DRAFT PROPOSED RULES FOR CHAPTER 37: SUBCHAPTER B COMMUNITY ATTENDANT SERVICES

Transcription

1 Community Care for Aged and Disabled Chapter 37 DRAFT PROPOSED RULES FOR CHAPTER 37: COMMUNITY CARE FOR AGED AND DISABLED SERVICES SUBCHAPTER B COMMUNITY ATTENDANT SERVICES

2 SUBCHAPTER B COMMUNITY ATTENDANT SERVICES Purpose Definitions Services Provided Age Eligibility Criteria Financial Eligibility Criteria Functional Eligibility Criteria Unmet Need Criteria Additional Program Eligibility Criteria Request for Services Assessment Process Determining Status Service Plan Development Referrals Certification and Authorization Monitoring Changes Reassessment CDS Option Retroactive Payment

3 Required Service Suspensions Required Immediate Suspension and Crisis Intervention Optional Service Suspensions Interdisciplinary Team (IDT) Denial of the Request for Services Reduction in Service Terminations Reinstatement of Services After Termination for Non-Compliance or Threats to Health and Safety Notice of Adverse Action and Right to Appeal

4 CHAPTER 37 SUBCHAPTER B COMMUNITY ATTENDANT SERVICES Purpose (a) This chapter establishes the eligibility requirements and provides information for a person to receive Community Attendant Services through the DADS Primary Home Care (PHC) Program. (b) Community Attendant Services (CAS) is a service under the PHC Program providing in-home attendant services to an individual with an approved medical need for assistance with personal care tasks. CAS services are provided under 1929(b) (2) (B) of Title XIX of the federal Social Security Act (relating to Grants to States for Medical Assistance Programs) Definitions ADL Activities of daily living. An activity that is essential to daily self-care, including bathing, dressing, grooming, routine hair and skin care, meal preparation, feeding, exercising, toileting, transferring, and ambulation. An ADL does not include a service that must be provided or supervised by licensed personnel. Applicant - A person who is applying for DADS services. Business Days Any day except a Saturday, Sunday, or legal holiday listed in Texas Government Code, Caregiver A relative, guardian, representative payee, or person who has contact with the individual that is frequent enough or regularly scheduled enough that a personal relationship exists or the individual perceives that person as having a role in helping the individual to meet basic needs. Case manager -- A DADS employee who is responsible for case management activities. Activities include eligibility determination, individual registration, assessment and

5 reassessment of an individual's needs, service delivery plan development, and intercession on the individual's behalf. CFR Code of Federal Regulations Community Attendant Services Provider - A licensed home and community support services agency that has a contract to provide services under the Primary Home Care program. Contract--The formal, written agreement between DADS and a provider to provide program services to an individual eligible under this chapter in exchange for reimbursement. Contract manager--a DADS employee who is responsible for the overall management of the contract with the provider. DADS Department of Aging and Disability Services Days Calendar days unless otherwise specified. Denial An action taken by DADS that does not approve: (a) an applicant's request for services; or (b) a request for an increase of a service above the amount that is currently authorized. Emancipated Minor -- A person under 18 who has the power and capacity of an adult. This includes a minor who has had the disabilities of minority removed by a court of law or a minor who, with or without parental consent, has been married. Marriage includes common-law marriage.

6 Functional Limitation An individual's degree of difficulty in performing one or more ADLs due to a physical limitation or disability. Functional Need- The tasks and services identified by the individual that requires assistance. HHSC- Health and Human Services Commission. Incarcerated To be confined to a jail or prison. Individual Except as otherwise provided in these rules, a person who is receiving DADS services. Interdisciplinary Team (IDT) A designated group including representatives from DADS, service providers and the individual or his representative who convene to discuss service delivery issues. Involuntary Protective Services Placement by a representative of the Texas Department of Family and Protective Services (TDFPS) Adult Protective Services (APS) into a structured service or program for the safety of an individual and including ongoing supervision by APS. Medicaid - A program funded jointly by the states and the federal government that provides medical benefits to groups of low-income people, some who may have no medical insurance or inadequate medical insurance. Medicaid Eligible An individual eligible for federal assistance through Supplemental Security Income (SSI) or Temporary Assistance for Needy Families (TANF) or otherwise determined eligible by the Health and Human Services Commission for full Medicaid benefits. Person - An individual that has not applied for and is not receiving DADS services.

7 Personal Representative- An individual's spouse, other responsible party, designated representative, or legally authorized representative. Referral- A written request from the case manager to a provider to evaluate an individual for service delivery when the case manager determines that the individual's is potentially eligible for services. Regional Provider Rotation Log A log kept by the regional staff listing all the providers contracted to provide a specific service in the contracted service delivery area. If an applicant/individual does not select a provider of services, a provider is assigned for the individual on a rotation basis among all the contracted providers. Service Plan The tasks and services authorized by the DADS case manager and agreed upon by the individual receiving services to be delivered by the contracted provider. U. S. C. United States Code Utilization Review - A planned, systematic review of service utilization to evaluate efficiency, quality, and appropriateness of services and service delivery plans. Utilization review may include routinely scheduled review of services or providers, or may be focused on an identified issue Service Array Community Attendant Services are limited to the following tasks: (a) personal care tasks related to the care of the individual's physical well-being are: (1) bathing, which is: (A) drawing water in sink, basin, or tub; (B) hauling or heating water; (C) laying out supplies; (D) assisting in or out of tub or shower; (E) sponge bathing and drying;

8 (F) bed bathing and drying; (G) tub bathing and drying; and (H) providing standby assistance for safety; (2) dressing, which is: (A) dressing the individual; (B) undressing the individual; and (C) laying out clothes; (3) meal preparation, which is: (A) cooking a full meal; (B) warming up prepared food; (C) planning meals; (D) helping prepare meals; and (E) cutting client's food for eating; (4) feeding/eating, which is: (A) spoon-feeding; (B) bottle-feeding; (C) assisting with using eating and drinking utensils and adaptive devices, not including tube feeding; and (D) providing standby assistance or encouragement; (5) exercise, which is walking with the individual; (6) grooming, shaving, or oral care, which is: (A) shaving; (B) brushing teeth; (C) shaving underarms and legs, when requested; (D) caring for nails; and (E) laying out supplies; (7) routine hair or skin care, which is: (A) washing hair; (B) drying hair; (C) assisting with setting, rolling, or braiding hair, not including styling, cutting, or chemical processing of hair; (D) combing or brushing hair; (E) applying nonprescription lotion to skin; (F) washing hands and face; (G) applying makeup; and (H) laying out supplies; (8) assistance with self-administered medications, which is assistance with medication as defined in 97.2(11) of this title (relating to Definitions); (9) toileting, which is: (A) changing diapers; (B) changing colostomy bag or emptying catheter bag; (C) assisting on or off bedpan; (D) assisting with the use of a urinal; (E) assisting with feminine hygiene needs; (F) assisting with clothing during toileting;

9 (G) assisting with toilet hygiene, including the use of toilet paper and washing hands; (H) changing external catheter; (I) preparing toileting supplies and equipment, not including preparing catheter equipment; and (J) providing standby assistance; (10) transfer, which is: (A) non-ambulatory movement from one stationary position to another, not including carrying; (B) adjusting or changing the individual's position in a bed or chair (positioning); and (C) assisting in rising from a sitting to a standing position; (11) ambulation, which is: (A) assisting in positioning for use of a walking apparatus; (B) assisting with putting on and removing leg braces and prostheses for ambulation; (C) assisting with ambulation or using steps; (D) assisting with wheelchair ambulation; and (E) providing standby assistance. (b) home management tasks that support the individual's health and safety, which are: (1) cleaning, which is: (A) cleaning up after the individual's personal care tasks; (B) emptying and cleaning the individual's bedside commode; (C) cleaning the individual's bathroom; (D) changing the individual's bed linens and making the individual's bed; (E) cleaning floor of living areas used by the individual; (F) dusting areas used by the individual; (G) carrying out the trash and setting out garbage for pick up; (H) cleaning stovetop and counters; (I) washing the individual's dishes; and (J) cleaning refrigerator and stove; (2) laundry, which is: (A) doing hand wash; (B) gathering and sorting; (C) loading and unloading machines in residence; (D) using laundromat machines; (E) hanging clothes to dry; (F) folding and putting away clothes; and (3) shopping, which is: (A) preparing a shopping list; (B) going to the store and purchasing or picking up items; (C) picking up medication; and (D) storing the individual's purchased items. (c) escorting, which is:

10 (1) accompanying the individual outside the home to support the individual in living in the community; (2) arranging for transportation, not including direct individual transportation; (3) accompanying the individual to a clinic, doctor's office, or location for medical diagnosis or treatment; and (4) waiting in the doctor's office or clinic with an individual if necessary due to individual s condition or distance from home Age Eligibility Criteria There is no age limit for Community Attendant Services Financial Eligibility Criteria To be eligible for Community Attendant Services, a person must: (1) not be eligible for SSI or SSI-related Medicaid or other mandatory Medicaid coverage as described in , Title 1, Part 15 of the Texas Administrative Code (TAC) (relating to Covered Groups) or Medicaid through Texas Health Steps. (2) be determined income eligible by the Health and Human Services Commission in accordance with (d) (1), Title 1, Part 15, TAC Functional Eligibility Criteria To be eligible for Community Attendant Services, a person must meet the minimum functional need criteria as set by DADS. DADS uses a standardized assessment instrument to measure the person s ability to perform activities of daily living. This yields a score, which is a measure of the person s level of functional need. DADS sets the minimum required score for a person to be eligible, which DADS may periodically adjust commensurate with available funding. DADS will seek stakeholder input before making any change in the minimum required score for functional eligibility Unmet Need Eligibility Criteria To be eligible for Community Attendant Services, a person must have an unmet need based on the standardized assessment instrument Additional Program Eligibility Criteria

11 In addition to meeting the age, financial, functional and unmet need criteria, to be eligible for Community Attendant Services, a person must meet the following criteria: (a) a person must: (1) have a medical need that causes the person s functional limitation in performing at least one personal care task as defined in (a) (1) of this chapter (relating to Service Array). Persons diagnosed with mental illness, intellectual disability (ID) or intellectual and developmental disability (IDD) do not meet medical need based solely on such diagnosis. These diagnoses do not disqualify a person for eligibility as long as the person s functional limitation is related to a coexisting medical need; (2) require at least six hours of service per week. A person requiring fewer than six hours of service per week may be eligible if the person: (A) requires Community Attendant Services to provide relief to the caregiver; (B) lives in the same household as another individual receiving DADS personal assistance services through Primary Home Care, Community Attendant Services, Family Care, Community Based Alternatives or managed care personal assistance services; (C) receives one or more of the following services (through DADS or other resources): (i) congregate or home-delivered meals; (ii) assistance with activities of daily living from a home health aide; (iii) day activity and health services; or (iv) special services to persons with disabilities in adult day care; (D) receives aid-and-attendance or housebound benefits from the Veterans Administration; (E) receives services through DADS In-Home and Family Support Program; or (F) is, based upon the functional standardized assessment instrument, to be at high risk of institutionalization without Community Attendant Services. DADS will set the required score to determine if a person is at risk of institutionalization. (b) The medical need must be established by a signed and dated practitioner's statement as obtained by the provider in accordance with of this title (relating to Medical

12 Need Determination) that includes a statement that the person has a current medical need resulting in a functional limitation. The practitioner s statement is required only at the initial eligibility determination. (c) To receive services, the person must reside in a place other than: (1) a hospital; (2) a nursing facility; (3) an intermediate care facility for persons with intellectual disabilities; (4) an assisted living facility; (5) a foster care setting; (6) a jail or prison; (7) a state supported living center; (8) a state hospital; or (9) any other setting where CAS tasks are provided as defined in of this chapter (relating to Service Array) Request for Services (a) A request for CAS may begin with: (1) a telephone, written, or walk-in request for services from a person or the person s relative, friend, or other interested party; or (2) a telephone or written request for services from another agency, organization, or DADS division. (b) All information collected about a person to determine eligibility for services is confidential and may be released only in accordance with federal and state laws and regulations. (c) Applicants or their representatives applying for CAS services must sign an application for assistance form. The date of application is the date the department receives the signed application Assessment Process (a) DADS conducts an initial face-to-face interview to begin determination of eligibility for Community Attendant Services. (i) DADS schedules an initial interview by telephone or in writing to take place in the person s home, if possible,

13 (ii) If the initial interview and assessment must be done in a location other than the person's home and services are subsequently initiated, DADS conducts a home visit within 30 days after service initiation to assess the home environment. (b) DADS takes no further action on the request for services, if the person withdraws the request before DADS begins the initial interview. (c) During the face-to-face interview, the applicant must provide information on his medical conditions, functional limitations, household composition, home environment, and resources available to meet his needs so that the DADS case manager can complete the standardized assessment instrument and the assessment process. (d) If the case manager is unable to contact the applicant after repeated attempts or the applicant refuses to cooperate with scheduling the visit or providing required information, within 30 days of the intake date, the DADS case manager closes the request for services and sends a denial notice to the applicant Determining Status (a) The DADS case manager determines an individual has priority status based on the standardized assessment instrument, if: (1) The individual is completely unable to perform one or more of the following activities without hands-on assistance from another person: (A) transferring himself into or out of bed or a chair or on or off a toilet; (B) feeding himself; (C) getting to or using the toilet; (D) preparing a meal; or (E) taking self-administered prescribed medications. (2) During a normally scheduled service shift, no one is readily available who is capable and who is willing to provide the needed assistance other than the attendant. (3) The DADS case manager determines that there is a high likelihood the individual's health, safety, or well-being would be jeopardized if services were not provided on a single given shift.

14 (b) All other individuals do not have priority status. (c) An individual with priority status may receive no more than 42 hours of service per week. An individual without priority status may receive no more than 50 hours of service per week Service Plan Development (a) The DADS case manager and the individual (to the extent of his ability), or the individual s designated personal representative, develop a service plan, based on the individual s needs, priority level and available resources. (b) The DADS case manager considers the use of other resources available through DADS, other agencies, community resources, and available caregivers in developing the service plan to meet the individual s needs. Services are only authorized if the individual s needs cannot be met through other resources. (c) The service plan determines the tasks to be purchased and the total hours per week of CAS the DADS case manager authorizes on the DADS' authorization for community care services form. (d) The individual must select a provider contracted to provide CAS services in his service area. The individual has freedom of choice among the contracted providers. If the individual does not select a provider within 14 calendar days after the face-to-face interview, the DADS case manager will assign a provider from the regional provider rotation log Referrals (a) After the DADS case manager has determined the applicant meets the initial eligibility criteria in , , , and , except for the Practitioner s Statement, and has developed the service plan, the DADS case manager sends a referral to the selected CAS provider to begin pre-initiation activities in accordance with of this title (relating to Pre-initiation Activities).

15 (b) The provider completes the pre-initiation activities and sends the Practitioner s Statement to the DADS regional nurse Certification and Authorization (a) After receiving the practitioner s statement from the provider, the DADS regional nurse makes the final eligibility determination. (1) If the applicant is determined eligible, the DADS regional nurse sends the final authorization for CAS to the provider and the case manager on the DADS authorization for community care services form. (2) If determined ineligible, the DADS regional nurse notifies the case manager. (b) The DADS case manager sends the applicant written notification of eligibility or ineligibility for CAS Monitoring (a) DADS conducts a face-to-face monitoring contact at least every 90 days for individuals receiving CAS. (b) The DADS case manager monitors the individual s status, satisfaction with services received, and adequacy of the service plan to meet the individual s needs. (c) If the individual is dissatisfied with services or requests changes in services, the DADS case manager takes the appropriate action to resolve the issue or authorize the change in service Changes (a) Eligibility. The individual must promptly report to the DADS case manager any changes that may affect eligibility as defined in , , , or of this chapter. The individual is subject to fraud prosecution if he willfully fails to report changes and continues to receive services for which he is not eligible.

16 (b) Service Plan Changes. The individual or the individual s designated personal representative may request changes in the tasks or hours authorized based on changes in the individual s medical condition, functional needs, or available resources. (c) The CAS provider must notify the DADS case manager of changes in accordance with of this title (regarding Service Delivery Plan Change) (d) The DADS case manager takes appropriate action on the request for a change. If approved, the DADS case manager: (1) develops the service plan in accordance with of this chapter (relating to Service Plan Development); (2) sends the DADS authorization for community care services form to the provider making the change, and (3) sends written notification to the individual advising of the change in the service plan. (4) If the change request is not approved, the DADS case manager sends a written notice in accordance with of this chapter (relating to Notice of Adverse Action and Right to Appeal) Reassessment (a) Annually, the DADS case manager re-determines the individual s eligibility for services and reassesses the individual s functional eligibility and needs. The individual must be available for the home visit. (b) To continue receiving services, the individual must meet eligibility requirements in accordance with , , , and (except b) of this chapter at the time of re-determination of eligibility.

17 (c) Annually, the Health and Human Services Commission reassesses the individual for financial eligibility. (d) If eligible, the DADS case manager sends the authorization for community care services form to the provider and the provider must request annual reauthorization from the DADS regional nurse for CAS in accordance with of this title (relating to Annual Reauthorization for Community Attendant Services (CAS). (e) The DADS regional nurse reauthorizes CAS services and sends the provider and the case manager a copy of the DADS authorization for community care services form. The DADS case manager sends written notification to the individual of any changes to the service plan. (f) If the individual does not meet all eligibility requirements, then he is no longer eligible and services are terminated. The DADS case manager sends a written notification in accordance with of this chapter (relating to Notice of Adverse Action and Right to Appeal) CDS Option (a) Consumer Directed Services is available to all CAS applicants and CAS certified individuals. DADS gives the individual a choice of receiving services through the agency option or through consumer directed services in accordance with Chapter (relating to Service Delivery Options) and Chapter 41 of this title (relating to Consumer Directed Services Option) Retroactive Services (a) Non-Medicaid applicants or their representatives applying for Medicaid-covered attendant services may be reimbursed for services provided up to three months prior to the month of receipt of a completed, signed, and dated application. An individual may be able to receive CAS before the date the case manager determines the individual s eligibility for the services, if all the following conditions are met:

18 (1) The individual appears to be CAS eligible in accordance with of this chapter (relating to Financial Eligibility Criteria); (2) The individual requires at least one personal care task in accordance with of this chapter (relating to Service Array); (3) the individual is not already receiving services under the Community Attendant Services Program from another provider agency; and (4) The provider agency must complete all requirements for retroactive payment in accordance with of this chapter (relating to Retroactive Payments). (b) If the applicant meets all eligibility criteria, DADS reimburses the provider for services allowed under CAS if delivered in accordance with of this title (relating to Retroactive Payment Procedures). (c) The DADS case manager notifies the applicant of eligibility or ineligibility for retroactive and ongoing services. (d) The provider agency may charge an individual for services delivered pending the eligibility determination. The provider must reimburse the entire amount of all payments if DADS determines the individual is eligible for CAS Required Service Suspensions (a) An individual s Community Attendant Services are suspended if (1) the individual permanently leaves the contracted service delivery area; (2) the individual moves to a location where services cannot be provided under the CAS Program; (3) the individual dies; (4) the individual is admitted to an institution, as defined in 47.71(a) of this title (relating to Suspensions). (5) the individual requests that services end; or (6) the Health and Human Services Commission denies the individual's financial eligibility for CAS.

19 (b) After receiving notice of suspension from the provider, the DADS case manager must verify if the individual is no longer available to receive services as listed in (a) (1)-(6). If verified, the DADS case manager terminates services in accordance with of this chapter (relating to Terminations) Required Immediate Suspension and Crisis Intervention (a) To receive services, the individual must maintain an environment that ensures the health and safety of the DADS program staff and service providers delivering services. If a situation exists as described in (a)(1) or (a)(2) that could result in imminent danger to the health and safety of DADS staff or services providers, DADS or the provider must immediately suspend services to the individual. (1) The individual or someone in the individual's home exhibits reckless behavior that could result in imminent danger to the health and safety of the individual, DADS staff, provider staff or other persons. Examples include; (A) exhibiting weapons; (B) making direct spoken threats of physical harm, force or death by the individual or someone in the individual s home; (C) physically attacking a person with or without a weapon; (D) evidence of using, manufacturing or selling illegal drugs; or (2) The individual s home environment or circumstances present hazardous conditions that could result in imminent danger to the health and safety of DADS staff or the service provider. Examples include: (A) an animal that could be hazardous and is not restrained; (B) an outbreak of pests that is not controlled; (C) an unsafe home structure or environment; or (D) an active tuberculosis diagnosis. (b) Upon suspension of services, the DADS case manager or the provider must make an immediate referral for appropriate crisis intervention services to:

20 (1) the Texas Department of Family and Protective Services (DFPS) Adult Protective Services (APS) or other appropriate agencies; or (2) local law enforcement, if appropriate. (c) The DADS case manager must follow up with the individual or his personal representatives and convene an interdisciplinary team meeting to discuss resolution on the issues, in accordance with of this chapter (relating to Interdisciplinary Team). Services do not continue during the suspension. (d) If the issue cannot be resolved, the DADS case manager must notify the individual of the termination of services and the right to appeal the decision in accordance with of this chapter (relating to Terminations) and in accordance with of this chapter (relating to Notice of Adverse Action and Right to Appeal). Services do not continue during the appeal process Optional Service Suspensions (a) To receive CAS services, an individual must comply with CAS program requirements and allow the determination of eligibility, the delivery of services according to the service plan and the monitoring of services. The DADS case manager or the provider may suspend CAS services for refusal to comply with the CAS program requirements. The provider suspends services if: (1) the individual or someone in the individual's home has a substantial and documented pattern of verbal abuse, harassment or sexual harassment of service providers, not related to the individual s disability, which results in an inability to provide service(s) to the individual; or (2) The individual or someone in the individual s home has a substantial and documented pattern of discrimination against the service providers or DADS staff on the basis of race, color, national origin, age, sex, or disability in violation of

21 applicable law, that has not improved with appropriate intervention and which results in an inability to provide service(s) to the individual; or (3) the individual refuses to allow services to be delivered according to the service delivery provisions or be available for required home visits or monitoring contacts for more than 30 consecutive days. (b ) The DADS case manager contacts the individual or his personal representatives and convenes an interdisciplinary team meeting to discuss resolution on the issues, in accordance with of this chapter (relating to Interdisciplinary Team). (c) After the interdisciplinary team (IDT) meeting, the DADS case manager sends a written notification to the individual detailing the results of the IDT meeting and advising that his services will be terminated if he does not comply with the CAS program requirements or if he continues to allow someone's behavior that results in noncompliance with CAS program requirements. (d) If there is a second occurrence, the DADS case manager convenes a second IDT meeting. If the issue is resolved during the IDT meeting, the DADS case manager sends the individual a second written notification in accordance with subsection (c) of this section (relating to Optional Service Suspensions). (e) If there is a third occurrence, the DADS case manager convenes a third IDT meeting and if the issue is resolved, sends the individual a third written notification in accordance with subsection (c) of this section (relating to Optional Service Suspensions)..(f) If there is a fourth occurrence of the individual repeatedly refusing to cooperate with CAS program requirements, the DADS case manager proceeds with the termination of services in accordance with of this chapter, (relating to Terminations), and provides notification of termination of services and offers the right to appeal Interdisciplinary Team (IDT)

22 (a) The IDT is a designated group that includes the following people who meet when the case manager or provider identifies the need to discuss service delivery issues or barriers to service delivery: (1) the individual or the individual's representative, or both; (2) a provider representative; and (3) a DADS representative, who may be: (A) the case manager (or designee); (B) the case manager's supervisor (or designee); (C) the contract manager (or designee); or (D) the regional nurse (or designee). (b)the IDT meeting is conducted in accordance with Chapter of this title. The case manager or provider must convene an IDT meeting: (1) within three working days after the date the provider suspends services to an individual under of this chapter (relating to Required Immediate Suspension and Crisis Intervention); or of this chapter (relating to Optional Suspensions); or (2) within seven working days after the date the provider identifies an issue that prevents the provider from carrying out a requirement of the CAS Program. (c) Requirements of the IDT meeting. (1) The IDT meeting may be conducted by telephone or in person. (2) The IDT must: (A) evaluate the issue and discuss the CAS program requirements for continued services. The issue requiring the suspension must be discussed; (B) identify any solutions to resolve the issue, including the individual s understanding of the issue and what must be done to resolve the issue; (C) document the requirements for continued services. (d) In situations of threats to health and safety, the case manager and provider may agree that a physician s statement of evaluation in accordance with (relating to Reinstatement of Service after Termination for Non-Compliance or Threats of Health and Safety) is required prior to the resumption of services, confirming the individual is no

23 longer a threat to health and safety. In this situation, the case manager must send a notice of suspension to the individual. (e) The IDT must conclude with one of the following courses of action: (1) The individual agrees to cooperate with CAS program requirements and services are reinstated. The provider within two business days after the IDT meeting must: (A) implement the recommendations of the IDT; or (B) discharge the individual from the provider and refer the individual to the case manager for referral to another provider. (2) The individual does not agree to cooperate with the CAS program requirements and the case manager begins the termination process. (f) The case manager must document the IDT meeting and the conclusions in the individual's file, including the: (1) specific reasons for calling the IDT meeting; (2) participants in the IDT meeting; (3) recommendations of the IDT; and (4) actions as a result of the IDT recommendations Denial of the Request for Services (a) An individual applying for CAS services is not eligible if he does not meet the eligibility requirements in: (1) (relating to Age Eligibility Criteria); (Links to Rule) (2) (relating to Financial Eligibility Criteria); (3) (relating to Functional Eligibility Criteria); (4) (relating to Unmet Need Eligibility Criteria); or (5) (relating to Other Program Eligibility Criteria). (b) If an individual receiving services requests an increase in services and the request does not meet program requirements, the DADS case manager may deny the request. (c) The DADS case manager notifies the individual in writing of the ineligibility or denial of a service request and the right to appeal the decision in accordance with of this chapter (relating to Notice of Adverse Action and Right to Appeal).

24 Reduction in Service (a) DADS may reduce the services an individual is receiving based on a reassessment by the case manager on the standardized assessment instrument or a review by utilization review staff. (b) The case manager notifies the individual in writing of the reduction in services and the right to appeal the decision in accordance with of this chapter (relating to Notice of Adverse Action and Right to Appeal) Terminations (a) DADS terminates CAS services when an individual: (1) dies; (2) is admitted to a nursing facility, state school, state hospital, or intermediate care facility for individuals with an intellectual disability for longer than 60 days; (3) is admitted to a hospital and the hospital stay exceeds 90 days; (4) is incarcerated for longer than 60 days; (4) is denied financial eligibility by HHSC; (5) requests service termination; (6) has repeatedly refused to allow CAS services to be delivered according to CAS program requirements in accordance with of this chapter (relating to Optional Service Suspensions), except in an involuntary protective services case; (7) has refused to comply with the service delivery provisions and the issue cannot be resolved in accordance with of this chapter, (relating to Optional Service Suspensions); (8) has threatened the health and safety of others or failed to maintain an environment that ensures the health and safety of others and the issue cannot be resolved in accordance with of this chapter (relating to Required Immediate Suspension and Crisis Intervention); or (9) moves to a location where services cannot be provided under the CAS Program.

25 (b) The case manager notifies the individual in writing of the termination in services and the right to appeal the decision in accordance with of this chapter (relating to Notice of Adverse Action and Right to Appeal). (c) Services do not continue during the appeal process, if services were terminated in accordance with (a) (8) of this chapter (relating to Terminations) Reinstatement of Services after Termination for Non-Compliance or Threats to Health and Safety (a) If an individual is terminated due to failure to comply with CAS Program requirements in accordance with of this chapter (relating to Optional Service Suspensions) and reapplies for services, the applicant must agree to comply with the CAS program requirements and with DADS staff and CAS provider staff to facilitate service delivery, if determined eligible for services. (b) If an individual, whose services were terminated due to threats to health or safety in any DADS program, reapplies for services, the individual must provide proof the issue resulting in the previous denial of services has been resolved and there is no longer a threat to the health and safety of others. This documentation must be submitted prior to being assessed for program eligibility and within 30 calendar days of the request for documentation. DADS may require the following actions: (1) the individual must furnish a letter signed and dated by a licensed or certified physician, psychiatrist, or psychologist, stating: (A) he has been treated or is receiving treatment and is no longer a threat to himself or others; or (B) the person in the home who posed the threat has been treated or is receiving treatment and is no longer a threat to himself or others; or (2) the individual must sign a DADS form authorizing release of information, and allow a collateral contact with his licensed or certified physician, psychiatrist,

26 or psychologist. The contact must provide information that the applicant has been treated or is receiving treatment and the applicant is no longer a threat to himself or others; or (3) the individual must have the person who posed a threat in his home sign a DADS form authorizing release of information and allow a collateral contact with his licensed or certified physician, psychiatrist, or psychologist. The contact must provide information that the person in the home who posed the threat has been treated or is receiving treatment and is no longer a threat to himself or others. (c) If an individual, whose services were terminated in any DADS program due to hazardous conditions in his home environment, reapplies for services, the individual must provide documentation that the hazardous condition no longer exists prior to being assessed for program eligibility and within 30 calendar days after the request for documentation. (d) After receiving the required confirmation that the individual, the other person in the home, or the home environment is no longer a threat to the health and safety of himself or others, the DADS case manager may proceed with the application process and assessment for program eligibility. (e) If the individual does not provide the required confirmation within the required time frames, the DADS case manager denies the request for services Notice of Adverse Action and Right to Appeal (a) The DADS case manager notifies the individual in writing of any action that approves, denies, suspends, increases, reduces or terminates services. The case manager sends a notice of adverse action to the individual at least 12 calendar days before the effective date of the action, except in situations as described in , Required Immediate Suspension and Crisis Intervention.

27 (b) In situations as described in , Required Immediate Suspension and Crisis Intervention, in which services have been suspended, the DADS case manager sends the written notice of adverse action without advance notice within two business days of the decision, if the crisis cannot be resolved. (c) An individual has the right to appeal any decision that denies, reduces, suspends or terminates his services and request a fair hearing in accordance with Title I, Texas Administrative Code (TAC) 357.