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every six months.
(V) Reassessment. Reassessments shall be conducted
and the care plan shall be amended as needed based on changes in client
status and provider effectiveness and may be conducted by phone or
in person.
(VI) Client Case Records. A confidential client case
record shall be maintained on each client served and shall be protected
from damage, theft and unauthorized inspection and shall contain at
least:
(-a-) the client needs assessment, including initial
referral date and date of completion of assessment; re-assessment(s),
if applicable;
(-b-) the care plan including amount, frequency and
duration of each service to be provided;
(-c-) names of service providers and informal caregivers
who render services to the client;
(-d-) a notation explaining any lapse in service;
(-e-) notation of hospital admission and/or discharge,
with dates;
(-f-) date and signature for each notation;
(-g-) record of all care manager contacts and visits;
(-h-) record of any client complaints and action taken;
(-i-) record of termination or closure; and
(-j-) list of names and phone numbers for notification
in event of an emergency.
(VII) Care management may not be provided by any entity
with a vested interest in the delivery of services purchased by the
area agency on aging without an approved waiver from the Department.
(VIII) Professional Conduct. Care managers must adhere
to the pledge of ethics and the standards of practice for professional
geriatric care managers as set forth by the National Association of
Professional Geriatric Care Managers and adopted by reference.
(p) Other key components of the area agency on aging
system of access and assistance include Benefits Counseling and Ombudsman
Services. The requirements for the Ombudsman Program are identified
in §260.11 of this title (relating to Ombudsman Services).
(1) Benefits Counseling. Benefits counseling includes
both legal assistance and legal awareness services.
(A) Legal Assistance. Legal assistance includes the
provision of client-specific advice, counseling and representation
on matters involving insurance issues, public/private benefits, consumer
problems and other legal issues.
(B) Legal Awareness. Legal awareness includes general
education and outreach on matters involving insurance issues, public/private
benefits, consumer problems and other legal issues.
(2) Targeting.
(A) Benefits counseling services shall be provided
to persons age 60 years and older and/or their family members or other
caregivers.
(B) Benefits counseling services shall be provided
to Medicare beneficiaries of any age under the provisions of funds
received from the Centers for Medicare and Medicaid Services.
(3) The area agency on aging shall focus its benefits
counseling services on the following priority issue areas:
(A) Income Maintenance/Public Benefit. Food Stamps,
Social Security, Social Security Disability, Supplemental Security
Income, veterans benefits, pensions, railroad retirement, child support,
unemployment compensation, general assistance and other income benefits.
(B) Medical Entitlements. Medicare, Medicaid, QMB/SLMB,
Veterans Administration Medical, indigent health and other medical
entitlements.
(C) Insurance. Medicare Supplement, HMO, long-term
care policies, individual health policies, group health policies/COBRA
and non-health insurance.
(D) Surrogate Decision Making. Advanced directives,
durable/general powers of attorney, money management, guardianship,
custody and other probate matters.
(E) Individual Rights. Age discrimination, disability
discrimination, abuse, neglect, exploitation and dispute resolution.
(F) Housing. Landlord/tenant issues, repair/modification,
utilities, rent subsidy, alternative housing, home equity lending/reverse
mortgage, homestead tax credit, weatherization, property tax, housing
relocation and general property.
(G) Institutional Care. Acute care, nursing facility
care, assisted living facility care and mental health care.
(H) Consumer Issues. Bankruptcy, collections, financial
counseling, bill reductions, solicitation and unfair sales practices/fraud.
(4) Benefits counseling services shall be provided
according to the following:
(A) If a request for assistance involving any of the
priority issue areas identified in paragraph (3) of this subsection
requires intervention by an attorney or paralegal, the benefits counselor
shall refer the client shall be referred to an appropriate provider
in the area.
(B) For the purpose of handling requests or referrals
which originate from sources other than the area agency on aging,
the benefits counselor, in consultation with the local legal provider(s),
shall develop an appropriate and timely referral process.
(C) Regardless of the referral source, the benefits
counselor shall determine whether or not the client may be assisted
with other resources, such as the Legal Hotline for Older Texans,
pro-bono or reduced-fee providers or through services funded by the
Legal Services Corporation.
(5) Relationship with Providers. The area agency on
aging shall establish the following procedures when working with providers
of benefits counseling and related legal services:
(A) To accomplish paragraph (4), subparagraph (A) of
this subsection, the area agency on aging shall coordinate with the
Legal Hotline for Older Texans, Texas Young Lawyers Association,
the private bar and local legal programs (such as law clinics or student
law programs), Legal Services Corporation grantees, the Ombudsman
Program or other programs.
(B) The area agency on aging shall utilize the Legal
Hotline for Older Texans to provide legal consultation and back-up
to access and assistance staff, as needed.
(C) If consultation/back-up is needed for access and
assistance staff in addition to paragraph (5), subparagraph (B) of
this subsection, such assistance may be obtained through agreements
with programs such as pro-bono or reduced-fee attorneys, law school
students, local legal programs or Legal Services Corporation grantees.
(6) Education and Outreach.
(A) Education and outreach activities include the dissemination
of accurate, timely and relevant information regarding any issue identified
under the priority areas in paragraph (3) of this subsection to persons
identified under paragraph (2) of this subsection.
(B) Education and outreach may be provided to individuals
or through a group setting such as forums, workshops, seminars and
training sessions and other public venues, and shall be reported as
legal awareness.
(7) Classification of Activities.
(A) The provision of activities described in paragraph
(6) of this subsection to eligible persons in a one-on-one setting
or by telephone where detailed information is provided but no client
intake is necessary shall be reported as legal awareness.
(B) The provision of advice, counseling and/or representation
on matters involving insurance issues, public/private benefits, consumer
problems and other legal issues shall be reported as legal assistance
if a client intake is completed.
(C) If a client has a simple request for information
on any topic including those identified under paragraph (3) of this
subsection, it shall be reported as information, referral and assistance.
(D) While education and outreach initiatives that include
the dissemination of information through mass media may be budgeted
as associated costs under legal awareness, the activities may not
be reported as units of service.
(E) Presentations or other activities that describe
the services of the area agency on aging in general including the
benefits counseling program may not be reported as units of service.
(8) The area agency on aging shall collaborate with
local, state and federal entities to provide education and outreach.
Such entities may include but are not limited to the Texas Department
of Insurance, Texas Legal Services Center, Texas Medical Foundation,
the Centers for Medicare and Medicaid Services and the Social Security
Administration.
(9) Benefits counselors shall complete the training
and certification requirements as set forth in the benefits counseling
certification manual issued by the Department.
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