Texas Administrative Code, Division 3, Section 260.77 - Renewal and Revision of an IPP and IPC | Texas Administrative Code

(a) Case manager's review.

(1) Beginning the effective date of an individual's IPC, as determined in accordance with § 260.69(j) of this subchapter (relating to HHSC's Review of Request for Enrollment), a case manager must, in accordance with the schedule in the Deaf Blind with Multiple Disabilities Program Manual, meet with the individual. and LAR in person at a time convenient to the individual and LAR in the individual's home, or if requested by the individual or LAR, in another location to:

(A) review whether the DBMD Program services and CFC services are being provided in accordance with the IPC and IPP;

(B) review the individual's progress toward achieving the goals and outcomes described in the IPP for each service listed on the individual's IPC;

(C) determine if the services are meeting the individual's needs;

(D) determine if the individual's needs have changed;

(E) review assessments, evaluations, and progress notes prepared by service providers since the previous review;

(F) if the individual's IPC includes nursing, intervener services, or CFC PAS/HAB, and none of these services are identified as critical to the individual's health and safety, discuss with the individual or LAR whether any of these services may now be critical to the individual's health and safety and needs a service backup plan; and

(G) if the individual has a service backup plan for nursing, intervener services, or CFC PAS/HAB, discuss with the individual or LAR:

(i) whether the service backup plan, if implemented, was effective;

(ii) whether the service backup plan needs to be revised; and

(iii) whether the service backup plan needs to be discontinued because the service is no longer critical to the individual's health and safety.

(2) A case manager must:

(A) document the results of a meeting described in paragraph (1) of this subsection in the individual's record using the HHSC IPP Service Review form or a form the program provider develops that includes the information on the HHSC form;

(B) document on the HHSC IPP Service Review form or a form the program provider developed:

(i) if nursing, intervener services, or CFC PAS/HAB has become critical to the individual's health and safety, and the individual does not have a service backup plan for the service, that the individual now needs a service backup plan for nursing, intervener services, or CFC PAS/HAB; and

(ii) if the individual has a service backup plan for nursing, intervener services, or CFC PAS/HAB, document on the IPP review form that:

(I) the service planning team did not revise the service backup plan because it was effective;

(II) the service planning team revised the service backup plan to address any problems or concerns regarding implementation of the service backup plan; or

(III) the service planning team discontinued the service backup plan because the service is no longer critical to the individual's health and safety;

(C) ensure the individual or LAR signs and dates the IPP review form; and

(D) provide a copy of the completed HHSC IPP Service Review form or a form the program provider developed to the individual or LAR within 10 business days after the date of the meeting described in paragraph (1) of this subsection.

(3) A case manager, no later than five business days after the date of a meeting described in paragraph (1) of this subsection, must convene a service planning team meeting:

(A) if the case manager:

(i) identifies needed changes in the individual's services; or

(ii) determines that nursing, intervener services, or CFC PAS/HAB services may now be critical to the individual's health and safety, as described in paragraph (1)(F) of this subsection, or that the service backup plan was ineffective, as described in paragraph (1)(G) of this subsection;

(B) if the individual or LAR requests a revision of the IPP or IPC; or

(C) if the service planning team determines that any of the requirements in §260.403(a)(1) - (6) of this chapter (relating to Requirements for Program Provider-Owned Residential Settings) must be modified.

(4) During a service planning team meeting described in paragraph (3) of this subsection, using the person-centered planning process, a case manager must:

(A) develop a revised IPP that meets the requirements described in § 260.65 of this subchapter (relating to Development of an Enrollment IPP);

(B) develop a proposed revised IPC that meets the requirements described in § 260.67(a)(1) and (b) of this subchapter (relating to Development of a Proposed Enrollment IPC); and

(C) if:

(i) the proposed revised IPC includes transportation provided as a residential habilitation activity or as an adaptive aid, develop an individual transportation plan; and

(ii) the proposed revised IPC includes nursing, intervener services, or CFC PAS/HAB services, ensure compliance with § 260.213 of this chapter (relating to Service Backup Plans).

(5) A case manager must:

(A) ensure the revised IPP and proposed revised IPC is signed and dated by each member of the service planning team; and

(B) no later than 10 business days after the date of the service planning team meeting, submit to HHSC:

(i) a copy of the signed and dated proposed revised IPC;

(ii) a copy of the signed and dated revision IPP;

(iii) an individual transportation plan, if required by paragraph (4)(C)(i) of this subsection;

(iv) an HHSC Rationale for Adaptive Aids, Medical Supplies, and Minor Home Modifications form, if required by § 260.303 of this chapter (relating to Requirements for Authorization to Purchase or Lease an Adaptive Aid), § 260.317 of this chapter (relating to Requesting Authorization to Purchase a Minor Home Modification that Costs Less than $1,000), or § 260.319 of this chapter (relating to Requesting Authorization to Purchase a Minor Home Modification that Costs $1,000 or More);

(v) an HHSC Specifications for Minor Home Modifications form, if required by § 260.321 of this chapter (relating to Specifications for a Minor Home Modification);

(vi) an HHSC Prior Authorization for Dental Services form, if required by § 260.339 of this chapter (relating to Dental Treatment); and

(vii) an HHSC Specialized Nursing Certification form, if required by § 260.347 of this chapter (relating to Nursing).

(b) Annual review by the service planning team.

(1) No more than 90 calendar days before the end of an individual's IPC period:

(A) the case manager must complete an ID/RC Assessment;

(B) an RN must complete an annual nursing assessment of the individual using the HHSC CLASS/DBMD Nursing Assessment form;

(C) an RN or the case manager must complete a Related Conditions Eligibility Screening Instrument;

(D) the case manager or an appropriate professional described in the assessment instructions must complete an adaptive behavior screening assessment:

(i) if at least five years have passed after the date of the most current assessment; or

(ii) if significant changes have occurred in the individual's functioning;

(E) the case manager must convene an in-person meeting of the service planning team to:

(i) review the HHSC CLASS/DBMD Nursing Assessment form completed by the RN;

(ii) address any information included in Addendum E of the HHSC CLASS/DBMD Nursing Assessment form, Recommendations/Coordination of Care, to ensure the individual's needs are met;

(iii) document on the HHSC CLASS/DBMD Coordination of Care form how the information in Addendum E of the HHSC CLASS/DBMD Nursing Assessment form was addressed;

(iv) develop a renewal IPP that meets the requirements in § 260.65 of this subchapter;

(v) develop a proposed renewal IPC that meets the requirements described in § 260.67(a)(1) and (b) of this subchapter;

(vi) develop the following if the proposed renewal IPC:

(I) includes transportation provided as a residential habilitation activity or as an adaptive aid, develop an individual transportation plan; or

(II) includes nursing, intervener services, or CFC PAS/HAB, develop a service backup plan or a service backup plan revision if required by § 260.213 of this chapter (relating to Service Backup Plans); and

(vii) ensure the renewal IPP and proposed renewal IPC is signed and dated by each member of the service planning team; and

(F) the case manager must:

(i) provide an oral and written explanation of the topics described in §260.61(c)(1) - (3) of this subchapter (relating to Process for Enrollment of an Individual) to the individual or LAR;

(ii) educate the individual and LAR about protecting the individual from abuse, neglect, and exploitation;

(iii) provide an oral explanation to the individual or LAR that the individual may transfer to a different program provider;

(iv) give the individual or LAR an HHSC Documentation of Provider Choice form and have the individual or LAR designate the selection of a DBMD program provider on the form;

(v) if the individual or LAR selects a different DBMD program provider on the HHSC Documentation of Provider Choice form, coordinate the individual's transfer in accordance with § 260.79 of this subchapter (relating to Coordination of Transfers);

(vi) orally explain that the individual or LAR may request the provision of transportation provided as a residential habilitation activity, case management, nursing, out-of-home respite in a camp, adaptive aids, intervener services, or CFC PAS/HAB while the individual is staying at a location outside the contracted service delivery area but within the state of Texas for a period of no more than 60 consecutive days; and

(vii) have documentation that the activities required under clauses (i) - (vi) of this subparagraph were performed.

(2) A case manager must, no later than 10 business days after the date of the service planning team meeting described in paragraph (1)(E) of this subsection, but at least 30 calendar days before the end of the current IPC period, submit to HHSC:

(A) the signed and dated proposed renewal IPC;

(B) the signed and dated renewal IPP;

(C) the PAS/HAB plan;

(D) the renewal ID/RC Assessment;

(E) the results of an adaptive behavior screening assessment, if completed as described in paragraph (1)(D) of this subsection;

(F) the HHSC Related Conditions Eligibility Screening Instrument form;

(G) the HHSC Non-Waiver Services form;

(H) the HHSC Documentation of Provider Choice form;

(I) the HHSC CLASS/DBMD Nursing Assessment form;

(J) an individual transportation plan, if required by subsection (a)(4)(C)(i) of this section; and

(K) the documentation described in subsection (a)(5)(B) of this section.

(c) Review and revision in an emergency. If a program provider delivers a DBMD Program service or CFC PAS/HAB to an individual in an emergency to ensure the individual's health and welfare and the service is not on the IPC and IPP or exceeds the amount on the IPP, a case manager must:

(1) as soon as possible, but no later than five business days after providing the service, convene a service planning team meeting at a time and location convenient to the individual or LAR to:

(A) develop a revised IPP that:

(i) meets the requirements described in § 260.65 of this subchapter; and

(ii) includes documentation of how the requested service addressed the emergency; and

(B) develop a proposed revised IPC that meets the requirements described in § 260.67(a)(1) and (b) of this chapter;

(2) if the revised IPP and proposed revised IPC includes nursing, intervener services, or CFC PAS/HAB, develop a service backup plan of service backup plan revision, if required by § 260.213 of this chapter;

(3) ensure the revised IPP and proposed revised IPC is signed and dated by each member of the service planning team; and

(4) no later than 10 business days after the service planning meeting described in paragraph (1) of this subsection, submit to HHSC:

(A) a copy of the signed and dated proposed revised IPC;

(B) a copy of the signed and dated revision IPP; and

(C) the documentation described in subsection (a)(5)(B) of this section.

(d) Review and revision other than the reviews described in subsections (a) - (c) of this section. If a program provider becomes aware at any time during an individual's IPC period that changes to the individual's services may be necessary, the case manager must:

(1) as soon as possible but no later than five business days after becoming aware that changes to the individual's services may be necessary, convene a service planning team meeting at a time and location convenient to the individual or LAR to review and, if determined necessary, develop:

(A) a revised IPP that meets the requirements described in § 260.65 of this chapter; and

(B) a proposed revised IPC that meets the requirements described in § 260.67(a)(1) and (b) of this subchapter;

(2) if the revised IPP and proposed revised IPC:

(A) include transportation provided as a residential habilitation activity or as an adaptive aid, develop an individual transportation plan; or

(B) include nursing, intervener services, or CFC PAS/HAB services, ensure compliance with § 260.213 of this chapter;

(3) ensure the revised IPP and proposed revised IPC are signed and dated by each member of the service planning team; and

(4) no later than 10 business days after the date of the service planning meeting described in paragraph (1) of this subsection, submit to HHSC:

(A) a copy of the signed and dated proposed revised IPC;

(B) a copy of the signed and dated revised IPP;

(C) an individual transportation plan, if required by paragraph (2)(A) of this subsection; and

(D) the documentation described in subsection (a)(5)(B) of this section.

(e) Determination by HHSC of whether an individual meets LOC VIII and additional criteria.

(1) HHSC reviews the documentation described in subsection (b)(1)(A) - (E) of this section to determine whether an individual meets the LOC VIII and additional criteria required by § 260.51(a)(2) and (3) of this subchapter (relating to Eligibility Criteria for DBMD Program Services and CFC Services).

(2) HHSC may request current data obtained from standardized evaluations and formal assessments related to an individual's LOC VIII. If HHSC makes such a request, the case manager must submit the information to HHSC no later than 10 calendar days after the date of the request.

(3) HHSC notifies a program provider, in writing, of whether or not an individual meets the LOC VIII. If HHSC determines that an individual meets the LOC VIII, the LOC VIII is effective:

(A) on a date determined by HHSC; and

(B) through the last calendar day of the IPC period.

(4) If an individual's LOC VIII expires before HHSC determines whether the individual meets the LOC VIII, as described in paragraphs (1) - (3) of this subsection:

(A) a program provider must continue to provide services to the individual until HHSC approves a proposed renewal IPC to ensure continuity of care and prevent the individual's health and welfare from being jeopardized; and

(B) if HHSC determines that an individual meets the LOC VIII, and the individual is otherwise eligible for the DBMD Program, HHSC will reimburse the program provider for services provided, as required by subparagraph (A) of this paragraph, for a period of not more than 180 calendar days before the date HHSC receives the documentation described in subsection (b)(2)(E) - (G) of this section.

(f) HHSC's review of a proposed revised IPC or a proposed renewal IPC.

(1) HHSC reviews a proposed revised IPC or a proposed renewal IPC to determine if the proposed IPC meets:

(A) the requirement described in § 260.51(a)(4) of this subchapter; and

(B) the requirements described in § 260.67(a)(1) and (b) of this subchapter.

(2) At HHSC's request, a case manager must submit additional documentation supporting a revised IPC or a proposed renewal IPC no later than 10 calendar days after the date of the request.

(3) If HHSC determines that a proposed revised IPC or a proposed renewal IPC meets the requirements:

(A) HHSC notifies the program provider, in writing, of its determination; and

(B) no later than 10 business days after receiving the written notice, the case manager must:

(i) provide to the individual or LAR a copy of the renewal IPC and renewal IPP, and if required by § 260.213 of this chapter, any new or revised service backup plan; and

(ii) if the individual will receive a service through the CDS option, send the FMSA a copy of the renewal IPC, the renewal IPP, and if required by this section, the individual transportation plan.

(g) If an individual's IPC period expires before HHSC approves a renewal IPC:

(1) a program provider must continue to provide services to the individual until HHSC approves the renewal IPC to ensure continuity of care and prevent the individual's health and welfare from being jeopardized; and

(2) if HHSC approves the renewal IPC as described in subsection (f) of this section, HHSC will reimburse the program provider for services provided, as required by paragraph (1) of this subsection, for a period of not more than 180 calendar days before the date HHSC receives the documentation described in subsection (b)(2) of this section.

(h) Verifying the IPC and MESAV are consistent. A program provider must:

(1) electronically access MESAV to determine if the information on a revised IPC or a renewal IPC is consistent with the information in MESAV; and

(2) if the information on the revised IPC or renewal IPC is inconsistent with the information in MESAV, notify HHSC of the inconsistency.

(i) Process to terminate, deny, or reduce program services. The process by which an individual's DBMD program services or CFC services are terminated, denied, or reduced based on HHSC's review of a revised IPC or a renewal IPC is described in §260.75(c) - (e) of this division (relating to Utilization Review of an IPC by HHSC).