22-1, 14000 Changes

Revision Notice 22-1; Effective February 4, 2022

The following change(s) were made:

Section Title Change
14000 Long-Term Care Regulatory Changes section title and throughout the section, changes “Waiver Survey and Certification (WSC)” with “Long-Term Care Regulatory (LTCR).” Changes “review” with “survey,” “talking with” to “interviewing,” “residential reviewer” to “LTCR staff,” “CARE” with “HHSC data system,” and “Consumer Rights and Services” with “IDD Ombudsman.”  
14100 Long-Term Care Regulatory, HCS and TxHmL Overview Clarifies the functions of LTCR, which includes completing initial certification and annual recertification surveys for contracts operated by program providers to ensure compliance with the certification principles located in the Texas Administrative Code (TAC), completing residential visits for Host Home/Companion Care and three- and four-person homes residences, and reviewing complaints and deaths in the program.
14200 Home and Community-based Services Surveys Changes section title and corrects TAC references to certification principles. Replaces “announced or unannounced reviews” with “intermittent survey.”
14210 Types of Surveys Changes section title and deletes provisional certification information. Adds that for recertification surveys, a program provider must demonstrate compliance with all certification principles to be certified for another 365-day period. Clarifies that if the program provider is out of compliance with any certification principles, LTCR sends a final report with a list of violations to the program provider within 14 calendar days after the day of exit and the program provider must submit a Plan of Correction (PoC ) within 14 calendar days of receipt of the report. Makes other minor wording changes and delineates the time frames needed for a critical and noncritical violation. For a critical violation, the PoC must include that corrective action will be completed within 30 calendar days after the date of the survey exit conference and an on-site follow-up survey will be conducted after the 30-day period to determine if the program provider completed the corrective action in accordance with their PoC. For a violation that is not critical, the PoC must include that corrective action will be completed within 45 calendar days after the date of the survey exit conference and an on-site follow-up survey is conducted after the 45-day period to determine if the program provider completed the corrective action in accordance with their PoC. If LTCR determines that the program provider has not completed the corrective action or they have failed to submit an acceptable PoC, HHSC imposes a vendor hold against the program provider or denies or terminates the certification. Adds that LTCR will conduct a follow-up survey at least 31 calendar days after the effective date of the vendor hold, and if the program provider has not completed the corrective action, HHSC will deny or terminate the certification. Adds that intermittent surveys are always unannounced and also based on internal HHSC referrals.
14220 Overview of the Home and Community-based Services Certification Survey Process Changes section title and makes minor wording changes. Removes that HCS program providers will generally be contacted before a certification review by the review facilitator, unless there is cause to conduct an unannounced review of the program. Removes “over 90 days” in certification review activities and removes “as a part of WSC reviews, reviewers note any issues related to service coordination and forward any concerns to HHSC Contract Accountability and Oversight (CAO) for follow up. HCS program providers may view notations related to their programs in the C-97 screen of the CARE system.” Removes “a citation can only be cleared if the original instance of noncompliance has been remediated, a new sample of individuals or records are in compliance for that principle, and the provider can show a change in process or policy that ensures no future occurrences of noncompliance.” Clarifies that if the survey team identifies an immediate threat, the program provider must immediately provide the survey team with a plan of removal. Replaces “informal review process” with “informal dispute resolution (IDR)” and explains if a program provider disagrees with the survey results, they may request an IDR. The IDR is an informal process by which a program provider can dispute, before an independent third party, the findings on which a violation is based. The outcome of the IDR serves as the independent third party’s recommendation to HHSC regarding the program provider’s compliance or noncompliance with program rules. The program provider must still submit an acceptable PoC no later than 14 calendar days after receiving Form 3724 from HHSC even if it chooses to use the IDR process.
14230 Plan of Correction (PoC) Changes section title from “Corrective Action Plan” to “Plan of Correction (PoC).” Clarifies within 14 calendar days after receiving the final survey report, the program provider must submit a PoC to address each violation that was identified during the survey. This applies even if the provider disagrees with the findings of violations or requests IDR. For violations that are critical, the PoC must include the corrective action(s) the program provider will take for each violation with a completion date within 30 calendar days from the survey exit conference.  For violations that are noncritical, the PoC must include the corrective action(s) the program provider will take for each violation with a completion date within 45 calendar days from the survey exit conference. HHSC will review the PoC and the program provider will be notified in writing whether the plan has been approved or denied. If the plan is denied, the program provider must submit a revised plan within five business days. Once the plan is approved, HHSC will request that the program provider submit evidence of the correction to HHSC and HHSC can conduct a follow-up survey to verify the corrections.
14240 Home and Community-based Services Review Checklists Deletes section.
14300 Texas Home Living Certification Surveys Changes section title, adds a TAC reference and replaces “announced or unannounced review” with “intermittent survey.”
14400 Residential Visits Deletes “the legislature funded annual inspections of HCS Host Home/Companion Care residences.” Clarifies that HHSC may conduct unannounced visits to each residence in which Host Home/Companion Care services are provided.
14410 Residential Visit Policy and Procedures Corrects that Form 3609, Waiver Survey and Certification Residential Checklist, is marked pass or fail, not yes or no. Adds a link to Provider Letter 2020-01 that provides information for how the Host Home/Companion Care provider or HCS provider can give feedback about a residential visit. Corrects that a letter notifying the program provider of the inaccuracy in the HHSC data system is sent to the HCS program provider, not the CEO, if the address on the HHSC data system is invalid.
14411 Residential Visit Results Clarifies that a program provider must submit an evidence of correction (EoC) to LTCR using the WSC Portal or by submitting Form 1573, Residential Review Evidence of Correction. If using Form 1573, the Residential Review ID must be listed on the form with accompanying evidence. The time frame to submit an EoC is included in the documentation received by the program provider. LTCR will not accept an EoC without the correct Residential Review ID. Clarifies the program provider must take action to address an item marked “fail” on the residential checklist. If a significant risk requires immediate corrective or mitigating action, such as locking up hazardous chemicals or securing a copy of the residence’s emergency plan, LTCR staff will not leave the residence until the program provider has taken immediate action and the significant risk is removed. LTCR will also contact the program provider contract contacts and inform such persons of the date, as determined by LTCR, by which the program provider must submit evidence of correction showing that action has been taken and the significant risk removed.
14500 Death Reviews Corrects a TAC reference for reporting a death in the HCS program and adds a TAC reference for the TxHmL program. Adds that Form 8493, Notification Regarding a Death in HCS, TxHmL and DBMD Programs, must be faxed to LTCR at 512-206-3999 or submitted through the WSC Portal.
14510 Death Review Policy and Procedures Adds “Statewide Intake” after Department of Family and Protective Services (DFPS) and replaces “family care” with “Host Home/Companion Care.” 
14600 Abuse, Neglect and Exploitation Follow Up Replaces WSC with the Risk Assessment coordinator (RAC) team.
14610 Abuse, Neglect and Exploitation Policy and Procedures Replaces “DFPS” with “HHSC Provider Investigations (PI).”
Deletes information related to the complaint process and deletes RACs review the allegation with the WSC risk assessment manager, assistant director, and director or designee prior to scheduling an on-site visit.
14700 Additional Monitoring Related to Risk Factors Makes minor wording changes.
14800 Complaints  Replaces “Consumer Rights and Services” with “IDD Ombudsman.”
14810 Complaints Policy and Procedures Updates the IDD Ombudsman phone number to 800-252-8154.
14900 Four-Person Residence Approvals Makes minor wording changes.
14910 Four-Person Residence Approval Policy and Procedures Adds an email address and fax number to send Form 8491, Request for a Four-Person Residence Approval, and supporting documents, and corrects a TAC reference.