CMS Final Rule 4-30-15 Published - Amazon S3 · the transition plans and other activities needed to comply with the CMS Final Rule. This presentation is meant to provide an overview

Pennsylvania Department of Human ServicesOffice of Developmental ProgramsCourse Number- C-008

1CMS Final Rule for HCBS Waiver Programs: An Overview

Pennsylvania Department of Human ServicesOffice of Developmental Programs

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Course Number- C-008



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For SCs and SC Supervisors, course requirements include successful completion of a pre‐test and post‐test.




Hello and welcome to this webcast, “Center for Medicare and Medicaid Services (CMS) Final Rule for Home and Community Based Waivers: An Overview.

I am Stephen Suroviec, Deputy Secretary for the Office of Developmental Programs.

It is our plan to provide you with both the opportunity to offer your suggestions and for us to give you information about our plans to meet the CMS Final Rule.

So the information within this recording is to provide you with:

1. Overview of CMS Final Rule , and2. Review of ODP’s Transition Plans

As you listen to and watch this webcast, please keep in mind the following:

In order to continue to use Federal funds to support our Waivers, we must comply with the CMS Final Rule by March 2019.

There has been and will continue to be, opportunities for stakeholder input.

Our policies to come into compliance will be based on the input of stakeholders.

This is the first in a series of webcasts we are planning to offer as we move through our transition plan.

This is an opportunity for all of us to review our Home and Community Based Service System to support community integration for the individuals supported by the Office of Developmental Programs.

Thank you for participating.

I am now going to turn this presentation over to Julie Mochon.




Hello, my name is Julie Mochon.

I am a Policy Supervisor at the Office of Developmental Programs (ODP) and the ODP Project Lead for CMS compliance. This webcast has been developed by staff within ODP’s intellectual disability and autism services programs.

For those new to services, CMS stands for the federal Centers for Medicare and Medicaid Services.




As Mr. Suroviec mentioned, this webcast is the first in a series addressing how the CMS Final Rule impacts ODP. ODP will be having additional webcasts as we begin to implement the transition plans and other activities needed to comply with the CMS Final Rule. This presentation is meant to provide an overview of the Rule and a review of ODP’s transition plans. It is our intent to keep all stakeholders informed as decisions are made and more detailed information becomes available.




The Consolidated, Person/Family Directed Support and Adult Autism waivers are mandated to meet the new CMS Final Rule requirements. In order to implement a Home and Community Based Service (HCBS) Waiver, a state must submit a waiver application to CMS. The application describes the waiver’s design and must include sufficient information to permit CMS to determine that the waiver meets applicable statutory and regulatory requirements. The Rule contains new regulatory requirements that each waiver must comply with to receive federal funding. Without federal funding, each waiver would not be able to provide the same services to the same number of individuals.




The CMS Final Rule does not apply to the Adult Community Autism Program, Intermediate Care Facilities for Persons with an Intellectual Disability or base funded services and programs.




CMS published the Final Rule amending regulations contained in 42 CFR 441.301 on January 16, 2014.

The Final Rule emphasizes contemporary practice in providing person‐centered supports in community settings.

‘Full access to the benefits of community living’ affords individuals with:• the same opportunities to participate in the their community as other citizens.• access and opportunities to receive support through natural supports.• opportunities to develop and establish relationships and socially valued roles

within their own community.

‘Opportunity to receive services in the most integrated setting appropriate for the person’ involves identifying, comparing, and choosing options. The appropriateness of the setting should be based on the individual’s strengths, preferences, and needs for support.

‘Enhanced quality of Home and Community‐Based Services’ is consistent with many initiatives from CMS focusing on the quality of services and supports individuals actually receive. Improving the quality of what we do for and with individual participants should result in outcomes that are personally important to them.

‘Provision of protections to participants’ reinforces respect for individuals’ rights, including specific residential requirements regarding due process rights in tenancy or eviction situations.

CMS intended for all waiver participants to benefit from the Final Rule. For this reason, the requirements that we will be discussing in the next slides apply to ALL waiver services.




The CMS Final Rule establishes requirements regarding:

• Settings that are not home and community‐based

• Settings presumed not to be home and community‐based

• Mandatory requirements for the qualities of home and community‐based settings including discretion of the federal Secretary of Health and Human Services to determine other appropriate qualities and

• Requirements for residential habilitation settings.




CMS initially stated that these four settings are considered not to be home and community‐based. Keep in mind that here, we are talking about the location where a home and community based waiver service may be provided. We are not talking about individuals that have been admitted to or reside in one of these settings. Recent guidance provided by CMS, however, now states that these settings will be presumed to have institutional characteristics. This guidance also includes that the federal regulations are considered aset of minimum requirements, but that individual states may elect to set more stringent requirements for what constitutes an acceptable home and community‐based setting.

For this reason, ODP plans to develop policies that will provide standards and objective criteria that will be utilized to evaluate whether a setting has home and community‐based characteristics or institutional characteristics. This could include stating that services provided in one of the settings on this slide automatically makes the service unallowable to be provided through the waivers. These policies will be developed based on input received from stakeholders.

Once ODP has developed these policies and monitored providers for compliance, ODP will then submit a list of providers that have been determined to have home and community‐based characteristics to CMS for a process called heightened scrutiny. The U.S. Secretary of Health and Human Services has the ultimate authority in determining whether or not the setting is home and community‐based.




As with the settings on the previous slide, these settings are presumed to have institutional characteristics. ODP will utilize the same process that will be developed for unallowable settings.




CMS has provided exploratory questions that individual states can utilize in developing their policies and assessing providers to ensure compliance with the qualifications found on the next three slides. These exploratory questions serve as suggestions to assist states and stakeholders in understanding what indicators might reflect the presence or absence of each quality in a setting. A copy of these exploratory questions is available as a resource where you accessed this webcast.

A few of the exploratory questions provided for the integration, employment and services requirements on this slide include:

• Does the setting provide opportunities for regular meaningful non‐work activities in integrated community settings for the period of time desired by the individual?

• Does the setting afford opportunities for individual schedules that focus on the needs and desires of an individual and an opportunity for growth?

• Does the setting afford opportunities for individuals to have knowledge of or access to information regarding age‐appropriate activities including competitive work, shopping, attending religious services, medical appointments, dining out, etc. outside of the setting, and who in the setting will facilitate and support access to these activities?




As with the previous slide, I will now go over some of The CMS Exploratory Questions for the settings requirements on this slide.

• Does the setting reflect individual needs and preferences and do its policies ensure informed choice of the individual?

• Do the setting options offered include non‐disability specific settings, such as competitive employment in an integrated public setting, volunteering in the community, or engaging in general non‐disabled community activities such as those available at a YMCA?

• Do the setting options include the opportunity for the individual to choose to combine more than one service delivery setting or type of HCBS in any given day/week (for example: combine competitive employment with community habilitation)?




CMS Exploratory Questions regarding an individual’s rights to privacy, dignity and respect as well as to freedom from coercion and restraint include the following:

• Is all information about individuals kept private? For instance, do paid staff and providers follow confidentiality policy and practices and does staff within the setting ensure that, for example, there are no posted schedules of individuals for Physical Therapy, Occupational Therapy, medications, restricted diets, etc., in a general open area?

• Does the setting support individuals who need assistance with their personal appearance to appear as they desire, and is personal assistance, provided in private, as appropriate?

CMS exploratory questions regarding optimization of individual initiative, autonomy and independence in making life choices include the following:

• Does the setting afford opportunities for individuals to choose with whom to do activities in the setting or outside the setting or are individuals assigned only to be with a certain group of people?

• Does the setting allow for individuals to have a meal or snacks at the time and place of their choosing? For instance, does the setting afford individuals full access to a dining area with comfortable seating and opportunity to converse with others during break or meal times, afford dignity to the diners (for example: individuals are treated age‐appropriately and not required to wear bibs)? Does the setting provide for an alternative meal and/or private dining if requested by the individual?

CMS exploratory questions regarding facilitating choice regarding services and who provides them include the following:

• Was the individual provided a choice regarding the services, provider and settings and the opportunity to visit and understand the options?

• Does the setting afford individuals the opportunity to regularly and periodically update or change their preferences?

• Does the setting post or provide information to individuals about how to make a request for additional HCBS (Waiver Services) or changes to their current services?




The next three slides provide requirements for Residential Habilitation settings only.

This regulatory language supports an individual’s tenancy rights, especially as it relates to protections from eviction in residential settings.

ODP is working with Pennsylvania Department of Human Services attorneys to develop guidance for compliance with these requirements. This may include the development of a template that providers can use as a legally enforceable agreement.




CMS utilizes several definitions of “unit” depending on the requirement.

It is ODP’s understanding at this time that the entire residential home or apartment as well as the individual’s bedroom door should be lockable by the individual.

While it is considered best practice for individuals to choose with whom they live, ODP recognizes that there are situations where this may not be possible. CMS requires that individuals have a choice of with whom they will share a bedroom.

At a minimum, individuals must be given the freedom to furnish their bedroom. Discussion should occur with the residential habilitation provider and the individuals residing in the home to determine the extent to which the rest of the home may be decorated and furnished. Any limitations on decorating the home should be specified in the scope of the lease.

CMS has stated that modifications or exceptions to these requirements can be made when specific information is documented in the Individual Support Plan. We will discuss these requirements later in this presentation.




Individuals should be supported in choosing and controlling a schedule that meets his or her wishes in accordance with the Individual Support Plan. Individuals should not be required to adhere to a set schedule for activities such as waking, bathing, eating and exercising. Each individual should have a schedule that varies from others in the home and meets his or her needs.

In regard to visitors, CMS has stated that the preferences of all residents must be respected. It is expected that communication and coordination between the provider and the individuals residing in the home will occur. CMS has also acknowledged that it would be reasonable for there to be limitations on the amount of time a visitor can stay as to avoid occupancy issues. Such limitations should be clearly stated in the lease, residency agreement, or other form of written agreement. Any other restrictions on individual choice of visitors must be focused on the health and welfare of the individual and the consideration of risk mitigation strategies.

Finally, the residential home should be physically accessible to all individuals who reside in the home. This also includes compliance with the Americans with Disabilities Act (ADA).




CMS regulations allow for modifications to some of the requirements. This slide and the next slide provide the basic criteria of what must be documented in the Individual Support Plan when a modification is needed.




To support these criteria, ODP will develop and publish guidelines regarding required Individual Support Plan documentation.




You may have noticed that the federal regulations also contain requirements for person‐centered planning. CMS limits the purpose of the transition plan to addressing the settings where waiver services are delivered. For this reason, the person‐centered planning requirements are not contained in this presentation. ODP will ensure compliance with the person‐centered planning requirements separate from the setting requirements and accompanying transition plans.




Now that we have gone over all of the requirements, you might be a little overwhelmed. Don’t panic! These changes will not happen overnight!




ODP has four years to come into compliance with the federal requirements. Full compliance must be achieved no later than March 2019.

CMS has stated that two different types of transition plans are required to be developed. Transition plans are documents in which states and waivers determine their compliance with the regulatory requirements for home and community‐based settings and describe to CMS how they will comply with the new requirements.

The two different types of transition plans are referred to as statewide transition plans and waiver specific transition plans. The difference between the statewide transition plan and the waiver specific transition plans are as follows:• The statewide transition plan will be more general since it will encompass all ten 1915

(c) home and community‐based waivers that are currently operating in Pennsylvania.• The waiver specific transition plans will include activities that apply to each of the

specific waivers. For example, the transition plans for the Consolidated and Adult Autism Waivers contain activities specific to residential habilitation providers. The transition plan for the P/FDS Waiver does not include such activities since residential habilitation is not a service covered in this waiver. The waiver specific transition plans can be found in the main section of each waiver amendment under the heading Attachments. This section is located after the signatures in the beginning of the waivers.




ODP’s Transition Plans (for the Consolidated, P/FDS, and Adult Autism Waiver) are structured into four distinct sections:

Section 1. IdentificationSection 2. AssessmentSection 3. Remediation StrategiesSection 4. Outreach and Engagement




In the Identification section of the waiver‐specific transition plans, measureable action steps are built into the structure of the plans to achieve compliance with the requirements. This will include a review of current licensing requirements, waiver, policies, regulations, rules, standards and statutes. This also includes identifying all waiver providers and all stakeholders that will be impacted by decisions made, as well as identifying whether changes will need to be made to ODP’s information technology systems to implement the requirements.




In the Assessment section, ODP outlines the steps that will be taken to review policy documents, provider enrollment documents and licensing requirements. The PennsylvaniaDepartment of Human Services also developed a survey for waiver providers to complete by April 30, 2015 that was included in this section. Completion of this survey did not result in providers being found non‐compliant; it simply helped the Department to get an overall understanding of the settings in which waiver services are being provided and help to determine the specifics of future assessment activities and inform policy development. Action items related to provider assessment are included in Section 3 Remediation Strategies for each requirement.




In the Remediation Strategy section, ODP outlines the steps that will be taken to achieve compliance with each requirement discussed previously in this presentation.




The Outreach and Engagement section outlines the steps that will be taken to incorporate stakeholder involvement into future decisions.




ODP will keep all stakeholders informed on the development and implementation of the transition plans as further information and guidance is available. Please watch for additional announcements, bulletins, and webcasts regarding these plans.




If you would like to receive email updates regarding the CMS Final Rule, you can send an email request to RA‐[email protected]




This webcast has been developed by the Pennsylvania Department of Human Services, Office of Developmental Programs and produced by The Columbus Organization.

Thank you for participating in this lesson.



Documents

CMS Final Rule 4-30-15 Published - Amazon S3 · the transition plans and other activities needed to comply with the CMS Final Rule. This presentation is meant to provide an overview