(a) Pre-initiation activities.
  (1) For each referral for the PHC Program or CAS Program or for each authorization for the FC Program, a supervisor must conduct an evaluation.
    (A) An evaluation must be a single document that includes the individual's self-report of:
      (i) the dates and reasons for any hospitalization within the last three months; and
      (ii) the assistance needed for the individual to perform ADLs and IADLs, including any assistive devices or medical equipment used by the individual.
    (B) If the provider determines during the evaluation that the individual exhibits reckless behavior that results in imminent danger to the health and safety of the individual or provider staff, the provider must convene an Interdisciplinary Team meeting as described in §47.49 of this subchapter (relating to Interdisciplinary Team) to discuss the barriers to service delivery.
  (2) For each referral for the PHC Program or CAS Program, or for each authorization for the FC Program, a supervisor must develop a service delivery plan that:
    (A) is agreed upon and signed by the individual and the provider;
    (B) indicates the location of service delivery; and
    (C) records the following:
      (i) the tasks which the individual is authorized to receive;
      (ii) the total weekly hours of service HHSC authorizes the individual to receive;
      (iii) the service schedule, which must include as necessary, based on an individual's needs, certain time periods for the delivery of specified tasks;
      (iv) frequency of supervisory visits; and
      (v) a statement that:
        (I) only the tasks described in §47.41 of this subchapter (relating to Allowable Tasks), and agreed to on the service delivery plan, may be provided; and
        (II) the provider is not responsible for meeting the applicant's needs other than by providing the tasks described in §47.41 of this subchapter and agreed to on the service delivery plan.
  (3) In the PHC Program or CAS Program, a provider must obtain a complete Practitioner's Statement of Medical Need form and submit the form for HHSC's review as described in §47.47 of this subchapter (relating to Determination of Medical Need).
    (A) Routine referrals.
      (i) A provider must send a copy of a complete Practitioner's Statement of Medical Need form to HHSC before HHSC may authorize an individual to receive services.
      (ii) A provider must send a copy of the form by fax, secure email, or mail.
    (B) Expedited referrals.
      (i) HHSC may authorize services for an individual if the provider notifies HHSC that the provider has received a complete practitioner's statement that documents the individual's medical condition is the cause of the individual's functional impairment.
      (ii) After notification that a provider has the completed practitioner's statement described in clause (i) of this subparagraph, HHSC and the provider will negotiate a service initiation date.
      (iii) For HHSC to pay a provider beginning on the negotiated service initiation date, the provider must send the complete practitioner's statement to HHSC within 7 working days after service initiation.
      (iv) If a provider does not send the complete practitioner's statement to HHSC within 7 working days after service initiation, HHSC does not pay the provider until HHSC receives the completed practitioner's statement. In this circumstance, HHSC changes the service initiation date to the date HHSC receives the completed practitioner's statement.
      (v) The signature date of the practitioner must be on or before the negotiated service initiation date.
(b) Service delivery plan variances.
  (1) A provider in the PHC Program and CAS Program must notify the case worker when the initial service delivery plan developed by the provider:
    (A) has more hours than the number of hours on the referral portion of HHSC's Authorization for Community Care Services form; or
    (B) has no ADLs.
  (2) A provider in the FC Program must:
    (A) notify the case worker when the initial service delivery plan developed by the provider has more hours than the number of hours authorized on HHSC's Authorization for Community Care Services form; and
    (B) provide services according to HHSC's Authorization for Community Care Services form until the provider receives a new form from the case worker.
(c) Pre-initiation activities due date. A provider must:
  (1) in the PHC Program or CAS Program complete the pre-initiation activities as follows:
    (A) for routine referrals, within 14 days after one of the following dates, whichever is later:
      (i) the referral date on HHSC's Authorization for Community Care Services form; or
      (ii) the date the provider receives the referral, unless the provider fails to stamp the receipt date on HHSC's Authorization for Community Care Services form, in which case the referral date will be used to determine timeliness; and
    (B) for expedited referrals, by the date negotiated between the case worker and provider, which must be less than 14 days after the oral request; and
  (2) in the FC Program, complete the pre-initiation activities within 14 days after the provider receives HHSC's Authorization for Community Care Services form.
(d) Delay in pre-initiation activities.
  (1) A provider may delay meeting the due dates in subsection (c) of this section only for reasons beyond its control such as natural or other disasters. The provider must continue efforts to complete pre-initiation activities and set a date, if possible, for completion of pre-initiation activities.
  (2) A provider must document any failure to complete the pre-initiation activities for routine referrals by the due date, including:
    (A) the reason for the delay;
    (B) either the date the provider anticipates it will complete the pre-initiation activities or specific reasons why the provider cannot anticipate a completion date; and
    (C) a description of the provider's ongoing efforts to complete pre-initiation activities.
  (3) A provider must notify the case worker of any failure to complete the pre-initiation activities for expedited referrals before the negotiated date for completion of pre-initiation activities. The case worker may refer the individual to another provider.
(e) Documentation of pre-initiation activities.
  (1) A provider may combine the evaluation and service delivery plan into a single document, but each item must be clearly identifiable.
  (2) A provider must maintain documentation of the pre-initiation activities in the individual's file.

Source Note: The provisions of this §277.45 adopted to be effective June 1, 2004, 29 TexReg 5113; amended to be effective June 1, 2009, 34 TexReg 2802; amended to be effective October 1, 2019, 44 TexReg 5138; transferred effective July 1, 2024, as published in the June 14, 2024, issue of the Texas Register, 49 TexReg 4436