Individualized Skills and Socialization

Preparing for an Inspection

Computer Based Training

Day Activity and Health Services

(DAHS)

Long-term Care Regulation

Health and Human Services Commission

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 Learning Objectives

The information contained in this Computer Based Training (CBT) seeks to help an Individualized Skills and Socialization Provider prepare for an inspection.

In this course you will prepare for inspection by:

• Identifying the inspection process found in Module 1.
• Identifying the general requirements which a provider must maintain compliance with, which include employee background checks, rights of individuals, reporting and required postings found in Module 2.
• Identifying the program requirements which a provider must maintain compliance with, which include staffing, staff qualifications, and accidents found in Module 3.
• Identifying the emergency plan requirements which a provider must maintain compliance with, which include the definitions, administration, eight core functions and staff training found in Module 4.

 Disclaimer

In 2014, the Centers for Medicare & Medicaid Services (CMS) issued regulations governing the settings in which Medicaid home and community-based services (HCBS) are provided. To comply with the regulations, HHSC will replace existing day habilitation services in the waiver programs with a new service for individuals with intellectual and developmental disabilities. This new, more integrated service is called individualized skills and socialization. These waiver programs are authorized by CMS in accordance with §1915(c) of the Social Security Act and relate to the following:

• DBMD program--Deaf Blind Multiple Disabilities program
• HCS program--Home and Community-based Services program
• TxHmL program--Texas Home Living program

 Introduction

Long-term Care Regulation (LTCR) conducts inspections which ensure that providers follow the requirements stated in the Texas Administrative Code (TAC) rules under a Day Activity and Health Services (DAHS) license in Title 26 Part 1, Chapter 559 Subchapter H.

These program services must also meet the standard set forth in §§260.503, 262.903 and 263.2003 (relating to description of individualized skills and socialization services) of Title 26. These rules are also in the process of being finalized and not yet published.

Inspection Process

Module One

 Inspection Process

When preparing for an inspection it is important to have all the required documentation and information accessible for the inspectors. Inspections are unannounced and you must ensure that you as a provider maintain compliance at all time. The inspection process that HHSC follows is divided into six tasks. An overview of the inspection process is listed below.

The inspection tasks include:

• Presurvey Preparation Task 1
• Entrance Conference Task 2
• Information Gathering Task 3
• Decision-Making Task 4
• Exit Conference Task 5
• Formation of the Statement of Violations Task 6

 Presurvey Preparation

During presurvey preparation an inspector will review the Texas Unified Licensing Information Portal (TULIP). TULIP is the database for provider information which includes:

• Address/location-onsite or offsite
• Administrator/alternate name
• License status/expiration date
• Census
• Last survey
• Complaints or incidents

Upon entering your location, the inspector will compare the information gained through their review against information gathering during the inspection.

For example, upon entry the inspector discovers you have a different administrator from the one listed in TULIP. If HHSC was not notified of this change, the inspector would cite you for failing to notify HHSC of this change.

 Entrance Conference

Upon arrival the inspector will request a place to meet for the entrance interview/conference. At each phase of the inspection process HHCS staff is gathering information to determine compliance.

During the entrance interview/conference the inspector will request the following:

• An area to work
• Unrestricted access to the clinical records
• Identity of the staff who can respond to questions
• Access to a photocopy machine

During the entrance interview/conference the inspector will provide the administrator general information which includes:

• Purpose of visit
• Timeframes
• What you can expect during the inspection

While not an all-inclusive list, the inspector may request the following:

• Census information
• List of individuals received services
• List of discharged individuals
• Organizational chart and structure
• Employee list and contact information
• Policies and procedures manual
• Complaint logs

 Information Gathering

During this phase of the inspection a variety of information is collected. The inspector may choose a sample of individuals based on your census. Depending upon the information collected, the inspector could expand the sample to include other individuals based on potential noncompliance. The inspector uses observations, interviews and record reviews to gather information. Besides the clinical record, the inspector may review records such as policies, transportation logs, personnel files, infection control logs, or medication administration records.

In addition to observation, interviews and record review, the inspector may also use diagrams, take photos and take written statements. The inspector will compare his/her findings with the rules. He/she will assess if those finding violated the rules.

The inspector may also be investigating complaints or incidents. The inspector will review factors such as:

• Did the incident occur at a specific time?
• Did the incident involve a specific staff member or multiple staff?
• Did the incident occur on a specific day of the week or across multiple weeks?

The inspector will communicate with you on a daily basis. The inspector will not alert you to specific individuals until the investigation has been completed unless there is an immediate threat identified.

If an immediate threat to the health and safety of any individual is compromised, there are steps the inspector must follow prior to notifying you. In the event a threat is identified you will be provided instructions on the specific nature of the threat and you must take steps to mitigate or remove the threat.

 Decision Making

During this phase of the process an inspector will gather all the information collected and analyze it. Based on the observations, interviews and record reviews the inspector evaluates the finding and determines if you have noncompliance.

The inspector will conduct the following actions in this phase of the inspection:

1. Examine any contradictions or inconsistencies in the evidence
2. Use professional judgment regarding inconsistencies
3. Weigh motives, values and biases in the evidence
4. Make determinations using supporting documentation
5. Justify conclusions with supporting documentation
6. Determine the severity of the violation

 Exit Conference

Before the exit conference the inspector will complete the preliminary findings list, HHSC Form 3701. The goal of the preliminary findings list is twofold. First, it is used to note the areas of potential noncompliance and provide enough information to inform you of issues identified during the inspection. Second, the list will provide you areas of noncompliance to immediately begin making corrections.

An exit conference is a meeting between the inspector and key staff. During the meeting the following tasks occur:

• Presentation of the preliminary findings of noncompliance
• Inspector may answer any questions about the rules
• Education on the timeline requirements for the Plan of Correction (PoC) and the Informal Dispute Resolution (IDR) process

 Formation of the Form 3724 Statement of Violations

Upon exit, the inspector completes the process by writing the findings of noncompliance on HHSC Form 3724. This form will be sent to you along with other information and instructions.

These instructions will provide information on how to complete your PoC and submit an informal dispute. Remember a PoC is not optional. You must develop a PoC for each citation. Preparing a PoC does not constitute guilt and you are still required to prepare a PoC even if you are planning on disputing the violations.

Module 2

§559.225 General Requirements

 Employee Background Check

According to § 559.225, you must comply with the provisions of Texas Health and Safety Code (HSC), Chapter 250 relating to Nurse Aide Registry (NAR), employee misconduct registry (EMR) and criminal history background checks. Before offering employment, search both the EMR and NAR to determine if a person is designated in either registry as unemployable. Both registries can be accessed at the HHS website.

Requirements for background checks include:

• Before hire conduct a search of the NAR and EMR to determine employability
• Provide information to employees regarding the background check (See 26 TAC §561.3)
• Conduct a search of the NAR and EMR at least every twelve months
• Retain the initial and annual background searches in the employee's personnel file
• Comply with all relevant federal and state standards
• Comply with all applicable provisions of the Human Resource Code (HRC), Chapter 102

 Rights of the Elderly

According to §559.225, you must provide an individual who is 55 years of age and older with a written list of the individual's rights, as outlined under HRC §102.004, Rights of the Elderly ; and protect and promote the rights of the individual.

Rights of the elderly include the following:

• Right to be treated with dignity and respect
• Right to make individual choices
• Right to be free from abuse, neglect or exploitation
• Right to designate a guardian or representative
• Right to be free from corporal punishment
• Right to be free from physical or chemical restraints
• Right to communicate in a language they desire
• Right to make complaints regarding care and treatment
• Right to privacy
• Right to participate in activities
• Right to manage their financial affairs
• Right to access medical records
• Right to choose physician and be informed of care
• Right to refuse treatment
• Right to have personal possessions
• Rights regarding discharge

 Reporting Abuse, Neglect and Exploitation (ANE) and Critical Incidents

According to § 559.225, you must:

• Report abuse, neglect, exploitation, and critical incidents (See §559.241)
• Maintain incident reports
• Ensure the confidentiality of records and other information
• Inform the individual orally and in writing of the individual's rights, responsibilities and grievance procedures in a language the individual understands

 Required Postings

According to §559.225, you must prominently and conspicuously post for display in a public area of the on-site location that is readily available to individuals, employees, and visitors the following information:

• License
• Complaint procedures
• Availability of inspection reports
• HHSC toll-free number
• Copy of the most recent inspection report
• Hours of operation
• Holidays
• Description of activities
• Emergency telephone numbers, including the abuse hotline telephone number, near all telephones

Module 3

§559.227 Program Requirements

 Staff Qualifications

Director Requirements

According to §559.227, you must employ a qualified director who is at least 18 years old with a high school diploma or equivalency. In the event of the director's absence you must have a policy which delegates the responsibilities of the director.

If the director does not have the high school diploma, then he/she must have documentation of a proficiency evaluation based on a written competency-based assessment which includes the delivery and observations of him/her providing services. In addition, the director must have at least three personal reference from persons not related by blood that indicate the ability to provide a safe, healthy environment.

Transportation Driver Requirements

• Valid driver's license
• Transport individuals in a vehicle insured in accordance with state law

Service Provider Requirements

• Must be 18 years or older
• High School Diploma or equivalent
• Proficiency evaluation based on a competency-based assessment
• Three personal references indicating the ability to provide a safe healthy environment

 Staffing

Staffing is an important resource to ensure you meet the needs of the individuals you serve. You must be able to meet the needs of each individual you admit. According to §559.227, you must ensure that an individual whose needs cannot be met is not admitted or retained.

Off-site and During Transport

According to §260.507, §260.917 and §260.2017, you must maintain a ratio of staff to individuals receiving services off-site and during transportation.

On-site

According to §559.227, there must be sufficient staff on duty at all times to ensure the following occurs based on the individual's needs:

• Health and safety
• Supervision
• Individual plan of care
• Individual program plan
• Person-directed plan
• Implementation plan

 Staff Responsibilities

The following are the main responsibilities of staff who provide individualized skills and socialization for individuals:

Director

• Manages onsite services
• Trains and Supervises Staff
• Maintains all records

Service provider

• Delivers services
• Assist with activities
• Provides supervision

 On-site and Off-Site Services

If you are an onsite provider, you must make off-site individualized skills and socialization available to an individual. You must not require an individual to take a skills test or meet other requirements to receive off-site individualized skills and socialization. If an individual does not want to participate in any activity you must document the decision not to participate in the individual's record. In addition, providers must have a community engagement plan with the information included below.

 Onsite Services:

• Must be provided in a building that is owned or leased by you.
• Must not be provided in a residence of an individual or another person, unless provided in an event open to the public.

Offsite Services:

• Must be provided in a community setting of the individuals choosing
• Must include transportation.
• Must not be conducted at an on-site location, residence of an individual or another person unless provided in an event open to the public.

Community Engagement Plan Requirements

• A plan of how you will make off-site individualized skills and socialization available to individuals.
• A plan how you will work with contracted program providers to obtain information from individuals' person-directed plans (PDP) and use that information to inform on-site and off-site activities that are aligned with an individual's PDP.
• A plan of how staff will respond to an emergency or other unexpected circumstance that may occur during the provision of on-site and off-site individualized skills and socialization to ensure the health and safety of all individuals.

 Training

You must conduct initial and ongoing training. Staff must be trained within three days of hire on the emergency response plan and staff must have the remainder of the eight-hour required training completed within the first three months. You must also provide a minimum of eight-hour training annually in the required subjects below.

Initial Training:

• Emergency response plan
• Cardiopulmonary Resuscitation (CPR)
• First aid
• Safe body functions and mechanics
• Personal care techniques and procedures
• Overview of the population served
• Identification and reporting of ANE

Ongoing Training:

• CPR
• Emergency response plan responsibilities (See §559.229)
• Infection control policies and procedures
• Identification and reporting of ANE

 Medication Administration

If an individual cannot or chooses not to self-administer their medications, you must ensure the individual's medications are administered by a licensed person.

You must ensure that medications are recorded, including over-the-counter medications, on the individual's medication profile record. The recorded information must be obtained from the prescription label and must include:

• Name
• Strength
• Dosage
• Doses received
• Directions for use
• Route of administration
• Prescription number
• Pharmacy
• Date issued

 Medication-General

You must immediately report to an individual's program provider any unusual reactions to a medication or treatment.

When you as a provider supervise or administer medications, you must document in writing if an individual does not receive or take the medication and treatment as prescribed. The documentation must include the date, time, dose, name and strength of the medication missed.

 Medication-Storage

You must provide a locked area for all medications, which may include a central storage area or medication cart. Each individual's medication must be stored separately within the storage area.

Refrigerated Medication

You must store medication requiring refrigeration in a locked refrigerator that is used only for medication storage or in a separate, permanently attached, locked medication storage box in a refrigerator.

Poisonous Substances

You must store poisonous substances and medications labeled for "external use only" separately within the locked area.

Schedule II Drugs

You must store drugs covered by Schedule II of the Controlled Substances Act of 1970 in a locked, permanently attached cabinet, box, or drawer that is separate from the locked storage area for other medications.

 Accident, Injury or Acute Illness

You must stock and maintain in a single location in the on-site location first aid supplies to treat burns, cuts, and poisoning. A provider that only delivers off-site individualized skills and socialization must ensure these first aid supplies are immediately available at all times during service provision. You must create and enforce written policies and procedures for infection control, including the spread of disease to ensure staff compliance with state law, Occupational Safety and Health Administration (OSHA), and Centers for Disease Control and Prevention (CDC).

In the event of accident or injury to an individual requiring emergency care, or in the event of death of an individual, you must:

• Make arrangements for emergency care or transfer to an appropriate place for treatment.
• Immediately notify an individual's program provider.
• Describe and document the accident, injury, illness and final disposition on a separate report.

Module 4

§559.229 Emergency Response Plan

 Emergency Response Plan: Definitions and Administration

Definition

According to §559.229, an emergency situation does not include a situation that arises from the medical condition of an individual such as cardiac arrest, obstructed airway, cerebrovascular accident but means an impending or actual situation that:

• Interferes with normal activities
• May cause injury or death
• May cause damage to property

Administration

An individualized skills and socialization provider must:

• Develop and implement a written emergency response plan
• Maintain a written copy of the plan that is accessible to all staff at all times
• Evaluate and revise the plan within 30 days after an emergency situation or annually
• Revise the plan within 30 days after information included in the plan changes

Emergency Response Plan: Requirements  

An emergency response plan must include:

• Risk assessment of all potential internal and external emergency situations relevant to your operations and geographical area
• Description of the services and assistance needed
• Eight core functions of emergency management
• Fire safety plan

 Emergency Plan: Eight Core Functions

Direction and control

You are required to designate by name or title the emergency preparedness coordinator (EPC) who is the staff person with the authority to manage the response to an emergency.

You will also designate by name or title the alternate EPC who is the staff person with the authority to act as the EPC if the EPC is unable to serve in that capacity.

You are required to document the name and contact information for the local emergency management coordinator (EMC) for the area where you are located, as identified by the office of the local mayor or county judge document   and coordination with the local EMC as required by the local EMC's guidelines relating to emergency situations.

 Eight Core Functions (Continued)

Warning

Your plan must contain a section for warning that includes the following:

• Describes how the EPC will be notified of an emergency situation
• Identifies who and when the EPC will notify of an emergency situation
• Ensures monitoring of local news and weather reports

 Eight Core Functions (Continued)

Communication

Your plan must identify the primary and alternate mode of communication to be used in the event of an emergency situation. The plan must include procedures for maintaining a current list of telephone numbers for individuals, their program providers, EPC and where staff can obtain this list quickly. The plan must describe how you will provide information to the public, staff, individuals or others associated with your plan.

Overall communication must include not only immediate needs to provide information but the ongoing dissemination of information such as the following:

• Notification to staff about an emergency situation
• Notification to any receiving facility about an impending or actual evacuation
• Notification to individuals, LARs, and other persons about an emergency situation
• General information to the public, such as the change in location, hours or closure
• Anyone who is transporting individuals to a secure location during an evacuation
• Notification to HHSC an emergency situation that caused the death or serious injury of an individual.

Note: In the event of a death or serious injury you must notify HHSC in the following manner and timeframes:

• Within 24 hours by calling 1-800-458-9858
• Within five working days a written investigation report on Form 3613A

 Eight Core Functions (Continued)

Sheltering-in-place

If you provide on-site services, then you must include in the plan a section that includes procedures to shelter individuals in place during an emergency situation.

Eight Core Functions (Continued)

Evacuation

If you provide on-site services, then you must post building evacuation routes prominently throughout the location, except in small, one-story buildings where all exits are obvious. The evacuation plan must include specific information about where the individuals are being evacuated too and who will be responsible during the evacuation.

The following procedures are required:

• Pre-arranged location to evacuate
• Mutual aid agreement with a receiving facility
• Primary and alternate evacuation destinations and routes which includes a map
• Staff accompany evacuating individuals
• Process to ensure no persons are present in the building after evacuation
• Individuals and staff are accounted for after they have been evacuated including those who are absent
• EMC is notified regarding evacuation and is contacted, if required to find out if it is safe to return
• Safety procedures to re-enter and occupy the building after an evacuation
• Notification of HHSC by telephone, at 1-800-458-9858, within 24 hours after an evacuation
• Notification of the HHSC Regulatory Services regional office within 48 hours of evacuation and return

 Eight Core Functions (Continued)

Transportation

If you provide on-site services, then you must have a plan that includes procedures for an effective evacuation. Both individuals and needed supplies must arrive at the receiving facility at the same time. Not only must you ensure the safe transport of individuals but also the following:

• Records
• Food
• Water
• Equipment
• Supplies

 Eight Core Functions (Continued)

Health and Medical Needs

You must identify all of the individuals with special needs including individuals with conditions requiring assistance during an evacuation; and ensure the needs of those individuals are met during an emergency.

 Eight Core Functions (Continued)

Resource Management

You must include in your plan procedures for the following:

• Accessing medications, records, food, water, equipment and supplies
• Identifying staff who are assigned to locate and ensure the transportation of items
• Ensuring medications are secure and stored at the proper temperatures during an emergency situation

 Emergency Response Plan: Training

According to §559.229, you must train staff on the emergency response plan both upon hire, annually and if the plan changes. If you offer on-site services, you must conduct unannounced drills with staff for severe weather and other emergency situations identified by the results of the risk assessment. You must complete specific task related to training. See the information below for the requirements.

You must have the following training, documentation and processes:

• Fire drill at least once every 90 days at expected and unexpected times and under varying conditions
• Relocate, during the fire drill, to a predetermined location where participants must remain until a recall or dismissal signal is given
• Complete the HHSC Fire Drill Report Form for each required fire drill
• Conduct a monthly fire prevention inspection performed by a trained and senior staff member and document the inspection results
• Maintain copies of the fire prevention inspection report, within the last 12 months
• Post a copy of the most recent fire prevention inspection report, in a conspicuous place

 Conclusion

If you have any questions about this CBT, please contact the Policy and Rules Section at (512) 438-3161 or by email at LTCRPolicy@hhs.tx.gov.