1. Proposed Changes to Rates & Update on the Transition Plan Home & Community Based Services Waiver for People with Intellectual & Developmental Disabilities September 17, 2015

2. Goals for Today  Discuss proposed amendments to rate methodologies for certain services.  Gather your feedback on our proposed waiver amendments. (All comments will be entered into the public record.)  Provide an update on our progress on our Transition Plan. 2

3. RATES DDS submitted proposed waiver amendments to CMS in February 2015 and received a series of questions about how the rates were developed. This resulted in our undertaking a full review of the rate methodology and proposing certain changes.

4. Updated Indirect Cost Calculations Waiver ServiceCurrent RateProposed Rate (2/2015) New Proposed Rate Individualized Day Supports (IDS) (1:2 ratio) $6.11/ 15 min$5.32/ 15 min$5.31/ 15 min IDS (1:1 ratio)New Service$9.32/15 min$9.40/ 15 min Respite$5.19/ 15 min $5.13/ 15 minutes Supported Employment Paraprofessional $6.33/ 15 min$7.22/ 15 min$7.14/ 15 min Supported Employment Professional $10.67$11.93/ 15 min$11.86/ 15 min

5. Hourly Rate Methods Components

6. IDS Indirect Calculation Mgr 75 hours $2,478.06 QIDP 30 hours $1,400.95 RN delegation 20 hours $1,089.46 Training 30 hours $1,208.89 Sub-total$6177.362 Program transportation staff/person 8 per trip times 125 days$2000 Program supplies and activities$2500 Total$10677.362 Annual Billable cost per DSP $49,318.67 Indirect Percentage22%

7. Respite Indirect Calculation QIDP 5 hours $233.49 RN delegation 7 hours $381.31 Training 20 hours $805.92 Sub-total $2,577.16 Transportation $8 per trip times 47 trips to one location $376.00 Program supplies and activities $300.00 Total $3,253.16 Annual Billable cost per DSP $34,632.00 Indirect Percentage9%

8. Supported Employment Para Indirect Calculation Mgr 52 hours $1,718.12 QIDP 20 hours $933.97 RN delegation 12 hours $653.68 Training 20 hours $805.92 Sub-total$4111.692 1.25 trips per day$2500 Program supplies job prep$2200 total$8811.692 Annual Billable cost per DSP $43,784.00 Indirect Percentage20%

9. Supported Employment Prof Indirect Calculation Mgr 52 hours $1,718.12 QIDP 30 hours $1,400.95 RN delegation 10 hours $544.73 Training 30 hours $1,208.89 Sub-total$4872.6916 2 trips per day$4000 Program supplies job prep$2500 Total$11372.6916 Annual Billable cost per DSP $75,924.99 Indirect Percentage15%

10. Supported Living with Transportation (Periodic) Rate increased to reflect the increases in costs associated with the time spent transporting the person to different locations for day and vocational services. Waiver ServiceCurrent RateProposed Rate (2/2015) New Proposed Rate Supported Living with Transportation $6.61/ 15 min $6.75/ 15 min

11. Day Services - # Program Days Reduces the number of program days to 249/ year to reflect 11 holidays. Waiver ServiceCurrent RateProposed Rate (2/2015) New Proposed Rate Day Habilitation$3.80/ 15 min$5.57/ 15 min$5.43/ 15 min Day Habilitation 1:1 $6.77/ 15 min$10.45/ 15 min$10.28/ 15 min Employment Readiness $3.80/ 15 min$4.90/ 15 min$4.68/ 15 min Small Group Day Habilitation New Service$9.22/ 15 min$8.20/ 15 min

12. Rate Modifier - Meals Meal for people who live independently or with family and attend Day Habilitation, Small Group Day Habilitation, or Individualized Day Supports: –$7.30/ meal, plus –$5.00 for meal delivery to a Day Habilitation or Small Group Day Habilitation setting.

13. Companion Match the rate for Personal Care Services Add a group rate for 1:2 or 1:3 Waiver ServiceCurrent RateProposed Rate (2/2015) New Proposed Rate Companion 1:1New Service$4.72/ 15 min Companion group New Service $2.91/ 15 min

14. Creative Arts Therapies Change in group rate (not to exceed 1:4) by $.01 Waiver ServiceCurrent RateProposed Rate (2/2015) New Proposed Rate Creative Arts Therapy Group New Service$25.00/45 min$24.99/ 45 min

15. Group Supported Employment Add a rate for Group Supported Employment Paraprofessional Individual Services: $2.85 / 15 minutes.

16. Comparison of ICF and Waiver Rate Components ICF/IDDFY 16 Staffing FY 15 MBI LW Rate DSP -1 $13.87$14.07 $14.08 DSP -2 $13.87$14.07 $14.08 DSP-3 $13.87$14.07 $14.08 CNA $17.39$17.63 $17.65 LPN $21.70$22.00 $22.02 RN $34.77$35.26 $35.28 QMRP $29.81$30.22 $30.24 Hse Manager $22.35$22.67 $22.68 current1.47%New/2015 DSP13.60 13.80 LPN22.85 0.33602923.19 RN36.61 0.53838237.15 QIDP31.38 0.46147131.84 Hse Manager23.53 0.34602923.88 DD Waiver Originally Proposed

17. HCBS IDD Waiver Transition Plan Review of the HCBS Settings Rule Update on Self-Assessments Initial Remediation Submissions for Heightened Scrutiny Next Steps

18. HCBS Settings Rule Title: Medicaid Program; State Plan Home and Community-Based Services, 5-Year Period for Waivers, Provider Payment Reassignment, and Home and Community-Based Setting Requirements for Community First Choice (Section 1915(k) of the Act) and Home and Community- Based Services (HCBS) Waivers (Section 1915(c) of the Act) or “The Settings Rule” Published in the Federal Register on 01/16/2014 Effective March 17, 2014 www.hcbsadvocacy.org 18

19. HCBS Settings Requirements The Home and Community-Based setting: Is integrated in and supports access to the greater community Provides opportunities to seek employment and work in competitive integrated settings, engage in community life, and control personal resources Ensures the individual receives services in the community to the same degree of access as individuals not receiving Medicaid home and community-based services

20. HCBS Settings Requirements The Home and Community-Based setting: Is selected by the individual from among setting options, including non-disability specific settings and an option for a private unit in a residential setting – Person-centered service plans document the options based on the individual’s needs, preferences; and for residential settings, the individual’s resources

21. HCBS Settings Requirements The Home and Community-Based setting: Ensures an individual’s rights of privacy, dignity, respect, and freedom from coercion and restraint Optimizes individual initiative, autonomy, and independence in making life choices Facilitates individual choice regarding services and supports, and who provides them

22. HCBS Settings Requirements Provider Owned and Controlled Settings – Additional Requirements Specific unit/dwelling is owned, rented, or occupied under legally enforceable agreement Same responsibilities/protections from eviction as all tenants under landlord tenant law of state, county, city or other designated entity If tenant laws do not apply, state ensures lease, residency agreement or other written agreement is in place providing protections to address eviction processes and appeals comparable to those provided under the jurisdiction’s landlord tenant law

23. HCBS Settings Requirements Provider Owned and Controlled Settings – Additional Requirements Each person has privacy in their sleeping or living unit Units have lockable entrance doors, with appropriate staff having keys to doors as needed People sharing units have a choice of roommates People have the freedom to furnish and decorate their sleeping or living units within the lease or other agreement

24. HCBS Settings Requirements Provider Owned and Controlled Settings – Additional Requirements People have freedom and support to control their schedules and activities and have access to food any time People may have visitors at any time Setting is physically accessible to the person

25. HCBS Settings Requirements Provider Owned and Controlled Settings – Additional Requirements Modifications of the additional requirements must be: – Supported by specific assessed need – Justified in the person-centered service plan – Documented in the person-centered service plan

26. Settings That Are Presumed Not HCBS Settings in a publicly or privately-owned facility providing inpatient treatment. Settings on grounds of, or adjacent to, a public institution. Settings with the effect of isolating individuals from the broader community of individuals not receiving Medicaid HCBS. 26

27. Settings That Tend to Isolate CMS Examples: The setting is designed specifically for people with disabilities, and often even for people with a certain type of disability. The people in the setting are primarily or exclusively people with disabilities and on- site staff provides many services to them.

28. Settings That Tend to Isolate The setting is designed to provide people with disabilities multiple types of services and activities on-site, including housing, day services, medical, behavioral and therapeutic services, and/or social and recreational activities. People in the setting have limited, if any, interaction with the broader community.

29. To Overcome the Presumption The State must submit the settings to CMS for Heightened Scrutiny review and present evidence that: The setting is integrated in the community to the extent that a person or persons without disabilities in the same community would consider it a part of their community and would not associate the setting with the provision of services to persons with disabilities. The individual participates regularly in typical community life activities outside of the setting to the extent the individual desires. Such activities do not include only those organized by the provider agency specifically for a group of individuals with disabilities and/or involving only paid staff; community activities should foster relationships with community members unaffiliated with the setting. Services to the individual, and activities in which the individual participates, are engaged with the broader community.

30. HCBS Waiver Transition Plan All states were required to develop an HCBS transition plan, that provides a comprehensive assessment of potential gaps in compliance with the new regulation, as well as strategies, timelines, and milestones for becoming compliant with the rule’s requirements by March 2019. DDS submitted its Statewide Transition Plan on March 17, 2015 and worked with stakeholders on our state self-assessment. Providers conducted self-assessments and are writing transition plans for their own organizations. Transition Plans are due September 21, 2015 Service coordinators are be talking to people who receives HCBS services about their experiences to inform our assessment. Ongoing

31. State Self-Assessment Work with HCBS Settings Advisory Group to review and make recommendations for remediation, where needed, on: All HCBS waiver service definitions and provider requirements. All regulations governing HCBS. DDS/DDA Provider Certification Review (PCR) process. DOH licensing requirements and regulations. All relevant DDS/DDA policies, procedures, and protocols, including Quality Management practices and tools. Provider training requirements. Human Care Agreements and rate methodologies. Information systems.

32. Draft Changes to General Provisions 1938 HOME AND COMMUNITY BASED SETTING REQUIREMENTS 1938.1All Supported Living, Supported Living with Transportation, Host Home, Respite Daily, Residential Habilitation, Day Habilitation, Small Group Day Habilitation, Individualized Day Supports, Supported Employment, Small Group Supported Employment and Employment Readiness settings must: be chosen by the person; ensure people’s right to privacy, dignity, and respect, and freedom from coercion and restraint; be physically accessible to the person and allow the person access to all common areas; support the person’s community integration and inclusion, including relationship-building and maintenance, support for self-determination and self-advocacy, and opportunities for employment and meaningful non-work activities in the community; provide information on individual rights; and allow visitors at any time, with any exception based on the person’s assessed need and justified in his or her person-centered plan.

33. Draft Changes to General Provisions 1938 HOME AND COMMUNITY BASED SETTING REQUIREMENTS 1938.2 All Supported Living, Supported Living with Transportation, Host Home, Residential Habilitation, and Respite Daily, settings must: Be integrated in the community and support access to the greater community; Provide opportunities for the person to engage in community life; Allow full access to the greater community; Be leased in the names of the people who are being supported. If this is not possible, then the provider must ensure that each person has a legally enforceable residency agreement or other written agreement that, at a minimum, provides the same responsibilities and protections from eviction that tenants have under relevant landlord/tenant law. This applies equally to leased and provider owned properties.

34. Draft Changes to General Provisions 1938 HOME AND COMMUNITY BASED SETTING REQUIREMENTS 1938.2(e) All Supported Living, Supported Living with Transportation, Host Home, Residential Habilitation, and Respite Daily, settings must: Develop and adhere to policies which ensure that each person receiving services has the right to the following: Privacy in his or her personal space, including entrances that are lockable by the person (with staff having keys as needed); Freedom to furnish and decorate his or her personal space (with the exception of Respite Daily); Control over his or her personal funds and bank accounts; Privacy for telephone calls, texts and/or emails; and Access to food at any time.

35. Draft Changes to General Provisions 1938 HOME AND COMMUNITY BASED SETTING REQUIREMENTS 1938.3 Any deviations from the requirements in § 1938.2(e) must be supported by a specific assessed need, justified in the person’s person- centered Individualized Support Plan, and reviewed and approved as a restriction by the Provider’s Human Rights Committee.

36. Draft Changes to General Provisions 1911INDIVIDUAL RIGHTS (New Additions) Each Waiver provider shall develop and adhere to policies which ensure that each person receiving services has the right to the following: Be informed orally and in writing of the following: Complaint and referral procedures including how to file an anonymous complaint; How to report an allegation of abuse, neglect and exploitation; For people receiving residential supports, the person’s rights as a tenant, and information about how to relocate and request new housing.

37. Draft Changes to General Provisions Provider Requirements (1904.4) Complete mandatory training in Person-Centered Thinking, Supported Decision-Making, Supporting Community Integration, and any other topics as determined by DDS. Develop and implement a continuous quality assurance and improvement system, that includes person-centered thinking, community integration, and compliance with the HCBS Settings Rule, to evaluate the effectiveness of services provided.

38. Draft Changes to General Provisions 1907 INDIVIDUAL SUPPORT PLAN (ISP) (Changes) The ISP is the plan that identifies the supports and services to be provided to the person and the evaluation of the person’s progress on an on-going basis to assure that the person’s needs and desired outcomes are being met, based on what is important to and for the person, specifically including identifying the person’s interest in employment, identifying goals for community integration and inclusion, and determining the most integrated setting available to meet the person’s needs. The ISP shall be developed by the person and his or her support team using Person-Centered Thinking and Discovery tools and skills.

39. Draft Changes to Day/ Voc Regs Ban payment of stipends for attendance or participation at day or vocational programs. Require development of PPP & JS/CPPP. Emphasis on community integration. Day Habilitation must include activities to support community integration and inclusion. These must occur in the community in groups not to exceed 4 participants and must be based on people’s interests and preferences as reflected in their Individualized Support Plan and Person-Centered Thinking and Discovery tools. Employment Readiness must include community-based employment preparation experiences that are related to the person’s employment goals.

40. Provider Self-Assessments CMS Recommended Assessment Question #Indicator Prevalence in Provider Setting (Select 1-6, above ) Provide name and hyperlink, if available, for specific evidence of compliance. If no specific evidence is available, please indicate that. Comments & Feedback: Please use this section to help us identify systemic support and barriers to achieving compliance with the HCBS Settings Rule; areas in which training, technical assistance and capacity building would be helpful; explanations, if needed, of your self-assessment score; etc. (a)The home ensures a person’s rights of privacy, dignity, respect and freedom from coercion and restraint. The following PCR question(s) may be helpful in responding to this section:  CQ.2- Is the person’s right to privacy acknowledged and practiced? (for 1 & 4 below)  CQ.3 – Is the person and/or their representative aware of actions they can take if they feel they have been treated unfairly, have concerns or are displeased with the services being provided? (for 2 below)  CQ.25 – Is the person and/or their representative able to communicate and/or demonstrate their rights as a consumer of waiver services? ( for 2 below)  OO.CQ.20- Does the provider ensure proper handling of all consumer records including security, confidentiality, and retention in accordance with DDS and federal policies (for 3 below) 1 People are provided personal care assistance in private, as appropriate. 2 Information is provided to people on how to make an anonymous complaint. 3People’s health and other personal information (e.g., mealtime protocols, therapy schedules) are kept private.

41. Personal Experience Assessments

42. Provider Transition Plans Any issues identified during the self assessment; and Continuous quality improvement plan to: –advance rights and choice; –support people to build and maintain relationships with and without people with disabilities; –fully engage in self-determination and supported decision-making; –work in competitive, integrated employment or engage in community-based, integrated retirement activities; –participate in a variety of community activities based upon their interests; etc.

43. Provider Transition Plans Type of Setting Issue# of Sites Remedial Strategy Lead Unit Target Date Ongoing Monitorin g Residential Habilitation Access to Visitors 10 Issue policy Operations11/1/2015 Quarterly review of visitor logs and interviews with people who receive supports. Train staffTraining12/1/2015 Inform and educate people we support and their families Operations12/1/2015

44. What’s Next? PPR & PCR Validation of Provider Transition Plans Update Provider Performance Review to include monitoring of Provider Transition Plans, by 10/2015 Revise Provider Certification Review by 12/2015 Transition Plan Update Transition Plan with timelines and milestones for compliance Submit providers for heightened scrutiny review Submit to CMS by 3/2016 Moving Forward Revise DDS additional policies, procedures and regulations by 4/2016 Training and support capacity building for providers, with a focus on employment Continued community engagement

45. For More Information Erin Leveton State Office of Disability Administration DC Department on Disability Services (202) 730-1754 Erin.Leveton@dc.gov http://dds.dc.gov/page/waiver- amendment-information