| (7) gifts purchased on behalf of a resident;
(8) flowers and plants;
(9) social events and entertainment offered outside
the scope of the activities program, provided under §19.702 of
this chapter;
(10) noncovered special care services, such as privately
hired nurses and aides;
(11) private room, except when therapeutically required,
such as isolation for infection control;
(12) specially-prepared or alternative food requested
instead of the food generally prepared by the facility, as required
in §19.1101 of this chapter; and
(13) incontinent briefs if the resident representative
submits a written request to the facility and the attending physician
and director of nurses (DON) determine and document in the clinical
record that there is no medical or psychosocial need for supplies.
(j) Request for items or services that may be charged
to a resident's personal funds.
(1) The facility can only charge a resident for an
item or service not included under §19.2601 of this chapter if
the resident or the resident representative specifically requests
the item or service.
(2) The facility must not require a resident or resident
representative to request any item or service as a condition of admission
or continued stay.
(3) The facility must inform, orally and in writing,
the resident or resident representative, when the resident or resident
representative requests an item or service for which a charge will
be made, that there will be a charge for the item or service and the
amount of the charge.
(k) Access to financial record. The individual financial
record must be available on request to the resident, resident representative,
and representative.
(l) Quarterly statement.
(1) The individual financial record must be available,
through quarterly statements and on request, to the resident, representative
payee, and resident representative.
(2) The statement must reflect any resident's funds
that the facility has deposited in an account as well as any resident's
funds held by the facility in a petty cash account.
(3) The statement must include at least the following:
(A) balance at the beginning of the statement period;
(B) total deposits and withdrawals;
(C) interest earned, if any;
(D) bank name and location of any account in which
the resident's personal funds have been deposited; and
(E) ending balance.
(m) Banking charges.
(1) Charges for checks, deposit slips, and services
for pooled checking accounts are the responsibility of the facility
and may not be charged to the resident or resident representative.
(2) Bank service charges and charges for checks and
deposit slips may be deducted from the individual checking accounts
if it is the resident's written, individual choice to have this type
of account.
(3) Bank fees on individual accounts established solely
for the convenience of the facility are the responsibility of the
facility and may not be charged to the resident or resident representative.
(4) The facility may not charge the resident or resident
for the administrative handling of either type of account.
(5) If the facility places any part of the resident's
funds in savings accounts, certificates of deposit, or any other plan
whereby interest or other benefits are accrued, the facility must
distribute the interest or benefit to participating residents on an
equitable basis. If pooled accounts are used, interest must be prorated
on the basis of actual earnings or end-of-quarter balances.
(n) Access to funds.
(1) Disbursements from the trust fund.
(A) A request for funds from the trust fund or trust
fund petty cash box may be made, either orally or in writing, by the
resident, or resident representative to cover a resident's expenses.
(B) The facility must respond to a request received
during normal business hours at the time of the request.
(C) The facility must respond to a request received
during hours other than normal business hours immediately at the beginning
of the next normal business hours.
(2) Discontinuing trust fund participation.
(A) If a resident or resident representative requests
that the facility discontinue managing the resident's personal funds
the facility must return to the resident or resident representative
all of the resident's personal funds held by the facility, including
any interest accrued.
(B) If the request is made during normal business hours,
the facility must immediately return the funds.
(C) If the request is made during hours other than
normal business hours, the facility must return the funds immediately
during the next normal business hours.
(3) Transfer or discharge. If a resident is transferred
or discharged from a facility, the facility must, within five working
days after the transfer or discharge, return to the resident or resident
representative all of the resident's personal funds held by the facility,
including any interest accrued.
(4) For purposes of this subsection, normal business
hours are 8:00 a.m. to 5:00 p.m., Monday through Friday, excluding
national holidays.
(o) Handling of monthly benefits. If the Social Security
Administration has determined that a Title II and Title XVI Supplemental
Security Income (SSI) benefit to which the resident is entitled should
be paid through a representative payee, the provisions in 20 CFR §§404.2001-
404.2065, for Old Age, Survivors, and Disability Insurance benefits
and 20 CFR §§416.601 - 416.665, for SSI benefits apply.
(p) Change of ownership. If the ownership of a facility
changes, the former owner must transfer the bank balances or trust
funds to the new owner with a list of the residents and their balances.
The former owner must get a receipt from the new owner for the transfer
of these funds. The former owner must keep this receipt for monitoring
or audit purposes.
(q) Alternate forms of documentation. Without HHSC's
prior written approval, a facility may not submit alternate forms
of documentation, including affidavits, to verify a resident's personal
fund expenditures or as proof of compliance with any requirements
specified in these requirements for the resident's personal funds.
(r) Limitation on certain charges. A nursing facility
may not impose charges for certain Medicaid-eligible individuals,
for nursing facility services that exceed the per diem amount established
by HHSC for such services. "Certain Medicaid-eligible individuals"
means an individual who is entitled to medical assistance for nursing
facility services, but for whom such benefits are not being paid because,
in determining the individual's income to be applied monthly to the
payment for the costs of nursing facility services, the amount of
such income exceeds the payment amounts established by HHSC.
(s) Trust fund monitoring and audits.
(1) HHSC may periodically monitor all trust fund accounts
to assure compliance with this section. HHSC notifies a facility of
monitoring plans and gives a report of the findings to the facility.
(2) HHSC may, as a result of monitoring, refer a facility
to the Office of Inspector General (OIG) for an audit.
(3) The facility must provide all records and other
documents required by subsection (d) of this section to HHSC upon
request.
(4) HHSC provides the facility with a report of the
findings, which may include corrective actions that the facility must
take and internal control recommendations that the facility may follow.
(5) The facility may request an informal review in
accordance with subsection (t) of this section or a formal hearing
in accordance with subsection (u) of this section to dispute the report
of findings.
(6) If the facility does not request an informal review
or a formal hearing and the report of findings requires corrective
actions, the facility must complete corrective actions within 60 days
after receiving the report of findings.
(7) If the facility does not complete corrective actions
required by HHSC within 60 days after receiving the report of findings,
HHSC may impose a vendor hold on payments due to the facility under
the provider agreement until the facility completes corrective actions.
(8) If HHSC imposes a vendor hold in accordance with
paragraph (7) of this subsection, the facility may request a formal
hearing in accordance with subsection (u)(5) of this section. If the
failure to correct is upheld, HHSC continues the vendor hold until
the facility completes the corrective actions.
(t) Informal review.
(1) A facility that disputes the report of findings
described in subsection (s)(4) of this section may request an informal
review under this section. The purpose of an informal review is to
provide for the informal and efficient resolution of the matters in
dispute and is conducted according to the following procedures.
(A) HHSC must receive a written request for an informal
review by United States mail, hand delivery, special mail delivery,
or fax no later than 15 days after the date on the written notification
of the report of findings described in subsection (s)(4) of this section.
If the 15th day is a Saturday, Sunday, national holiday, or state
holiday, then the first day following the 15th day is the final day
the written request will be accepted. A request for an informal review
that is not received by the stated deadline is not granted.
(B) A facility must submit a written request for an
informal review to the HHSC Trust Fund Monitoring Unit.
(C) A facility must, with its request for an informal
review:
(i) submit a concise statement of the specific findings
it disputes;
(ii) specify the procedures or rules that were not
followed;
(iii) identify the affected cases;
(iv) describe the reason the findings are being disputed;
and
(v) include supporting information and documentation
that directly demonstrates that each disputed finding is not correct.
(D) HHSC does not grant a request for an informal review
that does not meet the requirements of this subsection.
(2) Informal review process. Upon receipt of a request
for an informal review, the Trust Fund Monitoring Unit Manager coordinates
the review of the information submitted.
(A) Additional information may be requested by HHSC,
and must be received in writing no later than 15 days after the date
the facility receives the written request for additional information.
If the 15th day is a Saturday, Sunday, national holiday, or state
holiday, then the first day following the 15th day is the final day
the additional information will be accepted.
(B) HHSC sends its written decision to the facility
by certified mail, return receipt requested.
(i) If the original findings are upheld, HHSC continues
the schedule of deficiencies and requirement for corrective action.
(ii) If the original findings are reversed, HHSC issues
a corrected schedule of deficiencies with the written decision.
(iii) If the original findings are revised, HHSC issues
a revised schedule of deficiencies including any revised corrective
action.
(iv) If the original findings are upheld or revised,
the facility may request a formal hearing in accordance with subsection
(u) of this section.
(v) If the original findings are upheld or revised
and the facility does not request a formal hearing, the facility has
60 days from the date of receipt of the written decision to complete
the corrective actions. If the facility does not complete the corrective
actions by that date, HHSC may impose a vendor hold. If HHSC imposes
a vendor hold, the facility may request a formal hearing in accordance
with subsection (u)(5) of this section. If the failure to correct
is upheld, HHSC continues the vendor hold until the facility completes
the corrective action.
(u) Formal hearing.
(1) The facility must submit a written request for
a formal hearing under this section to the HHSC Appeals Division.
(2) The written request for a formal hearing must
be received within 15 days after:
(A) the date on the written notification of the report
of findings described in subsection (s)(4) of this section; or
(B) the facility receives the written decision sent
as described in subsection (t)(2)(B) of this section.
(3) A formal hearing is conducted in accordance with
Texas Administrative Code, Title 1, Chapter 357, Subchapter I (relating
to Hearings Under the Administrative Procedure Act).
(4) No later than 60 days after a final determination
is issued as a result of a formal hearing requested by a facility
under subsection (s)(8) or (t)(2)(B)(iv) of this section, the facility
must complete any corrective action required by HHSC or be subject
to a vendor hold on payments due to the facility under the provider
agreement until the facility completes corrective action. If HHSC
imposes a vendor hold, the facility may request a formal hearing in
accordance with paragraph (5) of this subsection. If the failure to
correct is upheld, HHSC continues the vendor hold until the facility
completes the corrective action.
(5) If HHSC imposes a vendor hold under subsections
(s)(7), (t)(2)(B)(v), or (u)(4) of this section, the facility may
request a formal hearing within 15 days after receiving notice of
the correction failure and the vendor hold. The formal hearing is
limited to the issue of whether the facility completed the corrective
action.
|
| Source Note: The provisions of this §554.405 adopted to be effective May 1, 1995, 20 TexReg 2393; amended to be effective September 1, 2003, 28 TexReg 6941; amended to be effective August 31, 2004, 29 TexReg 8140; amended to be effective November 20, 2012, 37 TexReg 9112; amended to be effective March 24, 2020, 45 TexReg 2025; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871 |
