GENERAL DESCRIPTION: Responsible for completing all requirements of the Pre-Admissions Screening and Resident Review (PASRR) evaluation (PE) for individuals identified in a Nursing Facility (NF) or being recommended for placement at a NF, whom are suspected as having an Intellectual and/or Development Disability (IDD) or a qualifying Mental Health (MH) diagnosis. Evaluations must be completed within the timeframe set forth by Health and Human Service Commission (HHSC) and meet all Performance Contract Requirements. Responsible for participating in the initial Interdisciplinary Team (IDT) and Service Planning Team (SPT) meeting to determine consumer needs. Facilitates discussion of appropriate referrals as a result PE at initial IDT/SPT. Discuss Community Living Options (CLO) as part of the evaluation process. Will serve as the Habilitation Coordinator (HC) for identified individuals as in Nursing Facility with IDD. Will develop Habilitation Service Plan (HSP) and monitor PASRR and Nursing Facility Specialized Services. Works closely with Nursing Facility staff, a network of internal and external service providers. Responsible for completing accurate documentation within the timeframes set forth by the unit and HHSC. Will be required to drive among the 5 different service counties to make face to face contacts, complete PEs and attend initial IDT/SPT and quarterly planning meetings of each individual.

ESSENTIAL DUTIES AND RESPONSIBILITIES:

• Adhere to the Work Values and Behavior Addendum ad demonstrate the qualities listed of: high ethical values, trustworthiness, integrity, cooperation, personal accountability, cultural sensitivity, conflict resolution and problem solving, appreciation and recognition, and respect and dignity. All of these qualities along with regular attendance, dependability, and promptness are required to provide quality and consistent services to IDD consumers.

• Interact effectively and create and maintain a professional working relationship with all individuals, internally as well as externally. Willing to accept coaching and constructive criticism from others while developing effective working relationships with all team members. Support team concepts and cooperate with others to achieve team objectives. Does not engage in gossip or negative talk, but instead is focused on solutions and ways to improve morale.

• PASRR Evaluation:
  • Initiates PASRR Level 1 upon notification of Pre-Admission to NF.
  • Initiates PASRR Evaluation within 72 hours of alert via TMHP Portal.
  • Completes the PASRR Evaluation within 7 days of alert.
  • Responsible for attending the IDT/SPT meeting within 14 days of admission for PASRR positive individuals.
  • Submit IDT confirmation via TMHP Portal within 5 days of IDT Meeting.
  • Send referral to appropriate Mental Health Clinic upon discovery of MH only PASRR individual.
  • Mail denial letter to individuals who have been identified as PASRR Negative.
  • Completes PASRR PE packets and enter diagnosis, financial and insurance information in Cerner.
  • Works closely with PASRR Supervisor when extenuating circumstances may require an extension be requested. Maintains extension information and informs PASRR Supervisor of status weekly.
  • Works closely with the Nursing Facility on PASRR Positive individuals to complete PASRR evaluations during a Change of Ownership with a Nursing Facility.

• Service Planning/Habilitation Coordination:
  • Complete Habilitation Assessment and Individual Profile-NF annually.
  • Facilitate the development of the individuals HSP (Habilitation Service Plan).
  • Facilitate revisions to the HSP, as needed.
  • Facilitate coordination between the individuals HSP and the nursing facility plan of care.
  • Facilitate the coordination of the individuals specialized services and monitors the delivery of all services and supports provided by the individual.
  • Submit a PASRR Comprehensive Service Plan- PCSP Form; initially, quarterly, and as needed for an update via Texas Medicaid and Healthcare Partnership- TMHP Portal within 5 days of meeting.
  • Convene a Quarterly Meeting with the individuals SPT. The quarterly SPT should take place 3 months after the initial SPT meeting or previous quarterly SPT meeting, on the same day of the month or 14 calendar days before or after the calculated date, with exception for limited reasons.
  • Discuss Community Living Options (CLO) using DADS developed materials, at PE initially, 6 months and annually for IDD individuals. .
  • Use For 1044 to document Refusal of Habilitation Coordination for Individuals Residing in Nursing Facilities, and complete CLO every six months and annually. Complete Habilitation Assessment annually.
  • Offer the individual and LAR opportunities for educational and informational activities.
  • Complete Transition request to ECC/SC for an individual who expresses interest in transitioning to the community, whos PASRR Evaluation reflects the individuals needs can be met in an appropriate community setting, or whos MDS indicates the individual is interested in speaking with someone about transitioning to the community.
  • Submit packets for initials, updates, and quarterly SPT Meetings to Supervisor within 10 days of holding the meeting.

• Referral and Monitoring:
  • • Responsible for making face to face contacts with consumers on assigned caseload.
  • Document service delivery, progress and satisfaction of outcomes and PASRR and NF Specialized Services as indicated in the HSP at least once every 90 days.
  • Refers IDD PASRR Positive clients to PASRR Supervisor for Habilitation Coordination assignment with 2 days of completion of PE.
  • Send referral to appropriate Mental Health Clinic upon discovery of MH only PASRR individual.
  • Maintains list of MI PASRR Positive clients and ensures that annual IDT meeting is held.
  • Facilitate the coordination of the individuals specialized services and monitors the delivery of all services and supports provided to the individual.
  • Use Form 1044, Refusal of Habilitation Coordination for Individuals Residing in Nursing Facilities, to document refusal.

• Documentation: Responsible for entering and final approving service tickets/progress notes into the Electronic Health Record (EHR) by 5 pm Monday for the previous week.

• Communication: Responsible for carrying a work cell phone and returning calls from the office phone and work cell phone by 5pm the next business day. Responsible for checking emails daily and responding by 5pm the next business day. Must contact Supervisor when out for the day or running more than 15 minutes late.

• On Call: Will be required to follow the on-call procedures on a rotating basis. Will be responsible to check TMHP during assigned weekends and holidays and respond to all PE alerts within 72 hours.

• Participate in the Random Moment Time Study as required, including completing the required training.

• May be required to drive to the different 5 service counties, as needed, to complete job duties. At times may be required to travel outside the catchment area for trainings or for cases with extenuating circumstances.

• Other duties as assigned.

GENERAL QUALIFICATIONS:

A. Experience/Education/Licensing/Certification

1). Bachelors degree in Psychology, Social Work or related social services area.

2). Must have one year experience working with individual with IDD or DD.

3). Must have a valid Drivers License.

B. Knowledge/Skills/Abilities

Central Counties Services incorporates principles of trauma-informed care, which includes cultural sensitivity, in all areas of service delivery. All job descriptions include the responsibility to learn about and implement trauma-informed practices within the scope of work for the position.

1). Ability to complete evaluations for individuals with Intellectual and Developmental Disability and/or Mental Illness in a Nursing Facility.

2). Ability to participate in planning team meetings based on the needs and desires of the consumer and family/guardian.

3). Ability to assess the consumers situation, revise the plan accordingly, and make appropriate referrals.

4). Ability to interview all relevant persons in the evaluation process.

5). Responds to consumer crises in a responsive and timely manner.

6). Ability to complete plan documentation and progress note documentation within timeframes set by the division. Documentation must be timely and accurate.

7). Ability to proficiently utilize computer programs, e.g., Microsoft Word and Excel.

8). Ability to see, hear and talk effectively within job requirements.

9). Ability to stand, sit and walk for extended periods.

10). Ability to effectively handle potentially aggressive behavior in a positive manner.

11) Ability to speak to groups regarding services.

12) This position is required to provide services in facilities that require proof of vaccination.

I have read and understand this position description and the duties identified herein. I understand that the duties identified above are not all inclusive. I also understand where applicable, reasonable accommodations may be made in accordance with the Americans with Disabilities Act (ADA).