Origins of Complaints Submitted to UR for Clinical Review
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Four cases were legislative complaints submitted to OMD from HHSC
legal to conduct a clinical review. These cases were routed through
the HPM complaints team.
One case was submitted to UR from HPM to conduct a clinical review.
The complaint was submitted to HPM complaints by the foster parent.
Six cases were brought to URs attention by Disability Rights of Texas
during the clinical review of the four legislative complaints.

2:1 cases
 7 cases total (14 members)
 4 reviewed by UR (8 members)
 3 cases left to review by UR (6 members)
Summary of Outcome - Legislative Inquiry-Senator Van Taylor
On December 20, 2016, HHSC met with Superior to discuss the private duty
nursing (PDN) Legislative Complaint and the Utilization Review (UR) Nurses
concerns/findings based on the clinical documentation submitted by Superior
and the Home Health Agency. During the call, Superior informed HHSC that
Superior will not be discussing specific cases due to cases pending fair
hearing. HHSC did provide Superior with the UR clinical consultation write
up for each case and Superior requested more detailed information on the
UR review. HHSC UR declined to provide any further documentation or
clarification regarding the UR review of the eleven Superior cases. UR
explained to Superior via email on December 20th, that the HHSC UR RN
clinical consultation does not equate to a determination for each case. UR
RNs do not perform a comprehensive assessment of the physical status of
the individual, or develop a nursing plan of care; this role falls on the
Superior contracted HCSSA RN. The UR RN provides recommendations to
help ensure the health and safety of the individual within the parameters of
the particular waiver or program, considering Texas Administrative Code,
RN/LVN licensure and scope of practice, and other mitigating
factors. However, HHSC UR did provide Superior with an overall summary of
issues identified within these cases.
Superior's PDN policy was also referenced during the call. HHSC reminded
Superior that any changes to this policy needs to be submitted to HHSC
review. Superior has made numerous changes to the PDN policy, specifically
the 2:1 ratio over the past few years and these changes were not approved

 by HHSC. HHSC Office of Policy will be reviewing Superior's PDN policy to
make sure the policy is in compliance with Medicaid Policy and TAC Rule. In
addition, Superior did ask HHSC for guidance on PDN and HHSC responded
that HHSC will be conducting a PDN webinar for HHSC staff and MCOs on
January 5, 2017. As of today, this PDN webinar has been cancelled and will
be rescheduled soon.

Members Superior Paired 2:1

Latest Update on all cases:

 Attachments

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Attachment A: Key findings about PDN issues with Superior

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Attachment B: UR clinical review document
Note: Cases paired 2:1 are separated by a solid black line

 Attachment A: Key findings about PDN issues with Superior Health Plan

Specific Items Identified during HHSC nursing utilization review of clinical
documentation submitted by Superior and the Home and Community
Support Services Agency (HCSSA) for individuals receiving private duty
nursing (PDN) services brought forward in Legislative complaints.
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Members who are individually authorized for 140+ hours of PDN
services, requiring significant respiratory care and nursing
interventions (i.e., observations, assessments, critical thinking,
evaluations, and medication administration) are now paired together in
a 2:1 member to nurse ratio instead of 1:1 ratio. This can lead
to health and safety risks as the member's needs for services
may overlap. (Refer to 1, 2, 6, 7 and 8 below).
Superior's PDN decision failed to understand the impact of the home
setting as a consideration in providing ongoing nursing services to a
client. Parents cannot be expected or required to provide
services (Refer to 2, 3, 6 and 7 below).
Superior's PDN policy does not appear to be in compliance with Title
XIX of the Social Security Act, 42 U.S.C. § 1396 et seq. which was
incorporated into the PDN Texas Administrative Code (TAC)
rules effective October 1, 2015 (Refer to 6, 7, and 8 below).
Superior's PDN policy is in conflict with the Medicaid Medical
Policy regarding an increased ratio of member to nurse
services (Refer to 1, 6, 7 and 8 below).
Superior reduced PDN hours without a change in medical
condition (Refer to 4, 5, 6, 7 and 8 below).

1. TMPPM Home Health and Private Duty Nursing Handbook:
PDN may be delivered in a provider to client ratio other than one-onone. A registered nurse (RN) or licensed vocational nurse (LVN) may
provide PDN services to more than one client over the span of
the day as long as each client’s care is based on an individualized
plan of care (POC), and each client’s needs and POC do not
overlap with another client’s needs and POC.
2. Title 1 TAC Part 15 Chapter 363, Subchapter C, Rule § 363.303(15)
states,
" Private duty nursing (PDN) Services--Nursing, described by the
Texas Occupations Code Chapter 301, and its implementing

 regulations at 22 TAC, Part 11 (relating to Texas Board of Nursing),
when the recipient requires more individual and continuous care
than is available from a visiting nurse or than is routinely
provided by the nursing staff of a hospital or skilled nursing
facility. PDN services include observation, assessment,
intervention, evaluation, rehabilitation, care and counsel, or
health teachings of a recipient who has a disability or chronic
health condition or who is experiencing a change in normal
health processes."
3. Title 1 TAC Part 15 Chapter 363, Subchapter C, Rule § 363.309(g)(13) states,
(g) HHSC may not: (1) require a recipient's responsible adult(s)
to provide PDN services to the recipient; (2) require a recipient or
a recipient's responsible adult(s) to designate an alternate caregiver to
provide PDN services; or (3) deny or reduce the amount of
requested PDN services because the recipient's responsible
adult(s) is trained and capable of performing such services, but
chooses not to do so.
4. Title 1 TAC Part 15 Chapter 363, Subchapter C, Rule § 363.309(p)
states,
"(p) HHSC may not deny or reduce PDN when the recipient's
nursing needs have not decreased."
5. Title 1 TAC Part 15 Chapter 363, Subchapter C, Rule § 363.311(f)(7)
states,
"(f) Process for authorizations. (7) Prior authorizations for PDN
services are not denied or reduced solely because the recipient's
condition or health status is stable or has not changed…"
6. Title 1 TAC Part 15 Chapter 363, Subchapter C, Rule § 363.311(g)(2)
states,
"(g) HHSC authorizes requested medically necessary PDN services
when: (2) the requested services are nursing services as defined by
the Texas Nursing Practice Act and its implementing regulations…"
7. Title 22 TAC Part 11 Chapter 217, Rule §217.11 states,
"Standards Specific to Registered Nurses. The registered nurse shall
assist in the determination of healthcare needs of clients and shall: (A)
Utilize a systematic approach to provide individualized, goal-directed,
nursing care by: (i) performing comprehensive nursing assessments
regarding the health status of the client; (ii) making nursing diagnoses

 that serve as the basis for the strategy of care; (iii) developing a plan
of care based on the assessment and nursing diagnosis; (iv)
implementing nursing care; and (v) evaluating the client's responses
to nursing interventions; (B) Delegate tasks to unlicensed personnel in
compliance with Chapter 224 of this title, relating to clients with acute
conditions or in acute are environments, and Chapter 225 of this title,
relating to independent living environments for clients with stable and
predictable conditions."
8. UMCC Section 7.02 MCO responsibility for compliance with laws and
regulations.
(a) MCO must comply, to the satisfaction of HHSC, with all
provisions set forth in this Contract, all provisions of state and
federal laws, rules, regulations, federal waivers, policies and
guidelines, and any court-ordered consent decrees, settlement
agreements, or other court orders that govern the performance
of the Scope of Work