6200, Nursing Services

Revision 18-2; Effective September 3, 2018

Nursing services are services that are within the scope of the Texas Nursing Practice Act and are provided by a registered nurse (RN) (or licensed vocational nurse (LVN) under the supervision of an RN) licensed to practice in the state. In the Texas state plan, nursing services are provided only for acute conditions or exacerbations of chronic conditions lasting less than 60 days. Nursing services provided in the STAR+PLUS Home and Community Based Services (HCBS) program cover nursing tasks associated with ongoing chronic conditions such as medication administration and supervising delegated tasks. This broadens the scope of these services beyond extended state plan services. Extended state plan services are services provided which exceed benefits allowed under the state plan.

Nursing services purchased through the STAR+PLUS HCBS program can be skilled or specialized in nature and do not replace a member's acute care benefit. Nursing services are assessment, planning and interventions provided by a person licensed to engage in professional nursing or vocational nursing in Texas, or licensed in a state that has adopted the Nurse Licensure Compact. Proof of valid licensure can be verified by viewing the nurse's license at the Texas Board of Nursing website at https://www.bon.texas.gov/.

To assure quality of care for members in the STAR+PLUS HCBS program, the managed care organization (MCO) is responsible for coordinating services following a significant change in the member's condition. The MCO may become aware of a significant change in condition through interaction with members, family or an authorized representative (AR), and by performing interim assessments on current STAR+PLUS HCBS program members. The MCO is responsible for initiating appropriate services and supports to meet the care and well-being of the member interventions on a timely basis.

6210 Settings

Revision 18-2; Effective September 3, 2018

Nursing services can be delivered in a member's own home or family home, in a personal care facility, assisted living facility (ALF) or an adult foster care (AFC) setting. Nursing services purchased through the STAR+PLUS Home and Community Based Services (HCBS) program may not be provided in the following settings as defined in 42 Code of Federal Regulations (CFR), §441.530(a)(2):

  • Nursing facilities (NFs);
  • Psychiatric hospitals;
  • Intermediate care facilities for individuals with intellectual disabilities (ICF/IID);
  • Hospitals providing long term care; and
  • Locations that have the qualities of an institution.

6220 Nursing Services to Meet Member Needs

Revision 21-2; Effective August 1, 2021

All STAR+PLUS Home and Community Based Services (HCBS) program members meet medical necessity (MN) and have a need for one or more nursing tasks, as described in the Texas Administrative Code (TAC), Title 40, §19.2401. It is the responsibility of the managed care organization (MCO) service coordinator to identify and document in the individual service plan (ISP) or Form H1700-2, Individual Service Plan – Addendum, how the member's nursing need(s) will be met.

The member's nursing needs may be met by direct or delegated nursing, health maintenance activity (HMA), informal support, or a combination, as described below:

  • Direct nursing provided by a registered nurse (RN) or a licensed vocation nurse (LVN). This includes nursing services with a third-party resource (TPR) as the payer and nursing with the STAR+PLUS HCBS program as the payer.
  • Delegation by an RN to an unlicensed assistive person (UAP), such as a personal attendant in accordance with Texas Board of Nursing rules, which may be delivered through Community First Choice (CFC) or the STAR+PLUS HCBS program.
  • RN determination that a nursing task(s) is an HMA in accordance with Texas Board of Nursing rules. HMAs include performance of nursing tasks by a paid attendant and by informal support. For a member who chooses the provider or service responsibility option (SRO), the MCO service coordinator, in conjunction with the agency RN, makes the determination that a nursing task is an HMA.
  • Informal support, such as unpaid family members, may be trained in the provision of nursing tasks to meet a member's needs. The MCO service coordinator must identify and document the tasks to be performed by the informal support on Form H1700-2, and the informal support must agree to perform the nursing tasks.

For information about delegation and HMAs, refer to the TAC for Texas Board of Nursing, Title 22, Part 11, Chapters 224 and 225.

6230 Nursing Services in Assisted Living Facilities

Revision 20-1; Effective March 16, 2020

Assisted living facilities (ALFs) must have sufficient staff to assist with member medication regimens (Texas Administrative Code (TAC), Title 26, §553.41). Nursing for this task may be included on the individual service plan (ISP), depending on the member’s needs and the facility type. Licensed nurses who own an ALF or are employed by the facility may directly administer medication to members residing in ALFs, but are not required to do so. In ALFs, delegation of nursing tasks to facility attendants is not allowed by licensure. See 7200, Assisted Living Services7224, Personal Care 3, and 7230, Other Services Available to Members.

If, because of licensure, an ALF does not provide nursing services, other facility employees may not deliver services other than personal assistance services (PAS) and administration of medications. If a resident needs additional services that are not available in the ALF, the managed care organization (MCO) must ensure the member’s needs are met. The MCO may do so through contract with a Home and Community Support Services Agency (HCSSA) or an independent health care provider.

PAS provided by the ALF include assistance with feeding, dressing, moving, bathing, or other personal needs or maintenance; or general supervision or oversight of the physical and mental well-being of a person who needs assistance to maintain a private and independent residence in the ALF; or assistance to a member to manage her or his personal life, regardless of whether a guardian has been appointed for the person.

6240 Nursing Services in Adult Foster Care Homes

Revision 18-2; Effective September 3, 2018

Based upon the assessment performed by the managed care organization (MCO) registered nurse (RN) service coordinator, the RN service coordinator determines a member’s classification level for adult foster care (AFC) services. MCOs must consider a need for limited or greater assistance with the performance of activities of daily living (ADLs) and behaviors that occur at least once a week in the assessment and determination, as well as other identified needs of the member. Nursing services may be purchased through the STAR+PLUS Home and Community Based Services (HCBS) program, depending on the member's assessed need and the AFC home classification. See 7133 Classification Levels, for additional information.

6250 Specialized Nursing

Revision 18-2; Effective September 3, 2018

Specialized nursing services delivered by a registered nurse (RN) or licensed vocational nurse (LVN) are available through the STAR+PLUS Home and Community Based Services (HCBS) program. Specialized nursing services may be used when a member requires, as determined by a physician, daily skilled nursing to:

  • cleanse, dress and suction a tracheostomy; or
  • provide assistance with ventilator or respirator care.