6900, Readmission to a Nursing Facility

Revision 23-1; Effective Dec. 20, 2023

If a person who has, at any time, received 365 days of enhanced community coordination (ECC) is readmitted to a nursing facility (NF) and wishes to return to the community, the ECC coordinator must determine: 

  • if the person was in the NF for more than 30 calendar days; or
  • if the person experienced a significant change of condition* during readmission to the NF.
  • If the ECC coordinator determines the readmission exceeded 30 calendar days or the person experienced a significant change of condition, the ECC coordinator must:
  • when appropriate, facilitate trial visits to program providers in the community for the person, including overnight or weekend visits where feasible, as requested by the person or LAR;
  • develop and revise, as necessary, Form 8665, Person-Directed Plan, using all available assessments, and include the person’s:
    • strengths and preferences; and
    • medical, nursing, clinical, nutritional management and any other support needs;
  • conduct a pre-move site review using Form 1042, Pre-Move Site Review, to:
    • ensure any concerns of the program provider, staff or family member are being addressed; and
    • determine whether all essential supports identified on Form 1053, Transition Plan, are in place before the person transitions; and
  • complete the following activities before the person transitions if, during the pre-move site review, any one of the essential supports is not in place or if issues are raised about the suitability of the site:
    • convene the SPT to resolve the issues; and
    • conduct another pre-move site review following resolution.
  • conduct and document on Form 1043, Post-Move Monitoring, at least three onsite post-move monitoring visits of community service delivery sites during the first 90 calendar days after the person’s move at the following times:
    • within the first seven calendar days after enrollment in the HCS program;
    • between eight and 45 calendar days after enrollment in the HCS program;
    • between 46 and 90** calendar days after enrollment in the HCS program; and
  • during the post-move monitoring visits:
    • assess whether essential and non-essential supports identified in Form 1053, Transition Plan, are in place;
    • document and address all concerns of the environment, program provider, staff or family member on Form 1043;
    • document all identified gaps in care on Form 1043; and
    • address such concerns and gaps, if any, to reduce the risk of crisis, re-admission to an NF or other negative outcome.

* Significant change of condition: any change requiring additional services, equipment, or minor home modifications (e.g., new enteral feeding tube, respiratory equipment, wheelchair).

**If, by the 60th day after the person returns to the community, the SPT believes the person may require more than 90 days of enhanced monitoring, the ECC coordinator must contact IDDMFPSupport@hhs.texas.gov for further guidance.

If a qualified person who has transitioned to the community is admitted or readmitted to an NF, and has never received ECC, an ECC coordinator must initiate one year of ECC as described in Section 6000 of this handbook, relating to monitoring activities for NF transitions.

If a person is readmitted to an NF while receiving their initial 365 days of ECC, ECC will resume upon discharge to the community, however, the 365-day time frame does not re-start after the discharge. For example, if a person is admitted to an NF on day 181 of ECC and is put on suspension, when the person discharges from the NF, ECC resumes on day 182.

A person who is readmitted to an NF for the purpose of respite does not qualify for ECC upon discharge unless the person is already receiving ECC at the time of readmission.