Community Attendant Services Act of Texas

Introduced by:

Referred to Committee on:

Date:

Subject: Long term services; personal assistance; home and
community personal attendant services; coordination of services

Statement of purpose:  This bill proposes to provide people with
disabilities and older Texans with a choice in long term service
options.  It will provide home and community-based long-term
services by establishing a statewide program of home and community
personal attendant services; redirecting long-term care dollars and
redesigning regulations to encourage home and community personal
attendant services in lieu of institutional services; and require
that home and community personal assistance service programs
conform to principles ensuring consumer control, choice of service
models, availability to eligible recipients, and eligibility based
on functional needs, not medical diagnosis, type of disability, or
age.

AN ACT RELATING TO THE CREATION OF A COMPREHENSIVE SYSTEM OF
HOME AND COMMUNITY PERSONAL ATTENDANT SERVICES.

It is hereby enacted by the 76th Legislature of the State of
Texas:

Sec. 1. DEVELOPMENT OF HOME AND COMMUNITY PERSONAL ATTENDANT
SERVICES PROGRAM; TYPES OF SERVICES OFFERED

(a) The long term services agency shall develop a comprehensive
program of home and community personal attendant service that
provides:

     (1) Personal care services including, but not limited to,
assistance with: bathing and personal hygiene, dressing,
grooming, lifting and transferring, feeding, bowel and bladder
care, and child care;

     (2) Household services, including but not limited to,
assistance with: meal preparation, shopping, cleaning, and
laundry;

     (3) Cognitive services including, but not limited to,
assistance with: money management, use of medications, and cueing
with activities of daily living (A.D.L.s):

     (4) Services to assist consumers with mobility, including
but not limited to, escort and driving;

     (5) Respite services;

     (6) Health-related tasks including, but not limited to,
medical tasks that can be done by an unlicensed person or
delegated to an unlicensed person by a licensed health
professional according to the Texas Nurse Practices Act and the
Texas Medical Practices Act.  Such tasks include but are not
limited to: administration of medications, ventilator care, tube
feeding, catheterization, and bowel care;

     (7) Where needed, other services designed to assure the well-
being of the recipient, such as case management, training,
assistance meeting developmental needs, crisis assistance, and
assistance with implementing behavioral plans.

(b) The program shall be based on the premise that recipients who
so desire should be able to avoid nursing home and other
institutional placement and choose their own preferred mode of home
and community long term care.  The program shall offer recipients
options in home and community personal attendant services that
maximize consumer-direction in all models of care.

Sec. 2. DEFINITIONS

(a) Activities of daily living (A.D.L.s). Personal care
activities that are routinely part of daily living, including but
not limited to: eating, toileting, dressing, grooming, personal
hygiene, bathing, and transferring.

(b) Agency. The agency of long term services.

(c) Agency provider service option. Method of service provision
whereby the personal assistant is hired, supervised and evaluated
by an agency, which is the personal assistant's employer of
record.
 
(d) Consumer. Recipient of home and community personal attendant
services.

(e) Consumer-directed. Mode of service delivery that allows the
recipient of home and community personal attendant services (the
consumer) maximum control to select, manage, train, and dismiss
his/her personal assistants regardless of who the employer of
record is. Allows the consumer control over manner in which
services are delivered.

(f) Direct cash reimbursement option. Method of service provision
whereby the consumer receives reimbursement for the costs of home
and community personal attendant services and associated employer
taxes.

(g) Fiscal intermediary.  An Internal Revenue Service designate who
acts as the employer's agent to perform such acts as are required
by the IRS of employers, such as income taxes, FICA, unemployment
taxes.

(h) Functional need.  Need for personal assistance based on
abilities and limitations of individual consumer, regardless of
age, medical diagnosis, or other category of disability.

(i) Health-related tasks. Tasks to preserve and/or improve health
that can safely be performed by a qualified unlicensed person or
delegated to a qualified unlicensed person by a health
professional, e.g. dispensing medication, ventilator care and
tube feeding.

(j) Independent living environment. An individual's non-
institutional residence, or other setting where the individual
participates in community activities, including but not limited
to: education, work, recreation, and community events.

(k) Home and community personal attendant services.  Action to
assist a person with a mental and/or physical disability in
accomplishing activities of daily living (A.D.L.s), instrumental
activities of daily living (I.A.D.L.s) and health-related tasks.
These include but are not limited to: Personal care services,
household services, cognitive services, personal safety services,
mobility services, and health-related tasks.

(l) Instrumental activities of daily living (I.A.D.L.s).
Activities that support the activities of daily living, including,
but not limited to: taking medications, managing money, preparing
meals, shopping, child care, light housekeeping, using the
telephone, or getting around the community.

(m) Personal attendant. Individual who directly provides personal
assistant services.

(n) Respite services.  Support options that are provided
temporarily for purpose of relief for a primary care giver in
providing care to individuals with disabilities who are of all
ages.

(o) Voucher service option. A method of service provision whereby
consumer receives vouchers from the state to pay for home and
community personal attendant services.


Sec. 3. DEVELOPMENT OF PROGRAM SERVICES; TRANSITION PLAN

     (a) The Health and Human Services Commission, in consultation
with the State Independent Living Council and the Texas Planning
Council for Developmental Disabilities, shall convene a Transition
Plan Implementation Committee to include consumers and family
members, advocates, individuals, state agency representatives (from
the Department of Human Services, Texas Mental Health and Mental
Retardation Authority, Texas Department on Aging, the Texas
Rehabilitation Commission and the Texas Department of Health) and
agency service providers to assist in the development and
implementation of the transition plan to move from the current
service system to one focused on home and community personal
attendant services.  The plan shall be developed by January 1,
1998, be based on principles and standards described in this Act,
and, at a minimum, shall --

     (1) Designate a lead long term services agency for the
delivery of home and community personal attendant services;

     (2) Create a home and community personal attendant services
policy board (Long Term Service Agency), appointed by the governor,
made up of a majority of people with disabilities with additional
representation composed of family members of people with
disabilities and advocates, to assist the state in the design,
implementation and evaluation of the state's home and community
personal attendant services program;

     (3) Outline a transition process, with action steps and
timelines, describing how the state will move from institutional
services to home and community personal attendant services that
are, in the aggregate, more cost-effective and responsive to the
desires and preferences of recipients;

     (4) Describe a process for consolidating all non-
institutional home and community programs funded through the
Medicaid program, the Medicaid waiver program, Title III of the
older Americans Act, Title XX Social Services Block Grant and the
state General Revenue by January 1, 2000;

     (5) Describe the type of home and community personal
attendant services to be provided;

     (6) Describe the methods of delivery of home and community
personal attendant services and how such services will be provided
statewide;

     (7) Evaluate the feasibility of further reducing costs and
addressing recipient needs and preferences through the provision
of auxiliary services such as durable medical equipment, assistive
technology and home modifications;

     (8) Describe an intake process that will be uniform
throughout the state;

     (9) Describe the comprehensive functional assessment tool that
will be used to determine eligibility;

     (10) Describe the standards and mechanisms for co-
payment/cost sharing and methods used to determine income of
people with disabilities;

     (11) Determine quality assurance outcomes and safeguards
against physical, emotional or financial abuse, and exploitation;

     (12) Describe the appeals process; and
     (13) Describe how the barriers and disincentives that
currently discourage people from becoming personal assistants
(e.g. low wages, lack of benefits, lack of certification
standards) will be removed; and

     (14) Address issues of provider and recipient liability
including but not limited to concerns, of the Internal Revenue
Service, fiscal intermediaries, Workman's' Compensation, and the
Occupational Safety and Health Administration.

Sec. 4. PROGRAM STANDARDS; ELIGIBILITY; ELIGIBILITY DETERMINATIONS

     (a) All non-institutional home and community personal
attendant services programs funded through or by the agency shall
meet the following minimum standards --

     (1) To the maximum extent possible, consumers who so desire
shall select, manage, and control their home and community
personal attendant services and have consistency of services
despite the method of service delivery.

     (2) Eligibility shall be based on functional needs, not
medical diagnosis, type of disability, or age.

     (3) Services will be provided in consumers' homes and other
independent living environments including, but not limited to,
school, work, church and recreational settings.

     (4) The service system shall be capable of providing
personal assistance 24 hours a day, 7 days a week, and, when
necessary, a pool of attendants for selection purposes,  back-up
and emergency home and community personal attendant services.

     (5) Co-payments and cost-sharing will be required of
consumers whose adjusted gross incomes exceed 225% of the federal
poverty level. However, co-payments and cost-sharing requirements
will be structured so that they are not a disincentive to
employment.

     (6) Each consumer's program of services will be based upon a
mutually-agreed upon, signed individual services plan jointly
developed by the consumer and the agency. Consumers will be given
an opportunity to choose between different service delivery options
including vouchers, consumer-directed individual provider models,
and consumer directed agency models. To the maximum extent
possible, consumers will be able to select and/or hire whomever
they choose as personal assistants, including family members.

     (7) Consumers will be offered optional training on how to
select, manage, and dismiss personal assistants as well as how to
manage finances for their home and community personal attendant
services.
     (8) All providers of home and community personal attendant
services shall assure that consumers are fully informed of and
accorded their rights and options with respect to selecting,
managing, and changing their home and community personal attendant
services and their rights to privacy and confidentiality.
Consumers who are dissatisfied with the administration of their
personal assistance program shall have a right to switch providers
and appeal to the lead long term services agency.

     (9) All persons providing personal assistance, regardless of
whether they are employed under a consumer-directed individual
provider model or consumer-directed agency model, shall be paid
at least 150% of the minimum wage or a comparable daily rate and
be offered health insurance and other benefits.

     (b) Eligibility for home and community personal attendant
services under this act shall be for persons of all ages who:

     (1) Are individuals with a cognitive, psychiatric, sensory,
and/or physical disability and who:

     (2) Have a functional need that limits ability to perform
one or more activities of daily living (A.D.L.s); or

     (3) Have a functional need that need limits ability to
perform two instrumental activities of daily living (I.A.D.L.s);
or

     (4) Require substantial supervision, episodic or short-term
crisis assistance, or;

     (5) Need assistance with the performance of health-related
tasks.

     (c) A comprehensive functional assessment of home and
community personal attendant services needs shall be made for each
applicant to determine eligibility for services and the applicant's
ability to perform each activity of daily living and each
instrumental activity of daily living.  The applicant's self-
evaluation of his or her needs and abilities shall be an integral
part of this assessment.

     (d) The long term services agency shall establish a
comprehensive functional instrument to assess eligibility for home
and community personal attendant services subject to the approval
of the personal assistance policy board described in Section 3 of
this Act.

Sec. 5. INDIVIDUALIZED SERVICE PLANS

     (a) An initial individualized plan of services shall be
developed for each consumer of home and community personal
attendant services as the time of assessment. The individualized
plan of services shall --
     (1) Be developed with the person with a disability of the
individual's representative and, when appropriate, family
members;

     (2) Be approved by the person with a disability, or, when
appropriate, his or her representative;

     (3) Be given to the consumer and family in writing or other
appropriate and understandable format;

     (4) Specify --

          (A) Services to be provided;

          (B) Numbers of hours of services to be provided;

          (C) Alternate sources for home and community personal
attendant services (informal support from friends, neighbors, etc.)
used;

          (D) Means to ensure a pool of personal assistants are
available, back-up and emergency home and community personal
attendant services will be provided, and method for consumer to
access these services;

          (E) Method of service delivery (i.e. voucher, agency
provider service option or individual provider service option);

          (F) Frequency of reassessment;

          (G) Means to adjust services and hours when changes
need occur;

          (H) Mechanism to coordinate home and community personal
attendant services with other health care services received by the
individual;

          (I) Degree and frequency of supervision necessary for
the effective delivery of home and community personal attendant
services;

          (J) Amount of CO-pay or cost sharing, if any;

          (K) Outcome measures used to assess the quality of
services;

          (L) Complaint and appeal procedures.

Sec. 6. QUALITY ASSURANCE AND SAFEGUARDS

     (a) The long term services agency shall develop a quality
assurance instrument that will assess service quality for each
consumer.
     (b) The service quality assessment shall be based on the
life outcomes of a person with a disability, including, but not
limited to, integration into the community, increased mobility,
increased productivity and/or self-direction.

     (c) The service quality instrument will also measure the
extent to which the services provided --

     (1) Safeguard the well being of the consumer, recognizing that
risk-taking by the person with a disability is an important
freedom;

     (2) Are developed with meaningful input by the consumer or his
or her representative;

     (3) Achieve the goals specified in the individualized plan
of services; and

     (4) Protect the consumer, to the maximum extent possible,
against abuse, neglect, and exploitation.

Sec. 7. HEALTH-RELATED PERSONAL ASSISTANCE BY QUALIFIED NON-
MEDICAL PERSONNEL

     (a) All personal assistance service delivery options should
provide a mechanism that allows for the delivery of health-
related personal assistance service tasks to people with
disabilities living in an independent living environment
through --

          (1) Physician delegation of tasks to a qualified
unlicensed person; or

          (2) Nurse delegation of tasks to a qualified unlicensed
person; or

          (3) Consumer directed training of unlicensed persons to
provide health-related tasks.

Sec. 7. CO-PAYMENTS FOR SERVICES

     (a) The long term services agency shall develop a mechanism
for co-payment and/or cost sharing for home and community personal
attendant services for consumers whose adjusted gross income is
above 225% of the federal poverty level. Priority in serving
eligible applicants shall be given to consumers whose income is at
or below 225% of poverty.

Sec. 8. REALLOCATION OF LONG-TERM CARE EXPENDITURES

     (a) No later than July 1, 1997, the Health and Human Services
Commission shall sit down with Health Care Finance Administration to
develop a Medicaid waiver that will redirect funds from nursing
homes, Skilled Home Health, Intermediate Care Facility for the
Mentally Retarded (ICF MR), all current 1915(c) waivers, Personal
Care Option and Frail Elderly funding, and state general revenue
funds to appropriate funding for the home and community personal
attendant services described in this Act.

     (b) Funds allocated for home and community based personal
attendant services in Title III of the Older Americans Act and
Title XX Social Services Block Grant shall be used to appropriate
funding for the home and community personal attendant services
described in this Act.

     (c) The funds reallocated from nursing home and ICF MR
services to home and community personal attendant services shall be
realized through a de-commissioning of institutional beds according
to a process developed by the Transition Plan Implementation
Committee.


Sec. 9. TITLE; SHORT FORM

     (a) This Act shall be known as the Community Attendant
Services Act of Texas of 1997.