(a) A nursing facility employee, nursing facility contractor, or nursing facility specialized services provider must report to the LIDDA the identity of any designated resident who expresses an interest in transitioning to the community.
(b) For a designated resident, a nursing facility must designate staff and necessary contractors to be members of the resident's SPT.
(c) A nursing facility must ensure its staff and contractors who are members of a designated resident's SPT:
  (1) attend and participate in the designated resident's SPT meetings as scheduled and convened by the service coordinator;
  (2) contribute to the development of the designated resident's ISP; and
  (3) assist the SPT by:
    (A) monitoring all nursing facility specialized services, LIDDA specialized services and LMHA specialized services, if applicable, provided to the designated resident to ensure the designated resident's needs are being met;
    (B) making timely referrals, service changes, and amendments to the ISP as needed;
    (C) ensuring that the designated resident's ISP, including nursing facility specialized services, nursing facility PASRR support activities, and LIDDA specialized services, is coordinated with the nursing facility's comprehensive care plan;
    (D) if the designated resident has expressed interest in community living:
      (i) developing a transition plan for the designated resident to live in the community; or
      (ii) identifying the action the SPT will take to address concerns and remove barriers to the designated resident living in the community; and
    (E) reviewing and discussing the information included in the ISP and transition plan with key nursing facility staff who work with the resident.
(d) A nursing facility must allow a service coordinator access to:
  (1) a designated resident on a monthly basis, or more frequently if needed; and
  (2) the designated resident's clinical facility records.

Source Note: The provisions of this §554.2706 adopted to be effective July 7, 2015, 40 TexReg 4373; amended to be effective September 10, 2017, 42 TexReg 4468; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871