

For additional information on food service sanitation, contact the Texas Department of State Health Services at P. O. Box 149347, Austin, Texas 78714-9347, or call 512-834-6670.

5740 Transportation

Revision 14-2; Effective November 7, 2014

 

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

Rules on vehicle maintenance by the DAHS facility is located in 40 TAC §98.206(5)(D), Program Requirements.

The rule on maintenance of attendance and transportation records is included in §98.209(b), Record Maintenance. A facility that provides transportation or has a subcontract with a private or public transportation entity must use Form 3682, Day Activity and Health Services Daily Transportation Record.

The provider must:

  • coordinate the use of other transportation resources within the community;
  • make every effort to have families transport individuals;
  • manage upkeep and operation of facility vehicles, including liability insurance. Vehicles used by the facility must be maintained in a condition to meet the vehicle inspection requirements of the Texas Department of Public Safety; and
  • have sufficient staff to ensure the safety of individuals being transported.

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

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

5750 Other Supportive Services

Revision 14-2; Effective November 7, 2014

 

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

Rule: 40 TAC §98.62 (d) (3) (A-E), Program Requirements, includes the responsibilities for the DAHS activities director.

A provider must have a supply of materials adequate for the participation of all individuals in program activities. Program activities include games, crafts, field trips, and any other activities that require the use of material or supplies.

A provider must offer at least three different scheduled activities daily. These activities must be chosen from the following categories:

  • exercises;
  • games;
  • educational or reality orientation; and
  • crafts.

On a weekly basis, a provider must offer at least two different activities from each category. See Appendix III, Examples of Day Activity and Health Services Activities, for examples of activities that can be provided under each category.

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

  • trips or special events; or
  • cultural enrichment.

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

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

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

A provider may schedule field trips on Saturday as special events, as long as the field trips are documented on the activities calendar. Refer to Section 1400, Required Services, for information on Saturday operations.

Examples:

  • Exercise Category — parachute, ball toss, kick ball, cookie walk, wheel chair.
  • Crafts Category — sewing, leather craft, woodwork, beading, painting, life journal.
  • Games Category — bingo, dominoes, cards, chess, ring toss, role play (drama).

Craft items must be provided without charge to the individual. Items for the individual's personal use are the individual's responsibility.

5760 Notifications

Revision 18-2; Effective December 4, 2018

 

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

If an individual receiving DAHS is diagnosed with active Tuberculosis (TB), the facility must immediately inform the individual’s physician of the condition. In order for the individual to remain at the facility, the individual’s physician must provide the facility a written statement that the tuberculosis is not infectious. Until the physician's statement is received by the facility, arrangements should be made with the individual’s family to keep the individual at home. If the physician reports in writing that the TB is not infectious, the individual may return to the facility.

To prevent the transmission of pulmonary TB in the infectious phase, isolation in a private room with ventilation to the outside is necessary according to the Centers for Disease Control and Prevention. Since Licensing Standards for Adult Day Care Facilities do not require facilities to provide this type of isolation room, DAHS facilities cannot be expected to provide the proper isolation to prevent the transmission of TB.

For information regarding TB, contact the Texas Department of State Health Services (DSHS) TB and Hansen’s Disease Program staff at one of the following numbers to be linked to TB personnel in the county or public health region in which the patient resides: 512-533-3000 for general information and 512-533-3144 for the nurse administrator. Contact information for each public health region can be found on the DSHS website at: http://www.dshs.texas.gov/regions/.

5761 Change in Ownership

Revision 14-2; Effective November 7, 2014

 

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

5770 Individual Rights and Responsibilities

Revision 14-2; Effective November 7, 2014

 

Rules: 40 TAC §98.61(c) and (d), General Requirements, Rights

40 TAC Chapter 49, Contracting for Community Services

5771 Complaints

Revision 14-2; Effective November 7, 2014

40 TAC Chapter 49, Contracting for Community Services

Section 2100, Contracting Requirements, specifies that procedures must be provided both verbally and in a written format each year.

The provider maintains a log of complaints and makes the review of complaints accessible to the contract manager. The provider also maintains documentation that it investigated and resolved all complaints within 30 calendar days of receipt of the complaint.

5800 Reporting Significant Changes

Revision 14-2; Effective November 7, 2014

 

The reporting of significant changes in DAHS is listed in 40 TAC §98.208(b), Notifications.

A provider must notify the case manager of any of the following circumstances that may require a change in the individual's plan of care:

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

Within 14 days of receipt of Form 2067, Case Information, the case manager:

  • reviews the individual's plan of care;
  • responds to the written request;
  • contacts the individual to confirm he is in agreement with proposed change; and
  • reviews the request for change which may affect eligibility or units of service.

The case manager must approve significant changes in the plan of care which may affect eligibility or units of service.

Case Manager Review and Approval

If the case manager . . . Then he . . .
agrees with the provider’s request for a plan of care change, updates Form 2101, Authorization for Community Care Services, to reflect the changes.
determines that a change to the individual's plan of care is not necessary, sends the provider Form 2067 stating the rationale for not changing the plan of care. If the provider still wants a change in the individual plan of care, the provider requests a review by the case manager's supervisor to resolve the difference in opinion.

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

5810 Individuals Who Fail to Comply with Service Delivery Provisions

Revision 14-2; Effective November 7, 2014

 

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

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

  • the individual or family may be left with no choice but for the facility to transport the individual home at the regular departure time along with other individuals; or
  • the facility can initiate a private pay rate with the individual or family members for the additional time the individual is in the facility after 10 hours.

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

5820 Individual Transfers

Revision 14-2; Effective November 7, 2014

 

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

Within 14 days of the individual's written or oral request to transfer to a new facility, the case manager:

  • updates Form 2101, Authorization for Community Care Services, by entering:
    • the new vendor number;
    • the effective date of the transfer; and
    • a statement in the comments section that this is an individual transfer;
  • sends the new facility the updated Form 2101; and
  • sends the old (losing) facility Form 2101 terminating services.

It is critical that the case manager coordinate individual transfers from one DAHS facility to another to ensure that no duplication of services or gaps in dates of coverage exist.

New physician’s orders are not required for individuals who transfer to a new DAHS facility operated under the same DAHS contract. New physician’s orders are required for individuals who transfer to a new DAHS facility operated by a different DAHS contractor.

5821 Health Assessment Before Transfer

Revision 14-2; Effective November 7, 2014

 

On or before the date an individual transfers to a new facility, the new facility must conduct a health assessment and an individual service plan. A provider must conduct the health assessment and individual service plan according to Section 5211, Health Assessment, and Section 5212, Individual Service Plan (ISP).

5830 Moves to Uncontracted Facilities

Revision 14-2; Effective November 7, 2014

 

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

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

The case manager:

    • explains to the individual that the facility does not have a contract with DADS and DADS cannot pay for services for the requesting facility; and
    • gives the individual the option of continuing to receive services from the current facility or having DADS services terminated.

If the individual chooses to receive services from the uncontracted facility, the individual is:

The reason for denial on Form 2101, Authorization for Community Care Services, should be Code 77, voluntary withdrawal. The comments section of the denial notice (Form 2065-C, Notification of Ineligibility or Suspension of Waiver Services) should state that DADS cannot pay for services at the new facility because the facility does not have a contract with DADS; and

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

5840 Suspension of Services

Revision 14-2; Effective November 7, 2014

 

Rule: 40 TAC §98.207, Suspension of Day Activity and Health Services

The case manager confirms the reason for the suspension and takes appropriate action. If the suspension results in case closure or termination of DAHS, the case manager coordinates closure and the termination date with the provider to allow time for individual notification of the right to appeal.

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

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

5900 Prior Approval Renewal Process

Revision 14-2; Effective November 7, 2014

 

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

5910 Renewal of Prior Approval by the Case Manager

Revision 14-2; Effective November 7, 2014

 

The case manager will send the DAHS facility Form 2101, Authorization for Community Care Services, when he reassesses the case if:

Although the coverage period is open-ended, the case manager will still:

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

Procedures to Renew Prior Approval

If the individual. . . Then the case manager . . .

is reassessed or redetermined eligible for services and there are no changes to the service plan,

verbally notifies the individual that services will continue at the same level.

is reassessed or redetermined eligible for services and there are changes to the service plan (units),

sends the individual Form 2065-A, Notification of Community Care Services, to notify him of the change in the service plan; and

  • sends the DAHS facility an updated and signed Form 2101 to notify the provider of the change.

    The effective date of the increase in units is seven days from the date Form 2101 is mailed to the provider.

    The effective date for a decrease is 12 days from the date Form 2101 is completed and mailed. Form 2065-A is completed and mailed within 12 days prior of the effective date of the decrease.

is reassessed or redetermined ineligible for services,

  • sends the individual Form 2065-C, Notification of Ineligibility or Suspension of Waiver Services, to notify him of the termination; and
  • sends the provider an updated and signed Form 2101 to notify the provider of the termination.

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

Revision 14-2; Effective November 7, 2014

 

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

The case manager uses procedures in Section 5910, Renewal of Prior Approval by the Case Manager, to renew prior approval if the renewal is done within the required time frames.

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

5920 Termination of Services

Revision 14-2; Effective November 7, 2014

 

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

  • sends Form 2065-A, Notification of Community Care Services, to the individual to terminate services; and
  • updates Form 2101, Authorization for Community Care Services, and sends to the provider to terminate services.

 

5100, Overview

Revision 14-2; Effective November 7, 2014

This section describes the interaction between the Texas Department of Aging and Disability Services (DADS) and facility staff. This material is presented in a normal and chronological sequence of events, following the individual from initial application for services through service delivery and suspension or termination of services.

5110 Enrollment Forms

Revision 15-4; Effective October 14, 2015

  • Form 2059, Summary of Client's Need for Service;
  • Form 2067, Case Information;
  • Form 2101, Authorization for Community Care Services;
  • Form 2110, Community Care Intake;
  • Form 3050, DAHS Health Assessment/Individual Service Plan;
  • Form 3055, Physician's Orders (DAHS); and
  • Form 3070, Day Activity and Health Services Notification of Critical Omissions.

5120 Referrals to Facility

Revision 14-2; Effective November 7, 2014

An applicant may be referred to a Day Activity and Health Services (DAHS) facility by the:

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

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

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

5130 Case Manager Service Planning Process

Revision 15-4; Effective October 14, 2015

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

  • Form H1200-EZ, Application for Assistance - Aged and Disabled;
  • Form 2059, Summary of Client's Need for Service;
  • Form 2059-W, Summary of Individual's Need for Services Worksheet; and
  • Form 2307, Rights and Responsibilities.

The DADS case manager determines whether the applicant meets the DAHS financial eligibility criteria and has unmet needs that can be met through DAHS. To avoid duplication of services, unmet need must be considered when the individual receives other community care services.

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

  • the individual’s preference; and
  • unmet need.

Units of service are designated on Form 2101, Authorization for Community Care Services, as follows:

  • one unit equals more than three hours but less than six hours (or half day); and
  • two units equal more than six hours (or one full day) up to 10 hours.

The case manager cannot authorize more than 10 units of DAHS per week.

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

The maximum number of units in the calendar month cannot exceed 46, provided within 23 possible calendar days.

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

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

Before referring the individual for DAHS, the case manager:

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

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

5140 Freedom of Choice

Revision 14-2; Effective November 7, 2014

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

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

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

5150 Interest Lists

Revision 14-2; Effective November 7, 2014

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

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

A facility operating at capacity may maintain a facility interest list for Title XIX and private-pay individuals.

6000, Billing and Recordkeeping Requirements

Revision 15-4, Effective October 14, 2015

 

6100 Billing Requirements

Revision 14-2; Effective November 7, 2014

 

A provider is entitled to payment for services only if the provider:

  • has prior approval for eligible individuals; and
  • bills according to Texas Department of Aging and Disability Services (DADS) requirements.

A provider is entitled to payment if the requirements are met according to Texas Administrative Code (TAC) Chapter 49, Contracting for Community Services.

The provider is not entitled to payment if the rules in TAC §98.211(b), Billing and Payment, are not met.

6110 Rejections and Resubmittals

Revision 14-2; Effective November 7, 2014

 

If DADS rejects a claim because of errors, the provider must research the errors and return the corrected claim to DADS. The provider must attach a copy of the MY 363 Output Report to the claim if the corrected claim is submitted 95 days or more after the end of the service month.

A provider may address any questions about claim rejections or error(s), or both, to the regional contract manager.

6120 Forms Needed

Revision 14-2; Effective November 7, 2014

 

Form 3682, Day Activity and Health Services Daily Transportation Record
Form 3683, Day Activity and Health Services Daily Attendance Record

6130 Reimbursement

Revision 14-2; Effective November 7, 2014

 

At the facility’s designated time of the month, the provider collects all units from Form 3683, Day Activity and Health Services Daily Attendance Record, and submits to DADS via Texas Medicaid & Healthcare Partnership (TMHP).

6131 Electronic Billing

Revision 14-2; Effective November 7, 2014

To obtain an enrollment application for the electronic billing systems, visit the Texas Medicaid & Healthcare Partnership (TMHP) website.

6132 Status of Claim

Revision 14-2; Effective November 7, 2014

 

To ask about the status of manual or electronic billing reimbursement claims, contact Texas Medicaid & Healthcare Partnership or the DADS contract manager.

6140 Payment

Revision 14-2; Effective November 7, 2014

 

Reimbursement payments are made by warrant or direct deposit.

 

6141 Warrants

Revision 14-2; Effective November 7, 2014

 

DADS and HHSC do not allow special handling of payments. Special handling includes sending payments by overnight express services or making warrants available at DADS.

6142 Direct Deposit

Revision 14-2; Effective November 7, 2014

 

A provider may choose to have reimbursements received as a direct deposit to the bank of its choice. Information packets regarding direct deposit may be obtained by calling claims correction, Fiscal Management Services, 512-438-4005.

6200 Record Documentation Requirements

Revision 14-2; Effective November 7, 2014

 

Form 3254, Community Services Contract (Provider Agreement). III. Recording, B, includes:

“A provider must keep financial records and supporting documents, individual files, service delivery records and any other records pertinent to the services for which a claim for payment is submitted to the Department or its agent. These records must be accurate and sufficiently detailed to document the extent of services provided under this contract and to support claims for payment submitted to the Department and its agent. These records must be retained in the form in which they are regularly kept by the Contractor for a minimum of six years after the end of the federal fiscal year in which the services were provided. If any litigation, claim or audit involving these records begins before the expiration of the six-year period, the Contractor must keep the records until all litigation, claims or audit findings are resolved. The matter is considered resolved when a final order is issued in litigation or when the Department and Contractor enter into a written agreement.”

DAHS providers must follow additional document retention requirements in order to comply with cost reports, budgets and other cost surveys, as stated in TAC Chapter 49, Contracting for Community Care Services.

Additional record maintenance on personnel, attendance and transportation requirements are located in §98.209, Record Maintenance.

6210 Cost Reports

Revision 14-2; Effective November 7, 2014

 

HHSC Rule: 1 TAC §355.105, General Reporting and Documentation Requirements, Methods and Procedures

Contract violation may result in DADS withholding all of a provider’s payments until the provider submits an acceptable cost report.

See Appendix II-A, Reimbursement Methodology, for cost reporting requirements.

6220 Record Retention

Revision 15-4; Effective October 14, 2015

 

Rules related to record retention are located in TAC Chapter 49, Contracting for Community Services.

A provider must maintain the following forms:

  1. Form 2059, Summary of Client’s Need for Service;
  2. Form 2101, Authorization for Community Care Services;
  3. Form 2067, Case Information;
  4. Form 3682, Day Activity and Health Services Daily Transportation Record; and
  5. Form 3683, Day Activity and Health Services Daily Attendance Record.

Medical Records

  1. Form 3050, DAHS Health Assessment/Individual Service Plan;
  2. Form 3055, Physician’s Orders (DAHS); and
  3. Other records containing individual medical information.

6230 Personnel Records

Revision 14-2; Effective November 7, 2014

 

The provider must keep personnel records on staff as indicated in TAC Chapter 49, Contracting for Community Services.

The provider must keep personnel records in accordance to requirements in §98.209 (a), Record Maintenance.

6240 Attendance and Transportation Records

Revision 14-2; Effective November 7, 2014

 

A provider must maintain daily records of individual attendance and transportation records in accordance with TAC §98.209 (b) and (c), Record Maintenance.

A provider may include the transportation time as part of the unit of service if the provider gives transportation to an individual to and from a:

  • facility approved to provide therapies; or
  • non-therapy medical facility.

Additionally, if a facility staff member escorts or stays with the individual during the visit, a provider may also include the escort time as part of the unit of service.

If the provider did not provide transportation but did provide an escort to a facility approved to provide therapies or a non-therapy medical facility, the provider may include the escort time as part of the unit of service.

A provider may only include transportation time as part of the unit of service if:

  • transportation is provided in a facility-owned vehicle; or
  • the provider had a subcontract for transportation services with a public or private transportation entity.

A provider may not include as part of the unit of service transportation provided by public transportation.

If the provider purchases tickets or passes for public transportation, the provider is not providing the transportation. The provider can claim the costs (tickets or passes) associated with this transportation on the annual cost report, but time spent in transit cannot be claimed in the unit of services.

A provider cannot charge the individual if it does provide the transportation.

6250 Availability of Records

Revision 14-2; Effective November 7, 2014

 

Record retention is addressed in Chapter 49, Contracting for Community Services.

6260 Service Delivery Documentation Requirements

Revision 15-4; Effective October 14, 2015

 

DAHS providers are responsible for maintaining records pertinent to the services for which a claim or cost report is submitted. Form 3050, DAHS Health Assessment/Individual Service Plan, requires providers to document treatments, monitoring and interventions, including the frequency for each. The DAHS provider may use monthly nursing notes, daily progress notes or other forms of clinical documentation, such as medication logs, to meet documentation requirements.

6261 Documentation of Personal Care

Revision 14-2; Effective November 7, 2014

 

Example: An individual requires assistance with personal care each day the individual attends DAHS. The individual’s notes completed monthly by the licensed nurse contain a statement that assistance with personal care was provided each day, as required in the individual’s service plan. This statement is sufficient to show that daily assistance was provided to the individual.

6262 Medical Care/Treatments

Revision 14-2; Effective November 7, 2014

 

Medical care/treatments should be documented based on the frequency that they are provided. For example, if the blood pressure or glucose is checked on a daily basis, the readings should be documented on a daily basis. This documentation could be combined with monthly nursing notes documenting skilled care, and would meet documentation requirements for the tasks indicated on the individual’s service plan.

 

7000, Monitoring

Revision 15-2, Effective June 5, 2015

 

7100 Monitoring Reviews

Revision 15-2; Effective June 5, 2015

 

The Department of Aging and Disability Services conducts monitoring reviews of program contracts it administers. Rules that apply to this section are 40 Texas Administrative Code, Chapter 49, Subchapter E.

7110 Contract Management

Revision 15-2; Effective June 5, 2015

 

The Department of Aging and Disability Services created a Contract and Fiscal Compliance Monitoring Tool for the Day Activity and Health Services (DAHS) Program. A provider agency should direct questions about the tool or requests for additional assistance to its contract manager. In addition, see Appendix X, DADS Contract Management.

 

7120 Review Period

Revision 15-2; Effective June 5, 2015

 

40 Texas Administrative Code (TAC) §49.534, Termination of Contract by DADS

40 TAC §98.209(b), Attendance Records

40 TAC §98.210, Financial Errors

 

7100, Monitoring Reviews

Revision 15-2; Effective June 5, 2015

The Department of Aging and Disability Services conducts monitoring reviews of program contracts it administers. Rules that apply to this section are 40 Texas Administrative Code, Chapter 49, Subchapter E.

7110 Contract Management

Revision 15-2; Effective June 5, 2015

The Department of Aging and Disability Services created a Contract and Fiscal Compliance Monitoring Tool for the Day Activity and Health Services (DAHS) Program. A provider agency should direct questions about the tool or requests for additional assistance to its contract manager. In addition, see Appendix X, DADS Contract Management.

7120 Review Period

Revision 15-2; Effective June 5, 2015

40 Texas Administrative Code (TAC) §49.534, Termination of Contract by DADS

40 TAC §98.209(b), Attendance Records

40 TAC §98.210, Financial Errors

8000, Sanctions, Fraud and Abuse

Revision 14-2, Effective November 7, 2014

8100 Provider Fraud and Abuse

Revision 14-2; Effective November 7, 2014

The Texas Department of Aging and Disability Services (DADS) is responsible for identifying, investigating and referring cases of suspected fraud or abuse of Medicare, Medicaid or social services programs.

To carry out this responsibility, DADS must:

  • be prepared to exclude from program reimbursement any provider that defrauds or abuses the Medicare or Medicaid program; and
  • suspend, in the event that the United States Department of Health and Human Services directs the suspension, any recipient of Medicaid reimbursement who has been convicted of a crime related to the delivery of medical care or services under Medicare, Medicaid or social services programs.

A fraud referral or abuse referral or both are initiated when a provider has defrauded or abused the Medicaid (Title XIX) program.

8110 Provider Agency Fraud

Revision 14-2; Effective November 7, 2014

DADS endorses the concept that people who provide services are essentially honest and are entitled to the same protection under the law as all other individuals. However, when there is an indication of potential fraud, the allegations must be investigated.

To determine the existence of fraud, the following must be established:

  • Intentional misstatement or concealment by the provider created a false impression.
  • DADS paid the provider based on the false impression, when the payment would not have been made if the truth had been known.

Examples of provider fraud include (list not all-inclusive):

  • billing for services which were not provided;
  • filing false claims;
  • continuing inappropriate billing after provider education visits; and
  • using improper billing practices.

8120 Abuse

Revision 14-2; Effective November 7, 2014

To determine the existence of abuse, the following must be established:

  • Provider practices are inconsistent with sound fiscal, business, or medical practices.
  • These inconsistent practices result in unnecessary cost to the Medicaid program, or reimbursement for services that are not medically necessary or that fail to meet professionally recognized standards of health care or standards required by contract, statute, regulation, or interpretations of a statue or regulation sent to the provider.

Examples of provider abuse include (list not all-inclusive):

  • services provided which are not medically necessary;
  • billing for services provided by inappropriate persons;
  • practicing without a proper license or obtaining a license under false pretenses; and
  • violating the contract or provider agreement.

8130 Civil Penalty

Revision 14-2; Effective November 7, 2014

Cases of fraud or abuse may also be referred to the Texas Health and Human Services Commission (HHSC) for civil penalties under the federal Civil Monetary Law of the Social Security Act. Under this provision, a provider agency (individual and corporate) may be assessed a fine of up to $2,000 and double damages for each line item identified as fraudulent or abusive billing. HHSC may also require a provider agency that has been assessed civil monetary penalties to be barred from participation in the Medicare or Medicaid program or both.

8140 Reporting Fraud and Abuse

Revision 14-2; Effective November 7, 2014

The Medical Provider Sanctions section, Texas Department of State Health Services (DSHS), has established a toll-free hotline for reporting suspected cases of Medicaid fraud and abuse. The number is 1-800-252-8263 and is available every day. Individuals who know of suspected fraud or abuse of assistance benefits, including eligibility and provider services, are urged to use this toll-free service.

8150 Development of the Fraud Referral Packet

Revision 14-2; Effective November 7, 2014

DADS staff must consult with the unit supervisor for guidance in determining the referral, and of the information being provided. If it is decided that a referral is to be submitted, DADS staff complete Form H4834, Individual or Recipient Provider Fraud Referral/Status Report, TIERS, GWS or call toll-free 1-800-436-6184. The following information should be included in the referral packet, if available and appropriate to the allegation:

  • Form H4834;
  • provider identification, including the name, provider type and specialty, business address, residence address and provider number(s);
  • identification of the alleged illegal act. DADS staff include specific data regarding potential witnesses, their addresses, and work/home telephone numbers. Also include names, mail codes and telephone numbers of all staff who can provide information;
  • identification of policy, regulation or procedural violation. DADS staff cite the appropriate numerical reference and manual title, the DADS rule or policy clearance letter. The reference should include the specific chapter, subchapter, page number and effective date of the manual or publication;
  • source. DADS staff indicate who or what initiated the allegation; and
  • other pertinent documentation. DADS staff include any other pertinent documentation relating to the case.

8151 Expedited Referrals

Revision 14-2; Effective November 7, 2014

If DADS staff have reason to believe that the conduct of the suspected provider is serious enough to require immediate action, it may be appropriate to expedite the referral. As with routine referrals, the DADS unit supervisor must first be consulted.

An expedited referral should be made when a delay would:

  • probably result in the loss, destruction or altering of valuable evidence;
  • probably result in harm to an individual;
  • probably result in significant monetary loss to DADS that would probably not be recoverable; or
  • hinder an investigation or criminal prosecution of the alleged offense.

In these situations, the case is immediately referred to the HHSC Medicaid Program Integrity Unit (512-490-0421) before the referral packet is produced. The HHSC representative will instruct DADS staff as to what portions of the required information should be completed and sent.

In addition, the Medicaid Program Integrity Unit maintains a 24-hour fraud line at 512-424-6519. Callers may use this toll-free hotline, 1-800-436-6184, to report Medicaid fraud and abuse.

8152 Referral of Potential Provider Fraud

Revision 14-2; Effective November 7, 2014

If the DADS unit supervisor determines that the criteria for fraud exists, a fraud referral to the Medicaid Program Integrity Unit at HHSC is initiated (even if the potential fraud does not affect Title XIX funds).

8160 Fraud

Revision 14-2; Effective November 7, 2014

See Section 8230, Development of Fraud Referral Packet, for contact information.

8200 Fraud Detection and Referral

Revision 14-2; Effective November 7, 2014

Individuals receiving long-term care services are perceived as essentially honest and entitled to the same protection under the law as all other individuals. However, when there is an indication of potential fraud, the allegations must be investigated.

8210 Definition of Fraud

Revision 14-2; Effective November 7, 2014

To determine the existence of fraud, the following must be established:

  • Intentional misstatement or concealment by the individual or authorized representative created a false impression.
  • DADS or the provider provided services based on the false impression, which would not have been provided if the truth had been known.

Examples of individual fraud include (list not all-inclusive):

  • knowingly providing false information regarding an applicant's financial, medical or functional status in order to be determined eligible for assistance;
  • withholding or concealing information pertaining to the applicant's financial, medical or functional status which may cause the applicant to be ineligible for services;
  • receiving services which the individual knows to be medically unnecessary; and
  • knowingly receiving services from individuals who do not have a proper license or who obtained a license under false pretenses.

8220 Responding to Allegations of Fraud

Revision 14-2; Effective November 7, 2014

When potential fraud is discovered, provider staff should follow these procedures:

  1. Record on Form 2067, Case Information, all pertinent facts relating to the specific case in as much detail as possible. This includes:
    • who engaged or participated in the alleged fraudulent conduct,
    • what the suspected violation was,
    • when the conduct occurred (dates or time periods),
    • where the conduct occurred,
    • how the fraudulent action was performed, and the names of individuals with knowledge of the situation and how they can be contacted.
  2. If fraud is alleged by a third party, try to obtain the complainant's name, address, home telephone number, and telephone number where the complainant can be reached during the day. Provider staff should advise informants who wish to remain anonymous that DADS needs a way to contact them during the investigation.
  3. Do not make any agreements or commitments to anyone regarding the investigation or any possible adverse action.
  4. Mail Form 2067 to the appropriate DADS case manager by the next workday.

8230 Development of Fraud Referral Packet

Revision 14-2; Effective November 7, 2014

Upon receipt of Form 2067, Case Information, the DADS case manager does not request restitution. Restitution is securing payment from an individual when fraud is not indicated. Once restitution is requested, the DADS case manager cannot refer the case for fraud.

The DADS case manager consults his unit supervisor for guidance in determining the appropriateness of the referral, and of the information being provided. If it is decided that a referral is to be submitted, the DADS case manager completes Form H4834, Individual or Recipient Provider Fraud Referral/Status Report, TIERS, GWS or call toll-free 1-800-436-6184. The following information should be included in the referral packet, if available and appropriate to the complaint or allegation:

  • a completed Form H4834;
  • identification of the individual or authorized representative. Include the name, relationship to the individual (if applicable), business address, residence address, individual number, type of coverage being received, beginning date of coverage, and end date of coverage (if applicable);
  • identification of the alleged illegal act. Include copies of all pertinent documents, as well as specific data regarding potential witnesses or knowledgeable sources, their addresses, and work/home telephone numbers. The DADS case manager also includes names, mail codes and telephone numbers of any staff who can provide information;
  • identification of policy, regulation or procedural violation. The DADS case manager cites the appropriate numerical reference and manual title, the department rule or policy clearance letter. The reference should include the specific chapter, subchapter, page number and effective date of the manual or publication;
  • source of the allegation. The DADS case manager indicates who or what initiated the allegation; and
  • other pertinent documentation. The DADS case manager includes any other pertinent documentation relating to the case.

8240 Expedited Referrals

Revision 14-2; Effective November 7, 2014

If the DADS case manager has reason to believe that the conduct of the suspected individual or authorized representative is serious enough to require immediate action, it may be appropriate to expedite the referral. As with routine referrals, the DADS unit supervisor must first be consulted. An expedited referral should be made when a delay would:

  • probably result in the loss, destruction or altering of valuable evidence;
  • probably result in harm to an individual;
  • probably result in significant monetary loss to DADS that would probably not be recoverable; or
  • hinder an investigation or criminal prosecution of the alleged offense.

In these situations, the case is immediately referred to the HHSC Medicaid Program Integrity Unit (512-490-0421) before the referral packet is produced. The HHSC representative will instruct DADS staff as to what portions of the required information should be completed and sent.

8250 Referral of Potential Fraud

Revision 14-2; Effective November 7, 2014

If the DADS unit supervisor determines that the criteria for fraud exists, a fraud referral to the Medicaid Program Integrity Unit at HHSC is initiated (even if the potential fraud does not affect Title XIX funds).

8260 Referral Response

Revision 14-2; Effective November 7, 2014

HHSC is responsible for ensuring that all pertinent information is obtained and may subsequently request additional information. Providing requested material to HHSC does not constitute a confidentiality violation. Staff in that division conduct an analysis and collect data to create a complete picture of the alleged incident.

After referring the case to HHSC, no other action is necessary. DADS staff and provider staff continue to maintain the case as usual. DADS staff and provider staff should preserve a professional working relationship with the individual or authorized representative while the fraud referral is being investigated. However, for the duration of the investigation, DADS staff and provider staff must not discuss the alleged violation with unauthorized personnel. This prevents the possibility of interference with the investigation.

8300 Sanctions

Revision 14-2; Effective November 7, 2014

8310 Medicaid Sanctions

Revision 14-2; Effective November 7, 2014

Rule: 40 TAC §98.212(a), Sanctions.

8320 Additional Sanctions

Revision 14-2; Effective November 7, 2014

In addition to the reasons specified above, DADS may take other sanctions against a provider, including client holds, vendor holds and renewals/terminations.

8330 Client Holds

Revision 14-2; Effective November 7, 2014

Rule: 40 TAC §49.523, Referral Hold

8340 Vendor Hold

Revision 14-2; Effective November 7, 2014

Rule: 40 TAC §49.532, Vendor Hold

An automatic vendor hold may be placed on a provider for failure to submit a current Home and Community Support Services Agency license before the expiration of the previous one.

Although a provider is not required to submit a Certificate of Good Standing on a yearly basis if a provider is subject to franchise taxes, the provider must ensure that it has a current Certificate of Good Standing issued by the Texas State Comptroller at all times for the duration of the provider's contract.

8350 Renewals/Terminations

Revision 14-2; Effective November 7, 2014

Rule: 40 TAC Chapter 49, Contracting for Community Services

8360 Right to Appeal

Revision 14-2; Effective November 7, 2014

Rule: 40 TAC §49.541, Contractor's Right to Appeal

Appendix I, Assignments of Contracts

Revision 98-1; Effective January 15, 1998

 

§49.5. Contract Assignment.

(a) A contract assignment must be made as part of an ownership change, a change in tax status, or a transfer from one legal entity to another through a legal process. No assignment is effective until approved, in writing, by the Texas Department of Human Services (DHS).

(b) If the provider agency plans to assign a contract, the assignor must inform the appropriate DHS staff, in writing, at least 60 days before assigning the contract. This notification must include the legal name of the entity that will be assuming the contract and must be submitted as soon as the provider agency decides to assign the contract. If the provider agency fails to provide this information in a timely manner, the contract assignment may be delayed. DHS reserves the right to deny any assignment if it is not in the best interest of DHS or its clients.

(c) If a contract assignment application is not completed according to subsection (e) of this section, DHS considers it unacceptable and returns it to the assignor.

(d) If the assignee does not meet the conditions for contracting, DHS immediately terminates the assignor's contract and transfers all clients to another provider agency.

(e) Before an assignment is made, the assignee must follow the requirements stipulated in paragraphs (1)-(3) of this subsection:

(1) resolve all audits completed or in progress;

(2) prepare a contract assignment agreement which includes the following statements:

(A) the reason(s) for the contract assignment;

(B) that both the assignee and assignor are each responsible for collecting and reporting financial and statistical data on DHS's cost report that corresponds to its respective contract periods;

(C) DHS reserves the right to require restitution for any audit exceptions from either agency;

(D) any adverse action pending or in place when the contract is assigned is applied to both the assignee and the assignor;

(E) the assignee adheres to the service contract, reimbursement method and amount, service delivery requirements, and standards established by DHS; and

(F) the assignee meets all service criteria for being a provider agency. Documentation of eligibility must be provided before DHS will agree to a contract assignment;

(3) include the following information in the contract assignment agreement:

(A) identify both legal entities;

(B) identify the current contract number(s) and service(s) to be assigned;

(C) be notarized and signed by the person authorized for each legal entity; and

(D) include a line for DHS's representative to sign and approve.

(f) The effective date of the contract assignment is the first day of the following month after the application has been fully processed by DHS. DHS may award a contract at an earlier date if it is in DHS's best interest.

All contract assignments must be completed according to these guidelines. Format and context of the contract assignment must be followed before the contract assignment can be made. Additionally, the assignee must complete a new enrollment application.

The contract assignment packet, which includes the assignee's enrollment application and the contract assignment, must be completed and returned to:

Texas Department of Human Services
Community Care Section, MC W-521
P.O. Box 149030
Austin Texas 78714-9030

DHS's Office of General Counsel must review and approve all contract assignments prior to their execution. The effective date of the contract assignment is the first day of the month after the application has been fully processed.

 

Appendix II-A, Assignments of Contracts

Revision 05-1; Effective February 1, 2005

 

§355.6907 Reimbursement Methodology for Day Activity and Health Services

This rule is available on the Secretary of State's Texas Administrative Code website at
http://texreg.sos.state.tx.us/public/readtac$ext.viewtac.

To access Texas Health and Human Services Commission rules, click on Title 1, Administration, then Part 15. Click on Chapter 355, Reimbursement Rates, then Subchapter G, Telemedicine Services and Other Community-Based Services, to access this rule.

 

Appendix VIII, Information Letters

Revision 03-2; Effective May 15, 2003

 

Visit this link for a list of online information letters: http://www.dads.state.tx.us/providers/communications/letters.cfm

 

Forms

ES = Spanish version available.

Form Title  
1290 Long Term Care Claim  
2059 Summary of Client's Need for Service  
2065-A Notification of Community Care Services  
2065-B Notification of Waiver Services  
2065-C Notification of Ineligibility or Suspension of Waiver Services  
2067 Case Information  
2076 Authorization to Release Medical Information ES
2101 Authorization for Community Care Services  
2110 Community Care Intake  
2239 Respite Care-Service Delivery Record  
3050 DAHS Health Assessment/Individual Service Plan  
3052 Practitioner's Statement of Medical Need  
3054 Primary Home Care Service Delivery Record ES
3055 Physician's Orders (DAHS)  
3062 DAHS Utilization Review Report  
3070 Day Activity and Health Services Notification of Critical Omissions  
3071 Individual Election/Cancellation/Update ES
3074 Physician Certification of Terminal Illness ES
3251 Assisted Living and Residential Care/CBA Adult Foster Care Daily Census Record  
3252 Title XX Residential Care Adult Foster Care Daily Service Delivery Record  
3681 Community Services Contract Application  
3681-A Community Services Contract Application - Addendum A  
3681-B Community Services Contract Application - Addendum B, Adult Foster Care Provider Questionnaire  
3682 Day Activity and Health Services Daily Transportation Record  
3683 Day Activity and Health Services Daily Attendance Record  
3691 Service Area Designation  
4719 Fire Drill Report  

19-1, Appendix Added

Revision Notice 19-1; Effective May 1, 2019

 

The following change(s) were made:

Section Title Change
Appendix VI Solicitation Prohibition Adds a new appendix shared with other handbooks regarding solicitation information.

18-2, Section 5760 Changes

Revision Notice 18-2, Effective December 4, 2018

 

The following change(s) were made:

Section Title Change
5760 Notifications Updates the telephone numbers and website for information about Tuberculosis.

18-1, Policy Clarifications Deleted

Revision Notice 18-1, Effective April 23, 2018

 

The following change(s) were made:

Section Title Change
Policy Clarifications CBA, CCAD, CLASS and DBMD Policy Clarifications Deletes all policy clarifications released between 1999 and 2005.

15-4, Miscellaneous Changes

Revision Notice 15-4, Effective October 14, 2015

 

The following change(s) were made:

Section Title Change
5110 Enrollment Forms Deletes a reference to Form 3049 (now obsolete as the information is contained in Form 3050) and changes the title of Form 3050, DAHS Health Assessment/Individual Service Plan.
5130 Case Manager Service Planning Process Deletes a reference to Form 2060, Needs Assessment Questionnaire and Task/Hour Guide.
5210 Referrals Deletes references to Form 3049 and updates the title of Form 3050.
5211 Health Assessment Deletes references to Form 3049, updates the title of Form 3050 and information for using Form 3050.
5212.1 Initial DAHS ISP Deletes references to Form 3049 and Form 3055, and updates the title of Form 3050 and information for using Form 3050.
5212.2 Updates to DAHS ISP Updates the title of Form 3050.
5212.3 Initial an Ongoing DAHS ISP Updates the title of Form 3050.
5213.1 Initial Physician’s Orders for Enrollment of Individual into DAHS Updates the title of Form 3050.
5213.3 Physician’s Orders and Signature Deletes if the physician does not want a copy of the health assessment document, the physician’s refusal of a copy must be in writing.
5220 Regional Nurse Prior Approval for Case Manager Referral Updates the title of Form 3050 and changes “acute” to “chronic” medical condition.
5310 Facility Response to Facility-Initiated Referrals Deletes references to Form 3049 and updates the title of Form 3050.
5411 Corrections of Critical Omissions or Errors Deletes a reference to Form 3049 and updates the title of Form 3050.
5700 Facility Responsibilities Deletes a reference to Form 3049 and updates the title of Form 3050.
6220 Record Retention Updates the title of Form 3050.
6260 Service Delivery Documentation Requirements Updates the title of Form 3050.

Policy Clarifications

Policy clarifications are used to communicate with appropriate HHSC staff and providers and to clarify current program policies or procedures.

Policy Clarifications

Number Description Date
None at this time.