Post acute brain injury services are provided for consumers with residual cognitive deficits - including behavioral and communication deficits - following acquired brain injury. Provision of these services is to reduce or eliminate the impact of these deficits, which enables the consumer to live as independently as possible and, if applicable, become employed.
A provider of post acute brain injury services is referred to in this chapter as a Community Rehabilitation Program (CRP).
In addition to the standards in this chapter, a post acute brain injury services provider also must comply with the standards in Chapter 1, Basic Standards for All Community Rehabilitation Programs.
A Case Manager collaborates with the interdisciplinary treatment team and external entities to assess, coordinate, implement, and evaluate all services required to meet a consumer's needs. This collaboration results in high-quality, cost-effective outcomes.
Cognitive Rehabilitation Services focus on development of cognitive skills - the ability to perceive, recognize, conceive, judge, imagine and reason - lost or altered as a result of neurological damage. The aim of treatment is to enhance a consumer's functional competence in real-world situations. The process includes direct retraining, use of compensatory strategies, and/or use of cognitive tools.
Cognitive Rehabilitation Services must be provided directly or supervised by:
An Individual Treatment Plan is a written document developed by the interdisciplinary treatment team for each consumer - based on individual needs - that includes at least the following elements:
The Interdisciplinary Treatment Team (ITT) is the group of individuals directly involved in the planning and delivery of consumer services. The ITT includes, at a minimum:
Other professional or paraprofessional members, such as vocational specialists, or physical, occupational or speech therapists, may be part of the ITT, as determined by the needs of each consumer.
Post-acute brain injury services are advanced rehabilitation services provided through an interdisciplinary team approach. Services are based on an assessment of the individual's cognitive deficits. The goal of treatment is to achieve functional changes in a consumer with a brain injury by reinforcing, strengthening, or re-establishing previously learned patterns of behavior and/or establishing new patterns of cognitive activity or compensatory mechanisms. Specific services may include, but are not limited to:
A therapeutic pass is a planned activity for which the consumer is away from the residential facility for an entire day—up to 24 hours. The purpose of the therapeutic pass is to facilitate a consumer's transition from the residential facility to the home and community. Staff from the residential facility are available to provide guidance and instruction—usually by phone—for a consumer, a consumer's family or others while a consumer is on a therapeutic pass.
Services are provided by qualified individuals and in accordance with the Individualized Treatment Plan.
Job Coaches must have
A neuropsychiatrist must be licensed by the State Board of Medical Examiners and certified in psychiatry by the American Medical Specialty Board, with specialized training/experience in the area of brain injury.
A neuropsychologist must be licensed by the State Board of Psychological Examiners, with specialized training/experience in the area of brain injury.
A paraprofessional is a person qualified, through experience or training or a combination thereof, to provide services for persons with brain injury. The paraprofessional:
The vocational specialist must have:
Related work experience is defined as job duties that include job information/placement, vocational assessment, and a general knowledge of brain injury.
At least one staff person must be available for every six consumers when treatment is provided.
An approved post acute brain injury services CRP must have policies addressing abuse, exploitation and neglect, and have procedures that provide for:
Refer to abuse, exploitation and neglect standards (paragraph 1-0440) in Chapter- 1, Basic Standards for All Community Rehabilitation Programs, Centers for Independent Living, and Special Providers of Rehabilitation Services, for additional requirements.
Each staff member of the ITT, as appropriate, assesses a consumer's abilities and limitations in relation to his or her specific area of expertise. The case manager compiles the results of this assessment into a written report within 30 days of a consumer's admission into the program. Copies of the final report are provided to each member of the ITT.
The assessment must address each of the following areas:
The ITT meets after the assessment is completed, but no later than 30 days after a consumer's admission to the program. This meeting is to develop the Individualized Treatment Plan.
The Individualized Treatment Plan is based on the findings of the assessment and must address all deficit areas noted therein. The planned Cognitive Rehabilitation Services are noted on the Individualized Treatment Plan.
The goals and objectives on the Individualized Treatment Plan are specified in measurable terms, and relate to increasing a consumer's functional ability to live more independently and, if applicable, to achieve an employment outcome.
The DARS DRS representative and the consumer's representative, if applicable, are notified at least one week in advance of the date, time and location of this meeting.
A copy of the assessment report and the Individualized Treatment Plan are provided to the DARS DRS representative within 10 working days after this ITT meeting. A copy is available to the consumer and the consumer's representative. Results of the assessment and the Individualized Treatment Plan may be combined into a single report. This report is signed, at a minimum, by the case manager and the consumer or the consumer's representative. The provider must be able to verify by fax, email, post, or signature of the DARS representative that the report was available to DARS within 10 working days of the ITT meeting.
Services are provided as necessary to achieve the goals and objectives listed on the Individualized Treatment Plan.
The scope and intensity of services relate to the unique needs of each consumer in order to provide a safe, comprehensive rehabilitation program.
When physical rehabilitation services are needed as part of the Individualized Treatment Plan, the CRP either provides these services directly or arranges for the provision of these services by licensed practitioners.
Available vocational services must include:
Job coaching, when necessary, is provided or arranged. When job-coaching services are provided by the CRP, DARS3458, Job Coach Service(s) Time Log, or equivalent, must be completed and a copy provided to the DARS DRS representative.
A schedule of daily activities, which address the goals identified in the Individual Treatment Plan, must be developed and made available to each consumer. Copies of all schedules for each consumer must be made available to DARS DRS counselors or monitors for review.
The CRP may use restraint as an emergency measure only if absolutely necessary to protect the consumer or others from injury.
The provider's policy must include the provision of training in appropriate physical restraint procedures and techniques for staff members with direct consumer contact. Procedures must identify training provided to all staff members at hire and at least annually thereafter.
Each time a consumer is restrained—whether on an emergency basis or as part of a behavior management plan—a written report must document the details surrounding the incident. This written report must be filed in the consumer file maintained by the CRP. Each report must be reviewed by the ITT at the next scheduled monthly team meeting to determine whether modifications to the treatment plan are needed.
If restrictive procedures are used as a behavior modification technique,
Use of chemical restraints to control inappropriate behavior must not be initiated until it can be justified that the harmful effects of the behavior clearly outweigh the potentially harmful effects of the restraint. The physician and the ITT must monitor such chemical restraint programs closely for desired responses and adverse consequences.
Each time a consumer is restrained, a written report must document the details surrounding the incident. This written report must be filed in the consumer file maintained by the CRP. Each report must be reviewed by the ITT at the next scheduled monthly team meeting to determine whether modifications to the treatment plan are needed.
The ITT meets formally at least monthly to:
All members of the ITT routinely participate in this meeting, and their attendance must be documented. The DARS DRS representative and the consumer's representative, if applicable, participate in this meeting when available.
The DARS DRS representative and the consumer's representative, if applicable, must be notified of the date, time and location of this meeting at least one week in advance.
The Individualized Treatment Plan must be reviewed at each monthly meeting by the Interdisciplinary Treatment Team and may be modified as necessary at that time.
Adjustments to the Individualized Treatment Plan, including discharge planning, are made as necessary.
The results of this meeting are documented in a written report and a copy of the report is provided to the DARS DRS representative within 10 working days after the meeting. A copy must be available to the consumer and/or the consumer's representative.
The ITT may, in addition to the required monthly meeting, meet as frequently as prudent and necessary to maintain an effective treatment program.
A discharge summary must be developed for each consumer and a copy provided to the DARS DRS representative within 10 working days after services are completed or terminated.
The discharge summary must include:
When residential services are provided, the CRP also must meet the following standards.
All residential post-acute brain injury CRPs that do business with DARS DRS must be licensed by at least one of the following regulatory agencies, as appropriate:
The license requirement may be waived for a residential chemical dependency treatment facility that has documentation from the former Texas Commission on Alcohol and Drug Abuse, now the Texas Department of State Health Services, Mental Health and Substance Abuse Division, of exemption as a state agency from its licensure requirements.
All residential post-acute brain injury CRPs that do business with DARS DRS must administer Mayo-Portland Adaptability Inventory (MPAI-4) surveys on all DARS consumers. The MPAI must be administered at the following times:
The CRP must report the survey results quarterly to the CRS program specialist.
All residential post-acute brain injury CRPs that do business with DARS DRS must maintain accreditation from the Commission on Accreditation of Rehabilitation Facilities (CARF), or Disease-Specific Care Certification in Brain Injury Rehabilitation from The Joint Commission (TJC). CRPs doing business with DARS that do not already meet this requirement are granted until August 2013 to obtain the accreditation or certification.
New CRPs doing business with DARS that do not already meet this requirement are granted up to two years from the date of their DARS contract for post-acute brain injury services to obtain the accreditation.
During evenings, nights, and weekends, at least two staff members—awake, on duty, and on-site—must be available for every 20 or fewer consumers.
The CRP must have a system for tracking the location of consumers 24 hours a day.
This system must include:
Consumers are allowed up to three therapeutic passes per month with reimbursement to the CRP at the contracted per diem rate.
The therapeutic pass must be planned in advance and included in the Individualized Treatment Plan.
The CRP will not be reimbursed for those days a consumer is away from the residential facility where a therapeutic pass is not planned on the Individualized Treatment Plan, or for therapeutic passes in excess of three per month.
The CRP must provide an adequate balanced diet three times a day, seven days a week. Menus or meal plans must be reviewed and approved by a designated staff member with responsibility for the adequacy and variety of the diet, preferably a dietitian or nutritionist. In the event a consumer is away from the facility at meal time—except for therapeutic pass—provision must be made for the consumer to have meals.
Consumers who apply for Food Stamps, or providers that apply for Food Stamps on behalf of consumers, must disclose information regarding DARS DRS sponsorship to the Department of Human Services. This information must include the monthly amount of assistance provided for room and board. Possible eligibility for this assistance will not proportionally reduce the monthly amount of DARS DRS sponsorship.
The physical plant must be large enough to comfortably house the number of residents to be served. Adequate space for sleeping, eating, cooking, living, and provision of rehabilitation services must be available.
Bedrooms, whether single, double, triple, or quadruple, must be large enough to allow space for a bed, and each consumer must have access to a dresser, closet, table, and chair without crowding the occupants.
The number of square feet per occupant must be in accordance with local building codes, but must be at least 60 square feet per resident in multiple occupant sleeping rooms and not less than 80 square feet in single occupant sleeping rooms.
There must be a clear floor space at least 30 inches by 48 inches that allows either a forward or parallel approach by a person using a wheelchair. Closets must have a clothes rack with 48 inches forward reach or 54 inches side reach.
There must be one or more living rooms. Each living room must be large enough to seat residents comfortably with sufficient space allowed for such articles as television, radio, and reading material.
Any consumer so desiring must have access to a locked storage area or drawer for private articles. A key to this storage area must be provided to an authorized staff member of the facility.
There must be one or more offices conveniently located that provide privacy for interviewing or counseling.
Space must be allowed for cabinets, dish storage, etc., in the dining or kitchen areas.
Toilets, bathtubs, and showers must provide for individual privacy, unless supervision is required as documented in the Individualized Treatment Plan.
Showers must be 36 inches by 36 inches or tub size and have a spray unit with a hose at least 60 inches long and a seat 17 to 19 inches from the floor. Grab bars are required in showers and tubs.
A facility must ensure that transportation, if offered to residents, is safe and accessible. Access to transportation must be available in accordance with the ADA and all applicable state laws. Each vehicle used to transport consumers must have
The Federal Transit Administration in Washington, D.C., has information on transportation accessibility, including small passenger vans. Contact the administration at (888) 446-4511 or (800) 877-8339 (TTD/Relay).
Home- and community-based service providers must meet the following standards.
All home- and community-based CRPs that do business with DARS DRS and are not licensed for residential services must be licensed by the Texas Department of Aging and Disability Services (DADS) as a home and community support services agency.
All home- and community-based CRPs that do business with DARS DRS must administer Mayo-Portland Adaptability Inventory (MPAI-4) surveys on all DARS consumers. The MPAI must be administered at the following times:
The CRP must report the survey results quarterly to the CRS program specialist. An MPAI-4 is not required at referral when the consumer has participated in another residential post-acute brain injury program sponsored by DARS within the previous 90 days.