As of 10/1/2017, this manual has been retired. For current policies, procedures, and standards for the Texas Workforce Commission Vocational Rehabilitation Division, please refer to the following manuals:

In this manual, references to DARS now refer to TWC. The manual includes both links to public content and links to content available only to staff.

Chapter 5: Standards for Post-Acute Brain Injury Service Providers

Entire chapter revised and replaced 09/01/2015

5.1 Overview

The Post-Acute Brain Injury (PABI) Services Standards for Providers chapter is the official reference document of provider requirements for contracted goods and services for the Division for Rehabilitation Services Vocational Rehabilitation (VR) PABI program.

The VR program PABI service arrays may be provided to eligible consumers diagnosed with traumatic brain injury and other types of acquired brain injuries with a stable or slowly progressive prognosis and the desire and potential for employment following the completion of short term, time-limited VR services. Policy excludes a diagnosis of acquired brain injury due to cancer unless the cancer has been treated and is in remission with a good prognosis as per the DARS3112 completed by the consumer's oncologist.

PABI services are available in residential and non-residential settings. There are two service types, including core and ancillary, although not all services within these service types will be used for each consumer.

Services are based on an assessment of the individual's needs. The goal of post-acute brain injury services for VR consumers is to establish new patterns of cognitive activity and compensatory mechanisms in order to achieve a specific employment outcome.

This standards chapter is available online; the website is VR's preferred method of providing access to the post-acute brain injury standards and all revisions. The service arrays also indicate the service modality (that is, whether the service is provided on an individual basis, group basis, or both), and what the general required provider qualifications are. See PABI Brain Injury Service Arrays by Setting from Texas Health and Human Services. Additional provider qualifications for some VR services are stated in the standards below.

Revisions to these standards are made periodically, and a log noting all revisions is available online. Each provider is contractually responsible for maintaining compliance with the most recent VR standards.

If you have questions about the DRS Standards for Providers, you can contact a DARS standards specialist by emailing: DRSStandards@twc.state.tx.us.

If you need a printed copy of the DRS Standards for Providers, you can contact the DARS Inquiries Unit by:

Phone: Toll-free 1-800-628-5115
Email: DARS.Inquiries@twc.state.tx.us
Fax: (512) 424-4730
Mail: DARS Inquiries Unit, 4800 N. Lamar, MC 1416, Austin, TX 78756

5.2 Definitions

The following definitions apply unless the context clearly indicates otherwise:

Abuse
the negligent or willful infliction of injury, unreasonable confinement, intimidation, or threat thereof, or cruel punishment with resulting physical or emotional harm or pain; or sexual abuse, including any involuntary or nonconsensual sexual conduct that would constitute the offenses of indecent exposure or assault, committed by the person's caretaker, family member, or other individual who has an ongoing relationship with the person.
Acquired Brain Injury
An acquired brain injury is an injury to the brain, which is not hereditary, congenital, degenerative, or induced by birth trauma. An acquired brain injury is an injury to the brain that has occurred after birth. Examples of acquired brain injury include stroke, an injury caused by an external force, near drowning, hypoxic or anoxic brain injury, tumor, neurotoxins, electric shock or lightning strike.
Agency
Department of Assistive and Rehabilitative Services (DARS) or its successor agencies.
Ancillary services
Goods and services that support VR post-acute brain injury services but are not primary interventions. Examples of ancillary services include supplies, medications, and transportation.
Aquatic therapy
A type of therapy that involves an exercise method in water to improve a person's range of motion, flexibility, muscular strength and toning, cardiovascular endurance, fitness, and/or mobility.
Art therapy
A type of therapy in which persons use art media, the creative process, and the resulting artwork to explore their feelings, reconcile emotional conflicts, foster self-awareness, manage behavior, develop social skills, improve reality orientation, reduce anxiety, and/or increase self-esteem.
Audiological services
Evaluation and treatment of hearing, balance, or related disorders.
Behavior management
A set of coordinated services that provide a person with specialized interventions designed to increase adaptive behaviors and to reduce maladaptive or socially unacceptable behaviors, up to and including violent dyscontrol, that prevent or interfere with the person's inclusion within the home environment and the community.
Case management
Services that assist consumer in the planning, coordination, monitoring, and evaluation of services with emphasis on quality of care, continuity of services, and cost-effectiveness.
Case manager
A case manager collaborates with the interdisciplinary team and external entities to assess, coordinate, implement, and evaluate all services required to meet a consumer's needs.
Certified professional
A person with the knowledge, experience, and skills to perform a specific job who is paid for performing that job. The person's expertise is verified by a certificate earned by passing an exam that is accredited by an organization or association that monitors and upholds prescribed standards for the profession involved. Examples of certified professionals include a certified brain injury specialist, certified nursing assistant, certified medical assistant, certified medication aide, and certified nurse aide.
Chemical dependency services
Planned services that are structured to help a person abstain from using drugs and/or alcohol. Services include identifying and changing behavior patterns that are maladaptive, destructive, or injurious to health and which are related to or result from substance-related disorders, and identifying and changing behavior patterns to restore appropriate levels of physical, psychological, and social functioning.
Cognitive rehabilitation therapy (CRT)
A type of therapy that helps a person to learn or relearn cognitive skills that have been lost or altered due to a traumatic brain injury. Services enable the person to compensate for lost cognitive functions and include reinforcing, strengthening, or reestablishing previously learned patterns of behavior or establishing new patterns of cognitive activity or compensatory mechanisms for impaired neurological systems.
Core services
A set of fundamental services that are essential to rehabilitation of persons who have a traumatic brain injury. Specific core services are based on assessed individualized needs.
Dietary and nutritional services
Services that develop a prescribed diet to meet basic or special therapeutic nutritional needs.
Durable medical equipment and supplies
Equipment that provides therapeutic benefits to a person whose medical conditions require the equipment and supplies.
Exploitation
The illegal or improper act or process of a caretaker, family member, or other individual who has an ongoing relationship with a person with a disability and uses the resources of the person, including social security number and other identifying information, without his or her informed consent, for monetary and/or personal benefit, profit, or gain.
Family and caregiver education and training services
Information that provides a foundation for relationships with a person who has a traumatic brain injury or traumatic spinal cord injury, or both.
Family therapy
A specialized type of psychotherapy that helps families and caregivers in intimate relationships to nurture healing and development.
Group therapy
A type of therapy with two or more persons in addition to a therapist who have a common therapeutic purpose or a common goal to achieve.
Home modification
The use of assistive or adaptive equipment or devices that may be installed in a person's home to enable the person to perform household tasks. This equipment must be removable from the residence without causing permanent damage to the property. Examples include grab bars in bathrooms or portable ramps for persons who use wheelchairs or who have other mobility impairments.
Interdisciplinary team (IDT)
A team of professionals that coordinates services to achieve treatment goals in order to minimize a consumer's physical or cognitive disabilities and to maximize functional capacity.
Individual therapy
A collaborative process between a therapist and one person that is intended to facilitate change and improve quality of life.
Individualized Plan for Employment (IPE)
A formal plan of services for consumers who have been determined eligible for vocational rehabilitation. The IPE provides details about the services that will be arranged, purchased, and or provided to assist the consumer in reaching a specific employment outcome. Services and goals are based on an assessment of the individual's unique strengths, resources, priorities, concerns, abilities, capabilities, interests, and informed choice.
Individualized Program Plan (IPP)
A document developed by the interdisciplinary team for each consumer, based on individual needs, that includes at least the following elements: long-term and short-term goals and objectives; the treatment modalities to be used in achieving these goals and objectives; the individual(s) responsible for each treatment modality; the target date by which each goal and objective is to be achieved; and the discharge plan.
Licensed professional
A person who has completed a prescribed program of study in a health field and who has obtained a license indicating his or her competence to practice in that field. Examples of licensed professionals include a registered nurse, physician, and social worker.
Limited skilled-nursing
Skilled-nursing for a limited time. This service involves providing or delegating personal care services and medication administration consistent with rules established by the Texas Board of Nursing; assessing a patient to determine the care required; and delivering temporary skilled-nursing services for minor illness, injury, or emergency for a period not to exceed 30 days.
Massage therapy
A type of therapy involving the manipulation of soft tissue by hand or through a mechanical or electrical apparatus for therapeutic purposes. Massage therapy constitutes a health care service if the massage therapy is for therapeutic purposes.
Medical services
Services or supplies that are needed for the diagnosis or treatment of medical conditions.
Mental restoration services
Limited or short term psychiatric services, including treatment and psychotherapy, for mental conditions that are stable or slowly progressive.
Music therapy
A type of therapy using musical or rhythmic interventions to restore, maintain, or improve a person's social or emotional functioning, mental processing, or physical health.
Neglect
The failure of a caretaker or facility, through indifference or carelessness, to provide goods or services, including medical services, that are necessary to avoid physical or emotional harm or pain.
Neuropsychological and neuropsychiatric services
A comprehensive battery of tests to evaluate neurocognitive, behavioral, and emotional strengths and weaknesses and their relationship to normal and abnormal central-nervous-system functioning.
Occupational therapy
A type of therapy using evaluation and treatment to develop, recover, or maintain the daily living skills of persons who have a physical, mental, and/or cognitive disorder consistent with the Occupational Therapy Practice Act, Occupations Code.
Orthosis
A custom-fabricated or custom-fitted medical device designed to provide for the support, alignment, prevention, or correction of a neuromuscular or musculoskeletal disease, injury, or deformity, consistent with the Orthotics and Prosthetics Act, Occupations Code.
Over-the-counter medication
Medication that can be obtained without a prescription.
Paraprofessional
A person to whom a particular aspect of a professional task is delegated, but who is not licensed as a fully qualified professional. A paraprofessional is qualified, through experience, training, or a combination thereof, to provide services. Paraprofessionals must have, at a minimum, a high school diploma or its equivalent.
Personal assistance services
Services provided in a residential setting to a person who needs prompts and hands-on supports to participate in services. Services may include, but are not limited to, providing order, safety, and cleanliness assistance; assisting with medication or therapeutic regimens; preparing and serving meals; assisting with laundry; providing supervision and care to meet basic needs; and ensuring evacuation in case of an emergency.
Personal attendant care services
Services provided in a home setting to persons with approved medical needs only, and only when provision of services in the home setting is necessary to enable the person to participate in VR service arrays, which may include assistance with toileting routines, transferring, bathing, dressing, medications, meals, and activities of daily living.
Physical restoration services
Services that correct or substantially modify, within a reasonable period of time, a physical condition that is stable or slowly progressive.
Physical therapy
A type of therapy that prevents, identifies, corrects, or alleviates acute or prolonged movement dysfunction or pain of anatomical or physiological origin.
Post-acute brain injury (PABI)
A brain injury at the post-acute stage, which is when the patient is medically stable and deemed ready to engage in intensive rehabilitation.
Post-acute brain injury services
Services provided as recommended by an interdisciplinary team to address deficits in functional and cognitive skills based on individualized assessed needs. Services may include behavior management, the development of coping skills, and compensatory strategies. These services may be provided in a residential or nonresidential setting.
Prescription medication
A medicine that legally requires a medical prescription to be dispensed.
Prosthesis
A custom-fabricated or custom-fitted medical device used to replace a missing limb, appendage, or other external human body part but that is not surgically implanted, consistent with the Orthotics and Prosthetics Act, Occupations Code. Accordingly, the term includes an artificial limb, hand, or foot.
Provider type
A term that refers to the types of service providers within the VR program, consisting of certified professionals, licensed professionals, and paraprofessionals.
Recreational therapy
A type of therapy involving recreational or leisure activities that assist in the restoration, remediation, or rehabilitation of a person's level of functioning and independence in life activities and that promote health and wellness and reduce or eliminate the activity limitations associated with traumatic brain injury, traumatic spinal cord injury, or both.
Rehabilitation technology
Equipment or technology designed to help persons with disabilities perform tasks that would otherwise require assistance.
Room and board
Shelter, facilities, and food, including the customary and usual diets in residential settings and any prescribed nutritional meals or supplements.
Service arrays
A set of services provided to eligible persons who have a post-acute brain injury. Services are based on assessed individualized rehabilitation needs.
Speech-language pathology
The application of nonmedical principles, methods, and procedures for measurement, testing, evaluation, prediction, counseling, habilitation, rehabilitation, or instruction related to the development and disorders of communication, including speech, voice, language, oral pharyngeal function ,or cognitive processes, for the purpose of evaluating, preventing, or modifying or offering to evaluate, prevent, or modify those disorders and conditions in an individual or a group, consistent with the Orthotics and Prosthetics Act, Occupations Code.
Therapeutic pass
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 members 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.
Traumatic brain injury (TBI)
An injury to the brain that is not degenerative or congenital and is caused by an external physical force, which may produce a diminished or altered state of consciousness, resulting in temporary or permanent impairment of cognitive abilities and/or physical functioning, and partial or total functional disability and/or psychosocial maladjustment.
Transportation
Travel and related expenses.
Vision services
A sequence of neurosensory and neuromuscular activities individually prescribed and monitored by a doctor to develop, rehabilitate, and enhance visual skills.

5.3 Licensure, Certification, and Accreditation

5.3.1 Overview

Division for Rehabilitation Services Vocational Rehabilitation (VR) purchases services only from providers that are in compliance with the appropriate standards in this manual and applicable federal and state licensing standards and/or certification. Each provider is required to undergo an enrollment approval process, and periodic monitoring ensures continued compliance with these standards. These standards apply only to services purchased by VR. Providers who enroll must demonstrate the ability to deliver all core services in the service array of choice. Delivery may be direct or via a third party. Not all services will be provided to all consumers.

5.3.2 Adding Services or Changing Service Locations

Once in place, the provider contract must list the facility physical location(s), if applicable, and the provider services that have been determined to be in compliance with these standards. If there is any change in the physical locations, or if you wish to offer additional service arrays, the contract manager must first determine that those changes comply with the relevant standards. A contract amendment must be developed and signed by both parties at least 60 days before the initiation of new services, or of services at a new location.

5.3.3 Licensure by Other Agencies

All residential post-acute rehabilitation facilities that do business with the Division for Rehabilitation Services Vocational Rehabilitation (VR) program must be licensed by at least one of the following regulatory agencies, as appropriate:

All nonresidential post-acute rehabilitation facilities that do business with VR and are not licensed by DADS as an ALF or as a nursing facility, or by DSHS as a hospital or chemical dependency center, must be:

5.3.4 Accreditation

All residential post-acute brain injury facilities that do business with Division for Rehabilitation Services Vocational Rehabilitation (VR) must maintain accreditation from the Commission on Accreditation of Rehabilitation Facilities (CARF), from the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), or from the Disease-Specific Care Certification in Brain Injury Rehabilitation Program.

New facilities doing business with VR that do not already meet this requirement are granted up to two years from the date of their VR contract for post-acute brain injury or post-acute spinal cord injury services to obtain the accreditation.

5.4 Program Monitoring

5.4.1 Ongoing Monitoring

Designated state agency staff members continuously monitor services provided to consumers and make regular on-site visits to provider facilities, which may include review of case files.

The monitoring process is focused on compliance with the contract for the provision and delivery of the contracted services. Ongoing monitoring includes, but is not limited to, the following:

5.4.2 On-Site Monitoring

All providers are subject to periodic administrative, programmatic and financial monitoring by agency staff members. Each fiscal year, the state and region assess providers to identify which will be monitored on-site during a 12-month period. If you are selected for an announced monitoring review, the lead monitor sends you a letter announcing the review, providing information about the scope of the review and instructions about how to prepare for it. As the Division for Rehabilitation Services Vocational Rehabilitation determines the need, providers that are not identified on the risk assessment may also be monitored.

5.4.3 Unannounced On-Site Monitoring Visits

Agency staff members may conduct an unannounced monitoring review if the Division for Rehabilitation Services Vocational Rehabilitation determines it necessary.

5.4.4 Monitoring Visit

The monitoring review may consist of:

5.4.5 Report of Monitoring Results

The lead monitor sends you a report about the results of the monitoring review after it is completed. This report:

5.4.6 Corrective Action Plan

You must, by the date requested in the report of findings:

The monitoring team reviews the CAP and may accept the CAP or recommend changes to it.

If you do not submit an acceptable CAP or make financial restitution when required, the agency may take adverse action against you in accordance with the contract.

5.4.7 Monitoring Closeout

If there are no findings, or when the monitoring team accepts the corrective action plan, the monitoring review is closed. A letter is sent to the provider documenting this result.

5.5 Organization and Administration

5.5.1 Records

You must make available to all agency staff members all documents, papers, and records related to the consumer.

Your records must document compliance with applicable Division for Rehabilitation Services Vocational Rehabilitation standards. These records must be:

5.5.2 Consumer Case Records

You must maintain records necessary to:

You must keep a current case record for each consumer; the case record must include the following:

All documentation relating to the VR consumer must include, but is not limited to, the following:

5.5.3 Confidentiality of Consumer or Employee Information

To protect the integrity and dignity of each consumer, staff members must maintain confidentiality with respect to consumer or employee information, per the Health Insurance Portability and Accountability Act (HIPPA), as applicable. The provider must have policy and procedures in place that facilitate access to confidential records.

You must develop and maintain a recordkeeping system that includes a separate record for each consumer, and you must keep confidential all information contained in the consumers' records, regardless of the form or storage method of the records.

You must develop and use physical safeguards for confidential records and ensure that the records are available to authorized staff members only. Consumer case records must be locked in a location where maximum protection against fire, water damage, and other hazards is in place.

5.5.4 Staff Ratios

The facility must provide sufficient direct-care staff members per state licensure requirements to manage and supervise consumers in accordance with their individual program plans (IPP). You must have enough direct-care staff members to provide care and services so that consumers do not injure themselves, others, or destroy property. Special staffing needs identified by the IPP (for example, one-to-one ratios) must be provided. Adequate numbers of direct care staff members must be available to supervise consumers during periods of time when other direct care staff members are unavailable (for example, during breaks, meals, meetings, training, etc.).

5.5.5 Staff Training

Staff members who provide direct services must receive, before assuming any job responsibilities and at least annually thereafter, in-service training in the following areas:

5.5.6 Substance Abuse

If the Division for Rehabilitation Services Vocational Rehabilitation (VR) consumer has a substance abuse disability and there are observations or other evidence of the consumer's use of alcohol or drugs, you must report the observations and evidence immediately to the VR counselor. You must maintain documentation that the counselor was informed of all observations and other evidence of the consumer's use of alcohol or drugs.

5.5.7 Emergency Restrictive Procedures

The facility 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 clearly indicate the training provided to all staff members at hire and at least annually thereafter.

Each time a Division for Rehabilitation Services Vocational Rehabilitation (VR) consumer is restrained, a written report must document the details of the incident. This written report must be filed in the consumer file maintained by the facility. Each report must be reviewed by the interdisciplinary team at the next scheduled monthly team meeting to determine whether modifications to the treatment plan are needed.

5.5.8 Staff Qualifications

Services are provided by qualified individuals and in accordance with state law and applicable licensing boards, or as specified in these standards below.

Aquatic Therapy

Aquatic therapy services must be delivered by a licensed physical or occupational therapist or a licensed physical or occupational therapist assistant.

Art Therapy

Art therapy services must be provided in accordance with state law by a licensed professional counselor art therapist (LPC-AT).

Assistance Services

Personal assistance services may be delivered by a paraprofessional and may be provided on an individual basis.

Personal attendant care services may be delivered by a paraprofessional with training and experience on an individual basis.

Behavior Management Plans

Behavior management plans and other evidence-based therapeutic modalities are designed to improve appropriate communication, frustration tolerance or anger management, and other necessary social skills. Behavior management plans must be developed by a board-certified behavior analyst, licensed clinical social worker, licensed professional counselor, psychiatrist, or psychologist.

Chemical Dependency Services

Services may be provided by licensed professionals with experience in service delivery to consumers with brain injury and may include licensed chemical dependency counselors, licensed professional counselors, or psychologists.

Cognitive Rehabilitation Therapy

Cognitive rehabilitation therapy focuses on development of cognitive skills—the abilities to perceive, recognize, conceive, judge, imagine, and reason—that were lost or altered as a result of neurological damage. The aim of treatment is to enhance a Division for Rehabilitation Services Vocational Rehabilitation (VR) consumer's functional competence. The process includes direct retraining, use of compensatory strategies, and/or use of cognitive tools.

Post-acute brain injury services must be provided directly by or supervised in accordance with licensing requirements by:

Dietary Services

The facility must provide each consumer an adequate balanced meal three times every day, including any prescribed dietary meals or supplements. Therapeutic diets as ordered by the resident's physician must be provided according to the service plan. Therapeutic diets that cannot customarily be prepared by a layperson must be calculated by a qualified dietitian. Therapeutic diets that can customarily be prepared by a person in a family setting may be served by the facility. If a consumer is away from the facility at meal time (except in the case of a therapeutic pass), provision must be made for the consumer to have meals.

Drivers

Providers must ensure that employees who transport consumers have the type of driver's license that is appropriate for the type of vehicle used (Class B or C). Drivers who transport consumers in motorized vehicles must prove an acceptable driving record with an official document from the Texas Department of Public Safety documenting that the driver has:

Family and Caregiver Training and Education

Family and caregiver training and education services may include learning wound care, blood-pressure monitoring, transferring skills, bowel and/or bladder routines, sexuality accommodations, memory strategies, safety routines for bathing, activities of daily living, or strategies for adjustment to disability. Licensed or certified professionals, including psychologists, therapists, and registered nurses, may provide these services.

Massage Therapy

Massage therapy services must be provided by a licensed massage therapist per Texas state law.

Music Therapy

Music therapy services are provided by an individual who is certified by the Certification Board for Music Therapists or listed with the National Music Therapy Registry.

Recreational Therapy

Recreational therapy is provided by individuals who have a current certification from the National Council for Therapeutic Recreation Certification (NCTRC).

5.6 Billing

5.6.1 Service Authorization

In order to receive a Division for Rehabilitation Services Vocational Rehabilitation authorization for services, the interdisciplinary team must submit an initial assessment and either a prescription or physician's orders, per state law, for any services.

Note: An initial assessment should include high-level information relating to a consumer's needs, goals, and proposed therapies.

5.6.2 Family Cost Share

The staff members of the Division for Rehabilitation Services Vocational Rehabilitation (VR) use net monthly income, liquid assets, and family-size related to the federal poverty guidelines for the current fiscal year to determine the amount a consumer must contribute to the cost of services. This is a monthly amount and is applied only in months that a billable service or good is provided that requires participation in cost of services. The family cost share amount cannot exceed the cost of the services provided in a given month. A consumer participating in the cost of goods and/or services directly pays the service provider and that amount is deducted from the provider's payment from DARS. The cost determined will be stated in the service authorization.

The provider is responsible for billing and collecting or write-off of cost-share amounts owed by the liable party.

5.6.3 Invoices

When applicable, billing must be submitted to third party payers promptly, and billing to DARS must be submitted upon payment or denial from third-party payers, less applicable family cost share. Invoices must be submitted at least monthly, no later than the fifteen of each month, on one of the following forms:

You must submit invoices to the address on the Division for Rehabilitation Services Vocational Rehabilitation (VR) service authorization, comply with the terms and conditions of the VR consumer contract, and include, at a minimum, the:

5.6.4 Billing Increments

For service components and subcomponents that have a unit of service of 15 minutes, a service event:

Example:

If a service provider performs billable activity for registered nursing from 12:00-12:30, performs activity that is not billable from 12:30-12:36, then performs additional billable activity from 12:36-12:48, two service events have occurred, one for 30 minutes (12:00-12:30), and another for 12 minutes (12:36-12:48).

Service Time

Professional Therapies

A Division for Rehabilitation Services Vocational Rehabilitation (VR) program provider must use the following formula for calculating the service time for professional therapies:

Number of service providers times the length of service event divided by the number of persons served equals service time.

In this formula, "person" means a person who receives a service funded by VR.

Examples

Table 1, Professional Therapy
Service Time Unit(s) of Service for Service Claim
at least 8 minutes – but less than 23 minutes 1 unit
at least 23 minutes – but less than 38 minutes 2 units
at least 38 minutes – but less than 53 minutes 3 units
at least 53 minutes – but less than 1 hour, 8 minutes 4 units
at least 1 hour, 8 minutes – but less than 1 hour, 23 minutes 5 units
at least 1 hour, 23 minutes – but less than 1 hour, 38 minutes 6 units
at least 1 hour, 38 minutes – but less than 1 hour, 53 minutes 7 units
at least 1 hour, 53 minutes – but less than 2 hours, 8 minutes 8 units
at least 2 hours, 8 minutes – but less than 2 hours, 23 minutes 9 units
at least 2 hours, 23 minutes – but less than 2 hours, 38 minutes 10 units
at least 2 hours, 38 minutes – but less than 2 hours, 53 minutes 11 units
at least 2 hours, 53 minutes – but less than 3 hours, 8 minutes 12 units
at least 3 hours, 8 minutes – but less than 3 hours, 23 minutes 13 units
at least 3 hours, 23 minutes – but less than 3 hours, 38 minutes 14 units
at least 3 hours, 38 minutes – but less than 3 hours, 53 minutes 15 units
at least 3 hours, 53 minutes – but less than 4 hours, 8 minutes 16 units
at least 4 hours, 8 minutes – but less than 4 hours, 23 minutes 17 units
at least 4 hours, 23 minutes – but less than 4 hours, 38 minutes 18 units
at least 4 hours, 38 minutes – but less than 4 hours, 53 minutes 19 units
at least 4 hours, 53 minutes – but less than 5 hours, 8 minutes 20 units
at least 5 hours, 8 minutes – but less than 5 hours, 23 minutes 21 units
at least 5 hours, 23 minutes – but less than 5 hours, 38 minutes 22 units
at least 5 hours, 38 minutes – but less than 5 hours, 53 minutes 23 units
at least 5 hours, 53 minutes – but less than 6 hours, 8 minutes 24 units
at least 6 hours, 8 minutes – but less than 6 hours, 23 minutes 25 units
at least 6 hours, 23 minutes – but less than 6 hours, 38 minutes 26 units
at least 6 hours, 38 minutes – but less than 6 hours, 53 minutes 27 units
at least 6 hours, 53 minutes – but less than 7 hours, 8 minutes 28 units
at least 7 hours, 8 minutes – but less than 7 hours, 23 minutes 29 units
at least 7 hours, 23 minutes – but less than 7 hours, 38 minutes 30 units
at least 7 hours, 38 minutes – but less than 7 hours, 53 minutes 31 units
at least 7 hours, 53 minutes – but less than 8 hours, 8 minutes 32 units
at least 8 hours, 8 minutes – but less than 8 hours, 23 minutes 33 units
at least 8 hours, 23 minutes – but less than 8 hours, 38 minutes 34 units
at least 8 hours, 38 minutes – but less than 8 hours, 53 minutes 35 units
at least 8 hours, 53 minutes – but less than 9 hours, 8 minutes 36 units
at least 9 hours, 8 minutes – but less than 9 hours, 23 minutes 37 units

5.6.5 Excused Consumer Absences and Holidays

You may be paid for excused consumer absences if the reason for the absence involves the health and welfare of the consumer. After the reason for the absence is discussed with the counselor or DRS representative, the counselor or DRS representative makes the final determination relating to whether the absence does or does not qualify as an excused absence. Excused absences must not exceed two consecutive days nor more than three per month.

You must document excused absences in an interim meeting note and communicate them to the VR counselor by email, fax, or telephone call within one working day.

When the facility is closed within a consumer's dates of service, then payment will not be made for that day.

5.6.6 Therapeutic Passes

The facility 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 Program Plan or for therapeutic passes in excess of three per month.

5.6.7 Reporting

You must submit the Division for Rehabilitation Services Vocational Rehabilitation (VR)'s Supplemental Billing Information Report detailing the actual services provided to consumers for all post-acute brain injury services invoiced for the month.

The VR Supplemental Billing Information Report must include all data elements required by VR. You may provide the data in a different format from the supplemental data report template provided with VR approval, or you may use the supplemental data report template for submission of the data.

The report must be submitted by close of business on the fifteen of the month following the month in which the services were invoiced (for example, 10/15/2015 for services invoiced from 9/1/2015 through 9/30/2015). Should the fifteen fall on a weekend or holiday, the report is due by close of business the following business day.

You must submit the report to the Supplemental Billing Mailbox using an encryption level that meets or exceeds DARS standards.

5.7 Environment Standards

The standards in this section apply to residential and non-residential facilities alike.

5.7.1 Accessibility

All services purchased by Division for Rehabilitation Services Vocational Rehabilitation (VR) for its consumers must be provided in an accessible manner.

Each provider subject to these standards must provide the results of a self-evaluation along with a written explanation, if necessary, of how your services will be provided in an accessible manner:

Self-evaluation materials are available at ADA's Checklist for Existing Facilities page.

If VR receives a complaint about the accessibility of services, VR investigates to determine whether a violation of contract terms has taken place.

The Architectural and Transportation Barriers Compliance Board has issued ADA Accessibility Guidelines (ADAAG) which must be applied during the design, construction, and alteration of buildings and facilities covered by Titles II and III of the Americans with Disabilities Act (ADA). The U.S. Department of Justice has adopted these guidelines as Appendix A to its ADA Title III rules. These guidelines are published on the United States Access Board's ADA Standards page.

To obtain a copy of ADAAG or other information from the U.S. Department of Justice, call (800) 514-0301 or (800) 514-0383 TTY. For technical questions, contact the Architectural and Transportation Barriers Compliance Board at 1-800-USA-ABLE.

In addition, the Texas Department of Licensing and Regulation administers the state Elimination of Architectural Barriers Act, Texas Government Code, Chapter 469. The Texas Accessibility Standards (TAS) are based on the ADAAG Standards and apply to buildings and facilities constructed on or after April 1, 1994.

5.7.2 Safety Program Description

You must identify a person or persons to constitute the governing body of the facility and who must exercise general policy, budget, and operating direction over the facility.

Your facility must be in compliance with all applicable provisions of federal, state, and local laws, regulations, and codes pertaining to health, safety, and sanitation. You must have a plan that ensures continuing attention to the safety and health of the staff, the consumers, and the visiting public. The plan must include:

You must have an incident reporting system in place. A form for staff reporting of incidents must be developed.

The minimum information required on the incident report form must include:

Upon request, you must make copies of incident reports pertinent to consumers available to agency staff members.

The following incidents must be reported to the referring VR counselor and liaison counselor by close of business the next working day:

5.7.3 Provider Vehicles

You must ensure that transportation is safe and accessible. Access to transportation must be available in accordance with the Americans with Disabilities Act (ADA) and with all applicable state laws. Each vehicle used to transport consumers must have:

The Federal Transit Administration in Washington, D.C., has information about transportation accessibility, including small passenger-vans. Contact the administration at (888) 446-4511 or (800) 877-8339 (TDD/Relay).

5.7.4 Building Occupancy Codes

Environmental safety must comply with local building occupancy codes, the Americans with Disabilities Act, National Fire Protection Association (NFPA) codes, and all applicable state laws and standards. You must provide documentation of compliance to the Division for Rehabilitative Vocational Rehabilitation (VR) at the time of the original approval and whenever location of services changes. Renters should contact their landlords to get such documentation. A certificate of occupancy from the local municipality is also required.

5.8 Allegations or Incidents of Abuse, Neglect or Exploitation of Persons with Disabilities

5.8.1 Overview

Texas law requires that you report immediately all allegations or suspected incidents of abuse, neglect, or exploitation of persons with disabilities to the appropriate investigatory agency, or, if taking place in other than a residential situation, the local law enforcement agency. If a licensed professional is involved, report to the appropriate professional licensure agency and the local law enforcement agency.

You must develop policies and procedures regarding the recognition and appropriate reporting of such allegations or incidents. If a Division for Rehabilitation Services Vocational Rehabilitation (VR) consumer is involved in an allegation of abuse, neglect, or exploitation, the appropriate VR counselor and the liaison counselor must be notified within one working day. The appropriate investigating agency's toll-free number and the VR liaison counselor's office number must be posted in a location that is readily accessible to consumers and to the staff.

5.8.2 Reporting Procedure

Upon notification of abuse, neglect, or exploitation allegations that involve a Division for Rehabilitation Services Vocational Rehabilitation (VR) consumer, your facility must cooperate with VR staff members with respect to providing information about the incident. The following documents must be provided to the designated VR staff member as they become available:

5.8.3 Division for Rehabilitation Services Vocational Rehabilitation (VR) Service Number

If you are a facility-based provider, you must post the DARS Inquiries toll-free telephone number, specifying that it is for VR applicant and VR consumer use. That number is 1-800-628-5115.

5.8.4 Grievance Procedure

A written grievance procedure for consumers must be distributed and explained to consumers and staff members.

Ombudsman Process and Assisted Living Facilities and Nursing Facilities

Information about the role and purpose of the ombudsman, as well as contact information, must be posted in a public area, where residents and visitors can view it.

5.9 Admission Policies and Procedures

You are required to have written criteria and procedures for admission. These policies and procedures do not release you from the obligation to obtain consent from the consumer and/or guardian regarding the use of restrictive procedures or behavior modification plans. Admission policy and procedures must be communicated clearly to Division for Rehabilitation Services Vocational Rehabilitation (VR) counselors.

You are encouraged to develop a referral form for counselors to use. The form should list available services and admission criteria, and capture information you require before the consumer is admitted.

5.9.1 Referrals to Division for Rehabilitation Services Vocational Rehabilitation (VR)

You may refer an individual to the VR program for services. It is important to understand and make clear to the consumer being referred that the VR counselor determines eligibility for services and that the VR counselor and consumer, having informed choices, jointly:

5.9.2 Intake Process

The intake process must orient the consumer to your program of services. This includes physical arrangements, your expectations of the consumer (such as attendance, hygiene, etc.), and what the consumer may expect to receive from the program.

5.9.3 Consumer Information

You must inform the consumer about his or her responsibilities, safety concerns, and other matters of importance. This information can take the form of a brochure, manual, or fact sheet. You must explain all program rules or "house rules" to the consumer, and the consumer must consent to all the rules.

5.10 Services

You must ensure that appropriate assessment and planning policies and procedures are in place so that each Division for Rehabilitation Services Vocational Rehabilitation (VR) consumer achieves maximum benefit from the post-acute brain injury program.

For any of the following services, use the links below to the section of the Standards for Providers that defines the scope, services, fee and staff qualifications. The CRP must have the service listed in their bi-lateral contract to provide the service to any consumer.

The services below are not included in the Post-acute brain injury services.

5.10.1 Overview, Assessment, and Planning

The interdisciplinary team (IDT) must prepare an Individualized Program Plan (IPP) that includes opportunities for consumer choice and self-management and identifies:

The IPP must be directed toward the development of the behaviors the consumer must have in order to function with as much self-determination and independence as possible. In addition, the IPP must be directed toward preventing or slowing regression and preventing the loss of current optimal functional status.

Each consumer must receive a continuous program of needed interventions and services in sufficient intensity and frequency to support the achievement of IPP objectives.

Except for those facets of the IPP that must be implemented only by licensed personnel, each consumer's IPP must be implemented by all staff members who work with the consumer, including professional and paraprofessional staff members. All those involved in the consumer's care must work together to provide a uniform, consistent approach to implementation of the IPP.

Accurate, measurable, functional data about the consumer's progress or lack of progress toward meeting the IPP objectives serve as the basis for revision to the program. At least monthly, the IPP is reviewed by the IDT for relevancy and is updated and revised as needed.

5.10.2 Individualized Program Plan Development

The interdisciplinary team (IDT) meets after the assessment is completed but no later than 30 days after a consumer's admission to the program. This meeting is held to develop the Individualized Program Plan (IPP).

The IPP is based on the findings of the assessment and must address all deficit areas noted therein. All planned and needed services must be documented in the IPP. All IDT members must participate in the IPP development, which must be documented by attendance sheets with signatures.

Note: "Participate" means to provide input through whatever means is necessary to ensure that the consumer's IPP is responsive to the consumer's needs. The IDT process is designed to allow team members to review and discuss information and recommendations relevant to the consumer's needs and to reach decisions as a team, rather than individually, about how best to address those needs.

5.10.3 Post-acute Brain Injury Service Arrays

Post-acute brain injury (PABI) services

PABI services are provided as recommended by an interdisciplinary team to address deficits in functional and cognitive skills based on individualized assessed needs. Services may include behavior management, the development of coping skills, and compensatory strategies. These services may be provided in a residential or non-residential setting.

PABI services – residential

For a detailed list of residential services, see Post-Acute Brain Injury (PABI) – Residential Services from Texas Health and Human Services.

PABI services – non-residential

For a detailed list of residential services, see Post-Acute Brain Injury (PABI) – Non-Residential Services from Texas Health and Human Services.

5.10.4 Exception Process

If services are medically necessary for rehabilitation purposes (that is, not acute medical conditions) and are not included as a core or ancillary service, a formal request process must be followed before services may be provided to Division for Rehabilitation Services Vocational Rehabilitation (VR) consumers.

Table 2, Requesting Services
Step Issue and Action Notes
1 The interdisciplinary team must identify a need for a service or therapy which is not offered in the applicable VR service array. Need is based on medical assessment.
2 The case manager provides the VR counselor with a written request for the service. The request for service must include supporting medical documentation and assessments to illustrate the need for the service or therapy and the proposed service codes which will be used for billing purposes.
3 The VR counselor will communicate to the provider the decision after coordination with DARS central office program specialist. If more information is needed for a decision, a VR representative will contact the facility.

5.10.5 Assessment

Each staff member of the interdisciplinary team (IDT), as appropriate, assesses a consumer's abilities and limitations in relation to that staff member's area of expertise. The case manager writes a report of the assessments within 30 days of a consumer's admission into the program. Each member of the IDT receives a copy of the report.

The assessment must address each of the following areas:

5.10.6 Therapeutic Passes

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 therapeutic pass must be planned and included in the Individualized Program Plan. The purpose of the therapeutic pass is to facilitate a consumer's transition from the residential facility to the home and community. Staff members 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. Division for Rehabilitation Services Vocational Rehabilitation consumers are allowed up to three therapeutic passes per month, with reimbursement to the facility at the contracted per diem rate.

5.10.7 Reports

You must provide a copy of the assessment report and the Individualized Program Plan (IPP) to the Division for Rehabilitation Services Vocational Rehabilitation (VR) representative within 10 working days of the IPP meeting. A copy is available to the consumer and to the consumer's representative. Results of the assessment and the IPP may be combined into a single report. This report is signed by all pertinent interdisciplinary team members. You must be able to verify by fax, email, post, or signature of the VR representative that the report was available to VR within 10 working days of the IPP meeting.

5.10.8 Individualized Program Plan Review

The goals and objectives on the Individualized Program Plan (IPP) include long-term and short-term goals that are stated in measurable terms and that relate to increasing a consumer's ability to live more independently.

The Division for Rehabilitation Services Vocational Rehabilitation counselor and the consumer's representative, if applicable, are notified at least one week in advance of the date, time, and location of the IPP review.

5.10.9 Monthly Interdisciplinary Team Meetings

The interdisciplinary team (IDT) meets formally at least monthly to:

All members of the IDT routinely participate in this meeting, and their attendance must be documented. When available, the Division for Rehabilitation Services Vocational Rehabilitation (VR) counselor, consumer, and consumer's legally authorized representative or advocate participate in this meeting.

The VR counselor, the consumer, and the consumer's legally authorized representative or advocate must be notified of the date, time, and location of this meeting at least one week in advance.

The Individualized Program Plan (IPP) must be reviewed at each monthly meeting by the IDT and may be modified as necessary at that time.

Adjustments to the IPP, 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 VR counselor within 10 working days after the meeting. A copy must be available to the consumer and/or the consumer's representative.

The IDT may, in addition to the required monthly meeting and based on need, meet as frequently as prudent and necessary to maintain an effective treatment program.

5.10.10 Activity Schedules

A schedule of daily activities that address the goals in the Individual Program Plan (IPP) must be developed and made available to each consumer. Copies of all schedules for each consumer must be made available to VR counselors or monitors for review.

The activity schedule directs the intensity of the daily work of the consumers in implementation of the IPP in both informal and formal training activities.

5.10.11 Behavior Management Plans

Behavior management plans are developed and monitored by licensed professionals or board certified professionals. Plans may include therapeutic medication; interventions that include positive reinforcement, verbal cues, and rewards.

If restrictive procedures are used as a behavior modification technique:

Standing or as-needed programs to control inappropriate behavior are not permitted. All interventions addressing the control of inappropriate behaviors must be justified by the assessment and the current level of behavior.

A behavior management plan must be:

Use of chemical restraints to control inappropriate behavior must be:

5.10.12 Emergency Restrictive Procedures

"Emergency restrictive procedures" are defined as use of the least restrictive procedures possible for the briefest time necessary to control severely aggressive or destructive behaviors that place the consumer or others in imminent danger when those behaviors could not have been reasonably anticipated, and only as the procedures are necessary within the context of positive behavioral programming.

Each time a consumer is restrained, a written report must document the details of the incident. This written report must be filed in the consumer file maintained by the facility. Each report must be reviewed by the IDT at the next scheduled monthly team meeting to determine whether modifications to the treatment plan are needed.

5.10.13 Mental Restoration Services

Mental restoration services may be provided individually or in a group setting. A licensed clinical social worker, licensed professional counselor, licensed psychologist or psychiatrist, psychiatric-mental health clinical nurse specialist, psychiatric-mental health nurse practitioner, physician assistant, or licensed marriage and family therapist must recommend, prescribe, and provide mental restoration services.

5.10.14 Chemical Dependency Services

Chemical dependency services may be delivered only to consumers who have a traumatic brain injury, either individually or in a group setting.

Chemical dependency services must be:

5.11 Division for Rehabilitation Services Vocational Rehabilitation Consumer Outcomes

(Revised 01/16)

Results of consumer outcomes will be used to measure progression or regression in relation to consumer rehabilitation.

5.11.1 Post-acute Brain Injury

All providers of Division for Rehabilitation Services Vocational Rehabilitation residential or non-residential post-acute brain injury services must administer Mayo-Portland Adaptability Inventory (MPAI-4) surveys and/or Functional Independence Measure (FIM) scores on all VR consumers. The test that will capture a consumer's abilities most appropriately will be determined by the facility. The MPAI or FIM score must be administered at the following times:

5.12 Discharge and Termination

You must develop and establish policies and procedures with respect to consumer discharge and termination.

5.12.1 Discharge Summary

You must develop a discharge summary for each consumer and provide a copy to the Division for Rehabilitation Services Vocational Rehabilitation representative within 10 business days of services being completed or terminated.

The discharge summary must include:

5.12.2 Termination from Program

You must inform the Division for Rehabilitation Services Vocational Rehabilitation counselor that a consumer's services are being terminated before the termination takes place. You must document that you informed the counselor of termination of services to a consumer. In addition, you must follow state and federal requirements as applicable to the license or certification relating to discharge procedures.

Some reasons for termination are:

5.13 Consumer Satisfaction

Consumer satisfaction measures input from consumers about benefits received from services.

Each facility may develop its own survey instrument and procedure. However, at a minimum, the survey instrument must include the following prompt:

Using the Likert scale in the table below, rate the following statements:

  1. I was treated in a friendly, caring, and respectful manner by the staff of [insert provider name].
  2. Services were provided in a timely manner.
  3. The services met my needs.
  4. I was satisfied with the services provided.
Likert Scale
1 Strongly disagree
2 Disagree
3 Neither agree nor disagree
4 Agree
5 Strongly agree

You must give all consumers, both successful and unsuccessful, an opportunity to respond upon discharge from the VR program. You must keep in the consumer's file all attempts to get the responses to the consumer satisfaction survey. The VR program may request the responses from the facility every sixth months.