Appendix XXIV Minimum Standards for STAR+PLUS AFC Homes and Home Providers
Adult Foster Care (AFC) Home Provider Qualifications
The AFC home provider must:
- be a responsible, mature, healthy adult (18 years of age or older) capable of meeting the needs of the residents in the home;
- be physically and mentally able to perform all the required duties and tasks;
- be able to communicate directly with the resident and the resident's family;
- show evidence of an examination for tuberculosis performed within six months prior to the date of enrollment from a licensed physician or a local health department with negative results or, if the results are positive, provide a physician's statement that the disease is non-communicable;
- not deliver direct services when the home provider has a communicable disease or illness, but ensure that a resident's needs are met by an approved substitute home provider;
- ensure that persons whose behavior or health status endangers the residents are not allowed at the home;
- provide, at the time of enrollment, three references for the home provider, and substitute home provider, from persons not related to the home provider (or substitute home provider);
- ensure the resident's spouse cannot be the home provider or substitute home provider;
- live in and share the same household (i.e., have common living areas not detached from the home) with the residents;
- be the primary caregiver of the resident;
- be the owner or lessee of the AFC home, or reside in the member's home,
- submit to the managed care organization (MCO), or MCO-contracted AFC provider agency, a statement providing information concerning any felony or misdemeanor convictions, and any pending criminal charges against the home provider before approval of the AFC home. The MCO, or the MCO-contracted AFC provider agency must be notified if the information changes during the term of its contract;
- have at least one approved substitute home provider, who the home provider is responsible for paying, or who is paid based on agreement between the MCO and AFC home provider, before the approval process is completed;
- receive orientation covering the AFC program requirements and minimum standards before serving residents, and familiarize all substitute home providers with the same requirements and standards;
- participate in six hours of in-service training annually on topics approved by the member's MCO, which must include:
- training on acquired immune deficiency syndrome, human immune deficiency virus, and cultural diversity, within one year after enrollment, unless the member's MCO grants a 60-day extension; and
- training on first aid within two years after enrollment, unless the member's MCO grants a 60-day extension, and annually thereafter;
- demonstrate the ability to read and comprehend the minimum standards for AFC, the resident and AFC home provider agreements, individual service plans, and any applicable Health and Human Services Commission (HHSC) directives and MCO and MCO-contracted AFC provider agency requirements;
- prior to initial enrollment, demonstrate and maintain financial stability independent of the MCO AFC home provider payment, and demonstrate the ability to meet existing financial obligations;
- not represent any other residential settings that the home provider owns or operates as MCO-approved homes;
- ensure the AFC home provider must report Texas Department of Family and Protective Services or Texas Department of State Health Services investigations of these settings to the member's MCO; and
- agree to abide by all policies and procedures of the member's MCO.
Substitute Home Provider Qualifications
A substitute home provider must meet the same requirements as the home provider qualifications. The member’s MCO, or MCO-contracted AFC provider agency, reserves the right to disapprove a substitute AFC home provider. The AFC home provider must orient any substitute home provider to the home and the residents to the following:
- the location of fire extinguishers;
- evacuation procedures;
- location of residents' records;
- location of telephone numbers for the residents' physicians, the AFC home provider, member's MCO, or the MCO-contracted provider agency, if applicable, and other emergency contacts;
- location of medications;
- introduction to residents; and
- instructions for caring for each resident.
Individuals Who May Not Provide AFC
Individuals who are disqualified under the Health and Safety Code, Chapter 250, may not provide AFC services.
AFC Home Enrollment Requirements
All items with an * may be exempted for AFC homes where the AFC home provider moves in with the AFC member.
All homes in which AFC is provided must:
- *have bedrooms with at least 80 square feet of floor space in a single occupancy room, and at least 60 square feet of floor space per resident in a double occupancy room. The bedrooms must:
- be close enough in proximity to the AFC home provider to alert the AFC home provider to nighttime needs or emergencies, or they must be equipped with a call bell or intercom;
- have been constructed as sleeping areas when the home was built, or have been remodeled under permit that meets local requirements;
- be finished with walls or partitions of standard construction which go from floor to ceiling;
- be ventilated and lighted with at least one window that will open freely and remain open from the inside without special tools;
- *provide each resident with a bed and sufficient drawer and closet space in the resident's bedroom;
- *have no more than two beds in any room;
- *have comfortable sleeping arrangements for residents;
- *provide at least one comfortable sitting chair per resident in each bedroom;
- provide at least one grab bar in the bathtub/shower area and a slip-proof surface in the bathtub/shower area;
- *have adequate supplies of soap and toilet paper for each bathroom. Residents must be provided with individual towels and wash cloths;
- provide a sketch of the home floor plan showing the dimensions and the purpose of all rooms and specifying where residents and household members will sleep. As arrangements change, an updated floor plan must be provided to the member's MCO or the MCO-contracted provider agency;
- have a conspicuously posted emergency/disaster evacuation plan that specifies what procedures residents follow in case of emergency, and document evacuation drills at least every six months with at least one of the two required annual drills occurring during sleeping hours, or according to the registered nurse assessment recommendations;
- *have at least one working telephone available in the home for residents to make calls. The member’s MCO or the MCO-contracted provider agency, the member, the member’s family or guardian, and the member’s physician must be kept informed of the home provider’s current telephone number. The member has the right to give out the telephone number. Limitations on the use of the telephone must be specified in the house rules. AFC home providers must not charge recipients for the use of the telephone for local calls;
- have emergency telephone numbers, including the member's MCO service coordinator number, located at or near the telephone;
- have an operational smoke detection system – battery operated detectors are acceptable;
- have a portable ABC-type fire extinguisher charged and ready for use;
- have first-aid supplies on the premises, as recommended by the American Red Cross;
- *have at least one communal dining table with adequate seating for all residents at the same time;
- *provide space and furniture for residents' visitors;
- provide laundry service for the residents as part of the room and board rate;
- *meet all applicable state and local building, zoning and housing codes;
- be maintained, repaired and cleaned so that the homes are not hazardous to residents in care (including yards). There must be no accumulation of garbage, debris, rubbish or offensive odors. If house pets are kept indoors, sanitation must be maintained. Swimming pools must be fenced;
- have screens on windows and doors used for ventilation;
- have equipment and furnishings that are safe for residents;
- have flammable and poisonous substances, explosives and firearms stored and inaccessible to residents;
- maintain room temperatures at levels which are comfortable to residents. Heating and cooling systems must be in good working order. Maintain hot water temperatures in resident areas between 100 degrees Fahrenheit and 125 degrees Fahrenheit;
- have food preparation areas and equipment clean, free of offensive odors and in good repair. Utensils, dishes and glassware must be washed in hot soapy water, rinsed and stored to prevent contamination; and
- store soiled linens and clothing in containers in an area separate from food storage, kitchen and dining areas.
Eligibility for Payment
To receive payment from the MCO, all AFC homes and AFC home providers must:
- meet all of the minimum standards and provide care for no more than three adults, whether MCO member, resident or residents, unless the home meets the appropriate certification or licensure, per 40 Texas Administrative Code (TAC), Chapter 92, outlined in the Licensure section of this Appendix. The home census may not exceed the capacity for which the home is approved or licensed;
- serve only those AFC and private pay residents approved by the MCO, or the MCO-contracted provider agency, to ensure that the AFC home provider can meet the needs of all residents;
- not provide room and board to any individuals who are under 18 years of age;
- comply with all applicable fire, health, and safety laws, ordinances and regulations;
- obtain the necessary fire safety and health inspections and comply with any resulting requirements;
- be inspected at least annually by fire safety authorities and meet or exceed the regulations. The AFC home provider must correct any hazardous conditions identified in the inspection within the time specified by the inspector, or before enrollment/reassessment of the home, whichever is earlier;
- be inspected at least annually by health authorities and meet or exceed the regulations. If local health authorities are unable to inspect the home, the MCO or MCO-contracted provider agency may conduct the inspection using the health inspection checklist. The AFC home provider must correct any unsanitary and unsafe conditions identified by the inspection within the time specified by the inspector, or before enrollment/reassessment of the home, whichever is earlier;
- document the ability to evacuate all residents from the home within three minutes;
- interview a prospective resident before or at the time of admission to determine the needs of the prospective resident and whether the home can meet these needs;
- orient any new resident, within 72 hours of arrival, on fire safety, how to respond to a fire alarm, and how to exit from the home in an emergency; and
- except in the case of emergency evacuations, notify the MCO, or MCO-contracted AFC provider agency, of a change of residence before the change. The new home must meet all adult foster care requirements and be approved in the adult foster care program before payments can be made. Approval is not retroactive.
In addition to AFC home enrollment requirements, AFC homes with four or more residents, exclusive of "live-in" house parents, family or staff, must be licensed with the appropriate licensure category, by the state of Texas licensing authority, found in 40 TAC, Chapter 92.
If there is conflict between the STAR+PLUS HCBS AFC standards and the licensing requirements, the strictest standards and/or rules shall apply.
AFC Home Provider Responsibilities
- Resident Care and Services
The AFC home provider must:
- provide services to residents according to the individual service plan and the member/AFC home provider agreement;
- meet all requirements and conditions stated on the member/AFC home provider agreement, approval of foster care, and member's individual service plan;
- ensure that an approved substitute AFC home provider is present in the home if at least one resident remains in the home when the AFC home provider plans to be absent from the home for more than three hours in a 24-hour period. Residents whose care plans specify the need for 24-hour supervision may not be left without the supervision of an approved substitute AFC home provider for any period of time;
- receive prior approval from the MCO, or MCO-contracted AFC provider agency, if he plans to be absent for more than 24 hours. The proposed substitute AFC home provider must have prior MCO approval. The AFC home provider must ensure that the substitute AFC home provider is aware of and takes responsibility for meeting resident needs and providing services according to the member's individual service plan and the requirements of these standards. If two adults in the home have been approved as dual AFC home providers, this notification is not necessary when one AFC home provider leaves for more than 24 hours;
- ensure residents are not abused, neglected or exploited while in foster care. Validated reports of the AFC home provider, the AFC home provider's family, or employees willfully inflicting injury, physical suffering, intimidation or mental anguish on any resident in the home shall constitute grounds for immediate removal of the home from enrollment;
- respond to, investigate, and document resident complaints and report unresolved complaints to the MCO within five days of receipt of the complaint;
- have clearly defined house rules, including smoking policies. House rules must be shared between the home provider and the resident before moving to the foster home;
- take appropriate action if he finds that a resident threatens the health or safety of others or himself; and
- provide the resident with a final accounting of the resident's funds and refund any monies owed to the resident within five days of discharge. Any unused room and board money must be reimbursed within 30 days.
The AFC home provider and the MCO, or MCO-contracted AFC provider agency, must:
- maintain for each resident a record with the following information:
- the names, addresses, and telephone numbers of:
- person(s), other than the MCO, to be notified in case of emergency (if any);
- the resident's physician (if any); and
- the resident's MCO;
- current and past copies of the resident and AFC home provider agreement, signed by the resident and/or responsible party, AFC home provider and the MCO;
- current and past copies of the approval of adult foster care;
- current and past copies of the individual service plan;
- any MCO communications regarding the resident;
- personal papers of the resident, such as life insurance policies, burial arrangements, savings accounts, etc., if requested by the resident; and
- records related to assistance provided the resident with money management, payments, distribution of personal allowance, expenditures, etc.;
- file claims for services according to MCO rules and requirements. Some residents are required to pay a co-payment, if applicable.
- the names, addresses, and telephone numbers of:
- maintain for each resident a record with the following information:
- Reporting and Notification
The AFC home provider must:
- report to the MCO, or the MCO-contracted AFC provider agency, within 24 hours or the next work day after awareness of the change, all significant changes in the resident's physical health, mental and/or behavior status;
- report to the MCO, and the MCO-contracted AFC provider agency, if applicable, pending resident hospitalizations before the hospitalization, and unplanned hospitalizations within 24 hours of the hospitalization or the next work day;
- report pending hospital discharges of approved residents to the MCO, and the MCO-contracted AFC provider agency, if applicable, before the actual discharge, or on the day the resident returns to the foster care setting, to ensure continued resident appropriateness;
- notify the MCO, or the MCO-contracted AFC provider agency, at a minimum, within 24 hours or the next work day after a resident is away from or vacates the adult foster home;
- notify the MCO, and the MCO-contracted AFC provider agency, if applicable, immediately by telephone upon becoming aware of the following: death of a resident, serious physical injury or distress of a resident, offense against the resident, or public indecency of a resident. The AFC home provider, or MCO-contracted AFC provider agency, must submit a written report to the MCO within 48 hours of the verbal report. The AFC home provider must also notify the police in the following situations: the death of a resident in the foster home, serious physical injury resulting from assault or battery, offenses against the resident, and public indecency;
- notify the MCO, and the MCO-contracted AFC provider agency, about serious occurrences involving the AFC home provider, the home or the residents. These may include, but are not limited to, fire, accidents, altercations among residents, break-ins or illness of the home provider or residents. The AFC home provider must notify the MCO, and the MCO-contracted AFC provider agency, by telephone no later than the next calendar day after awareness of the occurrence;
- notify the MCO, and the MCO-contracted AFC provider agency, if applicable, before any resident receives home health services;
- notify the MCO, and the MCO-contracted AFC provider agency, if applicable, when the AFC home provider, substitute AFC home provider or any adult member of the household is the subject of an adult protective services investigation. The AFC home provider must notify the MCO and the MCO-contracted AFC provider agency, if applicable, within 24 hours of the beginning of the investigation or the next work day; and
- report to the MCO any of the required notifications if the MCO primary contact (service coordinator) is not available to speak with the AFC home provider.
The AFC home provider must:
- upon awareness, obtain medical attention for a resident exhibiting signs of physical injury, pain or discomfort;
- seek medical attention/care on the same day of awareness for a resident exhibiting acute changes in physical health, mental or behavior status; and
- follow MCO AFC directives related to resident care within the specified time frames.
The AFC home provider must:
- provide a resident with at least three meals daily which meet each resident's dietary and nutritional needs;
- consider a resident's food preferences and make reasonable accommodations within his dietary needs;
- serve a variety of foods, within the resident's dietary needs; and
- follow special diets as prescribed in writing by the resident's physician.
The AFC home provider must comply with the following rules regarding the storage and management of medications:
- ensure prescription medications must be in the original container labeled with the resident's name, date, instructions, name of medication and dosage, and the physician's name;
- ensure medications requiring refrigeration must be separated from food in a clearly labeled, designated locked container;
- ensure medications must be transferred with the resident when the resident leaves the home. Medications must be disposed of when resident medication regimen changes, or when the medication is out of date;
- ensure medications prescribed for one resident must not be taken by or given to any other resident;
- ensure that a resident takes over-the-counter medications according to the package directions. Excessive use of these medications must be reported to the member's MCO;
- ensure that all medications are taken as prescribed and in a timely manner according to the instructions on the medication label or instructions from the resident's physician;
- administer medications only as allowed by state law or regulation, including applicable nurse delegation rules found in 22 TAC, Chapter 225; and
- ensure prescription medications are kept in a locked container.
- Resident Rights and Responsibilities
The AFC home provider must:
- inform the resident verbally and in writing, before or at the time of admission to the AFC home, of his rights and responsibilities. The rights and responsibilities include rules governing resident conduct, complaints, bedhold policies for hospital and personal leave, and discharge or eviction procedures. The policies must not violate the rules specified in this undesignated head nor adversely affect the resident's health or safety. All policies must have an effective date. If the AFC home provider amends any policy, each resident must be informed before the change becomes effective. A written copy of these policies must be given to the resident to initial and date. This copy must be filed in the resident's case folder. A copy of the policies must also be given to the resident. If the resident is unable to read or understand the policies, a copy must be given to the person responsible for him. Note: If the AFC home provider moves in with the AFC member, the member must establish house rules and expectations, which must be communicated verbally and in writing with the AFC home provider;
- allow the resident to manage his finances or trust funds. The AFC home provider must assist the resident in managing his finances only if the resident requests assistance in writing. The resident may rescind this authorization at any time by doing so in writing;
- investigate all problems, deficiencies and noncompliance with policies, procedures and standards which are reported by the resident or MCO, or the MCO-contracted AFC provider agency staff within five workdays from receipt of the report. A copy of the documented complaint must be submitted to the member's MCO within 30 days of the receipt of the report. For the AFC option where AFC is provided in the AFC member's home, investigations of problems, deficiencies, and non-compliance with policies, procedures and standards which are reported by the AFC Member, the MCO, or the MCO-contracted AFC provider agency, must be investigated and resolved as necessary;
- provide each resident with a general orientation about his needs and the tasks to be provided before or at the time the service begins;
- not require a resident to perform services for the AFC home provider or other residents; and
- treat each resident with dignity and respect. The home provider must guarantee certain basic rights to each resident living in his home. Such rights include the right to privacy, humane care and environment, safety of personal possessions and funds, receipt of visitors, confidentiality of personal records, freedom of religion, freedom from physical or mental abuse, including corporal punishment or physical or chemical restraints that are administered for the purpose of discipline or convenience and not required to treat the resident’s medical symptoms, freedom from neglect and exploitation, freedom from financial exploitation, and the right to voice grievances without retribution or intimidation.
Note: A provider may use physical or chemical restraints only if the use is authorized in writing by a physician or if the use is necessary in an emergency to protect the resident or others from injury. A physician's written authorization for the use of restraints must specify the circumstances under which the restraints may be used and the duration for which the restrains may be used. Except in an emergency, restraints may only be administered by qualified medical personnel. The use of seclusion in any AFC home is prohibited.
The AFC home provider must provide or make arrangements to meet the transportation needs of a resident for medical appointments/care, shopping for personal needs, and church activities, as identified by the member's MCO. An escort must also be provided, if specified in the individual service plan for a resident.
- AFC Home Provider Rights
For licensed AFC homes, the AFC home provider must post a home providers' bill of rights in a prominent place in the foster home. For homes of three or less, the bill of rights must be provided to each resident, and be available to residents at any time. The bill of rights must state that the AFC home provider has the right to:
- be shown consideration and respect that recognizes the dignity and individuality of the AFC home provider;
- terminate the resident/AFC home provider agreement after a written 30-day notice;
- terminate the resident/AFC home provider agreement immediately, after notice to the MCO, if the AFC home provider finds that a resident creates a serious or immediate threat to the health, safety or welfare of the AFC home provider or the other residents of the foster home;
- refuse to perform services for the resident or the resident's family other than those specified in the resident/AFC home provider agreement;
- refuse to accept a person referred to the AFC home if the referral is inappropriate;
- refuse to allow the presence of illegal drugs and weapons in the home; and
- be made aware of a resident's problems, including aggressive or violent behavior, disease, alcoholism or drug abuse.
- Termination of Services
The AFC home provider cannot terminate services to a resident without the prior approval of the MCO, unless the resident creates a serious or immediate threat to the health, safety or welfare of the AFC home provider or the other residents of the foster home.
For AFC options where the AFC home provider moves into the home of the AFC member, the MCO may terminate AFC services if the AFC home provider creates a serious or immediate threat to the health, safety or welfare of the AFC member or other residents.
- STAR+PLUS Handbook
- STAR+PLUS Program Support Unit Operational Procedures Handbook