Current through Reg. 50, No. 13; March 28, 2025
(a) A LIDDA must
request an LON for an applicant from HHSC at the time an applicant is enrolled
into the HCS Program. The LON is requested by entering the information from a
completed ID/RC Assessment, that includes the recommended LON and is signed and
dated by the service coordinator, in the HHSC data system and electronically
submitting the information to HHSC. The electronically submitted ID/RC
Assessment must contain information identical to the information on the signed
and dated ID/RC Assessment.
(b) A
program provider must request an LON for an individual from HHSC in accordance
with this subsection.
(1) Before the
expiration of an ID/RC Assessment, the program provider must enter the
information from the completed ID/RC Assessment in the HHSC data system and
electronically submit the information to HHSC that includes the recommended LON
and is signed and dated by the program provider.
(2) The program provider must ensure the
information from the completed ID/RC Assessment entered in the HHSC data system
and electronically submitted contains information that is identical to the
information on the signed and dated ID/RC Assessment.
(3) The program provider must, within three
calendar days after submission, provide the service coordinator with a copy of
the signed and dated ID/RC Assessment.
(4) If applicable, the program provider must
submit supporting documentation to HHSC as required by §
263.107(c) of
this chapter (relating to HHSC Review of LON).
(c) For an LON requested in accordance with
subsection (b) of this section, within seven calendar days after the program
provider enters the information from the completed ID/RC Assessment in the HHSC
data system and electronically submits the information:
(1) the service coordinator or a LIDDA
representative other than the service coordinator must review the ID/RC
Assessment in HHSC data system and enter in the HHSC data system:
(A) the service coordinator's name and date;
and
(B) whether the service
coordinator agrees or disagrees with how the ID/RC Assessment was entered in
the HHSC data system; and
(2) if the service coordinator disagrees with
how the ID/RC Assessment was entered in the HHSC data system, the service
coordinator and program provider must resolve the
disagreement.
(d) If the
service coordinator disagrees with the ID/RC Assessment for a reason other than
how the ID/RC Assessment was entered in the HHSC data system, the service
coordinator must notify the individual, LAR, HHSC, and the program provider of
the service coordinator's disagreement in accordance with HHSC
instructions.
(e) The service
coordinator's agreement or disagreement is considered in HHSC review of an
ID/RC Assessment submitted in accordance with subsection (b) of this
section.
(f) The program provider
must maintain documentation supporting the recommended LON in the individual's
record.
(g) HHSC assigns an LON to
an individual based on the individual's ICAP service level score, information
reported on the individual's ID/RC Assessment, and required supporting
documentation. Documentation supporting a recommended LON must be submitted to
HHSC in accordance with HHSC guidelines.
(h) HHSC assigns one of five LONs as follows:
(1) an intermittent LON (LON 1) is assigned
if the individual's ICAP service level score equals 7, 8, or 9;
(2) a limited LON (LON 5) is assigned if the
individual's ICAP service level score equals 4, 5, or 6;
(3) an extensive LON (LON 8) is assigned if
the individual's ICAP service level score equals 2 or 3;
(4) a pervasive LON (LON 6) is assigned if
the individual's ICAP service level score equals 1; and
(5) regardless of an individual's ICAP
service level score, a pervasive plus LON (LON 9) is assigned if the individual
meets the criteria set forth in subsection (j) of this
section.
(i) An LON 1, 5,
or 8, determined in accordance with subsection (g) of this section, is
increased to the next LON by HHSC, due to an individual's dangerous behavior,
if supporting documentation submitted to HHSC proves that:
(1) the individual exhibits dangerous
behavior that could cause serious physical injury to the individual or
others;
(2) a written behavior
support plan has been implemented that meets HHSC guidelines and is based on
ongoing written data, targets the dangerous behavior with individualized
objectives, and specifies intervention procedures to be followed when the
behavior occurs;
(3) more service
providers are needed and available than would be needed if the individual did
not exhibit dangerous behavior;
(4)
service providers are constantly prepared to physically prevent the dangerous
behavior or intervene when the behavior occurs; and
(5) the individual's ID/RC Assessment is
correctly scored with a "1" in the "Behavior" section.
(j) HHSC assigns an LON 9 if supporting
documentation submitted to HHSC proves that:
(1) the individual exhibits extremely
dangerous behavior that could be life threatening to the individual or to
others;
(2) a written behavior
support plan has been implemented that meets HHSC guidelines and is based on
ongoing written data, targets the extremely dangerous behavior with
individualized objectives, and specifies intervention procedures to be followed
when the behavior occurs;
(3)
management of the individual's behavior requires a service provider to
exclusively and constantly supervise the individual during the individual's
waking hours, which must be at least 16 hours per day;
(4) the service provider assigned to
supervise the individual has no other duties during such assignment;
and
(5) the individual's ID/RC
Assessment is correctly scored with a "2" in the "Behavior" section.
(k) An LON 1, 5, or 8, determined
in accordance with subsection (g) of this section, is increased to the next LON
by HHSC, due to an individual's high medical needs, if:
(1) the individual has an ID/RC Assessment
reflecting a frequency code of "6" in the "Nursing" section;
(2) a completed HHSC Level of Need (LON)
Review/Increase Cover Sheet form is submitted to HHSC; and
(3) supporting documentation described in
subsection (l) of this section submitted to HHSC with the cover sheet form
proves that the individual requires 181 minutes or more per week of:
(A) a nursing service listed in §
263.5(a)(14) -
(17) of this chapter (relating to Description
of HCS Program Services) provided in person;
(B) in-person nursing services provided by
another source; or
(C) a
combination of the nursing services described in subparagraphs (A) and (B) of
this paragraph.
(l) The following supporting documentation
must be submitted to HHSC as described in subsection (k)(3) of this section:
(1) a completed HHSC Medical Increase
Worksheet - HCS Program Only form, identifying:
(A) a description of the ongoing medical
condition requiring the individual to receive 181 minutes or more of in-person
nursing services per week;
(B) a
description of the in-person treatments that need to be provided to the
individual and the in-person nursing tasks that need to be performed for the
individual;
(C) the frequency of a
nursing task that needs to be performed and the amount of time required to
complete the nursing task; and
(D)
if applicable, extenuating circumstances that may contribute to the
individual's need to receive 181 minutes or more of in-person nursing services
per week;
(2) the
individual's most current:
(A) implementation
plan for the nursing services listed in §
263.5(a)(14) -
(17) of this chapter that are provided in
person;
(B) ICAP assessment booklet
and computer scoring sheet;
(D) comprehensive nursing
assessment;
(3) nursing
notes of all in-person nursing services provided to the individual within the
immediate 30 days before the date the ID/RC Assessment is electronically
submitted to HHSC;
(4) service
planning notes relating to the individual's ongoing medical issues completed
within the immediate 365 days before the ID/RC Assessment is electronically
submitted to HHSC;
(5) any
professional assessments that discuss the changes in the individual's medical
condition or changes in needed medical interventions completed within the
immediate 365 days before the date the ID/RC Assessment is electronically
submitted; and
(6) other documents
evidencing that the individual requires 181 minutes or more of in-person
nursing services per week, such as:
(A)
focused or quarterly nursing assessments;
(C) medication administration records;
and
(D) treatment sheets, if
used.
(m) A
program provider must conduct an ICAP assessment in accordance with this
subsection.
(1) A program provider must
conduct an ICAP assessment of an individual:
(A) within three years after the individual's
enrollment and every third year thereafter;
(B) if changes in the individual's functional
skills or behavior occur that are not expected to be of short duration or
cyclical in nature; or
(C) if the
individual's skills and behavior are inconsistent with the individual's
assigned LON.
(2) If the
results of an ICAP assessment demonstrate that the individual's LON assignment
may not be accurate, the program provider must submit a completed ID/RC
Assessment to HHSC recommending a revision of the individual's LON
assignment.