2800, Notifications, Suspensions, Denials and Terminations

2810 Individual Notification Procedures

Revision 17-1; Effective March 15, 2017

Program Standard: Notify the individual in writing using Form 2065-A, Notification of Community Care Services, of all eligibility/ineligibility decisions or any changes in the individual's service plan, to include: addition of service(s), increase or decrease in hours, increase or decrease in copayment, or loss of priority status based on the individual's request within two business days of the decision.

When notifying the applicant of eligibility, specify on Form 2065-A:

  • the Community Care Services Eligibility (CCSE) services for which the applicant is eligible or ineligible; and
  • if determined eligible:
    • the number of hours of services the applicant is authorized to receive or the number of days or half days the applicant is authorized to attend a Day Activity and Health Services (DAHS) facility;
    • if applicable, that the Family Care, Primary Home Care or Community Attendant Services applicant is eligible for priority status;
    • the initial and ongoing room and board payments for Residential Care and Adult Foster Care; and
    • the initial and ongoing copayments the Residential Care individual is to pay to the facility.

An applicant/individual certified for one CCSE service but determined ineligible for another must be notified in writing of both decisions. An applicant/individual certified for personal attendant services and/or Home-Delivered Meals must also be notified in writing of the hours per week or meals per week he is eligible to receive. If certified for DAHS, the applicant/individual must be notified in writing of the number of days per week the DAHS authorization covers. The written notice for all services must contain the case worker's name, telephone number and appeal procedures.

For ongoing individuals, on Form 2065-A, record the:

  • action taken and the effective date; and
  • name of the CCSE service(s) on which the action is based.

If the notification is an adverse action, the notice must also state the:

  • reason for the adverse action; and
  • Case Worker CCSE Handbook reference on which the adverse action is based.

See the Form 2065-A Attachment for handbook and rule references.

The case worker may notify an individual verbally of continued eligibility if the individual continues to qualify for the same service(s) and the number of hours/units of service remains the same. Document in the individual's case record the date the case worker verbally informed the individual of his continued eligibility.

 

2811 Effective Dates

Revision 17-1; Effective March 15, 2017

The Texas Health and Human Services Commission (HHSC) case worker notifies the applicant or individual in writing of any action that denies, suspends, reduces or terminates services. The HHSC case worker sends the notice of adverse action to the individual 12 calendar days before the effective date of the action, except in situations in which services have been suspended due to threats to health and safety. In those situations, the HHSC case worker sends the written notice of adverse action without advance notice if the crisis cannot be resolved.

An applicant or individual has the right to appeal any decision that denies, reduces or terminates his services and request a fair hearing in accordance with Title I, Texas Administrative Code (TAC) §357.

For information about calculating effective dates of reduction or termination of services, see Appendix IX, Notification/Effective Date of Decision, and Appendix XVIII, Time Calculation.

In general, the effective date of the reduction in services is 12 calendar days after the Form 2065-A, Notification of Community Care Services, date. The effective date of an increase in hours is seven calendar days after the Form 2101, Authorization for Community Care Services, date. For an adverse action, if the day after the effective date is a Saturday, Sunday or legal holiday, the period is extended to include the next day that is not a Saturday, Sunday or legal holiday. (See Appendix XVIII.)

The date at the top of Form 2065-A is the date the HHSC case worker completes the form. Since offices have different mail pickup times, staff are not required to consider the mail date when completing the form. Staff must ensure applicants and individuals are notified within the required time frames.

Services will be reduced or terminated at annual reassessment, or any other time the case worker becomes aware before the annual review, when the individual:

  • requests a reduction or termination;
  • gains a resource resulting in fewer unmet needs and the need to reduce service hours; or
  • is performing all or some activities of daily living due to long-term improvement in functional condition resulting in the need to reduce or terminate services.

An applicant or client may request an appeal of any decision that denies, reduces, or terminates his benefits. The effective date of the action depends on the situation, as shown in the following table:

If . . . Then . . .
Termination or reduction is because client lost his eligibility as an income eligible, failed to qualify as an income-eligible after a verbal referral, failed to meet the client needs assessment score or medical criteria for the service, repeatedly (more than three times), directly or knowingly and passively condoned the behavior of someone in his home and thus, refused to follow the service delivery provisions, experienced a change in his need for the specific service, or failed to pay fees for services, The action is effective 12 days from the date of the notice unless the action is appealed. In the event of appeal, services continue until the hearings officer gives a decision. The cost of providing services during this period is subject to recovery by the department from the client. Services to clients in Residential Care facilities are terminated five days after the hearings officer gives his decision.
Termination is because client lacks TANF, SSI, Medicaid, or Supplemental Nutrition Assistance Program eligibility, Services continue only to the end of the month that the client is determined ineligible, even if the action is appealed.
Termination is because client lacks physician's orders for the service, Services continue only through the date the previous orders end, even if the action is appealed.
Termination or reduction is because of budgetary constraints or changes in federal law or state regulations, and services are reduced or terminated for an entire categorical client group, Services continue only through the date of termination of a categorical client group, even if appealed.
Termination is because the client or someone in his home threatens the health or safety of others, or because the client threatens his own health or safety. Services may be terminated immediately under the following conditions:
  • a client receiving Residential Care, Adult Foster Care, DAHS, or special services to persons with disabilities threatens his own health or safety or that of others, or
  • someone in the client's home or an individual receiving Emergency Response Services, Home-Delivered Meals, waiver services, Family Care, Primary Home Care, or special services to persons with disabilities threatens the Texas Health and Human Services Commission (HHSC)  staff or provider's health or safety.

 

2812 Changes in the Individual's Need for Services

Revision 17-1; Effective March 15, 2017

Case workers determine if the individual's long-term improvement is expected to last through the current authorization period or beyond, before reducing or terminating services.

If it is determined that the individual's condition has temporarily improved because the individual is performing tasks previously done by the attendant, the individual and provider may agree to fewer hours per week.

Do not reduce or terminate services if it is determined the individual is experiencing temporary improvement in functional condition. If the individual feels he temporarily needs fewer hours, send the provider Form 2067, Case Information, informing the provider that fewer service hours may be provided if the individual agrees to the reduction. If the individual is experiencing temporary functional improvement, the case worker would not change the task/hour guide or authorization, or send Form 2065-A, Notification of Community Care Services, to the individual for reduction of hours.

The individual and provider may agree to change the delivery schedule for personal attendant services (PAS) hours based on the individual's needs without prior approval from the case worker.

Case worker approval or denial is required for all requests to increase PAS hours previously authorized or to add or delete priority status. In these situations, terminate or reduce services 12 calendar days after the Form 2065-A completion date.

 

2813 Situations in Which the 12-Day Adverse Action Period May Be Reduced

Revision 17-1; Effective March 15, 2017

There may be situations when an individual wants to waive or shorten the 12-day notice period before services are reduced or terminated. Some examples of applicable situations include the following:

  • A Family Care individual is being removed from an interest list for Title XX Day Activity and Health Services (DAHS) and wants to withdraw or have services reduced in less than 12 days in order to attend DAHS immediately; or
  • Community Care for Aged and Disabled individuals who prefer to receive 1915(c) waiver services may also wish to have the change take place in less than 12 calendar days.

If the individual indicates a desire to waive or reduce the 12-day advance notice, be very cautious and remember that an individual may change his mind. In most instances, the provider can be verbally notified to stop service and still maintain the formal effective date 12 calendar days in the future.

If the individual still wants to waive or shorten the 12-day advance notice, complete Form 2065-A, Notification of Community Care Services, with the effective date being the date the individual wants services to end or be reduced. Explain in the comments section that the individual is voluntarily waiving or reducing his right to the 12-day advance notice. The individual must:

  • sign this statement; and
  • be given the original and one copy of the notice.

 

2814 Transfers Between Primary Home Care, Community Attendant Services and Family Care

Revision 18-1; Effective June 15, 2018

Send Form 2065-A, Notification of Community Care Services, when an individual is transferred from any of the three programs listed to any of the other three programs listed: Primary Home Care (PHC), Community Attendant Services (CAS), or Family Care (FC). Do not send another form to terminate the previous service. Specify on the form the:

  • name and amount of the previous service,
  • name and amount of the new service,
  • effective date of the transfer, and
  • reason for the transfer.

Indicate in the comments section that the individual should not notice any difference in the amount or type of services received because of this transfer.

Example:
The service you were receiving, Primary Home Care, 16 hours a week, will change to Family Care, 16 hours a week, effective June 1, 2010.

Comments: Primary Home Care will terminate because you lost financial eligibility for that program. You should not notice any difference in the amount or type of services you will receive because of this transfer.

Although Form 2065-A must be sent when an individual transfers between PHC, CAS and FC, the effective date is either the negotiated date or the date following the Medicaid end date.

See Section 4600, Primary Home Care and Community Attendant Services, for additional transfer procedures.

Refer to Appendix IX, Notification/Effective Date of Decision, and Appendix XVIII, Time Calculation, for other exceptions to the 12-day notice requirement. The effective date of the transfer does have to be at least 12 days following the date of notification if the number of hours is decreased.

 

2820 Service Suspensions

Revision 17-1; Effective March 15, 2017

Services may be suspended by the provider or by the case worker.

 

2821 Service Suspension by Providers

Revision 17-1; Effective March 15, 2017

Providers may suspend services to individuals before the service approval period ends. See Section 4000, Specific CCSE Services, for information about suspension of each specific service.

On the day of suspension or by the first Texas Health and Human Services Commission workday following suspension, the provider must contact the case worker to explain the reason for suspending services. The Emergency Response Services provider must submit written notification (Form 2067, Case Information, optional) within five workdays of the oral notification or suspension of services.

If an individual meets the criteria for Adult Protective Services, refer him accordingly. Refer other individuals to other appropriate service resources as needed.

The case worker documents in the case record the incident that caused the suspension and the date of the incident. The results of any related interdisciplinary team meetings must be included in the documentation. After evaluating suspensions to determine whether services should be terminated and the case closed, the case worker takes the appropriate action. In some situations, the problems that caused the suspension can be resolved. If they are resolved:

  • send Form 2067 to the provider documenting the problem resolution; and
  • reach an agreement with the provider about the date on which services will be reinstated.

 

2822 Service Suspension by Case Workers

Revision 17-1; Effective March 15, 2017

40 Texas Administrative Code §48.3903 Denial, Reduction, and Termination of Benefits

(c) A client is not eligible for CCSE services when:

(1) he dies;
(2) he is admitted to an institution;
(3) his physician requests service termination (Medicaid services only); or
(4) he requests service termination or repeatedly refuses to accept help, except in an involuntary protective services case, or he refuses to comply with his service plan.

 

2822.1 Hospital and Nursing Facility Stays

Revision 20-3; Effective September 1, 2020

Suspend services when available information confirms that a nursing home or hospital stay will be longer than 30 days. Use Form 2067, Case Information, to notify the provider to suspend services effective the date of nursing home or hospital entry. It is not necessary to send updates to the provider.

Continue to monitor the situation. If the person has not returned home by the 30th day, contact the person or authorized representative (AR) to see if a discharge date is planned. If the person has a planned discharge date within the next 30 days, leave the case open and monitor on the planned discharge date.

Terminate services, using the date of admission as the effective date of termination, if information shows that the nursing facility or hospital stay will be longer than 30 days. Exception: The effective date of termination for Residential Care should be the 30th day after admission to the nursing facility or 60 days after admission to a hospital.

Consult with the person, family and others associated with the person to determine the length of stay. Be cautious about terminating Title XX services, especially if the region has an interest list for those services.

Emergency Response Services (ERS) may remain open until the decision is made to terminate all services because the nursing facility stay has become permanent. See Section 4300, Emergency Response Services, for suspension of ERS by the ERS provider.

The following situations should always be considered short-term and services should be suspended for up to 30 days, rather than terminated:

  • admission to a swing bed facility (by regulation, swing bed nursing home stays are limited to 30 days); and
  • admission to a hospital for mental illness treatment.

Services may be suspended indefinitely if the person is admitted to a rehabilitation hospital or to a rehabilitation floor or wing of a medical hospital.

 

2830 Refusal to Comply with Service Delivery Provisions

Revision 17-1; Effective March 15, 2017

Refer to 40 Texas Administrative Code §48.3903 Denial, Reduction, and Termination of Benefits

Examples of refusal to comply with the service delivery provisions include, but are not limited to, the following:

  • The individual is often away from his residence when service is scheduled and he repeatedly fails to notify the provider that he will be gone, even though he has been counseled about this problem and its implications.
  • The individual or someone in the individual's home regularly will not permit the in-home provider to perform one or more of the tasks in the service plan or the individual receives personal attendant services and refuses to allow the provider to perform the authorized tasks.
  • Despite several provider efforts to find and place an acceptable attendant in the home, the individual refuses to accept in-home services because of dissatisfaction with a particular attendant.
  • The individual or someone in the individual's home regularly behaves in a way that is so offensive to staff that they refuse to serve him, and the individual knowingly and passively condones the person's behavior, and staff are unable to provide services. (Examples of offensive behavior include sexual harassment, sexual misconduct and racial discrimination.)

If the provider notifies the Texas Health and Human Services Commission about a service delivery compliance problem, contact the individual or the responsible party. Attempt to resolve the problem in a way that is satisfactory to the individual and the parties involved. A joint staffing may be conducted at the individual's home to try to resolve the situation.

 

2830.1 Individuals Who Refuse to Comply with Electronic Visit Verification Requirements

Revision 17-1; Effective March 15, 2017

Individuals requesting or receiving attendant services from a Home and Community Support Services Agency (HCSSA) are required to participate in Electronic Visit Verification (EVV) by allowing the attendant to use their home landline to report the start of work and the end of work. If an individual does not have a home landline, or if the individual will not allow the attendant to use the home landline, the individual must agree to an alternate device installation in the home. Failure to cooperate with EVV requirements can result in suspension or termination of services.

It is the case worker’s responsibility to review the information on the rights and responsibilities form and adequately explain the EVV requirements to the applicant or individual receiving services. It is important to communicate that an individual’s failure to cooperate with EVV requirements can result in the suspension or termination of services. The case worker must explain the following points:

  • EVV is a telephone and computer-based system that electronically verifies service visits occur and documents the precise time service provision begins and ends. The purpose of EVV is to verify that individuals are receiving the services authorized for their support and for which the state is being billed.
  • EVV will not change the services the individual receives.
  • EVV is mandatory for all HCSSAs and individuals receiving services from an attendant, unless the individual receives services through the CDS option.
  • The attendant will need the individual’s permission to use the home landline toll-free number at the start and at the end of work. Under no circumstances should the individual call the toll-free number on behalf of the attendant. If the individual is asked to do this, they should report it to the provider agency.
  • If the individual does not have a home landline or does not want the attendant to use his telephone, an alternative device can be placed in the home, which is used only to verify the attendant’s start and end of work. This device must remain in the home at all times. If the individual notices the removal of the device, they should report it to the provider agency.
  • If the individual notices any other possible EVV violation such as an instance in which the attendant leaves the home without providing services after calling the toll-free number upon arrival , they should report it to the provider agency.
  • If the individual has additional questions, the case manager refers him to the selected HCSSA or Financial Management Services Agency (FMSA) for additional information on how EVV works.

For individuals using the CDS option, the case worker must explain that the individual receiving services, or a designated representative (DR), is the employer of record and can choose to use the EVV system or use paper time sheets. The three choices are:

  • Full Participation-Phone and Computer: The CDS employee(s) use the telephone portion of EVV, and the employer of record uses the computer portion of the system to perform visit maintenance.
  • Partial Participation-Phone Only: This option allows the employer of record to participate in EVV, but provides some help from the FMSA with visit maintenance. The CDS employee calls in when he or she starts work and calls out when they end work. The employer uses a paper time sheet to document service delivery. The FMSA performs visit maintenance to make sure the EVV system matches the paper time sheets approved by the CDS employer.
  • No EVV Participation: If the employer of record does not have access to a computer, assistive devices or other supports, or feels he cannot fully participate in EVV, he may choose to use a paper time sheet to document service delivery.

The FMSA will require the employer of record to complete Form 1722, Employer’s Selection for Electronic Visit Verification (EVV), to indicate his choice.

If an individual is refusing to cooperate with EVV requirements, it is considered as a refusal to comply with service delivery provisions and policies in Section 2831, Suspensions Due to Refusal to Comply with Service Delivery Provisions, are applicable. Some individuals whose provider is required to participate in EVV are not allowing the attendant to use their home phone and are also refusing to allow a Fixed Visit Verification (FVV) device to be placed in their home.

Providers are required to participate in EVV for services delivered by an attendant. Individuals who refuse to allow the attendant to record hours worked through EVV, either through the use of their home phone or a FVV device, are non-compliant with their service delivery plan. These individuals are essentially not allowing the provider to carry out services in accordance with provider requirements.

 

2831 Suspensions Due to Refusal to Comply with Service Delivery Provisions

Revision 17-10; Effective October 6, 2017

The provider or case worker may suspend services until an interdisciplinary team (IDT) meeting is scheduled and the situation is discussed. After the IDT meeting, the case worker must send the individual a letter within five working days stating services can be terminated if he does not comply with service delivery provisions and stating specifically what the individual must do to continue services.

If the situation is not resolved and the individual continues to refuse to comply, the case worker convenes a second IDT and sends the individual a second notice stating continued refusal to comply with service delivery provisions will result in the termination of services.

If the situation continues not to be resolved and a third situation arises, the case worker convenes a third IDT and must send a third and final letter to the individual stating continued refusal to comply with service delivery provisions will result in the termination of services.

If the situation continues, the case worker may terminate services by sending Form 2065-A, Notification of Community Care Services. See Section 2810, Individual Notification Procedures. Denials based on refusal to comply with service delivery provisions must be approved by the supervisor. Document the conference and approval in the case narrative.

There is no time period during which the instances of refusing to comply must occur.

 

2832 Documentation of Compliance Issues

Revision 17-1; Effective March 15, 2017

Documentation in the case narrative is required in all situations involving the individual's refusal to comply with service delivery provisions. Opinions or evaluative conclusions are not appropriate documentation to substantiate a denial of services. Documentation should stress a factual statement of actions constituting noncompliance.

Determine and document whether the individual is aware of and able to understand the consequences of his or other's actions. If the individual is not aware of his behavior or the behavior of someone in his home, discuss the issues with him.

Determine if the person seems to be abusing, neglecting or exploiting the individual, and refer the individual to Adult Protective Services (APS), if necessary. Continue services pending the APS investigation. APS may take appropriate action, such as obtaining a guardian, to resolve the problem if the individual is abused, neglected or exploited.

Document the date and content of each discussion with the:

  • individual;
  • interested family member;
  • provider; and
  • unit supervisor.

 

2833 Reauthorization of Services After Termination for Refusal to Comply

Revision 17-1; Effective March 15, 2017

If an individual's services have been terminated because of his refusal to comply with service delivery provisions that involve a provider, confer with the unit supervisor prior to referral to another. It may be necessary to discuss the individual's particular compliance issues before reauthorizing services. The unit supervisor must approve the referral. Note the approval in the comments section of Form 2101, Authorization for Community Care Services.

Follow these steps when an applicant who had been authorized services in the past, but whose services were terminated due to his failure to comply with service delivery provisions, reapplies:

  1. Before contacting the applicant, review with the supervisor circumstances of the previous denial and the steps to be taken with the applicant. Document the review in the case record.
  2. Review with the individual/responsible party:
    • the reason for the previous termination,
    • the responsibility of the individual/responsible representative to notify the provider and Texas Health and Human Services Commission (HHSC) about problems related to the service delivery provisions and the importance of good communication, and
    • each task to be authorized, emphasizing the only tasks to be performed by the attendant are those authorized by HHSC.
  3. Authorize services if the individual agrees to follow the service delivery provisions.
  4. Record the conversation with the individual in the case record narrative.
  5. Contact the individual or provider weekly for one month to assess the individual's compliance with service delivery provisions. If the individual continues to have problems complying with service delivery provisions, contact the individual and emphasize the need for him to comply.
  6. If the provider complains about the individual refusing to follow his service delivery provisions, contact the individual monthly after the first month of service. Discontinue monthly contacts when complaints cease.
  7. Terminate services if the individual refuses more than three times to comply with service delivery provisions.

 

2840 Threats to Health or Safety

Revision 17-1; Effective March 15, 2017

Occasionally, an individual or someone in his home might exhibit behavior that constitutes a threat to the health or safety of another person. Examples include, but are not limited to:

  • exhibiting weapons;
  • making direct spoken threats of physical harm, force or death;
  • physically attacking a person with or without a weapon;
  • threatening use of force by self or someone else;
  • using or selling illegal drugs; and
  • displaying dirty needles or the smell of toxic fumes from the manufacture and/or sale of illegal drugs in the individual's home environment.

If, during the initial contact or any other contact by the case worker or provider staff, an individual or someone in his home exhibits threatening behavior or makes comments that are threatening, hostile or of a nature that would cause concern for the individual, provider or Texas Health and Human Services Commission (HHSC) employee, the case worker must immediately notify management. Regional management must review these situations on a case-by-case basis and determine the most appropriate action to be taken. If the applicant's safety may be at risk, the case worker must follow current policy regarding notification to the Department of Family and Protective Services Adult Protective Services (APS). If the case worker believes there is a potential threat to others, regional management should determine the best method for notifying the provider and addressing the individual's needs without placing staff members at risk.

If an individual threatens his own health or safety by threatening or attempting suicide or self-injury and is at immediate risk, place a 911 call to report the emergency. A referral to APS must also be made. If the applicant or individual seems to be abused, neglected or exploited by the person who threatens the health or safety of others, refer the individual to APS.

In most cases where there is a potential for danger, services should be suspended immediately.

The case worker must send Form 2065-A, Notification of Community Care Services, by the next working day after receiving notice from the provider that services have been suspended for failure to comply or threats to health and safety. The notice must reference 40 Texas Administrative Code §48.3903, state the last day services are delivered, and include a clear statement in the comments explaining why services have been suspended.

Within three working days after the case worker becomes aware of the suspension, the case worker must arrange an interdisciplinary team (IDT) meeting to try to resolve the issue with the provider and the individual. Depending on the severity of the reason for the suspension, some IDT meetings may be conducted by telephone or some may require a face-to-face contact.

The case worker may conduct the IDT meeting by telephone or a face-to-face contact for all suspension reasons listed in this section. Case workers are required to discuss the specific case with their supervisors to determine the best approach for conducting the IDT. Case workers must document the rationale for conducting the IDT by telephone.

During the IDT meeting, the case worker, provider staff, the individual and the individual’s representative, if any, must evaluate the issue and discuss the program requirements for continued services. The IDT should identify any solutions to resolve the issue, including the individual’s understanding of the issue and what must be done to resolve the issue. The case worker must document the requirements for continued services. See Section 2831, Suspensions Due to Refusal to Comply with Service Delivery Provisions, and Section 2832, Documentation of Compliance Issues, for additional guidelines.

If the issue leading to suspension is resolved during the IDT, the provider must, within two business days after the IDT meeting, either implement the recommendations of the IDT or discharge the individual and refer the individual to the case worker for referral to another provider. The case worker must notify the individual orally or in writing of the reinstatement of services. If services continue, assess if the individual meets the guidelines for an individual at risk and if so, follow procedures outlined in Section 2550, Identifying Individuals at Risk. If the issue is not resolved and services cannot be continued, the case worker begins the termination process.

 

2840.1 Monitoring or Annual Home Visit Delay Due to Unsafe Environmental Circumstances

Revision 17-1; Effective March 15, 2017

The Texas Health and Human Services Commission (HHSC) case worker is required to make every reasonable attempt to complete the Community Attendant Services (CAS), Primary Home Care (PHC) and Family Care (FC) service monitoring or annual reassessment visit. All attempts to contact the individual must be documented in the case record to support the efforts to meet the requirements. In some situations, the case worker is unable to make the face-to-face home visit due to a dangerous environmental situation beyond the case worker or individual’s control. These situations may include but are not limited to:

  • current police activity (i.e., a car chase, weapons drawn, drug raids);
  • gathering of people on the streets demonstrating threatening or intimidating behavior directed at the case worker; and
  • illegal activities in close proximity (e.g., next door to the individual’s home) occurring at the time the case worker attempts the home visit.

When such situations occur and the case worker feels threatened, he or she can make the home visit at another time. The case worker must immediately notify regional management of his inability to conduct the home visit. The case worker must schedule another service monitoring or annual reassessment visit at the earliest possible opportunity. The case record must contain ongoing documentation of attempts to complete the visit and the reason for the delay until the monitoring visit has been completed.

If, during the home visit an individual or someone in his home exhibits threatening behavior or makes comments that are threatening or hostile, the case worker can end the service monitor or annual reassessment and reschedule for a later time. The case worker must immediately notify regional management of his or her inability to conduct the home visit. The case worker will refer to Section 2840, Threats to Health or Safety, to suspend or terminate services. If the threatening behavior is resolved, the case worker must schedule another service monitoring or annual reassessment visit at the earliest possible opportunity. The case record must contain documentation of all attempts to complete the visit, along with any reasons for delays until the monitoring visit has been completed.

 

2840.2 Chronic Contagion/Infestation Conditions

Revision 17-1; Effective March 15, 2017

While the chronic contagious medical condition or infestation of the individual’s home may not pose an immediate danger to the health and safety of the individual, provider agency staff or case worker, either situation may adversely affect the health of all such persons involved in supporting the individual’s services and may pose a risk of exposing other individuals to the contagious medical condition or environmental infestation. Examples of unresolved chronic adverse medical or environmental related condition(s) may include the presence of bed bugs, fleas, ticks, lice or scabies.
 
The case worker must assess the individual’s ability to comply with the request to eradicate contagions or infestations and should exhaust all efforts in arranging for assistance to eradicate contagions or infestations, based upon the assessment of the individual’s capabilities. The case worker should identify available local resources which may provide the needed assistance in meeting the individual’s specific needs in relation to resolving the risks associated with the spread of the contagion or environmental infestation to others.

As stated in Section 2831, Suspensions Due to Refusal to Comply with Service Delivery Provisions, the provider or case worker may suspend services until an interdisciplinary team (IDT) meeting is scheduled and the situation is discussed. Efforts to identify local resources and natural supports to assist the individual if any such resources and supports exist, should be well documented as part of the IDT meeting. Any specific actions and responsibilities required of the individual and other persons and an agreed-upon time frame for completion of the eradication should be documented. Information from a pest control professional must be the basis in the establishment of a timeline expectation for eradication, as each situation will be unique. The specific actions and responsibilities required of the individual or other persons, such as family members or friends, who have agreed to provide support as part of the eradication plan should be documented as service provision requirements.

If the eradiation plan is not followed and the situation is unresolved, the case worker refers to Section 2830, Refusal to Comply with Service Delivery Provisions, and Section 2831 for guidance in instances in which the individual is non-compliant with service delivery provisions.

The case worker follows policy in 40 Texas Administrative Code §48.3903, (f) Denial, Reduction or Terminations of Benefits, to provide adequate notice of possible termination of services if the individual fails to cooperate with service delivery provisions.

 

2840.3 Active Tuberculosis (TB) Diagnosis

Revision 18-3; Effective December 14, 2018

An applicant or individual with a TB diagnosis cannot have services denied or terminated as a consequence of his/her disease.

The regional HHSC staff will contact their regional health department to ensure staff are linked to the right TB personnel to address TB cases on a case-by-case basis. The HHSC unit case worker may confer with their unit supervisor for help with processing the case and may use the following web address to contact their regional health department: http://www.dshs.texas.gov/regions/. If the HHSC case worker/supervisor is unable to contact the local regional health department or needs more information, they may contact the Texas Department of State Health Services (DSHS) TB and Hansen’s Disease Program staff who are linked to TB personnel in the county in which the patient resides. The telephone number is 512-533-3000 for general information and 512-533-3144 for the nurse administrator. Upon receiving the physician's report, DSHS assigns a representative to monitor the case through "directly observed therapy." This process involves observation of the individual taking his/her medication; it may also involve health-related training and the provision of additional care of the individual.

For cases with active TB, a team meeting should be set up to include the regional nurse, case worker, provider and the local DSHS representative handling the case. These individuals will ensure coordination of care and determine if special precautions need to be taken.

It is possible that DSHS will instruct HHSC to suspend the case while the TB remains active; if so, it will provide care for the individual during this period. Most individuals become negative for TB within a few weeks of drug therapy.

Note: Refer to Section 1140, Disclosure of Information, regarding disclosure of information and national standards created under the Health Insurance Portability and Accountability Act to protect the confidentiality of individually identifiable health information.

 

2840.4 Sharing Information with New Providers Regarding Health and Safety Issues

Revision 17-1; Effective March 15, 2017

When services have been suspended due to health and safety reasons, HHSC staff are required to convene an interdisciplinary team (IDT) meeting to resolve the issues. If the issues cannot be resolved, the provider may report it will no longer serve the individual due to health and safety concerns.

In some situations, HHSC may terminate the individual’s services due to health and safety issues. In other situations, HHSC may initiate services with a new provider. If the HHSC case worker makes a referral to a new provider, he must determine how much information to share with the new provider regarding the previous actions.

The HHSC case worker must share sufficient information with the new provider to avoid putting the provider at risk. This allows the provider to adequately plan for safely delivering services to the individual, including selecting the appropriate service delivery staff and preparing the staff to handle situations that may arise. Providing information may avoid the issues that previously caused the termination or suspension.

Case workers must use good judgment in determining what information to share and, if in doubt, consult with their supervisors for guidance.

 

2841 Reinstatement of Services Terminated for Threats to Health or Safety

Revision 17-6; Effective June 28, 2017

An applicant whose services were terminated in the past due to his or someone in his home being a threat to the health or safety of the client, department staff, or provider agency staff may be authorized services if the applicant signs Form H0003, Agreement to Release Your Facts, authorizing release of information, and:

(1) The applicant/person in home who posed the threat has been treated or is receiving treatment by a licensed or certified physician, psychiatrist, or psychologist and can furnish a letter saying that he is no longer a threat to himself or others; or
(2)The applicant/person in home allows a collateral contact with his physician, psychiatrist, or psychologist and the contact indicates that the applicant is no longer a threat to himself or others; or
(3)The person in the home who posed the threat no longer poses the threat.

Complete the eligibility determination in the Service Authorization System Wizards within 30 calendar days after the date the signed application is received by the department. (See Section 2344, Individual Rights and Responsibilities.)

 

2841.1 Sharing Information on Previous Actions for Reinstatement

Revision 17-1; Effective March 15, 2017

If an individual who has been previously terminated from services due to health and safety reasons reapplies for services and meets the requirements in Section 2841, Reinstatement of Services Terminated for Threats to Health and Safety, information may need to be shared with a newly selected provider.

If the HHSC case worker makes a referral to a new provider, he must determine how much information to share with the new provider regarding the previous actions that resulted in termination of services. The case worker must share sufficient information with the new provider to avoid putting the provider at risk and allow the provider to adequately plan for safely delivering services to the individual. This includes selecting the appropriate service delivery staff and preparing the staff to handle situations that may arise. Providing information may avoid the issues that previously caused the termination or suspension.

Case workers must use good judgment in determining what information to share and, if in doubt, consult with their supervisors for guidance.