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Health and Human Services Commission/Texas Department of Aging and Disability Services Community Living Assistance and Support Services Provider ManualRevision: 16-1Effective: January 28, 2016Section 3000

Direct Services Agency (DSA)

3100 DSA Responsibilities

Revision 15-2; Effective November 20, 2015

All individuals who receive Community Living Assistance and Support Services (CLASS) program services and Community First Choice (CFC) Personal Assistance Services/Habilitation (PAS/HAB) must choose a Direct ServiceDirect Services Agency (DSA) with a valid provider agreement that operates in the catchment area in which the individual lives. Individuals who receive services in through the CLASS program may request to transfer to another DSA at any time.

A DSA provides CLASS program services, Community First Choice (CFC) Personal Assistance Services/ Habilitation (PAS/HAB) services, and CFC Emergency Response Services (ERS) to the individual as outlined in their Individual Plan of Care (IPC) and Individual Program Plan Addendum. An individual may elect to have some or all of their CLASS program and CFC services delivered by the DSA. Select services may be chosen for self-direction by the individual or legally authorized representative (LAR) using the Consumer Directed Services (CDS) option. For a complete list of CLASS and CFC services available using the CDS option, refer to Section 4000, Consumer Directed Services (CDS).

As outlined in this section, the individual's selected DSA is required to perform the following tasks on behalf of an individual in CLASS on an ongoing basis:

provide required documentation to DADSHHSC/DADS as is necessary to assess and renew the level of care for the individual;

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participate in developing a PAS/Habilitation Plan - CLASS/DBMD/CFC habilitation plan to outline the individual's habilitation CFC PAS/HAB needs and complete documentation of that plan;

participate in developing an IPC that addresses all of the individual's needs that will be met through the provision of CLASS or CFC services;

participate in developing the Individual Program Plan Addendum using person-centered planning processes for each individual;

provide all CLASS and CFC provider-managed services according to the Individual Program Plan Addendum and the Individual Program Plan (IPP);

Monitor monitor the DSA's service provision processes to ensure all services are delivered by qualified service providers in accordance with the Individual Program Plan Addendum and IPP; and

Coordinate with the Case Management Agency (CMA) and other service providers as necessary to ensure Individual Program Plan Addendum and IPC revisions are initiated as necessary in response to changes in the individual's needs.

CLASS program and CFC services, as a whole, enhance an individual's integration in the community and prevent admission to an institution while maintaining and improving independent functioning.

3110 Base of Operation


CLASS program and CFC providers must have a base of operation that includes a physical location and normal operating hours in each geographic catchment area for which they have a contract to provide CLASS program and CFC services.

1. A base of operation is a place in which business, clerical or professional activities are conducted. Each base of operation must:

o maintain individual records for the CLASS program contract in the catchment area;

o maintain personnel records for personnel who provide CLASS program and CFC services to individuals served in the catchment area;

o be staffed by qualified employees who have completed CLASS program training and can readily become familiar with the individuals being served in the catchment area; and

o maintain adequate staff to provide services and to supervise the provision of services within the catchment area.

2. Providers must identify the base of operation's normal operating hours. If the base of operations is closed during its normal operating hours or between the hours of 8:00 a.m. and 5:00 p.m. Monday through Friday, the provider must:

o post a notice in a visible location outside the base of operations to provide information regarding how to contact the person in charge; and

o leave a message on an answering machine or similar electronic mechanism to provide information regarding how to contact the person in charge.

3120 Service Planning Team (SPT) Meetings


SPT activities may occur via conference call in lieu of a face-to-face meeting at the discretion of the team. Annual reassessments must take place in person. Some individuals and families may prefer to have everyone participate in person and when this is the case, SPT members are expected to be sensitive to this and to make every effort to accommodate such requests. Participation in an SPT via conference call is not reimbursable to the DSA using habilitation.

Reference: Information Letter 11-79, New Service Limits and Elimination of Requisition and Specification Fees in the CLASS Program, attachment: "Guide For Service Limit Implementation," Page 2; published Sept. 8, 2011.

An individual's service plan must be signed in person by the SPT group at enrollment and renewal meetings. However, revisions of the current service plan may be signed by facsimile.

31320 DSA Staff Training Requirement

Revision 12-1; Effective January 13, 2012

31321 Initial Training for Direct Care Contact Staff

Revision 13-2; Effective September 6, 2013

Direct contact for the purposes of this manual means face to face contact with a CLASS individual a minimum of one time per calendar year. Direct Service Agency (DSA)A DSA program director(s) and any DSA staff person who has direct contact with an individual receiving services through the Community Living Assistance and Support Services (CLASS) program must complete one of the following within 60 calendar days of the employee beginning to work with the CLASS program:

In-person CLASS Provider Training provided by DADSHHSC/DADS; or Training developed by the DSA that includes, at a minimum:

o CLASS program overview;o Person-centered planning;o Philosophy and values of community integration;o Overview of related conditions and CLASS program eligibility criteria;o Service Planning Team (SPT) process;o Utilization Review process;o Consumer Directed Services; ando Individuals' rights and responsibilities including:

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Fair Hearing process; DSA's complaints process; Mandatory participation requirements; and Abuse, neglect and exploitation characteristics and reporting information.

The DSA could choose to conduct training at its location to meet the above requirements within 60 days of hiring the service provider. DSA staff who develop the curriculum used for initial training must have attended and successfully completed the CLASS Provider Training. The DSA must have a record to verify that the trainer has attended the CLASS Provider Training. The DSA may choose to send new employees to CLASS Provider Training at the next opportunity offered by DADSHHSC/DADS to further reinforce training provided by the DSA.

Documentation of completion of required training must include, at a minimum:

CLASS Provider Training completion certificate with the name of the employee, signed by DADSHHSC/DADS; or

Written documentation of completion of the DSA's training that includes: o Training topics covered;o Method of training (i.e., reading, video, discussion, etc.);o Name(s) and qualifications of instructor(s);o Name of the trainee;o Date the training was completed;o Signature and date of the instructor(s); ando Signature and date of the trainee verifying completion.

If a DSA develops curriculum to meet CLASS training requirements, the curriculum and training materials used must be maintained by the DSA and available to DADSHHSC/DADS employees during a contract monitoring review. DSA staff whothat develop the curriculum used for initial training must have attended and successfully completed the CLASS Provider Training. Verification of the DSA training instructor's completion of CLASS Provider Training must be maintained and available to DADSHHSC/DADS employees during a contract monitoring review.

31321.1 Initial Training for CFC PAS/HAB or CLASS Habilitation and Respite Service Providers


The Direct Service Agency (DSA)DSA must ensure CFC PAS/HAB or CLASS habilitation (Service Codes 10, 10A and 10B) and respite (Service Codes 11 and 11A) service providers:

Receive in-person training in the habilitation activities necessary to meet the needs and characteristics of the individual to whom the service provider is assigned.

o Training must occur in the individual's home with full participation from the individual, if possible; and

o Form 3599 , Habilitation Service Provider Orientation/Supervisory Visits, is used to document this orientation as stated in the directions for the form.

Complete two hours of habilitation training, developed by the DSA, before providing services to an individual in the CLASS program that includes at a minimum:

o CLASS program overview;o Overview of related conditions to include:

the definition of a related condition; and examples of a related condition.

For assessments with effective dates prior to Oct. 1, 2015, the information specific to related conditions above is contained in the list of ICD-9 approved diagnostic codes for persons with related conditions located on the DADS website at: http://www.dads.state.tx.us/providers/guidelines/ICD-9-CM_Diagnostic_Codes.pdf.For assessments with effective dates on or after Oct. 1, 2015, the list of ICD-10 approved diagnostic codes for persons with related conditions is located on the DADS website at: http://www.dads.state.tx.us/providers/guidelines/icd10-codes.pdf.

Receive an explanation of commonly performed tasks regarding CFC PAS/HAB habilitation.

Understand an individual's rights and responsibilities including: o DSA's complaints process;o mandatory participation requirements; ando abuse, neglect and exploitation characteristics and reporting information.

P roviders of CLASS transportation-habilitation, prevocational, and respite services must Ssuccessfully complete hands-on training in cardiopulmonary resuscitation (CPR) and choking prevention before delivering services, and annually maintain training status as current thereafterwhile providing CLASS transportation-habilitation services. The training thatmust includes an in-person evaluation by a qualified instructor verifying the service provider's ability to perform these actions.

If requested by the individual or LAR, providers of CFC PAS/HAB must complete hands-on training in cardiopulmonary resuscitation (CPR) and choking prevention that includes an in-person evaluation by a qualified instructor verifying the service provider's ability to perform these actions. Maintaining training status of CPR training and choking prevention as current is determined by the individual or LAR.

The information specific to related conditions above is contained in the list of ICD-10 approved diagnostic codes for persons with related conditions is located on the HHSC/DADS website at: https://hhs.texas.gov /sites/hhs/files//documents/doing-business-with-hhs/providers/health/icd10- codes.pdf.

Annual evaluations by the supervisor that take place with the individual/LAR ensures that the needs of the individual are being met. Form 3599 is used to document this evaluation, as stated in the instructions for the form. Documentation of transportation-habilitation, prevocational, and respite service provider training outlined above or any training of CFC PAS/HAB provider requested by the individual or LAR must include a signed certificate of completion stating:

Training topics covered; Method of training (i.e., reading, video, discussion, etc.);

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http://www.dads.state.tx.us/providers/guidelines/icd10-codes.pdf

http://www.dads.state.tx.us/providers/guidelines/ICD-9-CM_Diagnostic_Codes.pdf

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Name(s) and qualifications of instructor(s); Name of the trainee; Date the training was completed; Signature and date of the instructor(s); and Signature and date of the trainee verifying completion.

31322 Initial and Annual Training for All DSA Staff


Within 60 calendar days of the employee beginning to work with the CLASS program and every 12 months, all direct service agency (DSA)DSA staff must receive training on:

Abuse, Neglect and Exploitation (ANE) Prohibited Against Individuals o review of the statute on abuse, neglect and exploitation at Human Resources

Code, Chapter 48, §48.002 (2, 3 and 4);o signs and symptoms of ANE;o reporting requirements of ANE; ando how to report abuse, neglect and exploitation to DFPS at

www.dfps.state.tx.us/Contact_Us/report_abuse.asp. Rights and Responsibilities of Individuals

o information about the rights of the individual who receives CLASS/CFC services as outlined in the DADS Consumer Rights and Services booklet; and

o review of CLASS/CFC rules in Chapter 45, Subchapter C, §45.301 and §45.302 concerning the Rights and Responsibilities of an Individual.

DSA staff who develop the curriculum used for initial and annual training must have attended and successfully completed the CLASS Provider Training. Verification of a DSA training instructor’s completion of CLASS Provider Training must be maintained and available to DADSHHSC/DADS employees during a contract monitoring review. If a DSA develops curriculum to meet CLASS training requirements, the curriculum and training materials used must be maintained by the DSA and available to DADSHHSC/DADS employees during a contract monitoring review.

Any DSA staff person who is responsible for developing the PAS/Habilitation Plan - CLASS/DBMD/CFC must complete person-centered service planning training approved by HHSC according to this schedule:

by June 1, 2017, if the staff person was hired on or before June 1, 2015; or within two years after the hire date, if the staff person was hired after June 1, 2015.

31323 Types of CFC PAS/HAB or CLASS Transportation-Habilitation Service Providers


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http://www.dads.state.tx.us/news_info/publications/brochures/DADS273YourRightsCommunity.pdf

http://www.dfps.state.tx.us/Contact_Us/report_abuse.asp

The two types of CFC PAS/HAB or CLASS transportation-habilitation service providers are:

Regular CFC PAS/HAB or CLASS transportation-habilitation service providers who perform all of the habilitationCFC PAS/HAB services available within their scope of competency; and

Special CFC PAS/HAB or CLASS transportation-habilitation services providers who may be used to initiate services or prevent a break in service.

31324 Qualifications of CFC PAS/HAB or CLASS Transportation-Habilitation Service Providers


CFC PAS/HAB or CLASS Htransportation-habilitation services are performed by habilitation service providers who:

are employed by the direct service agencyDSA; and are not spouses of individuals and, if the individual is under 18, are not the parent; have a current Texas driver's license; and maintain vehicle liability insurance in accordance with state law..

31325 Required Training for CFC PAS/HAB or CLASS Transportation-Habilitation Service Providers


Before or when services begin, the CFC PAS/HAB or CLASS transportation-habilitation service provider must meet the supervisor or other staff member qualified to train the habilitation service provider in the specific needs of the individual at the individual’s home. The CFC PAS/HAB or CLASS transportation-habilitation service provider receives a general orientation with the full participation of the individual, if possible, in the CFC PAS/HAB or CLASS transportation-habilitation activities necessary to meet the needs and characteristics of the individual to whom the service provider is assigned.

31325.1 Required Training for Certain Special CFC PAS/HAB or Special Transportation-Habilitation Service Providers


Special transportation-habilitation service providers or special CFC PAS/HAB providers who have six continuous months of experience in delivering CFC PAS/HAB or CLASS transportation-habilitation services in any Medicaid program or a program that primarily serves individuals with intellectual disabilities can receive the orientation from the supervisor or other appropriate DSA staff by phone rather than in person. Orientation of the service provider to the specific needs of the individual must be documented on Form 3599, Habilitation Service Provider Orientation/Supervisory Visits.


The individual receiving CFC PAS/HAB services should participate in providing special CFC PAS/HAB providers any training on the activities necessary to meet the needs and characteristics of the individual and the specific needs of the individual at the individual’s home. The training must be documented on Form 3599, Habilitation Service Provider Orientation/Supervisory Visits.

After the first orientation to the special CFC PAS/HAB or special CLASS transportation-habilitation activities necessary to meet the needs and characteristics of an individual, the special CFC PAS/HAB or special CLASS transportation-habilitation service provider does not need to be reoriented if the individual’s condition, tasks and hours remain unchanged. There are no limits on the length of time a special CFC PAS/HAB or special CLASS transportation-habilitation service provider may be used. The special CFC PAS/HAB or special CLASS transportation-habilitation service provider may serve the individual without retraining, as long as the individual’s condition, tasks and hours remain unchanged. In addition, there are no restrictions with respect to the amount of time between the habilitation service provider’s assignments.

31326 Documentation of Required Experience for Special Service Provider Exception


Records provided by the employee, or records provided by a former or current employer that document the time the employee delivered direct care services, may be used to establish that a special CFC/PAS/HAB or special habilitation service provider meets requirements.

3200 Eligibility


The DSA is responsible for verifying the individual's eligibility for the CLASS program by ensuring the following criteria are met:

the individual is determined by DADSHHSC/DADS to meet the diagnostic and functional eligibility criteria for the CLASS program;

the individual has been diagnosed with a related condition that manifested before the individual was age 22 as described in the Texas Approved Diagnostic Codes for Persons with Related Conditions;

t he individual has a qualifying adaptive behavior level of II, III, or IV (i.e., moderate to extreme deficits in adaptive behavior) obtained by administering a standardized assessment of adaptive behavior;

the individual demonstrates a need for at least for CFC PAS/HAB; or at least one monitoring visit by the individual requires at least one CLASS program

service per month (a billable case management contact meets this criteria); ; the individual has an Individual Plan of Care (IPC) cost for CLASS program services at

or below $114,736.07, for an individual who meets the diagnostic eligibility criteria; t he individual is not enrolled in another Medicaid waiver program; and



the individual resides in his own home or family home. Note: An individual is not considered to reside in his own home or family home if he is admitted to one of the facilities outlined in Section 2430, Suspension, and Section 3430, Suspension, for more than 180 consecutive calendar days.

Individuals who receive CLASS program and CFC services must maintain continuous eligibility as outlined above. The DSA must assess the individual at the time of enrollment, at least annually, and as necessary when an individual's situation changes that may result in the individual no longer meeting all CLASS eligibility criteria.

The DSA must verify Medicaid eligibility each month by monitoring the Medicaid Eligibility Service Authorization Verification (MESAV) system. The DSA must verify the individual is eligible in the month that is being checked. Documentation of this monthly verification of eligibility for Medicaid must be maintained by the DSA and available for review by HHSC/DADS staff. On a monthly basis, the DSA is responsible to verify the status of Medicaid eligibility for all individuals served by the DSA. If an individual is found to be ineligible for Medicaid, the DSA must notify the case manager no later than the next business day. The DSA must maintain verifiable evidence of having completed these monthly checks and notifying the case manager.

CLASS program and CFC services may be terminated if the individual does not meet all eligibility criteria as outlined in Title 40 of the Texas Administrative Code (TAC) §45.406. For more information regarding termination of services, see Section 3400, Denial, Reduction, Suspension and Termination.

See Appendix V, ID/RC Processing, for additional information and detailed instructions for DSAs.

3300 Service Planning


A Direct Service Agency (DSA)DSA must ensure a representative from its agency participates as a member of an individual's service planning team (SPT). A DSA representative must be a:

program director or meet program director qualifications; registered nurse (RN); or licensed vocational nurse (LVN).

Meetings of the SPT to develop the Individual Program Plan Addendum, enrollment IPC and the renewal IPC should be held in the individual’s own home or family home whenever possible. If it is not possible, the SPT must document why the meeting could not be held in the individual’s home and the meeting must be at a time and location that is mutually agreed upon by all mandatory members.

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The case manager must use Form 3629, Individual Program Plan Addendum to document use of person-centered planning processes.

The case manager, using the discovery process as the basis for collecting information, develops the person-centered plan with the individual, legally authorized representative (LAR), the CMA, DSA representative, and others, as requested by the individual or LAR.

Examples of the discovery process include, but are not limited to: conversations with the individual, LAR and those who know the individual best, such as

a provider staff, caregiver, family member and friend; a method called Planning Alternative Tomorrows with Hope (PATH); methods taught by The Learning Community for Person Centered Practices

(TLCPCP);occur with the support of a group of people chosen by the individual (and the legally authorized representative (LAR) on the individual's behalf); and

The person-centered planning process accommodates the individual's style of interaction, communication and preferences

regarding time and setting identify the individual’s strengths, preferences, support needs and desired outcomes; identify what is important to the individual; identify and document the individual’s current and preferred living arrangement; determine the Habilitation (HAB), Personal Assistance Services (PAS), Emergency

Response Services (ERS) and Support Management needs of an individual; assess the individual's needs, functional impairments, ability to perform activities of daily

living (ADLs), instrumental activities of daily living (IADLs) and health-related tasks; identify natural supports available to the individual and needed service system supports; document the individual’s preferences for when to receive CFC services; document the risks to the individual’s health and safety, as well as a plan to mitigate

those risks; identify any special needs, requests or considerations staff should know when supporting

this individual; and document the individual’s unmet needs.

Additional guidance and information about person-centered planning can be found at http://www.learningcommunity.us.

The SPT should include, at a minimum, the individual/applicant or /legally authorized representative (LAR), case manager and a DSA representative. The individual or LAR may request the SPT include professionals who are qualified by certification or licensure, or training and experience in the habilitation needs of people with related conditions, or directly involved in the delivery of services and supports to the individual. If licensed or certified professionals attend the SPT meeting, this may be billed as a professional service only when the individual has an identified need for the service, and for actual time spent in the capacity of the respective discipline. The SPT may include any other people requested by the individual /or LAR. The SPT will make every effort to accommodate these requests by the individual or /LAR.

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SPT activities to revise a current IPC may occur via conference call in lieu of a face-to-face meeting. If the individual/LAR requests an in person meeting, SPT members must make every effort to accommodate the request. Participation in an SPT via conference call is not reimbursable to the DSA using CFC PAS/HAB or CLASS transportation-habilitation.

An IPC must be signed in person by the SPT at enrollment and renewal SPT meetings. Revisions of the current service plan may be signed by facsimile.

After all requirements for eligibility are met, and at least annually thereafter, the case manager, the applicant/individual/LAR, DSA representative(s) and other persons as requested by the applicant/individual/LAR must meet to develop Form 3629, Individual Program Plan Addendum and a proposed Form 3621, CLASS/CFC – Individual Plan of Care.

The proposed IPC must specify:

the type of CLASS program and CFC services to be provided to the individual; the number of units of each CFC or CLASS program service; the estimated annual cost of all CFC services, other than CFC support management, or

CLASS program services; and other services or supports to be provided to the individual through sources other than the

CFC or CLASS program.

The SPT will participate with the CMA to develop Form 3629, Individual Program Plan Addendum.

The SPT will develop Form 8606, Individual Program Plan (IPP).

An IPP is needed for each CLASS program and CFC service listed on the proposed IPC. Each IPP describes:

the CLASS program and CFC service to be provided; the frequency of service provision; the duration of services; observable and measurable goals and objectives; the title of person responsible for implementing and monitoring goals and objectives; justification for services based on needs identified by the SPT; and support services provided through non-CFC or non-CLASS resources.

Each CLASS program and CFC service must be provided to an individual in accordance with the Individual Program Plan Addendum, the individual's IPC, and the individual's IPP for that service. A DSA must inform the individual's case manager throughout the IPC year of changes needed to the individual's Individual Program Plan Addendum, IPC, or IPPs.

On an ongoing basis, the DSA's responsibilities include:

participating in the SPT;



developing the PAS/Habilitation Plan - CLASS/DBMD/CFC habilitation plan (only applicable to service(s) delivered through the provider-managed service delivery option);

developing service backup plans for individuals receiving nursing and/or CFC PAS/HAB habilitation services when the SPT has determined the service is critical to an individual’s health and safety (only applicable to nursing and/or habilitation CFC PAS/HAB service(s) delivered through the provider-managed service delivery option);

discussing with the individual and the service providers or natural supports identified in the service backup plan to determine whether or not the plan was effective, if the service backup plan is implemented;

documenting whether or not the plan was effective, revising the plan with input from the SPT, if the plan was determined to be ineffective; completing Form 8578, Intellectual Disability/Related Condition (ID/RC) Assessment,

submitting to DADSHHSC/DADS and providing additional information as requested by DADSHHSC/DADS for the purposes of authorizing the individual's level of care;

delivering an array of CLASS program and CFC services in accordance with the Individual Program Plan Addendum, IPC, and the IPP and in coordination with non-CLASS services;

providing services to the individual as defined in the Individual Program Plan Addendum and the IPP;

implementing the individual's observable and measurable goals and objectives; informing the individual of rights and responsibilities, including complaint procedures; reporting the individual's changing needs and goals to the case manager; working with community resources as necessary to ensure the provision of CLASS

program and CFC services achieves the goal to provide flexible resources that increase personal independence and integration into the community;

coordinating individual providers of CLASS program and CFC services; and documenting the provision of services and providing, upon requestbased on the schedule

in Appendix X of the CLASS Provider Manual, a quarterly periodic summary of IPC service balances accomplishments to the case manager.

3310 Enrollment


At the time an applicant receives a written offer of a CLASS program vacancy from DADSHHSC/DADS, the applicant must select a DSA within 30 calendar days days after the date of the written offer from DADSHHSC/DADS. DADSHHSC/DADS notifies the selected DSA the applicant has chosen the agency to provide direct services according to the DADSHHSC/DADS Selection Determination document.

The DSA must assign a registered nurse to perform and complete the following functions within 14 calendar days after receiving Form 3657, Pre-Enrollment Assessment, from the CMA, as evidenced by the fax transmittal date on the documents received from the CMA.

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an initial face-to-face, in-home visit with the individual/LAR; a nursing assessment of the individual using the CLASS/DBMD Nursing Assessment

form; an adaptive behavior assessments of the individual, as outlined described in Form 8578,

Intellectual Disability/Related Condition (ID/RC) Assessment instructions; the Related Conditions Eligibility Screening Instrument; and the ID/RC Assessment in accordance with form instructions.

The DSA must ensure:

the applicant's physician attests to the applicant's diagnosis on the enrollment ID/RC Assessment;

the completed ID/RC Assessment is submitted to DADSHHSC/DADS for approval within 30 days of notification of completion of the Pre-Enrollment Assessment conducted by the CMA;

the DADSHHSC/DADS-approved ID/RC and the completed CLASS/DBMD Nursing Assessment is transmitted to the applicant's CMA within one business day after receiving notification of approval of the ID/RC from DADSHHSC/DADS; and

a DSA representative is available to participate in the applicant's enrollment SPT meeting as convened by the case manager.

HHSC/DADS will notify the DSA of the IPC authorization through MESAV. Effective January 16, 2017, the CMA will no longer receive the authorized IPC from HHSC/DADS. Each DSA is responsible for verifying in MESAV that each individual’s enrollment, renewal, or revisions IPCs have been authorized by HHSC/DADS.

Form Resources

The following forms may need to be completed as part of the enrollment process:

Form 2067 , Case Information Form 3596 , PAS/Habilitation Plan - CLASS/DBMD/CFC Form 3597 , CLASS – Habilitation Training Plan Form 3599 , Habilitation Service Provider Orientation/Supervisory Visits Form 3621 , CLASS/CFC – Individual Plan of Care Form 3625 , CLASS/CFC – Documentation of Services Delivered Form 3627 , Specialized Nursing Certification Form 3628 , Provider Agency Model Service Backup Plan Form 3629, Individual Program Plan Addendum Form 6515 , CLASS/DBMD Nursing Assessment Form 8507, Understanding Program Eligibility - CLASS/DBMD Form 8662 , Related Conditions Eligibility Screening Instrument Form 8578 , Intellectual Disability/Related Condition Assessment Form 8606 , Individual Program Plan (IPP)

Submission Standard — ID/RC














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The following submission standards apply when submitting ID/RC paperwork to DADSHHSC/DADS:

Form 8578 , Intellectual Disability/Related Condition Assessment Form 8662 , Related Conditions Eligibility Screening Instrument ABL assessment scoring summary

Submission Standard — Pre-enrollment

The following submission standards apply when submitting paperwork containing funding proposals for pre-enrolment efforts to DADSHHSC/DADS:

Form 3625 , CLASS/CFC – Documentation of Services Delivered Form 8578 , Intellectual Disability/Related Condition Assessment

3320 DSA Renewal


Continuing eligibility must be determined at least annually. As with the initial assessment, the DSA RN is required to complete an annual nursing assessment of the individual using the Form 6515, CLASS/DBMD Nursing Assessment form, Form 8578, Intellectual Disability/Related Condition (ID/RC) Assessment, Form 8662, Related Conditions Eligibility Screening Instrument (RCESI) (these documents must be completed every year), and an adaptive behavior level (ABL) assessment if the current one is greater than five years old, or is no longer valid.

Form 6515, Form 8578, Form 8662, and results of the current ABL assessment must be sent to DADSHHSC/DADS at least 60 calendar days, but no more than 120 calendar days, before the expiration of an individual's Individual Plan of Care (IPC) to establish that an individual continues to meet diagnostic/functional eligibility criteria. Once DADSHHSC/DADS informs the DSA of the approval of diagnostic/functional eligibility, the DSA must submit a copy of the approved ID/RC and the completed CLASS/DBMD Nursing Assessment to the Case Management Agency (CMA) by the next business day.

If an individual's ABL assessment is more than five years old or the individual's needs significantly change, the DSA must complete one of the following ABL assessments according to the publisher's instructions:

Inventory for Client and Agency Planning (ICAP); Vineland Adaptive Behavior Scales, Second Edition (Vineland-II); Scales of Independent Behavior – Revised (SIB-R); or American Association of Intellectual and Developmental Disabilities (AAIDD) Adaptive

Behavior Scales (ABS).



http://www.dads.state.tx.us/forms/6515/





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A DSA representative, as defined in Section 3300, Service Planning, must participate as a member of the Service Planning Team (SPT) to develop:

a Individual Program Plan Addendum a renewal IPC — the CLASS program and CFC services on the proposed renewal IPC

must meet the following standards, which: o are necessary to protect the individual's health and welfare in the community;o address the individual's related condition;o are not available to the individual through any other source including the

Medicaid state plan, other governmental programs, private insurance or the individual's natural supports;

o are the most appropriate type and amount of CLASS program and CFC services to meet the individual's needs; and

o are cost effective. a renewal Individual Program Plan (IPP) for each service proposed on the renewal IPC; Form 3596 , PAS/Habilitation Plan - CLASS/DBMD/CFC, and Form 3597, CLASS –

Habilitation Training Plan (if applicable); and a service backup plan for the following services, if the SPT determines the service is

critical to the individual's health and safety and if the service is delivered by the DSA: o CFC PAS/HAB;o habilitation services;o habilitation delegated; ando nursing services.

CLASS program and CFC services as a whole enhance an individual's integration in the community and prevent admission to an institution while maintaining and improving independent functioning.

The DSA is responsible for assisting and providing documentation, as requested by the CMA.


Form Resources

The following forms may need to be completed as part of the renewal process:

Form 1740 , Service Backup Plan Form 2067 , Case Information Form 3596 , PAS/Habilitation Plan - CLASS/DBMD/CFC Form 3597 , CLASS – Habilitation Training Plan Form 3598 , Individual Transportation Plan Form 3621 , CLASS/CFC – Individual Plan of Care Form 3625 , CLASS/CFC – Documentation of Services Delivered











Form 3628 , Provider Agency Model Service Backup Plan Form 3629, Individual Program Plan Addendum Form 6515 , CLASS/DBMD Nursing Assessment Form 8578 , Intellectual Disability/Related Condition Assessment (Page 1 and Page 3) Form 8598 , Non-Waiver Services Form 8606 , Individual Program Plan (IPP) Form 8662 , Related Conditions Eligibility Screening Instrument

Submission Standard

The following submission standards apply when submitting ID/RC paperwork to DADSHHSC/DADS:

Form 6515 , CLASS/DBMD Nursing Assessment Form 8578 , Intellectual Disability/Related Condition Assessment Form 8662 , Related Conditions Eligibility Screening Instrument ABL assessment scoring summary

3330 Revision


When the DSA is notified of a needed revision to the IPC, the DSA representative must contact the CMA within one business day. The DSA is responsible for assisting and providing documentation, as requested by the CMA to ensure:

a proposed IPC revision includes an IPP for each service revised on the proposed IPC and a revised Form 3596, PAS/Habilitation Plan - CLASS/DBMD/CFC, if applicable;

Individual Program Plan Addendum is revised to be consistent with the IPC and IPPs; CLASS services as a whole enhance an individual's integration in the community and

prevent admission to an institution while maintaining and improving independent functioning; and

the CLASS program and CFC services on the proposed IPC revision must meet the following standards:

o are necessary to protect the individual's health and welfare in the community;o address the individual's related condition;o are not available to the individual through any other source including the

Medicaid state plan, other governmental programs, private insurance or the individual's natural supports;

o are the most appropriate type and amount of CLASS program and CFC services to meet the individual's needs; and

o are cost effective.











Within five business days after receipt of the Individual Program Plan Addendum, IPP, and IPC from the CMA, as evidenced by the fax transmittal date on the documents received from the CMA, the DSA must sign and return the Individual Program Plan Addendum, IPP, and IPC to the CMA. If any revised services provided by the DSA affect the service backup plan, PAS/Habilitation Plan - CLASS/DBMD/CFC habilitation plan or the Individual Program Plan Addendumhabilitation training plan, the DSA must revise the existing plan to reflect these changes to program services.


3331 Immediate Jeopardy of CLASS Individual


Immediate jeopardy is interpreted as a crisis situation in which the health and safety of an individual is at risk.

During circumstances when the individual's health and safety is placed in immediate jeopardy the Direct Service Agency (DSA)DSA must provide the following services:

licensed vocational nursing; specialized licensed vocational nursing; registered nursing; specialized registered nursing; CFC PAS/HAB habilitation; respite; dental treatment; or adaptive aid.

These services must be provided even if they are not included on the individual's Individual Plan of Care (IPC). The DSA must, within seven calendar days after providing the service, submit to the Case Management Agency (CMA):

a description of circumstances necessitating the provision of the new service or the increase in the amount of the existing service; and

documentation by a registered nurse of the nurse's determination the service was necessary to prevent the individual's health and safety from being placed in immediate jeopardy.

The CMA must use the date which the DSA RN documented determination the individual was subject to immediate jeopardy without the provision of additional habilitation, respite, nursing,

dental services, or an adaptive aid that is not included on the individual's IPC as the IPC revision effective date.

Form Resources

The following forms may need to be completed as part of the revision process:

Form 1740 , Service Backup Plan Form 2067 , Case Information Form 3596 , PAS/Habilitation Plan - CLASS/DBMD/CFC Form 3597 , CLASS – Habilitation Training Plan Form 3598 , Individual Transportation Plan Form 3621 , CLASS/CFC – Individual Plan of Care Form 3628 , Provider Agency Model Service Backup Plan Form 3629, Individual Program Plan Addendum Form 8606 , Individual Program Plan (IPP)

3340 Transfer

Revision 11-1; Effective June 13, 2011

If an individual plans to move to another CLASS provider, the case manager must provide the individual the most current Selection Determination document for the applicable catchment area. The requirements for the transferring DSA and receiving DSA are provided below.

3341 Transferring DSA


The transferring Direct Service Agency (DSA)DSA must provide the receiving DSA with the current balance of each service category based on most current CLASS/CFC Individual Plan of Care (IPC) authorized and actual delivery up to the transfer effective date — Form 3621-T, CLASS/CFC – IPC Service Delivery Transfer Worksheet. The total number of service units provided before the effective date of the transfer is the sum of the number of service units:

provided and paid, provided that have been billed but not yet paid, and to be provided until the transfer effective date.

Copies of the identified records must be delivered by the transferring DSA to the receiving DSA within five calendar days of notification by the case manager of the individual's decision to transfer to a different DSA. The records that must be provided include:

current CLASS/CFC IPC; current Form 3629, Individual Program Plan AddendumService Planning Team (SPT)

notes;

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current Individual Program Plan (IPP); current Form 8578, Intellectual Disability/Related Condition Assessment; current Form 8662, Related Conditions Eligibility Screening Instrument; current Form 3596, PAS/Habilitation Plan - CLASS/DBMD/CFC; current Form 3597, CLASS – Habilitation Training Plan, if applicable; records of all adaptive aids purchased during the current IPC period; records of all minor home modifications procured for the individual, regardless of date of

purchase and cost of each; all quarterly reviewsIPP Service Summaries performed by the DSA during the current

IPC period; current physician's orders; copies of DSA records for 90 calendar days prior to DSA transfer, including:

o CFC/PAS/HAB or CLASS habilitation;o medication administration record;o money management;o assessments and notes for any services listed on the IPC; ando all communications, including:

contact notes; progress notes; Form 2067 , Case Information; Form 3624 , Termination, Reduction or Denial of CLASS; incident reports; and complaints;

school/day programming information including: o Admission, Review and Dismissal (ARD) notes; ando Individual Education Plan (IEP); and

current service delivery schedules for all services.

The transferring DSA is required to maintain documentation of the specific records that were delivered to the receiving DSA, as well as the date of the delivery.

3342 Receiving DSA


The receiving DSA must initiate services on the transfer effective date, as identified on Form 3621-T, CLASS/CFC – IPC Service Delivery Transfer Worksheet. The total number of service units available to the receiving DSA is the number of service units to be provided from the transfer effective date until the end of the IPC effective period.

The receiving DSA must develop a Form 3628, Provider Agency Model Service Backup Plan, for those services requiring a backup plan as indicated on the IPC.

3350 IPP Service Summaries











CLASS service provider(s) must evaluate the effectiveness of CLASS program and CFC services delivered by the Direct Service Agency (DSA)DSA. The DSA is responsible for providing an Individual Program Plan (IPP) Service Summary to the Case Management Agency (CMA) in accordance with the schedule in Appendix X, Service Summary/Service ReviewQuarterly Due Dates Chart, from the effective date of the most recent enrollment or renewal CLASS/CFC Individual Plan of Care (IPC). The final review of the IPC year is combined with the meeting of the Service Planning Team (SPT) to develop a renewal IPC and update the Individual Program Plan Addendum. The case manager is responsible for documenting the service summary provided by the DSA since the preceding review. The evaluation must include an assessment of the individual's progress, evolving needs and plans to address those needs. The IPP Service Summary must document the service provider’s review of the individual's progress toward achieving the goals and objectives, as described on the IPP for each CLASS program and CFC service listed on the individual's IPC. There is not a DADSHHSC/DADS form for the IPP Service Summary; however, the DSA must provide this information in a written format.

A DSA is required to ensure that each CLASS program and CFC service is provided to an individual in accordance with Appendix C of the CLASS Waiver Application, available on the CLASS website at https://hhs.texas.gov/laws-regulations/policies-and-rules/waivers/class-waiver-applicationshttp://www.dads.state.tx.us/providers/CLASS/index.cfm.

An IPP is developed to describe the goals and objectives to be met by the provision of each CLASS program and CFC service on an individual's IPC that are supported by justifications, are measurable, and have timelines. Additionally, a DSA must ensure CLASS program and CFC services are documented in the individual's record, including the progress or lack of progress in achieving goals or outcomes in observable, measurable terms that directly relate to the specific goal or objective addressed.

The DSA must provide the case manager with the IPP Service sSummaries of from each service listed below provided by the DSA documenting the individual's progress and needs.

Within five business days of the service provider completing the IPP service summary, the DSA is responsible for providing copies of the summaries to the case manager, as evidenced by the fax transmittal date on the documents provided to the CMA. The DSA must maintain documentation of transmission of all necessary documents. An IPP service summary for each service listed below must be prepared based on the schedule in Appendix X from the effective date of the most recent enrollment or renewal IPC. The DSA verbally updates the case manager during the renewal SPT meeting with any relevant information regarding services delivered in the last quarter of the IPC year.

The summaries must include quarterly reports from providers of the following services:

auditory enhancement training; behavioral support; dietary services (nutritional services); habilitation training; occupational therapy;

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physical therapy; prevocational services; specialized therapies; speech and language pathology; cognitive rehabilitation therapy employment assistance; and supported employment services.

Each IPP Service Summary completed by the service provider must include all of the elements listed below:

current observable/measurable goals and objectives; frequency and duration of sessions attended; rationale for missed sessions; progress or lack of progress; actions taken, as applicable (e.g., in-servicing, counseling, etc.); and revisions of goals and objectives, as applicable.

Form Resources

The following forms may need to be completed as part of the summary:

Form 2067 , Case Information Form 3621 , CLASS/CFC – Individual Plan of Care

3400 Denial, Reduction, Suspension and Termination


An individual who has been denied enrollment or terminated from the CLASS program and CFC services, or an individual whose CLASS program and CFC services are denied, reduced, suspended or terminated must be given notice of adverse actions taken by DADSHHSC/DADS and is entitled to a fair hearing.

Program services may be terminated if the individual does not comply with the conditions as outlined in 40 TAC §45.406 or violates any of the conditions specified in 40 TAC §45.408. Program services may also be terminated if an individual does not comply with 40 TAC §45.407, or exhibits behavior that places the health and safety of the CMA's case manager or a DSA's service provider in immediate jeopardy as described in 40 TAC §45.409.

3410 Denial


Denial is a DADSHHSC/DADS action that disallows:



an individual's request for enrollment in the CLASS program; a service requested on the IPC that was not authorized on the a prior IPC; or a portion of the amount or level of the service requested on the IPC that was not

authorized on the a prior IPC.

3411 Denial of a Request for Enrollment into the CLASS Program


DADSHHSC/DADS denies an individual's request for enrollment into the CLASS program if:

the individual does not meet the eligibility criteria described in §45.201, Eligibility Criteria; or

the DSAs serving the catchment area in which the individual resides are not willing to provide CLASS program and CFC services to the individual because they have determined they cannot ensure the individual's health and safety.

If DADSHHSC/DADS denies an individual's request for enrollment, DADSHHSC/DADS sends written notice to the individual or LAR of the denial of the individual's request for enrollment into the CLASS program and includes in the notice the individual's right to request a fair hearing in accordance with §45.301, Individual's Right to a Fair Hearing. DADSHHSC/DADS sends a copy of the written notice to the individual's DSA, CMA and, if selected, Financial Management Services Agency (FMSA).

3412 Denial of a CLASS Program or CFC Service


CLASS program and CFC services as a whole enhance an individual's integration in the community and prevent admission to an institution while maintaining and improving independent functioning.

DADSHHSC/DADS denies a CLASS program or CFC service on an individual's IPC if services:

are not necessary to protect the individual's health and welfare in the community; do not address the individual's related condition; are available to the individual through any other source including the Medicaid state plan,

other governmental programs, private insurance or the individual's natural supports; are not the most appropriate type and amount of CLASS program and CFC services to

meet the individual's needs; or are not cost effective.

If HHSC/DADS determines one or more of the CLASS program or CFC services specified in the IPC do not meet the requirements for an IPC, HHSC/DADS:

for an enrollment IPC, approves enrollment in CLASS program with the modified IPC; denies or reduces the CLASS program or CFC service(s), as appropriate; modifies and authorizes the IPC; sends a copy of the modified IPC to the CMA; and notifies the individual's CMA, in writing, of the action taken.

Form Resources

The following forms may need to be completed as part of a denial of services:

Form 2067 , Case Information Form 3624 , Termination, Reduction or Denial of CLASS Form 3629, Individual Program Plan Addendum Form 4800-D , Fair Hearing Request Summary

3420 Reduction


Reduction is a DADSHHSC/DADS action taken as a result of a review of an IPC that decreases the amount or level of CLASS program or CFC servicesa service not authorized by DADSHHSC/DADS on a prior IPC.

DADSHHSC/DADS will perform a utilization review on all IPCs that meet criteria outlined in Section 5000, Utilization Review (UR). All CLASS program or CFC services and units of service included on a proposed IPC must be justified by the SPT.

CLASS Operations HHSC/DADS staff review the IPC to ensure the services on the IPC:

are necessary to protect the individual's health and welfare in the community; supplement rather than replace the individual's natural supports and other non-CLASS

program services and supports for which the individual may be eligible; CLASS program and CFC services as a whole enhance an individual's integration in the

community and prevent admission to an institution while maintaining and improving independent functioning;

are the most appropriate type and amount of CLASS program and CFC services to meet the individual's needs; and

are cost effective.

As necessary during the review of a proposed IPC, CLASS Operations PE/URHHSCHHSC/DADS staff will ask case managers to provide additional justification if the initial information submitted with a proposed IPC is not sufficient to demonstrate the need for a proposed CLASS program and CFC service(s). If information submitted to DADSHHSC/DADS by the case manager does not provide sufficient information to justify requested CLASS program

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and CFC services or amounts of CLASS program and CFC services, DADSHHSC/DADS will reduce the number of units of CLASS program and CFC services, as necessary, and will notify send the CMA a copy of the modified IPC.of the reduction in writing.

If an individual's services are reduced, the DSA is notified by the CMA in writing describing DADSHHSC/DADS reason for the reduction. The DSA is also notified by the CMA if and when the individual chooses to appeal the decision. If the individual or LAR requests a fair hearing within 10 days from date of notification, as specified in the written notice, the DSA must provide the service to the individual in the amount authorized in the prior IPC while the appeal is pending.

Form Resources

The following forms may need to be completed as part of a reduction of services:


3430 Suspension


Suspension is a DADSHHSC/DADS action that results in temporary loss of the individual's authorized services in the CLASS programCLASS program or CFC services. An individual may remain on suspension from CLASS for up to 180 calendar days. DADSHHSC/DADS may extend an individual's suspension for 30 calendar days upon the CMA's request.

Suspension is a DADSHHSC/DADS action taken as a result of:

an individual's admission, for up to 180 consecutive calendar days, to one of the following facilities:

o an ICF/IID licensed or subject to being licensed in accordance with Texas Health and Safety Code, Chapter 252, or certified by DADSHHSC/DADS, unless the individual is receiving out-of-home respite in the facility;

o a nursing facility licensed or subject to being licensed in accordance with Texas Health and Safety Code, Chapter 242, unless the individual is receiving out-of-home respite in the facility;

o an assisted living facility licensed or subject to being licensed in accordance with Texas Health and Safety Code, Chapter 247;

o a residential child-care operation licensed or subject to being licensed by the Department of Family and Protective Services (DFPS), unless it is a foster family home or a foster group home;




o a facility licensed or subject to being licensed by the Department of State Health Services (DSHS);

o a facility operated by the Department of Assistive and Rehabilitative Services (DARS);

o a residential facility operated by the Texas Youth Commission; oro a jail or prison;

an individual leaving the state for up to 180 consecutive calendar days, except for individuals receiving certain services available through the CDS option while the individual is temporarily staying at a location outside the State of Texas. For more information, see Information Letter No. 16-35, Receiving Services Outside the State of Texas in the CLASS and DBMD Programs.

Within two business days of learning of a situation that necessitates an individual's CLASS program and CFC services to be suspended, the DSA must send the CMA written notification using Form 2067, Case Information, including any supporting documentation.

Form Resources

The following forms may need to be completed as part of a suspension of services:


3440 Termination


Termination is a DADSHHSC/DADS action that results in the loss of the individual's eligibility for authorized services in the CLASS program and CFC services.

3441 Termination With Advanced Notice


DADSHHSC/DADS terminates an individual's CLASS program and CFC services if:

the individual does not meet program eligibility criteria; the individual is admitted for more than 180 consecutive calendar days to one of the

following facilities: o an ICF/IID licensed or subject to being licensed in accordance with Texas Health

and Safety Code, Chapter 252, or certified by DADSHHSC/DADS, unless the individual is receiving out-of-home respite in the facility;

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o a nursing facility licensed or subject to being licensed in accordance with Texas Health and Safety Code, Chapter 242, unless the individual is receiving out-of-home respite in the facility;

o an assisted living facility licensed or subject to being licensed in accordance with Texas Health and Safety Code, Chapter 247;

o a residential child-care operation licensed or subject to being licensed by the Department of Family and Protective Services, unless it is a foster family home or a foster group home;

o a facility licensed or subject to being licensed by the Department of State Health Services;

o a facility operated by Department of Assistive and Rehabilitative Services; oro a residential facility operated by the Texas Youth Commission, a jail or prison;

the individual leaves the state for more than 180 consecutive calendar days and DADSHHSC/DADS has not extended the individual's suspension;

Direct Service Agencies (DSAs) serving the catchment area in which the individual resides are not willing to provide CLASS program and CFC services to the individual on the basis of a reasonable expectation that the individual's medical and nursing needs cannot be met adequately in the individual's residence; or

the individual refuses to comply with one or more of the mandatory participation requirements as follows:

o not completing and submitting an application for Medicaid financial eligibility to the Health and Human Services Commission (HHSC) within 30 calendar days after the case manager's initial face-to-face, in-home visit (Note: If an individual or legally authorized representative (LAR) does not submit a Medicaid application to HHSC within 30 calendar days of the case manager's initial face-to-face, in-home visit as required, but is making good faith efforts to complete the application, DADSHHSC/DADS may extend this time frame in 30 calendar-day increments.);

o not participating with the Service Planning Team (SPT) to: develop Individual Program Plan Addendum using person develop an enrollment CFC/CLASS Individual Plan of Care (IPC); or renew and revise the IPC and Individual Program Plans (IPPs);

o not reviewing, agreeing to, signing and dating an IPC and IPPs;o not using natural supports and other non-CLASS services and supports for which

the individual may be eligible before using CLASS and CFC services;o not cooperating with the Case Management Agency (CMA) and DSA in the

delivery of CLASS and CFC services listed on the individual's IPC, including: not cooperating with the CMA and DSA in scheduling meetings; not attending scheduled meetings with the case manager or service

provider; not being available to receive the CLASS and CFC services; not notifying the CMA or DSA in advance if the individual or LAR is

unable to attend a scheduled meeting or is unavailable to receive services in the individual's own or family home;

not admitting CMA and DSA representatives to the individual's own home or family home for a scheduled meeting or to receive CLASS and CFC services;

o not cooperating with the DSA's service providers to ensure progress toward achieving the goals and objectives described in the IPP for each CLASS and CFC service listed on the IPC;

o not paying a required copayment in a timely manner as required by HHSC;o not completing the procedures for redetermining eligibility for Medicaid as

described in the Medicaid for the Elderly and People with Disabilities Handbook;o engaging or permitting a person present in the individual's own or family home to

engage in criminal behavior in the presence of the case manager or service provider;

o acting or permitting a person present in the individual's own or family home to act in a manner that is threatening to the health and safety of the case manager or service provider;

o exhibiting behavior or permitting a person present in the individual's residence to exhibit behavior that places the health and safety of the case manager or service provider in immediate jeopardy;

o initiating or participating in fraudulent health care practices; oro engaging or permitting a person present in the individual's own home or family

home to engage in behavior that endangers the individual's health or safety.

Within two business days after the DSA learns of one of the situations described above, the DSA must send the CMA a written notification per Form 2067, Case Information, including supporting documentation. The DSA is responsible for making reasonable attempts to accommodate a face-to-face meeting with the SPT as scheduled by the CMA.

If termination of services is requested based on a determination by the DSA on the basis of a reasonable expectation that the individual's medical and nursing needs cannot be met adequately in the individual's residence, the DSA must provide specific reason(s) to the CMA regarding why the DSA determined it cannot ensure the individual's health and safety.

Prior to termination of services, an individual may choose another DSA. The CMA must provide the most current Selection Determination document in catchment areas with multiple DSAs. If another DSA determines the individual’s medical and nursing needs can be adequately met, the DSA must assist the CMA to develop a transfer IPC as described in Section 3340 of the CLASS Provider Manual.

DADSHHSC/DADS notifies the individual's CMA, in writing, of whether it authorizes the proposed termination of CLASS program and CFC services. The DSA is notified by the CMA regarding the termination.

If CLASS program and CFC services are terminated due to an individual's IPC cost being over 200% of the estimated annualized per capita cost of providing services in an ICF/IID$114,736.07, DADSHHSC/DADS sends written notice to the individual or LAR of the proposal to terminate CLASS program and CFC services and includes in the notice the

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individual's right to request a fair hearing. DADSHHSC/DADS sends a copy of the written notice to the individual's DSA, CMA and, if selected, Financial Management Services Agency.

DADSHHSC/DADS notifies the individual's CMA, in writing, of whether it authorizes the proposed termination of CLASS program and CFC services. The DSA is notified by the CMA regarding the termination.

If the individual or LAR requests a fair hearing before the effective date of a proposed termination of CLASS program and CFC services, the DSA must provide services to the individual in the amounts authorized in the IPC while the appeal is pending.

3442 Termination Without Advanced Notice


DADSHHSC/DADS terminates an individual's CLASS program and CFC services without advanced notice if any of the following situations exist:

the CMA or DSA has factual information confirming the death of the individual; the CMA or DSA receives a clearly written statement signed by the individual that the

individual no longer wishes to continue to receive CLASS program and CFC services; the individual's whereabouts are unknown and the post office returns mail directed to him

or her by the CMA or DSA, indicating no forwarding address; the CMA or DSA establishes the individual has been accepted for Medicaid services by

another state; or an individual or a person in the individual's residence exhibits behavior that places the

health and safety of the CMA's case manager or a DSA's service provider in immediate jeopardy. For more information, see Section 3510, Immediate Jeopardy.

Within two business days after the DSA becomes aware of a situation such as described above, the DSA must send the CMA a written notification per Form 2067, Case Information, including supporting documentation.

DADSHHSC/DADS notifies the individual's CMA, in writing, of whether it authorizes the termination of CLASS and CFC services. The DSA is notified by the CMA regarding the termination.

DADSHHSC/DADS may terminate an individual's CLASS and CFC services if an individual or a person in the individual's residence exhibits behavior that places the health and safety of the case manager or a service provider in immediate jeopardy.

If a CMA or DSA becomes aware a situation exists that places the health and safety of the individual's case manager or CLASS program or CFC service provider in immediate jeopardy, the CMA or DSA must:



immediately file a report with the appropriate law enforcement agency and, if appropriate, make an immediate referral to DFPS;

notify the CMA or DSA, as appropriate, and DADSHHSC/DADS by telephone of the situation no later than the next business day; and

attempt to resolve the situation.

DADSHHSC/DADS notifies the individual's CMA, in writing, of whether it authorizes the proposed termination of CLASS and CFC services. The DSA is notified by the CMA regarding the termination.

Form Resources

The following forms may need to be completed as part of termination of services:

Form 2067 , Case Information Form 3624 , Termination, Reduction or Denial of CLASS Form 4800-D , Fair Hearing Request Summary

3500 Service Initiation


A DSA must ensure each CLASS and CFC service is provided to an individual in accordance with the individual's Individual Program Plan Addendum, IPC and IPP for each service.

A DSA must have a written process that ensures staff members are or can readily become familiar with individuals to whom they are not ordinarily assigned but to whom they may be required to provide a CLASS and CFC service.

A DSA must inform the individual's case manager of changes needed to the individual's IPC or IPPs.

3510 Immediate Jeopardy of CLASS and CFC Providers


HHSC/DADS may terminate an individual's CLASS program and CFC services if an individual or a person in the individual's residence exhibits behavior that places the health and safety of the CMA's case manager or a DSA's service provider in immediate jeopardy.

If a CMA or DSA becomes aware a situation exists that places the health and safety of the individual's case manager or DSA service provider in immediate jeopardy, the CMA or DSA must:




immediately file a report with the appropriate law enforcement agency and, if appropriate, make an immediate referral to DFPS; and

notify HHSC/DADS, CMA and DSA by telephone of the situation no later than one business day after the CMA or DSA becomes aware of the situation.

The CMA and DSA must attempt to resolve the situation. If, after making attempts to resolve the situation, the CMA determines that the situation cannot be resolved, the CMA must, within two business days after the CMA becomes aware of the situation, send a written request to terminate CLASS program and CFC services to HHSC/DADS. The written request must be accompanied by:

a description of the situation that resulted in the request to terminate the individual's CLASS program and CFC services;

a detailed description of the attempts by the CMA to resolve the situation; and if available, a copy of any report issued by a law enforcement agency or DFPS regarding

the situation.

HHSC/DADS notifies the individual's CMA in writing of whether it authorizes the proposed termination of CLASS program and CFC services.

Upon receipt of written notice from HHSC/DADS authorizing the termination of CLASS program and CFC services, the CMA must, no later than the date of the termination of services, send written notice to the individual or LAR of such termination. The CMA must provide a hard copy of the termination notice to the individual's DSA and, if selected, FMSA and SFS provider. The CMA must include in the notice the individual's right to request a fair hearing.

The CMA and DSA must maintain documentation of completion of these requirements in the individual's record.

Immediate jeopardy is interpreted as a crisis situation in which the health and safety of an individual is at risk.

During circumstances when the individual's health and safety is placed in immediate jeopardy, the Direct Service Agency (DSA) must provide the following services:

licensed vocational nursing; specialized licensed vocational nursing; registered nursing; specialized registered nursing; habilitation; respite; dental treatment; or adaptive aid.

These services must be provided even if they are not included on the individual's Individual Plan of Care (IPC), if a registered nurse determines the service is necessary to prevent the individual's

health and safety from being placed in immediate jeopardy. In such an event, the DSA must, within seven calendar days after providing the service, submit to the Case Management Agency (CMA):

documentation describing the circumstances necessitating the provision of the new service or the increase in the amount of the existing service; and

documentation by an RN of the nurse's determination the service was necessary to prevent the individual's health and safety from being placed in immediate jeopardy.

The CMA must use the date which the DSA RN documented determination the individual was subject to immediate jeopardy without the provision of additional habilitation, respite, nursing, dental services, or an adaptive aid that is not included on the individual's IPC as the IPC revision effective date. DADS authorizes the IPC once submitted by the CMA only if DADS determines the service was necessary to prevent the individual's health and safety from being placed in immediate jeopardy.

DADS notifies the DSA, through the online billing system, of whether the proposed IPC is authorized.

3520 Adaptive Aids Costing Less than $500


Once the Direct Service Agency (DSA)DSA has determined the cost of the requested adaptive aid, the DSA must request in writing the case manager initiate an Individual Plan of Care (IPC) revision. The DSA must inform the individual's case manager of the cost of the requested adaptive aid.

DADSHHSC/DADS authorizes the IPC once submitted by the Case Management Agency (CMA) if, after reviewing the documentation, it determines the requested adaptive aid meets the standards outlined in Appendix I, Adaptive Aids.

The DSA must ensure the individual receives the adaptive aid within 14 business days after the date DADSHHSC/DADS authorizes the proposed IPC that includes the recommended adaptive aid; or the effective date of the individual's IPC as determined by the Service Planning Team (SPT) (whichever is later). The DSA must complete Form 8605, Documentation of Completion of Purchase, that serves as the primary document for completion of purchases of authorized adaptive aids/medical supply items or minor home modifications made by the service provider for individuals.

For an adaptive aid that is a medical supply, a DSA must ensure the individual receives the medical supply as follows:

for a medical supply that is not immediately needed by the individual, within five business days after the date DADSHHSC/DADS authorizes the proposed IPC that


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includes the recommended adaptive aid; or the effective date of the individual's IPC as determined by the SPT (whichever is later); or

for a medical supply that is immediately needed by the individual, within two business days after the date DADSHHSC/DADS authorizes the IPC that includes the recommended adaptive aid.

If the DSA cannot provide the adaptive aid in the time frame described, the DSA must:

notify the individual and the individual's case manager, orally or in writing, before the 14-day time frame expires, that the adaptive aid will not be provided within the 14-day time frame; and

notify the individual and the individual's case manager of a new proposed date for provision of the adaptive aid.

If the DSA cannot provide an adaptive aid that is a medical supply and is not immediately necessary by the individual, the DSA must:

notify the individual and the individual's case manager, orally or in writing, before the five-day time frame expires, that the adaptive aid will not be provided within the five-day time frame;

provide the reason(s) why the medical supply will not be provided within the five-day time frame; and

notify the individual and the individual's case manager of a new proposed date for provision of the medical supply.

3530 Adaptive Aid Costing $500 or More


Once the Service Planning Team (SPT) has agreed the applicant/individual is in need of an adaptive aid with an anticipated cost that is more than $500, the Direct Service Agency (DSA)DSA must request in writing that the case manager initiate an Individual Plan of Care (IPC) revision including funds for obtaining an assessment of the individual by the appropriate licensed professional as described in Appendix I of CLASS Provider Manual, practicing within the scope of his/her licensure., that The assessment must includes a description and a recommendation for an adaptive aid that meets the individual’s need(s). This assessment must identify how this adaptive aid will meet the needs of the individual and must include consideration of other alternatives known to the appropriate licensed professional to meet the individual’s need(s). Detailed descriptions, to the extent possible, must accompany the licensed professional’s recommendation for adaptive aids when the cost is more than $500.

After DADSHHSC/DADS authorizes the proposed IPC for payment of the adaptive aid assessment, the DSA must obtain the assessment from the appropriate licensed professional that describes the adaptive aid within 30 calendar days. The assessment by the licensed professional

that describes the specific need(s) of the individual must include recommendations for the adaptive aid that, in the opinion of the licensed professional, will best meet the needs identified in the assessment.

Based on the recommendations contained in the assessment, the DSA will consult with the most appropriate vendor person to determine the most cost-effective item(s) that meet the recommendations in the assessment. The description of the item(s) as contained in the assessment must be used to develop the specifications to obtain bids from all vendors. The DSA must obtain comparable bids for the requested adaptive aid from three vendors within 60 calendar days of obtaining the specifications.

A bid obtained must be based on the specifications and include:

the total cost of the requested adaptive aid, which may be from a catalog, website or brochure price list;

the amount of any additional expenses related to the delivery of the adaptive aid, including shipping and handling, taxes, installation and other labor charges;

the date of the bids; the name, address and telephone number of the vendor, who may not be a relative of the

individual; a complete description of the adaptive aid and any associated items or modifications as

identified in the completed Form 3660, Request for Adaptive Aids, Medical Supplies, Minor Home Modifications or Dental Services/Sedation, which may include pictures or other descriptive information from a catalog, website or brochure; and

the number of hours of the service or training to be provided in person and the hourly rate of the service for interpreter services and specialized training for augmentative communication programs.

The DSA must:

obtain the assessment from a licensed professional for the adaptive aid as described in Appendix I, Adaptive Aids;

ensure the assessment includes a complete description of the adaptive aid; and provide a copy of the assessment and the specifications to the Case Management Agency

(CMA).

For purchases of an adaptive aid or medical supply costing over $500, the CMA, DSA and individual/legally authorized representative must complete and sign Form 3849-A, Specifications for Adaptive Aids/Medical Supplies/Minor Home Modifications, to signify agreement with the specifications.

The DSA may obtain only one bid or two comparable bids for an adaptive aid if the DSA has written justification for obtaining less than three bids because the adaptive aid is available from a limited number of vendors.


http://www.dads.state.tx.us/forms/3849-A

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the total cost of the requested adaptive aid, which may be from a catalog, website or brochure price list;

the amount of any additional expenses related to the delivery of the adaptive aid, including shipping and handling, taxes, installation and other labor charges;

the date of the bid; the name, address and telephone number of the vendor, who may not be a relative of the

individual; a complete description of the adaptive aid and any associated items or modifications as

identified in the completed Form 3660, which may include pictures or other descriptive information from a catalog, website or brochure; and

the number of hours of the service or training to be provided in person and the hourly rate of the service for interpreter services and specialized training for augmentative communication programs

A DSA may obtain only one bid or two comparable bids for an adaptive aid if the DSA has written justification for obtaining less than three bids because the adaptive aid is available from a limited number of vendors.

If a DSA requests to purchase an adaptive aid that is not based on the lowest bid, the DSA must have written justification for payment of a higher bid. The following are examples of justifications that support payment of a higher bid:

the higher bid is based on the inclusion of a longer warranty for the adaptive aid; and the higher bid is from a vendor that is more accessible to the individual than another

vendor.

Requests for interpreter services or specialized training for augmentative communication devices must include:

the total number of hours of the service or training to be provided in-person; and the hourly rate of the service.

If the requested adaptive aid is a vehicle modification, a DSA must obtain proof the individual or individual's family member owns the vehicle for which the vehicle modification is requested. Requests for vehicle modifications to accommodate modifications or additions to the primary transportation vehicle must include an assessment by the appropriate licensed professional as indicated in Appendix I.

A DSA may not disclose information regarding a submitted bid to any other vendor who has submitted a bid or to a vendor who may submit a bid.

The DSA must request in writing the case manager initiate an IPC revision. At this point, the DSA must inform the individual's case manager of the cost of the requested adaptive aid.

DADSHHSC/DADS authorizes the IPC once submitted by the CMA if, after reviewing the documentation, it determines the requested adaptive aid meets the standards outlined in Appendix I, Adaptive Aids.

The DSA must ensure the individual receives the adaptive aid within 30 business days after the date DADSHHSC/DADS authorizes the proposed IPC that includes the recommended adaptive aid; or the effective date of the individual's IPC as determined by the SPT (whichever is later). The DSA must complete Form 8605, Documentation of Completion of Purchase, that serves as the primary document for purchases of authorized adaptive aids/medical supply items or minor home modifications made by the service provider for individuals.

For an adaptive aid that is a medical supply, the DSA must ensure the individual receives the medical supply as follows:

for a medical supply that is not immediately needed by the individual, within five business days after the date DADSHHSC/DADS authorizes the proposed IPC that includes the recommended adaptive aid; or the effective date of the individual's IPC as determined by the service planning teamSPT (whichever is later); or

for a medical supply that is immediately needed by the individual, within two business days after the date DADSHHSC/DADS authorizes the IPC that includes the recommended adaptive aid.

If the DSA cannot provide the adaptive aid in the time frame described, the DSA must:

notify the individual and the individual's case manager, orally or in writing, before the 30-day time frame expires, the adaptive aid will not be provided within the 30-day time frame; and

notify the individual and the individual's case manager of a new proposed date for provision of the adaptive aid.

For an adaptive aid that is a medical supply and not immediately needed by the individual, the DSA must:

notify the individual and the individual's case manager, orally or in writing, before the five-day time frame expires the adaptive aid will not be provided within the five-day time frame;

provide the reasons why the medical supply will not be provided within the five-day time frame; and

notify the individual and the individual's case manager of a new proposed date for provision of the medical supply.

3540 Minor Home Modification



Once the Service Planning Team (SPT) has agreed the applicant/individual might require a minor home modification, the Direct Service Agency (DSA)DSA must request in writing that the case manager initiate an Individual Plan of Care (IPC) revision that includes funds for obtaining an assessment of the individual by the appropriate licensed professional to determine the specific minor home modification necessary to meet the needs of the individual, as defined in the assessment.

Once DADSHHSC/DADS notifies a DSA through the electronic billing system of a service authorization for an assessment by the appropriate licensed professional of the individual’s need(s), the DSA must obtain the assessment within 30 calendar days after the date DADSHHSC/DADS authorizes the IPC.

After DADSHHSC/DADS authorizes the proposed IPC for payment for the assessment of the individual, the DSA must obtain the specifications from a person who has experience in home modifications within 30 calendar days.

The DSA must:

obtain an assessment of the individual from a licensed professional that describes the specific minor home modification, as described in Appendix II, Minor Home Modification Services. The assessment must include a complete description of the specific need(s) of the individual and recommendations for the minor home modification that will meet the needs identified in the assessment.

provide a copy of the assessment to the Case Management Agency (CMA). obtain the specifications from a person who has experience in constructing home

modifications, based on the assessment completed by the professional. ensure the specifications meet the following standards:

o include a complete description of the minor home modification and any required installations identified in the specifications;

o include a drawing or picture of both the existing room, structure or other area and the proposed modification made to scale;

o be approved in writing by each member of the SPT by completing Form 3849-A, Specifications for Adaptive Aids/Medical Supplies/Minor Home Modifications; and

o comply with the Texas Accessibility Standards promulgated by the Texas Department of Licensing and Regulation unless:

DSA determines it is not structurally feasible to do so and the DSA documents, in writing, the basis for its determination; or

the individual or legally authorized representative (LAR) requests, in writing, the specifications not be in compliance with the Texas Accessibility Standards;

be approved, in writing, by the individual or LAR and the DSA by completing Form 3849-A, as described in Appendix II; and

provide a copy of the specifications to the CMA.

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The CMA, DSA and individual/LAR must complete and sign Form 3849-A to signify agreement with the specifications.

The DSA must obtain comparable bids for a minor home modification from three vendors if the modification costs more than $1,000, within 60 calendar days after obtaining the specifications.


an itemized list of materials and labor necessary to construct the modification; the cost of each material and labor listed; the date of the bid; the name, address and telephone number of the vendor, who may not be a relative of the

individual; a detailed explanation of the vendor's warranty for the modification, if any; and a statement that the minor home modification will be made in accordance with all

applicable state and local building codes.

A DSA may obtain one bid or two comparable bids for a minor home modification if the DSA has written justification for obtaining less than three bids because the minor home modification is available from a limited number of vendors.

If a DSA requests to purchase a minor home modification that is not based on the lowest bid, the DSA must have written justification for payment of a higher bid. The following are examples of justifications that support payment of a higher bid:

the higher bid is based on the inclusion of a longer warranty for the minor home modification; and

the higher bid is from a vendor that is more accessible to the individual than another vendor.

The person who developed the specifications may also offer one of the bids. A DSA may not disclose information regarding a submitted bid to any other vendor who has submitted a bid or to a vendor who may submit a bid.

After the DSA has successfully obtained a sufficient number of bids, the DSA must:

select a vendor to complete construction of the minor home modification; obtain written approval for construction of the modification from the owner of the

property in question, unless such approval is granted in an applicable lease agreement; ensure the selected vendor obtains any required building permits; and advise the CMA regarding the cost of the minor home modification and the cost of the

inspection of the modification, so that an IPC revision can be initiated.

Once DADSHHSC/DADS notifies a DSA through the electronic billing system of a service authorization for a planned minor home modification and the cost of the inspection of the modification, the DSA must direct the vendor to begin construction of the modification within

seven calendar days after the date DADSHHSC/DADS authorizes the proposed IPC; or the effective date of the IPC as determined by the SPT (whichever is later).

A DSA must ensure a minor home modification is completed within 60 calendar days after the date DADSHHSC/DADS authorizes the proposed IPC that includes the cost of the modification and inspection or the effective date of the IPC as determined by the SPT (whichever is later).

If the DSA determines the minor home modification will not be completed within the time frame required, the DSA must notify the individual or LAR in writing of a new proposed date of completion. The proposed date may not exceed 30 calendar days after the date outlined before.

The DSA must conduct an in-person inspection of the minor home modification within seven business days after it receives information the modification is completed. The inspection may be performed by the person who developed the specifications unless that person is affiliated with the vendor who completed the minor home modification. The inspection will determine if the:

minor home modification has been completed; modification has been made in accordance with the specifications; and quality of workmanship of the modification is adequate.

If the DSA determines the minor home modification meets the conditions of the inspection, the DSA must send a completed Form 8605, Documentation of Completion of Purchase, to the individual's CMA within seven business days after completion of the inspection.

If the DSA determines the minor home modification does not meet the conditions of the inspection, the DSA must ensure the vendor meets the conditions within 30 calendar days after the DSA's determination.

3600 CFC PAS/HAB or CLASS Habilitation Services Documentation


If the individual receives CFC PAS/HAB or CLASS habilitation services as part of their service plan, the DSA must document and maintain the following in the individual record (except for items that are not relevant):

the need for specific CFC PAS/HAB or CLASS habilitation tasks; standing physician's orders for any delegated tasks; the provider's annual assessment of the person's ability to manage their own CFC

PAS/HAB or CLASS habilitation services; any training and/or other support provided including support management to the

individual to enable the individual to manage their own CFC PAS/HAB or CLASS transportation-habilitation services;

individual’s participation in support management services; conflicts/problems between the individual and the CFC PAS/HAB or CLASS

transportation-habilitation staff, and how these conflicts/problems were resolved; and


annual documentation of the satisfaction with CFC PAS/HAB or CLASS transportation-habilitation using Form 3599, Habilitation Service Provider Orientation/Supervisory Visits.

Tasks performed by CFC PAS/HAB or CLASS transportation-habilitation provider attendants must be provided with proper regard for the individual's health, safety, welfare and personal autonomy. CFC PAS/HAB must be performed in a manner that comports with the individual’s personal, cultural or religious preferences.

The DSA must provide CFC PAS/HAB services that meet the individual's needs as specified in the IPC and IPP. The individual or LAR must be afforded an informed choice of settings, techniques and objectives. The individual or LAR may request CFC PAS/HAB services be modified to accommodate individual needs.

CFC PAS/HAB must be provided in community settings; that is, places where the individual lives or works and in settings similar to these. The training must teach skills the individual can practice and apply in daily life.

If any of the following services are provided, the DSA must evaluate and document the effectiveness at least once per quarter:

habilitation training services, prevocational services, employment assistance, or supported employment services.

The evaluation must include an assessment of the individual's progress, evolving needs and plans to address identified needs.

The DSA must also inform the case manager of any significant changes in the service plan and provide the case manager with quarterly service summaries of the individual's progress and needs.

The DSA must provide habilitation CFC PAS/HAB training services that meet the individual's needs as specified in the IPC and IPP. The individual or LAR must be afforded an informed choice of settings, techniques and training objectives. The individual or LAR may request training be modified to accommodate individual needs.

Training must be provided in community settings; that is, places where the individual lives or works and in settings similar to these. The training must teach skills the individual can practice and apply in daily life. The habilitation trainer must provide and document the following in the individual's record, if relevant:

evaluations of progress and needs; times, dates and content of training; observable and measurable goals and objectives of training;


evidence of how training is integrated with other services such as residential habilitation and therapies; and

individual involvement in choosing the training program.

Form Resources

The following forms may need to be completed:

Form 2067 , Case Information Form 3596 , PAS/Habilitation Plan - CLASS/DBMD/CFC Form 3597 , CLASS – Habilitation Training Plan Form 3599 , Habilitation Service Provider Orientation/Supervisory Visits Form 3621 , CLASS/CFC – Individual Plan of Care Form 3625 , Documentation of Services Delivered Form 8606 , Individual Program Plan (IPP)

3700 Money Management/Trust Fund


The SPT will address the individual's need for money management assistance. If an individual requires assistance with money management, this can be addressed during completion of Form 3596, PAS/Habilitation Plan - CLASS/DBMD/CFC.

Individuals receiving CLASS and CFC services will be encouraged to practice responsible personal money management. If the DSA maintains the individual's finances, it must do so in a way that protects the financial interests of the individual receiving CLASS and CFC services.

Individuals receiving CLASS and CFC services will be encouraged and allowed to manage their own finances, whenever possible.

Individuals who are capable of managing their own finances will:

receive training by the DSA as needed to enable them to do so; and establish a secure place to store cash.

If the individual does not manage his own funds, the DSA must explain in writing why the individual is unable to perform the activity and what steps are being taken to increase the individual's independence. The provider must also maintain the funds in accordance with trust fund requirements as noted in 40 TAC §19.405, Additional Requirements for Trust Funds in Medicaid-certified Facilities.

3800 Changes in Individual Status











The DSA must report changes in an individual's status within 24 hours of awareness of the change to the case manager on Form 2067, Case Information.

The following are examples of changes in the individual's condition or circumstances that require notification to the case manager:

the individual no longer needs services; the individual is admitted to the hospital; the individual is discharged from a hospital; problems exist with family relationships that impact service delivery; the individual is evicted or otherwise loses their housing that impacts service delivery; the individual relocates; the individual has an illness or injury that impacts service delivery; and the individual loses Medicaid eligibility.


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