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TITLE 40SOCIAL SERVICES AND ASSISTANCE
PART 1DEPARTMENT OF AGING AND DISABILITY SERVICES
CHAPTER 42DEAF BLIND WITH MULTIPLE DISABILITIES (DBMD) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) SERVICES
SUBCHAPTER DADDITIONAL PROGRAM PROVIDER PROVISIONS
RULE §42.404Service Delivery

(a) A program provider must ensure that:

  (1) a full-time case manager is assigned to provide case management services to no more than 30 individuals or other persons receiving services through another Medicaid waiver at one time;

  (2) a part-time case manager is assigned to provide case management services to no more than 15 individuals or other persons receiving services through another Medicaid waiver at one time; and

  (3) for a month in which a case manager does not meet with an individual or LAR as required by §42.223(a) of this chapter (relating to Periodic Review and Update of IPC and IPP), the case manager has a face-to-face or telephone contact with the individual, LAR, primary caregiver, or actively involved family members and friends, to provide case management.

(b) In determining the number of individuals or other persons receiving services through another Medicaid waiver at one time to whom a case manager will be assigned, the program provider must take into consideration:

  (1) the intensity of needs of each individual or person;

  (2) the frequency and duration of contacts the case manager will need to make with the individual or person; and

  (3) the amount of travel time involved in making such contacts.

(c) A program provider must have:

  (1) a sufficient number of case managers available at all times to ensure the provision of case management services; and

  (2) a written process that ensures a case manager can readily become familiar with an individual to whom the case manager is not ordinarily assigned but to whom the case manager may be required to provide case management services.

(d) A program provider must have written policies and procedures that ensure backup service providers are or can readily become familiar with individuals to whom they are not ordinarily assigned but to whom they may be required to deliver services.

(e) A program provider must provide each DBMD Program service and CFC service authorized in an individual's IPC in accordance with:

  (1) the individual's current IPC;

  (2) the individual's current IPP; and

  (3) the requirements in this chapter.

(f) A program provider must:

  (1) provide or ensure the provision of each DBMD Program service listed in §42.104(d) of this chapter (relating to Description of Deaf Blind with Multiple Disabilities (DBMD) Waiver Program and CFC);

  (2) provide the assisted living service as either licensed assisted living or licensed home health assisted living in accordance with §42.630 of this chapter (relating to Residential Services);

  (3) provide or ensure the provision of each CFC service listed in §42.104(f)(1) - (3) of this chapter; and

  (4) ensure that CFC support management is provided to an individual or LAR as described in the DBMD Provider Manual if:

    (A) the individual is receiving CFC PAS/HAB; and

    (B) the individual or LAR requests to receive CFC support management.

(g) A program provider must offer an individual choices and opportunities for accessing and participating in community activities, including employment opportunities and experiences available to peers without disabilities, and provide supports necessary for the individual to participate in such activities consistent with an individual's or LAR's choice and the individual's IPC and IPP.

(h) A program provider may accept or decline the request of an individual or LAR for the provision of residential habilitation, nursing, out-of-home respite in a camp, case management, adaptive aids, intervener services, or CFC PAS/HAB to the individual while the individual is temporarily staying at a location outside the program provider's contracted service delivery area but within the state of Texas.

(i) If the program provider accepts the request of an individual or LAR, as described in subsection (h) of this section, the program provider:

  (1) may provide residential habilitation, nursing, out-of-home respite in a camp, adaptive aids, intervener services, CFC PAS/HAB, and case management services as described in §42.623(a)(2) - (4)(A), (B), and (D) of this chapter (relating to Case Management) as well as by telephone contact with the individual;

  (2) must document in the service delivery log:

    (A) that the individual is receiving services outside the program provider's contracted service delivery area;

    (B) the location where the individual is receiving the services;

    (C) the estimated length of time the individual is expected to be outside the program provider's contracted service delivery area; and

    (D) contact information for the individual or LAR;

  (3) must, if the individual receives services outside the program provider's contracted service delivery area for 30 consecutive days, inform the individual or LAR, on or before the 35th day, that:

    (A) to ensure the continued provision of the services, the individual must do one of the following before the 61st day:

      (i) transfer to a program provider that has a contracted service delivery area that includes the area in which the individual is receiving the services; or

      (ii) return to the program provider's contracted service delivery area; and

    (B) if the individual receives services outside the program provider's contracted service delivery area during a period of 60 consecutive days, the individual must return to the contracted service delivery area and receive services in that area before the program provider may accept another request from the individual or LAR for the provision of the services outside the program provider's contracted service delivery area; and

  (4) must, if the individual expresses a desire for the individual to transfer to a program provider that has a contracted service delivery area that includes the area in which the individual is receiving services:

    (A) give the individual and LAR the Documentation of Provider Choice form for the contracted service delivery area in which the individual is receiving the services;

    (B) have the individual or LAR select a program provider and designate that selection on the Documentation of Provider Choice form; and

    (C) coordinate the individual's transfer in accordance with §42.231 of this chapter (relating to Coordination of Transfers).

(j) If the program provider declines the request of an individual or LAR as described in subsection (h) of this section, the program provider must:

  (1) inform the individual or LAR orally or in writing:

    (A) of the reasons for declining the request; and

    (B) that the individual may request a service planning team meeting to discuss the reasons for declining the request; and

  (2) document the discussion and the final outcome if the service planning team meeting is held.

(k) If a program provider or case manager is unable to meet a timeframe specified in this chapter, it must be for a reason not directly caused by the program provider or case manager, or for a reason beyond the program provider's or case manager's control, such as a man-made or natural disaster. The program provider or case manager must document the program provider's or case manager's efforts to meet a timeframe and maintain the documentation in the individual's record. The documentation must include:

  (1) the reason the timeframe could not be met, which must be beyond the program provider's or case manager's control; and

  (2) a description of the program provider's or case manager's ongoing efforts to meet a timeframe.


Source Note: The provisions of this §42.404 adopted to be effective June 15, 2010, 35 TexReg 5042; amended to be effective October 1, 2013, 38 TexReg 6604; amended to be effective September 1, 2014, 39 TexReg 6609; amended to be effective March 20, 2016, 41 TexReg 1927

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