| (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;
(C) PDP; and
(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;
Cont'd... |
