Texas Administrative Code › Title 26 - HEALTH AND HUMAN SERVICES › Part 1 - HEALTH AND HUMAN SERVICES COMMISSION › Chapter 565 - HOME AND COMMUNITY-BASED (HCS) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) CERTIFICATION STANDARDS › Subchapter E - CERTIFICATION STANDARDS: SERVICE DELIVERY › Section 565.11 - Service Delivery

Current through Reg. 49, No. 28; July 12, 2024
(a) The program
				  provider must:
(1) serve an eligible
				  applicant who has selected the program provider unless the program provider's
				  enrollment has reached its service capacity as identified in the Texas Health
				  and Human Services Commission (HHSC) data system;
(2) serve an eligible applicant without
				  regard to age, sex, race, or level of disability;
(3) provide or obtain as needed and without
				  delay all Home and Community-based Services Program (HCS) Program and Community
				  First Choice (CFC) services for an individual;
(4) maintain a system of delivering HCS
				  Program and CFC services that is continuously responsive to changes in the
				  individual's personal goals, condition, abilities, and needs as identified by
				  the service planning team;
(5)
				  ensure that each applicant or individual, or legally authorized representative
				  (LAR), chooses where the individual or applicant will reside from available
				  options consistent with the applicant's or individual's needs;
(6) ensure that an individual's rights as
				  identified in §
											565.5 of this chapter (relating to
				  Rights of Individuals) are not violated, unless contraindications are
				  documented with justification in a Behavior Support Plan;
(7) notify the service coordinator if a
				  change in an individual's condition necessitates a change in residential,
				  educational, or work settings;
(8)
				  inform appropriate staff members, service providers, and the service
				  coordinator when a circumstance or event occurs in an individual's life or a
				  change to an individual's condition affects the provision of services to the
				  individual;
(9) notify the service
				  coordinator if the program provider has reason to believe that an individual is
				  no longer eligible for HCS Program services or CFC services or an individual or
				  LAR has requested termination of all HCS Program services or all CFC
				  services;
(10) ensure that the
				  individual plan of care (IPC) for each individual:
(A) is renewed or revised in accordance with
				  §
												263.302 of this title (relating to
				  Renewal and Revision of an IPC); and
(B) is authorized by the Health and Human
				  Services Commission in accordance with §
												263.303 of this title (relating to
				  HHSC Review of an IPC);
(11) ensure that HCS Program and CFC services
				  identified in the individual's implementation plan and transportation plan are
				  provided in an individualized manner and are based on the results of
				  assessments of the individual's and the family's strengths, the individual's
				  personal goals, the family's goals for the individual, and the individual's
				  needs rather than which services are available;
(12) ensure that each individual's progress
				  or lack of progress toward desired outcomes is documented in observable,
				  measurable, or outcome-oriented terms;
(13) ensure that individuals who perform work
				  for the program provider are paid on the basis of their production or
				  performance and at a wage level commensurate with that paid to persons who are
				  without disabilities and who would otherwise perform that work, and that
				  compensation is based on local, state, and federal regulations, including
				  Department of Labor regulations, as applicable;
(14) ensure that individuals who produce
				  marketable goods and services in habilitation training programs are paid at a
				  wage level commensurate with that paid to persons who are without disabilities
				  and who would otherwise perform that work. Compensation is based on
				  requirements contained in the Fair Labor Standards Act, which include:
(A) accurate recordings of individual
				  production or performance;
(B)
				  valid and current time studies or monitoring as appropriate; and
(C) prevailing wage
				  rates;
(15) ensure that
				  individuals provide no training, supervision, or care to other individuals
				  unless they are qualified and compensated in accordance with local, state, and
				  federal regulations, including Department of Labor regulations;
(16) ensure that adaptive aids are provided
				  in accordance with the individual's person-directed plan (PDP), IPC,
				  implementation plan, and Appendix C of the HCS Program waiver application,
				  approved by the Centers for Medicare and Medicaid Services (CMS) and found on
				  the HHSC website, and include the full range of lifts, mobility aids, control
				  switches/pneumatic switches and devices, environmental control units, medically
				  necessary supplies, and communication aids and repair and maintenance of the
				  aids, as determined by the individual's needs;
(17) ensure the coordination and
				  compatibility of HCS Program and CFC services with non-HCS Program services and
				  non-CFC services together with an individual's service coordinator;
(18) ensure that an individual has a current
				  implementation plan;
(19) ensure
				  professional therapies:
(A) are provided in
				  accordance with the individual's PDP, IPC, implementation plan, and Appendix C
				  of the HCS Program waiver application approved by CMS and found on the HHSC
				  website:
(i) audiology services;
(ii) speech/language pathology
				  services;
(iii) occupational
				  therapy services;
(iv) physical
				  therapy services;
(v) dietary
				  services;
(vi) social work
				  services;
(vii) behavioral support;
				  and
(viii) cognitive rehabilitation
				  therapy; and
(B) if the
				  service planning team determines that an individual may need cognitive
				  rehabilitation therapy, the program provider:
(i) in coordination with the service
				  coordinator, assists the individual in obtaining, in accordance with the
				  Medicaid State Plan, a neurobehavioral or neuropsychological assessment and
				  plan of care from a qualified professional as a non-HCS Program service;
				  and
(ii) use a qualified
				  professional as described in §
													565.7 of this chapter (relating to
				  Staff Member and Service Provider Requirements) to provide and monitor the
				  provision of cognitive rehabilitation therapy to the individual in accordance
				  with the plan of care described in clause (i) of this subparagraph;
(20) ensure that
				  individualized skills and socialization is provided in accordance with the
				  individual's PDP, IPC, implementation plan, and Appendix C of the HCS Program
				  waiver application approved by CMS and found on the HHSC website;
(21) ensure that dental treatment is provided
				  in accordance with the individual's PDP, IPC, implementation plan, and Appendix
				  C of the HCS Program waiver application approved by CMS and found on the HHSC
				  website including:
(A) emergency dental
				  treatment;
(B) preventive dental
				  treatment;
(C) therapeutic dental
				  treatment; and
(D) orthodontic
				  dental treatment, excluding cosmetic orthodontia;
(22) ensure that minor home modifications are
				  provided in accordance with the individual's PDP, IPC, implementation plan, and
				  Appendix C of the HCS Program waiver application approved by CMS and found on
				  the HHSC website but are limited to the following categories:
(A) purchase and repair of wheelchair
				  ramps;
(B) modifications to
				  bathroom facilities;
(C)
				  modifications to kitchen facilities;
(D) specialized accessibility and safety
				  adaptations or additions; and
(E)
				  repair and maintenance of minor home modifications not covered by a
				  warranty;
(23) ensure
				  that supported home living:
(A) is available
				  only to an individual who is not receiving:
(i) host home/companion care;
(ii) supervised living; or
(ii) residential support;
				  and
(B) is available to
				  an individual who is receiving foster care services from
				  DFPS;
(24) ensure that
				  supported home living is provided in accordance with the individual's PDP, IPC,
				  implementation plan, transportation plan, and Appendix C of the HCS Program
				  waiver application approved by CMS and found on the HHSC website and includes
				  the following elements:
(A) direct personal
				  assistance with activities of daily living (grooming, eating, bathing,
				  dressing, and personal hygiene);
(B) assisting with meal planning and
				  preparation;
(C) providing
				  transportation;
(D) securing
				  transportation;
(E) assisting with
				  housekeeping;
(F) assisting with
				  ambulation and mobility;
(G)
				  reinforcing professional therapy activities;
(H) assisting with medications and the
				  performing tasks delegated by a registered nurse (RN);
(I) supervising of individuals' safety and
				  security;
(J) facilitating
				  inclusion in community activities, use of natural supports, social interaction,
				  participation in leisure activities, and development of socially valued
				  behaviors; and
(K) habilitation,
				  exclusive of individualized skills and socialization;
(25) ensure that HCS host home/companion care
				  is provided:
(A) by a host home/companion care
				  provider who lives in the residence in which no more than three individuals or
				  other persons receiving similar services are living at any one time;
				  and
(B) in a residence in which the
				  program provider does not hold a property interest;
(26) ensure that host home/companion care is
				  provided in accordance with the individual's PDP, IPC, implementation plan, and
				  Appendix C of the HCS Program waiver application approved by CMS and found on
				  the HHSC website and includes the following elements:
(A) direct personal assistance with
				  activities of daily living (grooming, eating, bathing, dressing, and personal
				  hygiene);
(B) assisting with meal
				  planning and preparation;
(C)
				  securing and providing transportation;
(D) assisting with housekeeping;
(E) assisting with ambulation and
				  mobility;
(F) reinforcing
				  professional therapy activities;
(G) assisting with medications and the
				  performance of tasks delegated by an RN;
(H) supervising of safety and
				  security;
(I) facilitating
				  inclusion in community activities, use of natural supports, social interaction,
				  participation in leisure activities, and development of socially valued
				  behaviors; and
(J) habilitation,
				  exclusive of individualized skills and socialization;
(27) ensure that supervised living is
				  provided:
(A) in a four-person residence that
				  is approved in accordance with §
												565.23(i) of this
				  chapter (relating to Residential Requirements) or a three-person
				  residence;
(B) by a service
				  provider who provides services and supports as needed by the individuals
				  residing in the residence and is present in the residence and able to respond
				  to the needs of the individuals during normal sleeping hours; and
(C) only with approval by the HHSC
				  commissioner or designee for the initial six months and one six-month extension
				  and only with approval by the HHSC Executive Commissioner after such 12-month
				  period, if provided to an individual under 22 years of age;
(28) ensure that supervised living
				  is provided in accordance with the individual's PDP, IPC, implementation plan,
				  and Appendix C of the HCS Program waiver application approved by CMS and found
				  on the HHSC website and includes the following elements:
(A) direct personal assistance with
				  activities of daily living (grooming, eating, bathing, dressing, and personal
				  hygiene);
(B) assisting with meal
				  planning and preparation;
(C)
				  securing and providing transportation;
(D) assisting with housekeeping;
(E) assisting with ambulation and
				  mobility;
(F) reinforcing
				  professional therapy activities;
(G) assisting with medications and the
				  performance of tasks delegated by an RN;
(H) supervising of individuals' safety and
				  security;
(I) facilitating
				  inclusion in community activities, use of natural supports, social interaction,
				  participation in leisure activities, and development of socially valued
				  behaviors; and
(J) habilitation,
				  exclusive of individualized skills and socialization;
(29) ensure that residential support is
				  provided:
(A) in a four-person residence that
				  is approved in accordance with §
												565.23(i) of this
				  chapter or in a three-person residence;
(B) by a service provider who is present in
				  the residence and awake whenever an individual is present in the
				  residence;
(C) by service providers
				  assigned on a daily shift schedule that includes at least one complete change
				  of service providers each day; and
(D) only with approval by the HHSC
				  commissioner or designee for the initial six months and one six-month extension
				  and only with approval by the HHSC Executive Commissioner after such 12-month
				  period, if provided to an individual under 22 years of age;
(30) ensure that residential support is
				  provided in accordance with the individual's PDP, IPC, implementation plan, and
				  Appendix C of the HCS Program waiver application approved by CMS and found on
				  the HHSC website, and includes the following elements:
(A) direct personal assistance with
				  activities of daily living (grooming, eating, bathing, dressing, and personal
				  hygiene);
(B) assisting with meal
				  planning and preparation;
(C)
				  securing and providing transportation;
(D) assisting with housekeeping;
(E) assisting with ambulation and
				  mobility;
(F) reinforcing
				  professional therapy activities;
(G) assisting with medications and the
				  performance of tasks delegated by an RN;
(H) supervising of individuals' safety and
				  security;
(I) facilitating
				  inclusion in community activities, use of natural supports, social interaction,
				  participation in leisure activities, and development of socially valued
				  behaviors; and
(J) habilitation,
				  exclusive of individualized skills and socialization;
(31) if making a recommendation to the
				  service planning team that the individual receive residential support, document
				  the reasons for the recommendation, which may include:
(A) the individual's medical
				  condition;
(B) a behavior displayed
				  by the individual that poses a danger to the individual or to others;
				  or
(C) the individual's need for
				  assistance with activities of daily living during normal sleeping
				  hours;
(32) ensure that
				  respite is available on a 24-hour increment or any part of that increment to
				  individuals living in their family homes;
(33) ensure that respite is provided in
				  accordance with the individual's PDP, IPC, implementation plan, and Appendix C
				  of the HCS Program waiver application approved by CMS and found on the HHSC
				  website; and:
(A) includes:
(i) training in self-help and independent
				  living skills;
(ii) providing room
				  and board when respite is provided in a setting other than the individual's
				  normal residence;
(iii) assisting
				  with:
(I) ongoing provision of needed waiver
				  services; and
(II) securing and
				  providing transportation; and
(B) is only provided:
(i) to individuals who are not receiving
				  residential support, supervised living, or host home/companion care;
				  and
(ii) when the unpaid caregiver
				  is temporarily unavailable to provide supports;
(34) provide respite in the residence of an
				  individual or in other locations, including residences in which host
				  home/companion care, supervised living, or residential support is provided or
				  in a respite facility or camp, that:
(A)
				  meets HCS Program requirements and is an environment that ensures the health
				  and safety of the individual; and
(B) if respite is provided:
(i) in the residence of another individual,
				  the program provider must obtain permission from that individual or LAR and
				  ensure that the respite visit will cause no threat to the health, safety, or
				  welfare of either individual;
(ii)
				  in a respite facility, the program provider must obtain written approval from
				  the local fire authority having jurisdiction stating that the facility and its
				  operation meet the local fire ordinances before initiating services in the
				  facility if more than three individuals receive services in the facility at any
				  one time; or
(iii) in a camp
				  setting, the program provider must ensure the camp is accredited by the
				  American Camp Association;
(iv) in
				  a home and community-based setting, the setting must comply with §
													263.501(b) of
				  this title (relating to Requirements for Home and Community-Based
				  Settings);
(35)
				  ensure that employment assistance:
(A) is
				  provided to an individual to help the individual locate competitive employment
				  in the community;
(B) consists of a
				  service provider:
(i) identifying an
				  individual's employment preferences, job skills, and requirements for a work
				  setting and work conditions;
(ii)
				  locating prospective employers offering employment compatible with an
				  individual's identified preferences, skills, and requirements;
(iii) contacting a prospective employer on
				  behalf of an individual and negotiating the individual's employment;
(iv) transporting an individual to help the
				  individual locate competitive employment in the community; and
(v) participating in service planning team
				  meetings;
(C) is provided
				  in accordance with an individual's PDP, IPC, implementation plan, and with
				  Appendix C of the HCS Program waiver application approved by CMS and found on
				  the HHSC website;
(D) is not
				  provided to an individual with the individual present at the same time that
				  respite, supported home living, individualized skills and socialization,
				  supported employment, or CFC personal assistance services/habilitation (CFC
				  PAS/HAB) is provided; and
(E) does
				  not include using Medicaid funds paid by HHSC to the program provider for
				  incentive payments, subsidies, or unrelated vocational training expenses, such
				  as:
(i) paying an employer:
(I) to encourage the employer to hire an
				  individual; or
(II) for
				  supervision, training, support, or adaptations for an individual that the
				  employer typically makes available to other workers without disabilities
				  filling similar positions in the business; or
(ii) paying an individual:
(I) as an incentive to participate in
				  employment assistance activities; or
(II) for expenses associated with the
				  start-up costs or operating expenses of the individual's
				  business;
(36) ensure that supported employment:
(A) is assistance provided to an individual:
(i) who, because of a disability, requires
				  intensive, ongoing support to be self-employed, work from home, or perform in a
				  work setting at which persons without disabilities are employed;
(ii) in order for the individual to sustain
				  competitive employment; and
(iii)
				  in accordance with the individual's PDP, IPC, implementation plan, and Appendix
				  C of the HCS Program waiver application approved by CMS and found on the HHSC
				  website;
(B) consists of
				  a service provider:
(i) making employment
				  adaptations, supervising, and providing training related to an individual's
				  assessed needs;
(ii) transporting
				  an individual to support the individual to be self-employed, work from home, or
				  perform in a work setting; and
(iii) participating in service planning team
				  meetings;
(C) is not
				  provided to an individual with the individual present at the same time that
				  respite, supported home living, individualized skills and socialization,
				  employment assistance, or CFC PAS/HAB is provided; and
(D) does not include:
(i) sheltered work or other similar types of
				  vocational services furnished in specialized facilities; or
(ii) using Medicaid funds paid by HHSC to the
				  program provider for incentive payments, subsidies, or unrelated vocational
				  training expenses such as:
(I) paying an
				  employer:
(-a-) to encourage the employer to
				  hire an individual; or
(-b-) to
				  supervise, train, support, or make adaptations for an individual that the
				  employer typically makes available to other workers without disabilities
				  filling similar positions in the business; or
(II) paying an individual:
(-a-) as an incentive to participate in
				  supported employment activities; or
(-b-) for expenses associated with the
				  start-up costs or operating expenses of the individual's
				  business;
(37) ensure that CFC PAS/HAB is provided in
				  accordance with the individual's PDP, IPC, and implementation plan;
(38) ensure that CFC support management is
				  provided to an individual or LAR if:
(A) the
				  individual is receiving CFC PAS/HAB; and
(B) the individual or LAR requests to receive
				  CFC support management;
(39) inform the service coordinator of
				  changes related to an individual's residential setting that do not require a
				  change to the individual's IPC;
(40) maintain current information in the HHSC
				  data system about the individual and the individual's LAR, including:
(A) the individual's full name, address,
				  location code, and phone number; and
(B) the LAR's full name, address, and phone
				  number;
(41) maintain a
				  single record related to HCS Program and CFC services provided to an individual
				  for an IPC year that includes:
(A) the
				  IPC;
(B) the PDP and, if CFC
				  PAS/HAB is included on the PDP, the completed HHSC HCS/TxHmL CFC PAS/HAB
				  Assessment form;
(C) the
				  implementation plan;
(D) a behavior
				  support plan, if one has been developed;
(E) a transportation plan, if one is
				  required;
(F) documentation that
				  describes the individual's progress or lack of progress on the implementation
				  plan;
(G) documentation that
				  describes any changes to an individual's personal goals, condition, abilities,
				  or needs;
(H) the Intellectual
				  Disability/Related Conditions Assessment (ID/RC Assessment);
(I) documentation supporting the recommended
				  level of need, including the Inventory for Client and Agency Planning booklet,
				  assessments and interventions by qualified professionals, and time sheets of
				  service providers;
(J) results and
				  recommendations from individualized assessments that support the individual's
				  current need for each service included in the IPC;
(K) documentation concerning any use of
				  restraint as described in §
												565.33(a)(2) and
				  (3) of this chapter (relating to
				  Restraints);
(L) documentation
				  related to the suspension of an individual's HCS Program services or CFC
				  services;
(M) for an individual
				  under 22 years of age, a copy of the permanency plan; and
(N) documentation required by subsection
				  §
												565.17(a)(2) of
				  this subchapter (relating to Pre-enrollment Minor Home Modification) and
				  subsection §
												565.21(a)(2) of
				  this subchapter (relating to Transitional Assistance Service
				  (TAS));
(42) upon request
				  by the service coordinator:
(A) permit the
				  service coordinator access to the record that is required by paragraph (41) of
				  this subsection; and
(B) provide
				  the service coordinator a legible copy, including an electronic copy, of a
				  document in the record at no charge to the service
				  coordinator;
(43) provide
				  a copy of the following documents to the service coordinator:
(A) an individual's IPC; and
(B) an individual's ID/RC
				  Assessment;
(44) if a
				  physician delegates a medical act to an unlicensed service provider in
				  accordance with Texas Occupations Code Chapter 157, and the program provider
				  has concerns about the health or safety of the individual in performance of the
				  medical act, communicate the concern to the delegating physician and take
				  additional steps as necessary to ensure the health and safety of the
				  individual;
(45) for an individual
				  receiving host home/companion care, residential support, or supervised living,
				  ensure that the individual or LAR is involved in planning the individual's
				  residential relocation, except in the case of an emergency;
(46) for an HCS Program or CFC service
				  identified on the PDP as critical to meeting the individual's health and
				  safety:
(A) develop a service backup plan
				  that:
(i) contains the name of the critical
				  service;
(ii) specifies the time
				  period in which an interruption to the critical service would result in an
				  adverse effect to the individual's health or safety; and
(iii) in the event of a service interruption
				  resulting in an adverse effect, as described in clause (ii) of this
				  subparagraph, describe the actions the program provider will take to ensure the
				  individual's health and safety;
(B) ensure that:
(i) if the action in the service backup plan
				  required by subparagraph (A) of this paragraph identifies a natural support,
				  that the natural support receives pertinent information about the individual's
				  needs and can protect the individual's health and safety; and
(ii) a person identified in the service
				  backup plan, if paid to provide the service, meets the qualifications described
				  in this subchapter; and
(C) if the service backup plan required by
				  subparagraph (A) of this paragraph is implemented:
(i) discuss the implementation of the service
				  backup plan with the individual and the service providers or natural supports
				  identified in the service backup plan to determine whether the plan was
				  effective;
(ii) document whether
				  the plan was effective; and
(iii)
				  revise the plan if the program provider determines the plan was
				  ineffective;
(47) for an applicant 21 years of age or
				  older who is residing in a nursing facility and enrolling in the HCS Program:
(A) participate as a member of the service
				  planning team, which includes attending service planning team meetings
				  scheduled by the service coordinator;
(B) assist in the implementation of the
				  applicant's transition plan as described in the plan; and
(C) be physically present for the pre-move
				  site review and assist the service coordinator during the review as requested;
				  and
(48) for 365 calendar
				  days after an individual 21 years of age or older has enrolled in the HCS
				  Program from a nursing facility or has enrolled in the HCS Program as a
				  diversion from admission to a nursing facility:
(A) be physically present for each post-move
				  monitoring visit and assist the service coordinator during the visit as
				  requested;
(B) assist in the
				  implementation of the individual's transition plan as described in the
				  plan;
(C) participate as a member
				  of the service planning team, which includes attending service planning team
				  meetings scheduled by the service coordinator; and
(D) within one calendar day after becoming
				  aware of an event or condition that may put the individual at risk of admission
				  or readmission to a nursing facility, notify the service planning team of the
				  event or condition.