SECTION 263.106. LON Assignment

(a) A LIDDA must request an LON for an applicant from HHSC at the time an applicant is enrolled into the HCS Program. The LON is requested by entering the information from a completed ID/RC Assessment, that includes the recommended LON and is signed and dated by the service coordinator, in the HHSC data system and electronically submitting the information to HHSC. The electronically submitted ID/RC Assessment must contain information identical to the information on the signed and dated ID/RC Assessment.

(b) A program provider must request an LON for an individual from HHSC in accordance with this subsection.

(1) Before the expiration of an ID/RC Assessment, the program provider must enter the information from the completed ID/RC Assessment in the HHSC data system and electronically submit the information to HHSC that includes the recommended LON and is signed and dated by the program provider.

(2) The program provider must ensure the information from the completed ID/RC Assessment entered in the HHSC data system and electronically submitted contains information that is identical to the information on the signed and dated ID/RC Assessment.

(3) The program provider must, within three calendar days after submission, provide the service coordinator with a copy of the signed and dated ID/RC Assessment.

(4) If applicable, the program provider must submit supporting documentation to HHSC as required by §263.107(c) of this chapter (relating to HHSC Review of LON).

(c) For an LON requested in accordance with subsection (b) of this section, within seven calendar days after the program provider enters the information from the completed ID/RC Assessment in the HHSC data system and electronically submits the information:

(1) the service coordinator or a LIDDA representative other than the service coordinator must review the ID/RC Assessment in HHSC data system and enter in the HHSC data system:

(A) the service coordinator's name and date; and

(B) whether the service coordinator agrees or disagrees with how the ID/RC Assessment was entered in the HHSC data system; and

(2) if the service coordinator disagrees with how the ID/RC Assessment was entered in the HHSC data system, the service coordinator and program provider must resolve the disagreement.

(d) If the service coordinator disagrees with the ID/RC Assessment for a reason other than how the ID/RC Assessment was entered in the HHSC data system, the service coordinator must notify the individual, LAR, HHSC, and the program provider of the service coordinator's disagreement in accordance with HHSC instructions.

(e) The service coordinator's agreement or disagreement is considered in HHSC review of an ID/RC Assessment submitted in accordance with subsection (b) of this section.

(f) The program provider must maintain documentation supporting the recommended LON in the individual's record.

(g) HHSC assigns an LON to an individual based on the individual's ICAP service level score, information reported on the individual's ID/RC Assessment, and required supporting documentation. Documentation supporting a recommended LON must be submitted to HHSC in accordance with HHSC guidelines.

(h) HHSC assigns one of five LONs as follows:

(1) an intermittent LON (LON 1) is assigned if the individual's ICAP service level score equals 7, 8, or 9;

(2) a limited LON (LON 5) is assigned if the individual's ICAP service level score equals 4, 5, or 6;

(3) an extensive LON (LON 8) is assigned if the individual's ICAP service level score equals 2 or 3;

(4) a pervasive LON (LON 6) is assigned if the individual's ICAP service level score equals 1; and

(5) regardless of an individual's ICAP service level score, a pervasive plus LON (LON 9) is assigned if the individual meets the criteria set forth in subsection (j) of this section.

(i) An LON 1, 5, or 8, determined in accordance with subsection (g) of this section, is increased to the next LON by HHSC, due to an individual's dangerous behavior, if supporting documentation submitted to HHSC proves that:

(1) the individual exhibits dangerous behavior that could cause serious physical injury to the individual or others;

(2) a written behavior support plan has been implemented that meets HHSC guidelines and is based on ongoing written data, targets the dangerous behavior with individualized objectives, and specifies intervention procedures to be followed when the behavior occurs;

(3) more service providers are needed and available than would be needed if the individual did not exhibit dangerous behavior;

(4) service providers are constantly prepared to physically prevent the dangerous behavior or intervene when the behavior occurs; and

(5) the individual's ID/RC Assessment is correctly scored with a "1" in the "Behavior" section.

(j) HHSC assigns an LON 9 if supporting documentation submitted to HHSC proves that:

(1) the individual exhibits extremely dangerous behavior that could be life threatening to the individual or to others;

(2) a written behavior support plan has been implemented that meets HHSC guidelines and is based on ongoing written data, targets the extremely dangerous behavior with individualized objectives, and specifies intervention procedures to be followed when the behavior occurs;

(3) management of the individual's behavior requires a service provider to exclusively and constantly supervise the individual during the individual's waking hours, which must be at least 16 hours per day;

(4) the service provider assigned to supervise the individual has no other duties during such assignment; and

(5) the individual's ID/RC Assessment is correctly scored with a "2" in the "Behavior" section.

(k) An LON 1, 5, or 8, determined in accordance with subsection (g) of this section, is increased to the next LON by HHSC, due to an individual's high medical needs, if:

(1) the individual has an ID/RC Assessment reflecting a frequency code of "6" in the "Nursing" section;

(2) a completed HHSC Level of Need (LON) Review/Increase Cover Sheet form is submitted to HHSC; and

(3) supporting documentation described in subsection (l) of this section submitted to HHSC with the cover sheet form proves that the individual requires 181 minutes or more per week of:

(A) a nursing service listed in §263.5(a)(14) - (17) of this chapter (relating to Description of HCS Program Services) provided in person;

(B) in-person nursing services provided by another source; or

(C) a combination of the nursing services described in subparagraphs (A) and (B) of this paragraph.

(l) The following supporting documentation must be submitted to HHSC as described in subsection (k)(3) of this section:

(1) a completed HHSC Medical Increase Worksheet - HCS Program Only form, identifying:

(A) a description of the ongoing medical condition requiring the individual to receive 181 minutes or more of in-person nursing services per week;

(B) a description of the in-person treatments that need to be provided to the individual and the in-person nursing tasks that need to be performed for the individual;

(C) the frequency of a nursing task that needs to be performed and the amount of time required to complete the nursing task; and

(D) if applicable, extenuating circumstances that may contribute to the individual's need to receive 181 minutes or more of in-person nursing services per week;

(2) the individual's most current:

(A) implementation plan for the nursing services listed in §263.5(a)(14) - (17) of this chapter that are provided in person;

(B) ICAP assessment booklet and computer scoring sheet;

(C) PDP; and

(D) comprehensive nursing assessment;

(3) nursing notes of all in-person nursing services provided to the individual within the immediate 30 days before the date the ID/RC Assessment is electronically submitted to HHSC;

(4) service planning notes relating to the individual's ongoing medical issues completed within the immediate 365 days before the ID/RC Assessment is electronically submitted to HHSC;

(5) any professional assessments that discuss the changes in the individual's medical condition or changes in needed medical interventions completed within the immediate 365 days before the date the ID/RC Assessment is electronically submitted; and

(6) other documents evidencing that the individual requires 181 minutes or more of in-person nursing services per week, such as:

(A) focused or quarterly nursing assessments;

(B) physician's orders;

(C) medication administration records; and

(D) treatment sheets, if used.

(m) A program provider must conduct an ICAP assessment in accordance with this subsection.

(1) A program provider must conduct an ICAP assessment of an individual:

(A) within three years after the individual's enrollment and every third year thereafter;

(B) if changes in the individual's functional skills or behavior occur that are not expected to be of short duration or cyclical in nature; or

(C) if the individual's skills and behavior are inconsistent with the individual's assigned LON.

(2) If the results of an ICAP assessment demonstrate that the individual's LON assignment may not be accurate, the program provider must submit a completed ID/RC Assessment to HHSC recommending a revision of the individual's LON assignment.

Source Note: The provisions of this §263.106 adopted to be effective March 1, 2023, 48 TexReg 1080