| (a) A nursing facility employee, nursing facility contractor,
or nursing facility specialized services provider must report to the
LIDDA the identity of any designated resident who expresses an interest
in transitioning to the community.
(b) For a designated resident, a nursing facility must
designate staff and necessary contractors to be members of the resident's
SPT.
(c) A nursing facility must ensure its staff and contractors
who are members of a designated resident's SPT:
(1) attend and participate in the designated resident's
SPT meetings as scheduled and convened by the service coordinator;
(2) contribute to the development of the designated
resident's ISP; and
(3) assist the SPT by:
(A) monitoring all nursing facility specialized services,
LIDDA specialized services and LMHA specialized services, if applicable,
provided to the designated resident to ensure the designated resident's
needs are being met;
(B) making timely referrals, service changes, and amendments
to the ISP as needed;
(C) ensuring that the designated resident's ISP, including
nursing facility specialized services, nursing facility PASRR support
activities, and LIDDA specialized services, is coordinated with the
nursing facility's comprehensive care plan;
(D) if the designated resident has expressed interest
in community living:
(i) developing a transition plan for the designated
resident to live in the community; or
(ii) identifying the action the SPT will take to address
concerns and remove barriers to the designated resident living in
the community; and
(E) reviewing and discussing the information included
in the ISP and transition plan with key nursing facility staff who
work with the resident.
(d) A nursing facility must allow a service coordinator
access to:
(1) a designated resident on a monthly basis, or more
frequently if needed; and
(2) the designated resident's clinical facility records.
|
| Source Note: The provisions of this §554.2706 adopted to be effective July 7, 2015, 40 TexReg 4373; amended to be effective September 10, 2017, 42 TexReg 4468; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871 |
