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 possibleServices in the workplace when possibleIndividually tailored servicesCoordinate with schools and other trainingareasMaximize other financial resourcesMinimize 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).
11 In-home Residential Support Services Service Definition
12 In-home Residential Support Service Definition Training and assistance or specialized supervisionMost training occurs in an individual’s home or residence considered to be his/her homeIn-home support does not include room and boardEnables an individual to acquire, improve, or maintain:Activities of daily living (ADLs)Access community resourcesAdapt to the community/daily environmentSafety skills and health status
13 In-home Residential Support Services Supplemental to the care provided by a parent or similar caregiverMay support an individual whose level of independence does not require a primarycaregiver
14 In-home Residential Support Service Definition May not be provided for a continuous 24-hour periodTraining is provided in the home or communitySupports are delivered on a 1:1 staff to individual ratioIn 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 lifestyleHelp 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 ActivitiesTraining 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 tasksMonitoring health, physical condition and medical needsEnsure 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 servicesMust be prior-authorizedShould be provided at frequency allowing for systematic training and maintenance of functional supportsIndividual 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 POCDocumentation of dates, times, and services providedAny circumstances that prevented the individual from receiving all scheduled hoursIf 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-billableExamples of General Supervision:Awake staff coverage at night if the individual generally sleeps throughout the nightOversight of leisure activitiesRoutine bed checksAsleep staff at night on the premises for security and/or safety reasonsStaff “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 occurActivities must relate to the assessed health and safety needs of the individualProvides 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 requestOngoing need for this service should be documented in semi-annual reviewsIf, 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.
28 In-home Residential Support Documentation Supporting Documentation (457) indicates:Need for the serviceAmount and type of activities (objectives and goals)Schedule of servicesTotal hours per dayTotal hours per weekAssessment 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 basisAdditional hours when clearly justified need to be requested through the case managerReimbursed for hours of direct staff time with individual only
30 In-home Residential Support Documentation Must be authorized by DMASServices 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 individualGeneral status of individualSignificant eventsIndividual/family satisfaction with servicesAny revision to Plan of Care (POC) and supporting documentationSubmitted to case manager
33 In-home Residential Support Documentation Supervision of direct care staff:Monthly contacts/Semi-annual home visitsSignature of responsible supervisorDate of contact/observationPerson contacted/observedStaff performance and service deliveryProblems, concerns, individual satisfaction with servicesActions planned/taken to correct problemsDifference 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 )
37 Day Support Service Definitions Variety of trainingAssistanceSupportSpecialized supervision (other than home or individual residence)Peer InteractionsSpecialized supervision for the acquisitionRetentionImprovement of self helpSocializationAdaptive 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 awarenessSensory, gross and fine motor skillsCommunicationPersonal careProblem-solving skillsUsing community resourcesCommunity safetyPeer interactions
40 Day Support CriteriaMust have demonstrated need for training, assistance and supervisionin settings outside of hometo access in-home residential servicesto increase current level of independenceto sustain skillsIndividuals cannot benefit from Supported Employment
41 Day Support CriteriaFunctional 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-BasedNon Center-BasedLevels:RegularIntensive
43 Day Support Intensive Level Criteria Must meet at least one of the following criteria:Need for physical assistance for caring for personal needsExtensive disability-related difficulties, requiring additional staff supportExtensive 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)
45 Day Support Services Documentation Supporting Documentation (457) indicates:Need for the serviceAmount and type of activities (objectives and goals)Schedule of servicesTotal hours per dayTotal hours per weekMaximum 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 CareService cannot be provided in individual’s home without prior authorization from Kepro
47 Day Support Services Documentation Documentation must confirm the following:AttendanceAmount of individual’s time in serviceSpecific information regarding individual’s response to various settings
48 Day Support Services Documentation Supports as agreed to in the supporting documentation objectivesAssessment 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 revisionsSubmit 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-basedRegular or intensive levelAttendance log or similar document must be maintained indicating the following:DateType of services rendered
51 Day Support Service Blocks hours =1 blockhours = 2 block7 or more hours = 3 block
57 Supported Employment Service Description Paid employmentCommunity worksites with people without disabilitiesSpecialized supervision and trainingOngoing support
58 Supported Employment Activities Training in specific job and related skillsOngoing or intermittent assistanceSpecialized supervision to ensure health and safetyContacts 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 servicesAssessment must clearly reflect need for ongoing supports on the jobReimbursed only for services included in POC
60 Supported Employment Individual Model Regular community jobJob coach servicesUsually one to oneIntermittent supportReimbursement for specific interventions only, including collateral contacts, not time on the job
61 Supported Employment Group Model 8 or fewer people with disabilitiesIntegration with people without disabilitiesEnclaveWork CrewEntrepreneurialBenchwork/Electronics Assembly
62 Supported Employment Service Limitations Transportation not included in serviceCase 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 serviceAmount and type of activities (objectives and goals)Schedule of servicesTotal hours per dayTotal hours per weekMaximum 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:DateType of services renderedNumber of Hours or Units provided (including specific time frame)Center-based or non center-basedRegular or intensive level
65 Supported Employment Service Units Individual Supported Employment (SE) billed hourlyGroup Supported Employment billed at unit rate:hours = 1 blockshours = 2 blocks7 or more hours = 3 blocksThe case manager will submit to Kepro a request for services form for authorization.
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: PsychologyRehabilitationOccupational TherapyBehavioral ConsultationPsychiatrySocial WorkTherapeutic RecreationPsychiatric 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 institutionalizationTC 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 informationTargeted objectives, timeframes, expected outcomesSpecific consultation activitiesWritten support plan detailing interventions or support strategies
78 Therapeutic Consultation Documentation continued Monthly and contact notes:Summary of consultative activities for the monthDates, locations, times of service deliverySupporting documentation objectives addressedSpecific details of the activities conductedServices delivered as planned or modifiedEffectiveness 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 managerActivities related to therapeutic consultation supporting documentationIndividual status and satisfaction with servicesConsultation 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 utilizedObjectives metUnresolved issuesConsultant recommendations12VAC (6)
82 Service Units and Limitations Unit of service is one hourServices must be explicitly detailed in supporting documentationCase managers must submit prior authorization to KeproIn order to receive over 12 hours additional documentation must be received to verify hours.