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Department of Medical Assistance Services

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1 Department of Medical Assistance Services
DD Waiver Services Division of Long-Term Care Department of Medical Assistance Services 2013 1

2 Objectives of Training
Train in-home and day support providers on the associated requirements for Individual and Family Developmental Disabilities Support (DD) Waiver.

3 Development of the DD waiver

4 Development of the (DD) Waiver
DMAS was directed by the 1999 General Assembly session to develop a new waiver for persons with developmental disabilities. DMAS formed a work group consisting of consumers, advocates, providers and state agencies that met nine times from May 10, 1999 through May 18, 2000 to discuss waiver development issues.

5 Work Group Goals Option to institutionalization
Consumer-directed whenever possible Services in the workplace when possible Individually tailored services Coordinate with schools and other training areas Maximize other financial resources Minimize duplication of resources

6 Development of the (DD) Waiver
DMAS submitted a report to the 2000 General Assembly session proposing the development of a new waiver. DMAS requested and received approval from the Centers for Medicare and Medicaid services (CMS) in May 2000 to begin implementation of the DD waiver on July 1, 2000. This waiver would be more consumer-driven and provide additional supports to families.

7 Development of DD Waiver
In order to get waiver approval from CMS, there must be an alternative institutional placement. For the DD waiver the alternative placement must be an Intermediate Care Facility for the Mentally Retarded (ICF/MR).

8 Eligible for (DD) Waiver
The individual must be 6 years of age and older and meet the “related conditions” requirements of C.F.R. § , including autism; May not have a diagnosis of intellectual disability (ID) as defined by the American Association on Developmental Disabilities (AAIDD)

9 Individual and Family Developmental Disabilities Support (DD) Waiver
Meet the level of care for admission to an Intermediate Care Facility for the Mentally Retarded (ICF/MR).

10 Covered Services Adult Companion Services Assistive Technology
Crisis Stabilization Crisis Supervision Environmental Modifications In-home Residential Support Day Support Skilled Nursing Supported Employment Therapeutic Consultation Personal Emergency Response System Family/Caregiver Training Respite Care Personal Attendant Services Prevocational Services Transition services- MFP Case Management (State Plan Option)

11 In-home Residential Support Services Service Definition

12 In-home Residential Support Service Definition
Training and assistance or specialized supervision Most training occurs in an individual’s home or residence considered to be his/her home In-home support does not include room and board Enables an individual to acquire, improve, or maintain: Activities of daily living (ADLs) Access community resources Adapt to the community/daily environment Safety skills and health status

13 In-home Residential Support Services
Supplemental to the care provided by a parent or similar caregiver May support an individual whose level of independence does not require a primary caregiver

14 In-home Residential Support Service Definition
May not be provided for a continuous 24-hour period Training is provided in the home or community Supports are delivered on a 1:1 staff to individual ratio In home should not take the role of the parent’s care it only supplements.

15 Person Centered Approach
This service should provide empowerment and support to the individual so that he or she may develop his or her own individual lifestyle Help the individual plan not just for this year’s CSP meeting but think past today. It is about the individual’s future. Examples: Individual wants to move out from parent. What are you doing to prepare the individual? What’s the plan? Have you started talking with the parents about the goal? Remember, the goals and objectives should be focused on the individual. Not generic goals used for everyone.

16 In-home Residential Support Training and Assistance Activities

17 In-home Residential Support Activities
Functional skills training in personal care activities such as: Toileting, Bathing, Grooming, Dressing, Eating, Mobility, Communication, Household Chores, Food Preparation, Money Management, Shopping etc. Functional skills training in use of community resources such as: Transportation, Shopping, Social/Recreational Activities Training to help the individual adapt his behavior to home and community environments

18 In-home Residential Support Activities Continued
Assistance with personal care tasks, e.g. ADLs and community resources, if the individual is physically unable to learn these tasks Monitoring health, physical condition and medical needs Ensure completion of hygiene, nutrition and other tasks essential to health and welfare. Support with shopping, banking, laundry, arranging transportation etc. There must be documentation on the schedule for the type of assistance being provided.

19 In-home Residential Support Criteria
May not be provided simultaneously with personal care, respite care, attendant care or CD respite care services Must be prior-authorized Should be provided at frequency allowing for systematic training and maintenance of functional supports Individual must be present

20 In-home Residential Support Criteria
Functional Assessment must be conducted by the provider to evaluate each individual in his home environment and community settings. 12VAC (B) (2) You must have a copy of the LOF conducted by DMAS in your record along with your functional assessment.

21 In-home Residential Support hours and limitations
Total billing can not exceed total hours approved by DMAS on the individual’s POC Documentation of dates, times, and services provided Any circumstances that prevented the individual from receiving all scheduled hours If fewer than all the hours scheduled on the POC are delivered on a regular basis, over a 60-day period, the provider should determine if there is a need to request a revised POC reducing the hours

22 In-home Residential Support hours and limitations
General Supervision is non-billable Examples of General Supervision: Awake staff coverage at night if the individual generally sleeps throughout the night Oversight of leisure activities Routine bed checks Asleep staff at night on the premises for security and/or safety reasons Staff “on call” during the day while the individual is participates in work/day support/school activities

23 In-home Residential Support
Specialized Supervision

24 In-home Residential Support Specialized Supervision
Provider DMAS 457 form must contain a specialized supervision objective outlining the staff’s activities and specific times that these activities will occur Activities must relate to the assessed health and safety needs of the individual Provides staff presence for ongoing or intermittent intervention to ensure the individual’s health and safety. DMAS 457 must clearly document the individual’s need for this support.

25 In-home Residential Support Specialized Supervision
May include hours throughout the entire night, but only if documentation supports the request Ongoing need for this service should be documented in semi-annual reviews If, over a 60-day period, the hours of Specialized Supervision actually provided are consistently less than the scheduled-upon, approved, and determined amount, the provider is expected to revise the DMAS-457 form, the weekly schedule, and amount to reflect this reduction.

26 In-home Residential Restrictions With Other Services
In-Home Residential Support services will not be authorized for the primary purpose of supervision or personal care.

27 In-home Residential Support Documentation

28 In-home Residential Support Documentation
Supporting Documentation (457) indicates: Need for the service Amount and type of activities (objectives and goals) Schedule of services Total hours per day Total hours per week Assessment of individual is based on your functional assessment and the LOF

29 In-home Residential Support Documentation
In-home may not necessarily be required daily, but POC must reflect needs and appropriate allowable activities to be provided on a periodic basis Additional hours when clearly justified need to be requested through the case manager Reimbursed for hours of direct staff time with individual only

30 In-home Residential Support Documentation
Must be authorized by DMAS Services explicitly detailed in Supporting Documentation

31 In-home Residential Support Documentation
A formal, written behavioral program is required to address behaviors, including self-injury, aggression or self stimulation. 12 VAC (B)(4)

32 In-home Residential Support Documentation
Semi-annual Reviews: Must be reviewed with individual General status of individual Significant events Individual/family satisfaction with services Any revision to Plan of Care (POC) and supporting documentation Submitted to case manager

33 In-home Residential Support Documentation
Supervision of direct care staff: Monthly contacts/Semi-annual home visits Signature of responsible supervisor Date of contact/observation Person contacted/observed Staff performance and service delivery Problems, concerns, individual satisfaction with services Actions planned/taken to correct problems Difference between DD and ID/MR In-home the requirement for documentation of supervision.

34 In home Residential Support Documentation
Provider must maintain documentation of the date, times the services that were provided, and specific circumstances preventing the provision of any scheduled services. 12VAC ( C )

35 In-home Supporting Documentation Overview

36 Day Support Services

37 Day Support Service Definitions
Variety of training Assistance Support Specialized supervision (other than home or individual residence) Peer Interactions Specialized supervision for the acquisition Retention Improvement of self help Socialization Adaptive skills

38 Day Support Service Definition Continued
Providers are reimbursed only for the amount and type of day support services included in the individual’s approved Plan of Care. This does not include prevocational services. 12VAC (A)

39 Day Support Activities
Functional training in: Self, social & environmental awareness Sensory, gross and fine motor skills Communication Personal care Problem-solving skills Using community resources Community safety Peer interactions

40 Day Support Criteria Must have demonstrated need for training, assistance and supervision in settings outside of home to access in-home residential services to increase current level of independence to sustain skills Individuals cannot benefit from Supported Employment

41 Day Support Criteria Functional Assessment must be conducted by the provider to evaluate each individual in his home environment and community settings.

42 Day Support Types and Levels
Center-Based Non Center-Based Levels: Regular Intensive

43 Day Support Intensive Level Criteria
Must meet at least one of the following criteria: Need for physical assistance for caring for personal needs Extensive disability-related difficulties, requiring additional staff support Extensive constant supervision to reduce or eliminate behaviors that preclude full participation in the program. Formal behavioral plan is required to address behaviors (Withdrawal, self injury, aggression or self stimulation)

44 Day Support Services Documentation

45 Day Support Services Documentation
Supporting Documentation (457) indicates: Need for the service Amount and type of activities (objectives and goals) Schedule of services Total hours per day Total hours per week Maximum not to exceed 780 units per plan year

46 Day Support Services Documentation
Services and documentation must be separate and distinguishable from In-Home Residential Support or Personal Care Service cannot be provided in individual’s home without prior authorization from Kepro

47 Day Support Services Documentation
Documentation must confirm the following: Attendance Amount of individual’s time in service Specific information regarding individual’s response to various settings

48 Day Support Services Documentation
Supports as agreed to in the supporting documentation objectives Assessment results must be available in at least a daily note or weekly summary

49 Day Support Services Documentation
Provider must review the supporting documentation with the individual or family/caregiver for annual review and revisions Submit to case manager at least semiannually

50 Day Support Services Documentation
Number of Hours or Units provided (including specific time frame) Center-based or non center-based Regular or intensive level Attendance log or similar document must be maintained indicating the following: Date Type of services rendered

51 Day Support Service Blocks
hours =1 block hours = 2 block 7 or more hours = 3 block

52 Day Support Supporting Documentation Overview

53 Questions

54 Quality Management Review (QMR)

55 Division of Long-Term Care
Contact Information Long-Term Care Division Division of Long-Term Care Telephone Fax

56 Supported Employment Services

57 Supported Employment Service Description
Paid employment Community worksites with people without disabilities Specialized supervision and training Ongoing support

58 Supported Employment Activities
Training in specific job and related skills Ongoing or intermittent assistance Specialized supervision to ensure health and safety Contacts with employer, family members, other support services needed for initiating, maintaining and evaluating employment

59 Supported Employment Criteria
Service cannot be available from DRS or school system (must be documented) Generally follows DRS time-limited services Assessment must clearly reflect need for ongoing supports on the job Reimbursed only for services included in POC

60 Supported Employment Individual Model
Regular community job Job coach services Usually one to one Intermittent support Reimbursement for specific interventions only, including collateral contacts, not time on the job

61 Supported Employment Group Model
8 or fewer people with disabilities Integration with people without disabilities Enclave Work Crew Entrepreneurial Benchwork/Electronics Assembly

62 Supported Employment Service Limitations
Transportation not included in service Case manager must determine and document supported employment services not available from DRS or school

63 Supported Employment Documentation
Supporting Documentation (457) indicates: Need for the service Amount and type of activities (objectives and goals) Schedule of services Total hours per day Total hours per week Maximum not to exceed 780 units per plan year for SE enclave

64 Supported Employment Documentation
Attendance log or similar document must be maintained indicating the following: Date Type of services rendered Number of Hours or Units provided (including specific time frame) Center-based or non center-based Regular or intensive level

65 Supported Employment Service Units
Individual Supported Employment (SE) billed hourly Group Supported Employment billed at unit rate: hours = 1 blocks hours = 2 blocks 7 or more hours = 3 blocks The case manager will submit to Kepro a request for services form for authorization.

66 Supported Employment Supporting Documentation Overview

67 Therapeutic Consultation Services

68 Therapeutic Consultation Service Definition
Therapeutic consultation provides expertise, training, and technical assistance in any of the following specialty areas to assist family members, caregivers, and other service providers in supporting the individual.

69 Specialty Areas for Therapeutic Consultation are:
Psychology Rehabilitation Occupational Therapy Behavioral Consultation Psychiatry Social Work Therapeutic Recreation Psychiatric Clinical Nursing

70 Therapeutic Consultation Activities
1. Interviewing the individual and relevant family members, caregivers, and other service providers to identify issues to be addressed and desired outcomes of consultation; 2. Observing the individual in natural and structured settings, or both; 3. Developing data collection mechanisms and direct collection of baseline data;

71 Therapeutic Consultation Activities Continued
4. Assessing the individual’s present and potential level of functioning, including the use of instruments to measure areas of adaptation or skills (but not to measure intelligence); 5. Observing and assessing current intervention or support strategies being used with the consumer; 6. Design and develop supporting documentation detailing interventions and support strategies to address identified issues and desired outcomes;

72 Therapeutic Consultation Activities Continued
7. Demonstrate specialized, therapeutic interventions or supports; 8. Train relevant persons to implement specific interventions or support techniques; 9. Train relevant persons to observe individual, record data, and monitor implementation of therapeutic interventions or support strategies; 10. Review documentation and evaluate activities conducted by family members, caregivers, or program staff; and

73 Therapeutic Consultation Activities Continued
11. Train and provide technical assistance to family members, caregivers and other individual primarily responsible for carrying out the Individual’s Service Plan

74 Therapeutic Consultation Criteria Continued
The Plan of Care (POC) must clearly reflect individual’s needs, for specialized consultation provided to caregivers in order to implement the plan of care effectively.

75 Therapeutic Consultation Criteria Continued
Therapeutic Consultation services may not include direct therapy, nor duplicate the activities of other services available to the individual through the State Plan for Medical Assistance.

76 Therapeutic Consultation Criteria Continued
Behavioral Consultation may be provided in absence of other DD Waiver services when consultation provided to informal caregivers is necessary to prevent institutionalization TC services, other than behavior consultation, may be provided in In-Home Residential or Day Support settings or in office settings in conjunction with another Waiver service.

77 Therapeutic Consultation Documentation
The following information is required in the supporting documentation: Identifying information Targeted objectives, timeframes, expected outcomes Specific consultation activities Written support plan detailing interventions or support strategies

78 Therapeutic Consultation Documentation continued
Monthly and contact notes: Summary of consultative activities for the month Dates, locations, times of service delivery Supporting documentation objectives addressed Specific details of the activities conducted Services delivered as planned or modified Effectiveness of the strategies and satisfaction of services

79 Therapeutic Consultation Documentation continued
Semi-annual Reviews are required if provider extends three months longer should be forwarded to case manager Activities related to therapeutic consultation supporting documentation Individual status and satisfaction with services Consultation outcomes and effectiveness

80 Therapeutic Consultation Documentation continued
If consultation services extend less than three months: Forward a copy of monthly contact notes or a summary to case manager for semi annual review

81 Therapeutic Consultation Documentation continued
A final disposition summary must be forwarded to the case manager within 30 days following the end of this service must include: Strategies utilized Objectives met Unresolved issues Consultant recommendations 12VAC (6)

82 Service Units and Limitations
Unit of service is one hour Services must be explicitly detailed in supporting documentation Case managers must submit prior authorization to Kepro In order to receive over 12 hours additional documentation must be received to verify hours.

83 Therapeutic Consultation Supporting Documentation

84 Questions? This is your time to ask questions. How may we help you?

85 Division of Long-Term Care
Contact Information Long-Term Care Division Division of Long-Term Care Telephone Fax


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