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1
DEVELOPMENTAL DISABILITIES ADMINISTRATION
RESOURCE COORDINATION SERVICES
Training #1June 5, 2012
Community
Employment
Holistic
CoordinationQuality
Assurances QualityMonitorin
g
Performance Outcomes
RCFunding
Serv
ices
2
AGENDA Welcome
Quality Framework and Continuous Quality Improvement
Resource Coordination Service Framework FY 2013
Process, Policies, and FormsUpdatesHelpful StrategiesRemindersPerformance Measure Links
*Please make a note or flag topics you would like to see more in-depth training
3
WELCOMEBy: Stanley Butkus
DDA Deputy Director
4
RESOURCE COORDINATION
Helpful information What resource coordination is (and isn’t) How it works Key functions Connections to services Interagency activities Responsibilities
Stanley Butkus
5
RESOURCE COORDINATION – THE
WHY Assist and support individuals in leading life
of quality and meaning to them.
Be realistic but understand that a person is not the sum of their deficits and diagnosis.
We deal with the whole person and the standard is how would we want to be treated in similar circumstances.
6
RESOURCE COORDINATION – THE
WHY For all the good work of agencies, networks and
systems and the wise guidance of policies, procedures and funding formulas; we are ultimately dealing with people’s lives, individual biographies. And we do it one person at a time.
Resource coordination is: the face of the service system for the person
and those people who are important in their lives;
the eyes and ears of our system; and the first level of monitoring.
7
RESOURCE COORDINATION – THE
WHY No two people or those in their lives are the
same.
There may not be agreement between the person and their family members about what is best or appropriate which can be a source of conflict.
Some are very involved some are distant, even disengaged in some situations.
There may be some situations where you are as close as it gets to being a family member.
8
RESOURCE COORDINATION – THE WHY
The resource coordinator is the agent of the person, an advocate and problem solver.
A connector through the individual plan to their communities.
One expert in our field ( David Pitonyak) has said that the biggest problem people with intellectual and cognitive disabilities face is loneliness.
You may be able to think of situations in your own life where something was just beyond your grasp intellectually and when there is no one there to check in with you can feel alone-IT does this to me.
9
RESOURCE COORDINATION – THE WHY
Resource coordinators are independent of agencies providing other services.
This provides the opportunity to act and advocate in concert with the wishes and best interests of people when there are issues that need to be addressed.
The resource coordinator serves expressive and instrumental roles that vary by time and circumstance.
Expressive in the sense of providing emotional and empathic support and instrumental in making sure that as needed the person is supported appropriately residentially, in day and employment situations and for related needs.
10
RESOURCE COORDINATION – THE WHY
Essential role is the resource coordinator’s connection to the plan.
Developing a plan that is authentic to the person, identifying how life goals will be met taking needs and preferences into account and overseeing, and monitoring progress is at the heart of resource coordination.
In other words, assuring that people get what they need, when they need it, by people who know what they are doing. Matching person needs with care and service provider strengths/preferences for those they serve and support is the key to success. Cross training has its place but everybody cannot work well with everybody.
11
RESOURCE COORDINATION DAILY COMMITMENT
Listen to understand the person’s story
Hold the person in positive regard- because any of us are capable of doing anything (good or bad) that anybody else did in human history if we were in a similar circumstance.
Begin where the person is
Use a positive behavior supports frame
12
RESOURCE COORDINATION DAILY COMMITMENT
Expectations-overtime we have as a field systematically underestimated what people with disabilities can achieve. As we have learned better approaches they have done better. Conversely, with the best of intentions we have expected them to be better citizens than the rest of us-not make any mistakes-creating the unintended consequence of increasing dependency.
Sensitivity to diversity, and socio-economic factors, e.g. 49% of waiver recipients in the US have a family income of less than $25,000 per year
13
RESOURCE COORDINATION DAILY COMMITMENT
These are stressful jobs. You need to take care of yourself. Burnout
occurs when what you want to is out of reach with what you can do.
Be clear on what your functions are and stick to those.
Seek guidance from your supervisor on how to prioritize when you get overloaded.
Know the rules, processes, assurances, and resources and seek additional training or advice.
Someone once said the only place in town where there is no conflict is in the cemetery so if you get a chance get some training in conflict resolution and mediation.
14
DDA PHILOSOPHY People with developmental disabilities are
valuable and contributing members of their community.
People and families should have access to necessary services and supports, from various resources, in the least restrictive, most appropriate, and most effective environment possible.
15
DDA SERVICE DELIVERY OVERVIEW
DDA provides a coordinated service delivery system so that people with developmental disabilities receive appropriate services oriented toward the goal of integration into the community.
16
DDA SERVICE DELIVERY OVERVIEW
DDA services are provided through both State and federal funding and programs provided by a wide array of community-based services delivered, State Residential Centers (SRC), and Forensic Residential Centers (FRC).
Community-Based
Services*Waivers*State Funded
State Residenti
al Centers
Forensic Residenti
al Centers
State $
Federal
$
17
DDA SERVICE DELIVERY OVERVIEW
Resource coordinators must: Be familiar with and maintain compliance
with these State and federal laws and regulations, which may be amended during the upcoming fiscal year;
Be knowledgeable and trained in DDA’s: Waiver and State funded procedures and
quality assurances; and Priorities and initiatives.
18
DDA IS COMMITTED TO COORDINATING SERVICES AND SUPPORTS THAT ARE:
Individualized, reflecting a continuum of services and/or supports, both formal and informal, based on the unique strengths of each person and their family/caregivers;
Provided in the least restrictive, most natural setting appropriate to meet the needs of the person and family;
Person directed;
Family-driven and child/youth-guided, with families, children, and youth engaged as active participants at all levels of planning, organization and service delivery;
19
DDA IS COMMITTED TO COORDINATING SERVICES AND SUPPORTS THAT ARE:
Community-based, coordinated and integrated with various services and supports including generic (i.e. services available to the public at large), community, local, federal, and State programs for needed medical, social, educational, and other services including community housing agencies, connecting the person with self advocacy groups, recreation, social, and DDA services;
Culturally and linguistically competent, with agencies, programs, services and supports that are responsive to the cultural, racial and ethnic differences of the populations we serve;
Prevent and reduce crisis, emergencies, hospitalization, and institutionalization;
20
DDA IS COMMITTED TO COORDINATING SERVICES AND SUPPORTS THAT ARE:
Holistic including generic, local, State, federal, and other resources and funding beyond DDA;
Promote integration with the community at large;
Protective of the rights of children, youth, adults, and their family/caregivers; and,
Collaborative across long term services and support systems, involving Medicaid and other insurances, mental health, child welfare, juvenile services, education, substance abuse, somatic health and other system partners who are responsible for providing services and supports to people eligible for DDA funding.
21
Waiver Roles & Responsibilities Person – self determination and self-directed (if
desired) Resource Coordinator
Initial application Service planning – holistic Monitoring – proactively monitoring services, due
dates (plan, LOC, financial redetermination, etc.) circumstances, and needs
Eligibility –annual requirements including Medicaid Financial documentation, LOC, annual plans within 365 days,
Support Broker – Human Resource functions FMS – Accounting and payroll functions Service providers – staff that work for the waiver
participant
22
CONTINUOUS QUALITY IMPROVEMENT
The DDA is committed to conduct ongoing system-wide reviews of ways to improve the effectiveness of services and supports so people can achieve personally developed outcome through: better coordination and delivery of
services; accountability of funding; federal assurances; and alignment of priorities and strategies.
23
CONTINUOUS QUALITY IMPROVEMENT
This commitment includes strategies to continuously support DDA’s system of highly qualified and resourceful resource coordinators that are knowledgeable of community resources and creative problem solvers to assist people with becoming fully integrated in their communities.
24
CONTINUOUS QUALITY IMPROVEMENT
Linking people and families to natural and informal networks leads to improved outcomes and reduced reliance on formal services.
These linkages are essential to be fully integrated in one’s community.
25
CONTINUOUS QUALITY IMPROVEMENT
Quality and the cost of service are both important and inter-related.
Services
Cost
Quality
26
CONTINUOUS QUALITY IMPROVEMENT
Lack of monitoring of quality of services may negatively impact health and safety and progress toward goals.
Poor planning and lack of brokering community resources, to include natural supports, may over commit funding for one person which deprives another person of needed services.
It is also true that failing to seek funding in the interest of “cost savings” may impede health and safety, quality, and increase cost pressures in other parts of the system (such as emergency rooms and institutions).
27
DDA RESOURCE COORDINATION
CORE SERVICE CATEGORIES
Eligibility &
Access
Waiting List
Community
Coordination
Transitioning to Commu
nity
28
SYSTEM GOVERNANCE AND REGULATIONS
State and federal statutes and regulations govern the DDA service delivery system.
• Health General• COMAR 10.22
DDA CMS stands for the Federal Center for Medicaid and Medicare Services
29
MEDICAID WAIVER BASICSBackground Community Pathways and New Directions are
both Medicaid programs referred to as 1915 (c) Home and Community-Based Service (HCBS) waivers.
Medicaid is a joint federal/State funding program that pays for most long term care provided to low income, older persons and persons with disabilities.
The HCBS waiver allows states to use Medicaid funding to provide services and supports to persons living in their homes or in other community-based settings (e.g. group homes, alternative living units, IFC (DDA’s adult foster homes)).
Reference: CMS Training for Case Managers on HCBS Waiver Assurances
Link: http://www.hcbsassurances.org/index.html
30
WAIVER BASICS - CONTINUED Persons are eligible to receive HCBS waiver
services if they meet federal qualification criteria.
A state must apply to the CMS through an HCBS waiver application for permission to operate an HCBS waiver.
Regardless of the HCBS waiver design, every application must address how a state intends to meet specific CMS requirements known as the HCBS waiver assurances.
The assurances were put into place by Congress to address the unique challenges of assuring the quality of services delivered to vulnerable persons living in their community.
Reference: CMS Training for Case Managers on HCBS Waiver Assurances
31
WAIVER BASICS - CONTINUEDHCBS Waiver programs must include the following:
Reference: CMS Training for Case Managers on HCBS Waiver Assurances
Waiver Design
Performance
Measures
Discovery Methods
Remediation
System Improvem
ent
32
WAIVER BASICS - CONTINUED
Waiver Design: The population and geographic area to be served, the mix of services offered, the quality standards, including provider qualifications, policies and payment methods.
Performance Measures: The standards a state will use to evaluate how well the HCBS waiver is meeting each of the federal assurances and subassurances.
Reference: CMS Training for Case Managers on HCBS Waiver Assurances
33
WAIVER BASICS - CONTINUED
Discovery Methods: The data a state collects to measure how well it is meeting each performance measure; the method and frequency of data collection and analysis; and the person or entity responsible for using the data for decision-making.
Remediation: How a state will take action when individual problems are found.
System improvement: Method to prevent similar problems from happening to others or to make the HCBS waiver more effective and efficient.
Reference: CMS Training for Case Managers on HCBS Waiver Assurances
34
REMEDIATION Focus of remediation is to address and resolve all
individual problems uncovered in the course of discovery.
The rate of compliance is measured through the waiver’s performance measures.
CMS expects states to be in compliance with the statutory assurances.
If a performance measure indicates that the state achieved less than 100% compliance, the state must remediate all instances of non-compliance discovered.
35
HCBS WAIVERS ARE:
Person centered;
Encourage people to play active roles in deciding the services they want to receive and when; and
Can make a big difference in the person’s and families quality of life.
Reference: CMS Training for Case Managers on HCBS Waiver Assurances
36
CHALLENGES IN ASSURING QUALITY IN HOME-BASED SETTINGS
Delivering services in home and community settings raises new challenges to assure the quality of these programs. There is no one on site to monitor care and services
at all times. Participants rely on many people for their care and
safety. Participants may be vulnerable and unable to seek
help. People may be afraid of losing their services if they
report problems.
So what are the assurances, and how do they relate to you?
Reference: CMS Training for Case Managers on HCBS Waiver Assurances
QA?
37
FEDERAL HCBS WAIVER ASSURANCES
Level of Care
Service Plan
Qualified Providers
Health &
Welfare
Financial Accountability
Administrative
Authority
38
FEDERAL HCBS WAIVER ASSURANCES
Level of Care: Participants enrolled in the HCBS waiver meet the level of care criteria consistent with those residing in institutions.
Service Plan: A person's needs and preferences are assessed and reflected in a person-centered service plan.
Qualified Providers: Agencies and workers providing services are qualified.
Reference: CMS Training for Case Managers on HCBS Waiver Assurances
39
FEDERAL HCBS WAIVER ASSURANCES
Health and Welfare: Participants are protected from abuse, neglect and exploitation and get help when things go wrong or bad things happen.
Financial Accountability: A state Medicaid Agency pays only for services that are approved and provided, the cost of which does not exceed the cost of a nursing facility or institutional care on a per person or aggregate basis (as determined by the state).
Administrative Authority: A state Medicaid Agency is fully accountable for HCBS waiver design, operations and performances
Reference: CMS Training for Case Managers on HCBS Waiver Assurances
40
FEDERAL HCBS SUBASSURANCES EXAMPLES
Reference: Understanding Medicaid Home and Community Services: A Primer, 2010ase Managers on HCBS Waiver Assurances (PDF Version: http://aspe.hhs.gov/daltcp/reports/2010/primer10.pdf (253 PDF pages))
TABLE 2. Examples of Subassurances(Version 3.5 of the §1915(c) Waiver Application)
Level of Care The levels of care of enrolled participants are reevaluated at least annually or as specified in the approved waiver
Service Plan Service plans are updated/revised at least annually or when warranted by changes in the waiver participant’s needs
Service Plan Services are delivered in accordance with the service plan, including in the type, scope, amount, and frequency specified in the service plan.
Service Plan Participants are afforded choice: between waiver services and institutional care; and between/among waiver services and providers.
Provider Qualifications
The state verifies that providers initially and continually meet required licensure and/or certification standards and adhere to other state standards prior to their furnishing waiver services.
41
FEDERAL HCBS WAIVER ASSURANCES
ASSURANCES
SUBASSURANCES
PERFORMANCE MEASURES
42
MARYLAND’S DD WAIVERSFEDERAL ASSURANCES
PERFORMANCE MEASURES
Performance Measures
43
PERFORMANCE MEASURES
#1 - Number and percent of new waiver enrollees who had a level of care indicating the need for institutional level of care (ICF/ID) prior to receipt of services.
#2 - Number of completed annual LOC re-certifications over the number of active waiver participants.
*Performance Measures for both Community Pathways and New Directions Waivers
44
PERFORMANCE MEASURES
#1- Number of IPs containing required information per COMAR 10.22.05.02
#2- Number of IPs surveyed that document supports necessary to achieve goals
#3- Number of IP reviewed within a year (365 days)
*Performance Measures for both Community Pathways and New Directions Waivers
45
PERFORMANCE MEASURES
#4- Number of people receiving services specified on their IP
#5- Number of people provided choice between community based services and institutional care
#6 - Number of people with choice between and among waiver services and providers
*Performance Measures for both Community Pathways and New Directions Waivers
46
PERFORMANCE MEASURES
#1- Number of providers licensed prior to the delivery of waiver services
#2- Number of licensed providers that offer all required direct care staff training
#3- Number of direct care staff that have completed all required training
*Performance Measures for both Community Pathways and New Directions Waivers
47
PERFORMANCE MEASURES
#4- Number of licensed service providers that have current approved QA plans
#5- Number of direct care staff that has undergone a criminal background check (New Directions Only)
#6- Number of Support Brokers that have completed all required training (New Directions Only)
*Performance Measures for both Community Pathways and New Directions Waivers unless otherwise indicated.
48
PERFORMANCE MEASURES#1- Number of people who receive medical services as recommended by their physician(s)
#2- Number of people reporting they are free from mistreatment
#3- Number of incidents involving unauthorized or inappropriate use of restraints
#4-Percent of deaths based on population count vs. percent of deaths of Maryland population and US population
*Performance Measures for both Community Pathways and New Directions Waivers unless otherwise indicated.
49
PERFORMANCE MEASURES#5 - Number of budget modifications reviewed by resource coordinators (New Directions Only)
#6- Number of people with 2 level back up plans in their IP&B (New Directions Only)
#7- Number of critical incidents reported (New Directions Only)
#8 -Number of reportable incidents that are reported within required timeframes (New Directions Only)
*Performance Measures for both Community Pathways and New Directions Waivers unless otherwise indicated.
50
PERFORMANCE MEASURES
#1 - Number of DDA licensed waiver providers appropriately billing for services rendered
#2 - Number and percent of waiver service claims reviewed that were submitted for participants who were enrolled in the waiver on the date that the services was delivered
#3 - Number of rate based DDA licensed providers with completed annual independent audits
*Performance Measures for both Community Pathways and New Directions Waivers unless otherwise indicated.
51
FEDERAL HCBS WAIVER ASSURANCES
Knowledge Check Question 1Which of the following statements is not true?A. HCBS stands for Home and Community Based
Services.B. The HCBS waiver is an alternative to institutional
care.C. Everyone who needs long term care is eligible for
an HCBS waiver.D. States must apply to CMS for permission to operate
an HCBS waiver.E. States have flexibility in how they design their HCBS
waiver.
F. All of these statements are true.
Reference: CMS Training for Case Managers on HCBS Waiver Assurances
52
FEDERAL HCBS WAIVER ASSURANCES
Knowledge Check Question 1 - Answer
C. Everyone who needs long term care is eligible for an HCBS waiver.
Statement C is not true. HCBS is a Medicaid program serving low-income individuals. In addition to meeting programmatic eligibility, such as a need for institutional level of care, individuals must also be financially eligible for HCBS.
Reference: CMS Training for Case Managers on HCBS Waiver Assurances
53
FEDERAL HCBS WAIVER ASSURANCES
Knowledge Check Question 2Which of the following is not a federal assurance?A. Level of Care B. Service PlanC. Qualified Providers D. Health and Welfare E. Standard Design F. Financial Accountability G. Administrative Accountability H. All are Assurances
Reference: CMS Training for Case Managers on HCBS Waiver Assurances
54
FEDERAL HCBS WAIVER ASSURANCES
Knowledge Check Question 2 - AnswerWhich of the following is not a federal assurance?E. Standard Design
Correct. Standard Design is not an Assurance. CMS allows some flexibility in how states design their HCBS programs. For instance, states can decide the target population to be served, how many people to be served, the services to be provided, the geographic area to be served and the administrative structure for operating the waiver.
Reference: CMS Training for Case Managers on HCBS Waiver Assurances
55
FEDERAL HCBS WAIVER ASSURANCES
Knowledge Check Question 3The federal assurances are:A. Assurances that states make to CMS in order to
operate an HCBS waiver.B. Designed to promote quality.C. Directly relate to the role of the resource
coordinator. D. All of the above.
Reference: CMS Training for Case Managers on HCBS Waiver Assurances
56
FEDERAL HCBS WAIVER ASSURANCES
Knowledge Check Question 3 - AnswerThe federal assurances are:A. Assurances that states make to CMS in order to
operate an HCBS waiver.B. Designed to promote quality.C. Directly relate to the role of the resource
coordinator. D. All of the above.
All three of these statements are true.
Reference: CMS Training for Case Managers on HCBS Waiver Assurances
57
FEDERAL HCBS WAIVER ASSURANCES
Why is it important for you to know about the six assurances and performance measures?
Because the assurances and performance measures have an impact on your work each and every day.
Reference: CMS Training for Case Managers on HCBS Waiver Assurances
Much of what you are asked to do, and particularly how you are asked to document what you do, tie back to the assurances and performance measures.
58
RC QUALITY ROLES AND RESPONSIBILITIES
RC is critical for connecting people and their families to services and supports within DDA and various other systems or community resources including medical services, educational services, housing assistance, food stamps, public transportation, social activities, etc.
As a resource coordinator, you play a key role in assuring that the services and the waivers work to meet participant needs and improve outcomes.
Resource coordinators understand how quality services and supports protect vulnerable people and keep families together.
59
QUALITY ROLES AND RESPONSIBILITIES
RC covers a wide range of assessment, planning and coordination, referral, and monitoring activities to assist a person to obtain and retain services needed, including comprehensive assistance in gaining access to needed supports and services regardless of how the services are financed.
But others are involved in this process as well. In fact, the HCBS waiver quality cycle has multiple partners with multiple roles.
60
WAIVER QUALITY REQUIREMENTS
RCRC
RC
- Resource Coordinator
Reference: CMS Training for Case Managers on HCBS Waiver Assurances
61
CMS WAIVER QUALITY REQUIREMENTS
RCRC
RC
- Resource Coordinator
Reference: CMS Training for Case Managers on HCBS Waiver Assurances
62
WAIVER QUALITY REQUIREMENTSThe quality cycle begins with the federal
role and the responsibilities of CMS.
CMS RoleCMS defines HCBS waiver requirements and is
responsible for determining that each HCBS waiver meets the six federal assurances. CMS oversight of HCBS waivers also includes:
Sets policy and requirements for HCBS waivers based on the assurances.
Approves HCBS waiver applications submitted by a state.
Reviews the state’s evidence to determine if the HCBS waiver meets federal assurances. Some of this evidence may come from your records.
Reports to Congress on the performance of HCBS waiver programs.Reference: CMS Training for Case Managers on HCBS Waiver Assurances
63
WAIVER QUALITY REQUIREMENTS
If a state meets the six assurances, as determined by a review of evidence, CMS will approve the state’s renewal application and the state will be able to continue providing HCBS waiver services.
Reference: CMS Training for Case Managers on HCBS Waiver Assurances
Level of Care
Service Plan
Qualified Providers
Health & Welfare
Financial Accounta
bility
Administrative
Authority
64
WAIVER QUALITY REQUIREMENTS
Where does that state evidence come from?
In part, it comes from you such as IPs and other data from records to assess federal assurances.
States combines these data with reviews from other agencies (i.e. OHCQ, Medicaid) to produce reports, known as evidence.
As part of the waiver renewal process, a state must provide evidence demonstrating a continuous quality improvement process and compliance with the HCBS waiver assurances.
If a state meets the six assurances, as determined by a review of evidence, CMS will approve the state’s renewal application and the state will be able to continue providing HCBS waiver services.
Reference: CMS Training for Case Managers on HCBS Waiver Assurances
65
WAIVER QUALITY REQUIREMENTS
If the evidence is found to be insufficient, states are required to develop an improvement plan for collecting the evidence and/or improving areas known to be weak.
If states persistently fail to provide evidence or fail to meet HCBS waiver assurances, CMS has the authority to terminate the HCBS waiver program.
Reference: CMS Training for Case Managers on HCBS Waiver Assurances
66
CONTINUOUS QUALITY IMPROVEMENT
DDA is committed to improving quality is all waiver assurances and conducting ongoing system-wide reviews of ways to improve.
Coordination
Service Delivery
Accountability of
Funding
Federal Assurance
s
CQI
67
MEDICAID’S WAIVER QUALITY REQUIREMENTS
RCRC
RC
- Resource Coordinator
Reference: CMS Training for Case Managers on HCBS Waiver Assurances
DDA
&DDA’s
68
WAIVER QUALITY REQUIREMENTS
State Medicaid Agency RoleThe state Medicaid Agency is accountable to
CMS for the design and operation of its HCBS waivers.
The DD waivers are managed by Sandra Brownell from the Office of Health Services (OHS).
DDA manages or operates the DD waiver programs, but the state Medicaid Agency has final authority.
Reference: CMS Training for Case Managers on HCBS Waiver Assurances
69
WAIVER QUALITY REQUIREMENTSWhat does our state Medicaid agency do? Determines the rules and policies under which
the HCBS waiver operates in your state. These rules must be consistent with Federal assurances.
Monitors that rules and policies are being met. Your state looks at participant records, provider agency records, program data and results of participant surveys to assess performance.
Works with other state agencies with responsibilities for quality (e.g., state licensure, protective services).
Arranges special investigations and hearings on serious issues.
Reference: CMS Training for Case Managers on HCBS Waiver Assurances
70
WAIVER QUALITY REQUIREMENTSWhat does your state Medicaid agency
do?
Identifies and supports quality improvement initiatives.
Enforces rules and policies through sanctions, fines and termination.
Reports to CMS, including evidence reports showing that it meets the terms of the HCBS waiver and the assurances.
Reference: CMS Training for Case Managers on HCBS Waiver Assurances
71
WAIVER QUALITY REQUIREMENTSWhat does your state Medicaid agency
do?
Identifies and supports quality improvement initiatives.
Enforces rules and policies through sanctions, fines and termination.
Reports to CMS, including evidence reports showing that it meets the terms of the HCBS waiver and the assurances.
Reference: CMS Training for Case Managers on HCBS Waiver Assurances
72
WAIVER QUALITY REQUIREMENTSWhat is DDA responsible for? Determines the rules and policies under
which the providers (including resource coordination, support brokers, fiscal management services, and service providers) perform.
Monitoring providers including reviewing participant records, provider agency records, program data and results of participant surveys to assess performance.
Quality – discovery, remediation, and system improvements.
73
ONE DDA QUALITY SYSTEM
DDA
74
One DDA Quality System with Multiple Strategies and Activities
74
75
RC’S WAIVER QUALITY REQUIREMENTS
RC
RC
- Resource Coordinator
Reference: CMS Training for Case Managers on HCBS Waiver Assurances
DDA
76
QUALITY PERSON-CENTERED SERVICES AND SUPPORTS
At the center of the system are the people we serve: the entire system is created to assure that participants get the individualized services and supports they need.
But who is responsible for assuring the quality of those services?
77
WAIVER QUALITY REQUIREMENTS
Resource Coordinator’s Quality Role Ultimately, quality services and supports
begin with the interaction between a participant and a resource coordinator; quality depends on your ability to implement the safeguards contained in the federal assurances.
Reference: CMS Training for Case Managers on HCBS Waiver Assurances
78
WAIVER QUALITY REQUIREMENTSResource Coordinator’s perform the following
core functions in assuring the quality of an HCBS waiver:
Reference: CMS Training for Case Managers on HCBS Waiver Assurances
Assessment
Plan Developm
ent
Information &
Referral
Monitoring
Remediation
Quality
79
RC CORE FUNCTIONS
Assessment: The foundation of your work is an accurate evaluation of a participant’s strengths, needs, preferences, supports and desired outcomes.
Service plan development: You work with participants to design a service plan that enables them to meet their goals.
Information and Referral: You provide information to help participants choose qualified providers and make arrangements to assure providers follow the service plan.
Reference: CMS Training for Case Managers on HCBS Waiver Assurances
80
RC CORE FUNCTIONS
Monitoring: You make sure participants get authorized services and that services meet individual needs and goals.
Remediation: You resolve problems when something goes wrong as well as anticipate the potential for problems including health and safety issues (i.e. provider failure to take person for medical follow up, late annual plans, etc.)
Reference: CMS Training for Case Managers on HCBS Waiver Assurances
81
RC CORE FUNCTIONS
In addition to the important work you do to promote quality directly with participants, as resource coordinator you have an equally important role in documenting what you do.
Good documentation: Allows you to review your work and track
changes.
Provides continuity for others who work with the person.
Helps you, service providers, DDA, and Medicaid identify opportunities for quality improvement.
Provides the evidence required by Medicaid and DDA to meet the federal assurances.
Reference: CMS Training for Case Managers on HCBS Waiver Assurances
82
RC QA CORE FUNCTIONS
The information you provide through your documentation not only provides evidence that you are meeting the assurances, it also impacts future services.
This is the quality improvement aspect of this cycle.
Reference: CMS Training for Case Managers on HCBS Waiver Assurances
Documentation &
Information
Lesson’s Learned
Knowledge and
Experiences
New HCBS Services
Better Outcomes for People
83
RESOURCE COORDINATION
SERVICE FRAMEWORK FISCAL YEAR 2013
84
RC SERVICES WILL SUPPORT:
1. People in community services -regardless of Waiver or Stated funded
2. People on the Waiting List – all people in crisis resolution,
crisis preventions, and current request based on available resources and methodology
3. People transitioning from a facility to the community
Note: DDA primary services are “habilitative” compared to rehabilitative, medical, and behavioral health services.
85
DDA RC SERVICES OVERVIEW
Eligibility Assistance Services
Waiting List
Coordination
Services
Community
Coordination
Services
Transition Coordinat
ion Services
86
DDA RC SERVICE CORE FUNCTIONS
Resource Coordinator’s perform the following core functions in assuring the quality of an HCBS waiver:
Reference: CMS Training for Case Managers on HCBS Waiver Assurances
Assessment
Referral & Related
Activities
Plan Developm
entMonitorin
g
Remediation
Quality
87
ELIGIBILITY ASSISTANCE SERVICES - ASSESSMENT
Comprehensive Assessment of the person’s needs and supports to determine eligibility within 45 days of referral by DDA including analysis of the following:
General medical, developmental, and mental condition;
Desires, expectations, dreams, aspirations, and goals;
Environmental, social, and functional status; Full range of service needs and preferences;
and Completion of the DDA Critical Needs
Recommendation form. LOC
Performance Measure
88
ELIGIBILITY ASSISTANCE SERVICES - ASSESSMENT
Assistance with information gathering such as obtaining professional evaluations and assessments necessary to document and confirm eligibility and priority for services;
DD Eligible SO Eligible
Crisis Resolution
Crisis Prevention
Current Request
Future Need
or
or or
or
89
ELIGIBILITY ASSISTANCE SERVICES - STRATEGIES
Become expert on the DDA Eligibility Criteria – DD, SO, and priority
Recommendations based on facts and supporting evidence as it relates to the established criteria in Health General and COMAR
Eligibility process should be transparent to people and families
New Eligibility Guide (Under development)
90
ELIGIBILITY ASSISTANCE SERVICES - STRATEGIES
Eligibility AppealsDuring appeals, 90% or more are settled
before they ever go to hearing.
After the family receives clarification about the matter through dialogue with staff, many appeals are withdrawn.
If we communicate the process better from the beginning we can minimize confusion, frustration, and time
91
REFERRAL AND RELATED ACTIVITIES
Referral and related activities occur: At time of initial meeting and
Any follow up contacts, such as sharing information, making referrals, monitoring, and assisting the person with applications to: Community connections, generic, and
natural supports; and State and federal programs.
92
MONITORING AND FOLLOW-UP ACTIVITIES
Monitoring of progress and services are essential for people to achieve their outcomes and goals.
Person specific plans and services that:Demonstrate no or negative results, Maintain people in restrictive settings, or Impede employment opportunities
shall be re-evaluated and redesigned to more effectively meet the needs of the person
93
MONITORING AND FOLLOW-UP ACTIVITIES
Monitoring of progress and services are essential for people to achieve their outcomes and goals.
Person specific plans and services that demonstrate:No or negative results, Maintain people in restrictive settings, or Impede employment opportunities
shall be re-evaluated and redesigned to more effectively meet the needs of the person
94
MONITORING AND FOLLOW-UP ACTIVITIES
Monitoring and follow-up activities, in format approved by the DDA, which includes:
Within thirty (30) days of service initiation, review the IP and update or modify as needed.
Minimum quarterly face-to-face contact with the person to assess current needs and satisfaction
Meetings shall be conducted in the different settings where DDA services are being rendered (i.e. own home, day program, group home/alternative living unit);
95
MONITORING AND FOLLOW-UP ACTIVITIES
Monitoring, follow-up, and documentation (in format approved by the DDA) on the implementation of the plan to include assessment of:
Service PlanPerformance
Measures
Services being rendered as specified in the plan,
Progress toward goals, Routine medical care, needed health
services, and follow up, Request for service change and
modifications to meet health and safety needs and goals,
Back up plans for direct care staff and natural disasters;
H & WPerformance Measures
96
MONITORING AND FOLLOW-UP ACTIVITIES
Assist with on-going referrals as needed;
Assistance with transitioning to new services, providers, and/or unpaid supports;
Monitoring, follow-up, and documentation on all reportable incidents as defined in DDA’s Policy on Reportable Events ( http://dda.dhmh.maryland.gov/SitePages/policies.aspx).
Submitting person specific updates to DDA as needed or requested.
97
MONITORING AND FOLLOW-UP ACTIVITIES
Maintaining Waiver Eligibility which includes:
Assessment of and completion of certificate of need form (LOC) annually within 365 days of the previous assessment forms;
Assessment of Medicaid financial eligibility annually or more frequently as needed; and
Re-application if gap in eligibility occurs.
LOC Performance Measure
98
MONITORING AND FOLLOW-UP ACTIVITIES HELPFUL STRATEGIES
Questions to Ask:1. How are services going?
2. How are you progressing toward your goals?
3. Updates on medical recommendations, demographics, etc
4. Are services meeting your needs/goal?
5. Do you need any new services (I&R)?
99
MONITORING AND FOLLOW-UP ACTIVITIES HELPFUL STRATEGIES
Service Delivery Questions to Ask:
1. Initial service implementation meeting needs and goals?
2. Have all services been established? (Residential identified but no Day/Employment?)
3. Most integrated setting?
100
MONITORING AND FOLLOW-UP ACTIVITIES HELPFUL STRATEGIES
New Information or referral needs?
Share community services and resource list and updates on new ones (LISS, SC Impact Fund, Respite, disability specific programs, self advocacy groups, education, employment, etc.)
At least one generic resource should be provided each time.
101
MONITORING AND FOLLOW-UP ACTIVITIES HELPFUL STRATEGIES
Follow up on: Emergency situations Short term solution such as funding during the
day to allow for person to locate day placement Temporary respite to protect health and safety
while options explored, and services identified Medical Care
102
PROCESS, POLICY, & FORMSUPDATESHELPFUL STRATEGIESREMINDERSPERFORMANCE MEASURES
LINKS
103
DDA APPLICATION
DDA application being updated New Consumer friendly instruction
guide to be included To be shared at next training Target implementation July 1, 2012
104
DDA INITIATION OF SERVICES
Initiation of service delivery to an eligible individual seeking DDA-funded services shall be dependent upon:
(1) Assigned service priority, except for family support services and low intensity support services which are provided on a first-come, first-served basis;
(2) Availability and allocation of funds(3) Availability of an appropriate community
services; and (4) The individual's completing an application for
Medical Assistance or other alternative funding.
Note: If an emergency situation arises and immediate services are needed to resolve a crisis, DDA may authorize the initiation of servicesReference: COMAR 10.22.12.11
105
DDA INITIATION OF SERVICES
Except in an emergency situation or a case approved by the Director because of extenuating circumstances, DDA may not fund services for individuals with State-only dollars unless the individual has been denied:
(1) Medical Assistance including waiver services; and
(2) Related alternative funding.
106
DDA WAIVER & MEDICAID ENROLLMENT
INITIATIVE
100 % State
General $
vs.
50% State General $
and 50% Federal
$
Note: Process, tracking, and procedure to be shared soon
Maximize all DDA State General Funds
INTEGRATION IT SYSTEM(S)
107
IT System
Plans
RCRFSCFiscal
PORII
HRST
Notes: Multiple efforts underway currently which includes stakeholder input, coordination with Medicaid and Dept IT office and other partners.Additional information shared in each subject area
108
INTEGRATED IT SYSTEMSeveral efforts are under way to develop an
integrated information technology system
An integrated system will provide information, data, and evidence in a more efficient and effective manner
An integrated system will support quality efforts
Discovery
Remediation
Reporting
System
Improvement
109
INTEGRATED IT SYSTEMAn integrated system will support system
accountabilitySystem
Accountability
* •Eligibility and Service Access
* •Federal and State Assurances
* •Contract Monitoring
* •Fiscal Accountability
110
INTEGRATED IT SYSTEM
Input on Resource Coordination related components and formats to be obtained via the Resource Coordination Coalition
ELIGIBILITY & ACCESS
CRITICAL NEEDS RECOMMENDATION FORM (CNR)
ON-GOING ASSESSMENT & UPDATES111
112
ELIGIBILITY AND ON-GOING ASSESSMENT
People in Crisis (crisis resolution) Advise DDA Regional Office (RO)
immediately Address immediate health and safety Contact the police, APS, CPS, EMS (911) Complete Critical Needs Recommendation
form and send to RO ASAP Brain storm temporary strategies with your
supervisor
113
ELIGIBILITY AND ON-GOING ASSESSMENT
People at risk of crisis (crisis prevention)√ Assist people and families is both short term and long
term planning to address risks and achieve outcomes
√ Assist in obtaining the best quality and most appropriate services and supports within available theirs and generic community resources
√ Assist people and families with applying for various services (including LISS and non DDA services such as Medicaid, food stamps, mortgage and utility assistance)
114
ELIGIBILITY AND ON-GOING ASSESSMENT
People with no crisis risk (current request/future need)
√ Explore/advise of informal and formal supports, generic and community services including LISS, respite, park and planning, Self Advocacy Networks, etc .
√ Encourage both short term and long term planning for the future
115
WAITING LIST ON-GOING ASSESSMENT
Inquire about current situation and needs with every contact
Complete CNR updates and forward to RO as situations and needs change
Immediately contact the RO for people in crisis
All people determined to no longer meet their current priority category will be notified of change in determination and advised of their appeal rights as per regulations and standard operational procedures
116
CNR FORM UPDATES
Statewide Critical Needs Recommendation Form to be shared at next training.
Effective implementation date is July 1, 2012
117
PCIS UPDATES
Demographic changes such as phone numbers, addresses, corrections to PCIS, etc.
Changes to designated “Contacts”
Changes to primary caregiver and caregiver age
Share changes with designated resource coordinator(s) in your agency with PCIS change permission or the DDA Regional Office
Statewide PCIS “updates/changes” protocol under development
118
SYSTEM RESPONSIVENESS
Collectively our system must be responsive to people
Timely action is essential: To protect health and safety for people in crisis and
at risk of crisis
Component of customer services
Quality indicator
119
SYSTEM RESPONSIVENESS
For people in crisis – The application and eligibility recommendations,
waiver packet, and plan (provisional, initial, or IP) should be developed during the first encounter and must be submitted as soon as possible
Further in-depth planning, additional service, and options can be explored as the situation is stabilized
SERVICE PLAN DEVELOPMENT
120
Updates Helpful StrategiesReminders
121
PLAN DEVELOPMENT – IDENTIFYING SERVICES There are several things to consider when identifying
services and support to meet people’s needs including:
1. Services, items, and supports 2. Urgency for establishing services and supports3. Impact of the services and supports to meet goals4. Cost of services and supports5. Identifying service providers
What questions do you use to guide identifying services and service planning?
122
SERVICES, ITEMS, AND SUPPORTS
Does the plan reflect all services – natural, informal, generic, State and federal programs, and DDA funded services?
Does the service/item align with the need identified to support the goal?
Is the person self directing? Is a support broker and fiscal management service provider needed?
Are there special or unique services (e.g. assistive technology, home modification, customized wheelchair) needed?
Is the services needed Habilitative? Rehabilitative? Medical? Dental? Other?
What services/resources were explored? Is this service available from another source?
(Duplicative?) Is the service/item recommended by a professional? For
what purpose? For how long? For what outcome? Is the service/items a DDA waiver service? Is the person eligible for DDA funding today?
123
URGENCY
Is the person’s health and safety currently at risk?
Are there any allegations or indicators of possible abuse, exploitation, or neglect?
If at risk, what informal or formal services or supports can be established immediately to support health and safety?
Will the person be transitioning from foster care, an institution, or court order? When?
Is the funding source time limited?
124
IMPACT
Does the services support the person in the most integrated environment?
Does the services support or lead to employment? Retirement?
Does the services and support address or seek to resolve or prevent reoccurrence of the crisis trigger?
Does the services support the person’s health and safety?
125
COST
Is the cost for services a reasonable and customary cost?
Is there any lower cost service or item available that will meet the identified need?
Is the service/items covered under the DDA waiver or State funds?
Fair Cost
126
PROVIDERS OF SERVICES
It is important to identify the appropriate service provider to provide the services to meet the person’s needs.
Can they provide the services, supports, and/or items needed to support the person’s goals?
How soon can they start? How will the services be monitored? How will progress be reported to the person and
their team? If a DDA licensed provider, does the service
funding plan match the IP?
127
INTERVENTION SERVICESIntervention services can help people and families
find ways of creating strategies and/or alternative supports that can eliminate or minimize the potential for future crisis.
The service(s) can vary from person to person and may be of a short duration, or may be very intense and time consuming upfront, that diminishes over time.
PLANS
128
•People on Waiting List
Waiting List Plan
•People In ServicesIP•People transitioning from a facility
Transition Plan
129
WAITING LIST PLAN
• People on DDA Waiting List
Waiting List Plan
130
WAITING LIST PLAN Focuses on the provision of non-DDA services in the
most integrated setting
Is developed in collaboration with the person and their identified representatives
Is completed within the first thirty (30) days of initial meeting, in a format as approved and required by the DDA
Update and revise the plan as circumstances change
Annual Plan Update to be conducted within 365 days of the previous initial plan
131
WAITING LIST PLAN Provides an action plan for the person and
and/or their family to follow in several key areas such as:
Provides a snapshot of resources recommended, contact information, and follow up actions
Home School/Work/Day Medical
Transportation
Social/ Recreational
Financial Assistance
Other
132
WAITING LIST PLAN
Resource Coordinator Name and Phone Number: Jani Smith, 410-827-4538
HOME
Resource TypeResource Name and Contact
Information Person to Follow-Up &
When
Front porch ramp LISS, 1-877- 230-4951 or 1- 877-282-8202
Tammy Jones, by 7/1/12
Stair glide DORS, 410-554-9442 Ms. Jones, mother, by 6/25/12
SCHOOL/WORK/DAY
Resource TypeResource Name and Contact
InformationPerson to Follow-Up &
When
Behavioral Supports Anne Arundel County Public Schools, 410-222-5312
Ms. Jones, mother, 6/20/12
Behavioral Supports TAS through Humanim, 410-381-7171
Jani Smith, Resource Coordinator by 6/20/12
Draft Example
133
WAITING LIST PLAN
Draft Example
MEDICAL
Resource TypeResource Name and Contact Information
Person to Follow-Up & When
Dental Services Donated Dental Services, 410-964-1944
Tammy Jones, by July 1, 2012
TRANSPORTATION
Resource TypeResource Name and Contact Information
Person to Follow-Up & When
Transportation to churchContact Ms. Ella (Youth Ministry), 410-284-7134
Tammy Jones, by 6/15/12
New electric scooter
Contact MA Health Choice Special Needs Coordinator re: coverage by 410- 853-3000
Ms. Jones, mother, by 8/1/12
134
WAITING LIST PLAN
Draft Example
SOCIAL/RECREATIONAL
Resource TypeResource Name and Contact Information
Person to Follow-Up & When
YMCA membership
Request discount from YMCA, 443-322-8000 and pay monthly fee from paycheck
Tammy Jones, by 9/1/12
FINANCIAL ASSISTANCE (for items such as utility bills, camp, etc.)
Resource TypeResource Name and Contact Information
Person to Follow-Up & When
BGE bill paymentBGE Energy Assistance,
410-685-0123 Ms. Jones, mother, by 6/15/12
Dental services LISS, 1-877- 230-4951 or 1- 877-282-8202
Tammy Jones, by 6/15/12
135
WAITING LIST PLAN
Draft Example
OTHER
Resource TypeResource Name and Contact Information
Person to Follow-Up & When
Legal Advocacy MDLC, 410-727-6352Tammy Jones, by
6/10/12
136
WAITING LIST PLAN People in crisis or at risk of crisis may only
emphasize need in that specific area.
It is important that we explore all areas of an person’s life (holistic) to ensure the needs of the whole person are being addressed and start application processes
Always take appropriate action and seek immediate assistance for life threatening situations
Responsible person for follow up actions should be decided at meeting
137
WAITING LIST PLAN Monitoring and follow-up, based on the
minimum frequency in UFA/MOU/Contract, or more frequently as needed, to include:
Follow up on current circumstances, progress toward goals, and referral status;
Identification of new support and resource options for intake and referral; and
Submit updates to DDA Regional Office on circumstances related to health and safety or changes to priority status.
138
WAITING LIST PLAN
Input on the final Waiting List Plan components and format to be obtained via the Resource Coordination Coalition
Format and user guide will be shared statewide
139
INDIVIDUAL PLAN
• People In ServicesIP
140
INDIVIDUAL PLAN
My Hopes
My Dreams
My Strengths
My Values
My Support
My Goals
My Team
My Hobbies
PERSON
Holistic
141
IP UPDATES AND REMINDERS
Development of plan: Focuses on services in the most integrated setting;
Is developed in collaboration with the person and their identified representatives;
Includes supports necessary to achieve goals
Offering people choice of services and services providers;
Contains all elements noted in COMAR 10.22.05;
Is completed within the first thirty (30) days of initial meeting; and
Includes back up plans for direct care staff and natural disasters.
Service Plan
Performance Measures
142
IP UPDATES AND REMINDERS
Resource Coordinators shall: Facilitate and coordinate interim meetings as
needed with the person
Update and revise the IP as circumstances change; and
Facilitate and coordinate the annual IP update to be conducted within 365 days of the previous plan.
Service PlanPerformance
Measures
143
IP UPDATES AND REMINDERS
Ensure the IP is a working document, accurately reflecting a person’s goals, strengths and needs in a manner that someone unfamiliar with the person can read it and understand specifically how to support that person
144
IP UPDATES Automation efforts to include ability to upload
data from existing IP software used by some agencies
Incorporation of federal assurance data elements
Additional stakeholder input is underway
IP Requirement - Refer to IP memo dated February 6,
2012 at http://dda.dhmh.maryland.gov/SitePages/Developments/Feb2012/IP-Feb-2012.pdf
Target system training December 2012
Target implementation March 2013
145
TRANSITION PLAN
• People transitioning from a facility
Transition Plan
146
TRANSITION PLAN
Development of plan : Focuses on transition from the
institutional setting to the community;
Is developed in collaboration with the person and their identified representatives;
Offers people choice of services and services providers;
Addresses challenges to transitioning;
Is completed within the first thirty (30) days of initial meeting;
Community
147
WRITTEN PLAN OF HABILITATION
Assessment and completion annually of the automated Written Plan of Habilitation form within the DDA’s information system (PCIS2) for people residing in an State Residential Center only which includes: Identification of various service and support
needs of the person to transition to the community;
Recommendation of a range of the most integrated setting service options both licensed through and outside the DDA; and
Identification of community-based Medicaid waiver services and any other services and supports that may be available.
148
TRANSITION PLANResource Coordinators: Facilitate and coordinate interim meetings as
needed with the person;
Update and revise the plan as circumstances change; and
Facilitate and coordinate the annual plan update to be conducted within 365 days of the previous plan.
149
TRANSITION PLANMonitoring and follow-up activities to include:
Follow-up on current circumstances, progress toward goals, and referral status;
Identification of new support and resource options for intake and referral;
Submitting updates to DDA Regional Office regarding changes in circumstances and as requested; and
Increased contact frequency as needed based on active transition process.
150
WAIVER
UPDATES HELPFUL STRATEGIESREMINDERS
151
WAIVER ENROLLMENT FORMS
1. Community Pathways or New Directions Waiver Enrollment Checklist s
2. Initial Certificate of Need3. Waiver Applicant Verification Form (WC-2C)4. Freedom of Choice5. Medicaid Application6. Plan
Note: Form revised effective 7-1-12 is available on DDA website
152
COMMUNITY PATHWAYS WAIVER ENROLLMENT
FORMS1. Community Pathways Waiver Enrollment
Checklist
Complete all information that appliesNote person’s current address at the time of
enrollment; not the address of a facilityCheck all waiver services that applyInclude the date of the Medicaid application – it
must be dated within six months of the waiver effective date
Include fax number and email address of the resource coordinator
Note: Form revised effective 7-1-12 is available on DDA website
153
NEW DIRECTIONS WAIVER
ENROLLMENT FORMS1. New Directions Waiver Enrollment Checklist
Complete all information that applies
Note person’s current address at the time of enrollment; not the address of a facility
154
WAIVER ENROLLMENT FORMS
2. Initial Certificate of Need*
Indicate Community Pathways or New Directions (there are no longer 2 separate forms)
Level of Care effective date is the date of the waiver meeting. (Not a future or past date.)
Include the CNR date Sign and Date
Note: Form revised effective 7-1-12 is available on DDA website
LOC Performance
Measure
Note: Same form used for both Community Pathway and New Directions.
155
COMMUNITY PATHWAYS WAIVER ENROLLMENT
FORMS3. Waiver Applicant Verification Form (WC-2C)
Complete all information that applies If the person is discharged from a facility,
include the actual discharge date Indicate the appropriate funding source, i.e., TY,
WLEF, CR, etc. Include the person’s site address, not the
agency address
Note: Form revised effective 7-1-12 is available on DDA website
156
NEW DIRECTIONS WAIVER ENROLLMENT
FORMS3. Waiver Applicant Verification From (WC-2C)
Complete all information that applies
Include the person’s address
157
WAIVER ENROLLMENT FORMS
4. Freedom of Choice* Indicate Community Pathways or New Directions
(there are no longer 2 separate forms) Person, Authorized Representative or Guardian
must indicate they have been given a choice between waiver services and institutional services.
Individual, Authorized Representative or Guardian/Parent must indicate they have been given a choice between waiver service options and providers.
Note: Form revised and includes fact sheet. Revision effective 7-1-12 and available on DDA website
*Note: DDA LOC Performance Measure : #5- Number of people provided choice between community based services and institutional care
Note: Same form used for both Community Pathway and New Directions.
158
WAIVER ENROLLMENT FORMS
5. Medicaid Application (MA) (Short or long form?) Based upon Medicaid coverage group
Note: Use current Medicaid Application dated 7/1/11. DREP Instruction & DREP Form revised effective 7-1-12 is available on DDA website
1st
•Complete the Community Check Fax Request/Response Combination Form
2nd
•Fax to the DHMH - Division of Recipient Eligibility Programs (DREP) Fax Number (410) 333-5087
3rd• Complete the “long” or
“short” form based on response from DREP
Steps
159
COMMUNITY PATHWAYS WAIVER ENROLLMENT
FORMS6. Plan Waiver Service Plan Initial, Provisional, or Full Plan (IP) with enrollment
Various Person Centered Planning methodologies (i.e. ELP, MAPS, PATHS, ETC.) can be used
All services shall be listed such as: Resource Coordination Supported Employment
Providers of services can be “tbd” if unknown or undecided
160
NEW DIRECTIONS WAIVER ENROLLMENT
FORMS6. Plan Waiver Service Plan
*All About Me *Demographics *Rate
*Important *Goals of Pay
People *Preferences *Unit of Service
*Supports *Frequency
*Transportation
*Health Related
Person Centered
PlanPlan Budget IP & B
(Example)
Note: ND participants may use any PCP or Plan (IP) but should use the “budget” form. IP & B is available on the DDA website
161
WAIVER“REPORTING” FORMS
1. WC12 - A Reporting Form
2. WC12 - B Discharge Reporting Form
3. WC12 – C Change in Service
4. WC12 – D Financial Reporting
162
WAIVER“REPORTING” FORMS
1. WC12 - A Reporting Form Address
Change in placement (transfer of services)* Transfer to CSLA or F/ISS require copy of SFP
Transfer of provider agencies
Transfer of Resource Coordination Agency
Admission to Nursing Home or Chronic Rehabilitation Facility
163
WAIVER“REPORTING” FORMS
2. WC12 - B Discharge Reporting Form
Discharge from Waiver
Actual date of discharge (last date of waiver service)
Note: Some people may be discharged from the waiver but still receive DDA services via State funds.
164
WAIVER“REPORTING” FORMS
3. WC12 – C Change in Service
New service (Copy of SFP required) for Community Pathways
Discontinuing a service
Relates to contribution of care for Community Pathways
165
WAIVER“REPORTING” FORMS
4. WC12 – D Financial Reporting
Changes in person’s income
Changes in insurance
Changes in resources
Note: This form is to be sent to DEWS only
166
MEDICAID HELPFUL STRATEGIES & REMINDERS
Ask to be one of the person’s MA application contacts
Advise people of supporting documents needed when you set up appointment so they can gather
Financial information is based on the “person’s” not the parents or family income/resources
Once the MA application is signed it is live – it must be processed so do not hold
167
MEDICAID HELPFUL STRATEGIES & REMINDERS
MA (including waivers) requires annual financial redetermination unless person has SSI or unscheduled review
Prevent loss of waiver eligibility - Redetermination date is based on waiver enrollment date so flag 3 months prior to start discussion and monitor to prevent loss of waiver eligibility
Report income/insurance/resource changes via WC12-D as they arise
168
MEDICAID HELPFUL STRATEGIES & REMINDERS
DEWS will send letter to person (and their contacts listed on MA app) regarding redetermination, need for information, and loss of eligibility
People and families may not respond to DEWS letter so follow up
Alert DDA RO of any resistance to applying for waiver or providing requested documentation
169
LOC HELPFUL STRATEGIES & REMINDERS
LOC Recertification is required annually
Must be completed prior to anniversary date and mailed to HQ Waiver Unit
LOC Recertification Report is shared with each RC Agency – so track, monitor, and complete on time
You are certifying the person still meets ICF/ID LOC
Do not complete for people discharged from waiver or inactive people
*Note: DDA LOC Performance Measure #2 - Number of completed annual LOC re-certifications over the number of active waiver participants.
170
PLANS HELPFUL STRATEGIES &
REMINDERS Develop Professional IPs (do your best!)
No drafts
Be informed, educated on services, processes, procedures, and rules
Seek additional training and help as needed
High Quality Customer Services Schedule PCP within reasonable time frame Answer questions and seek answers What is you or your family member needed a plan
before you could be considered for services?
171
PLANS HELPFUL STRATEGIES &
REMINDERS Develop Professional IPs (do your best!) Be informed, educated on processes, procedures, and rules Seek additional training and help as needed IP must contain all elements noted in COMAR 10.22.05
Annual plans (IP) must be completed within 365 of previous plan – so track, monitor, and plan ahead
All outstanding plans must be remediated immediately*
*Note: DDA Plan Performance Measure #1 -Number of IPs containing required information per COMAR 10.22.05.02
*Note: DDA Plan Performance Measure #3- Number of IP reviewed within a year (365 days)
*Reference: IP Memo dated February 6, 2012Note: Some RC agencies have developed IP Component checklist. Check with your agency
172
PLAN HELPFUL STRATEGIES & REMINDERS
Become an expert in the waiver services See waiver applications scope of service & type
of providers Know which services require DDA pre-authorization New Waiver Regulations in process
Advise people they have choice among services and service providers
All annual IP must be submitted to the RO*
Report suspected cases of fraud to DDA
*Note: DDA Plan Performance Measure #6 - Number of people with choice between and among waiver services and providers
*Reference: IP Memo dated February 6, 2012
173
FACILITIES TRANSITIONS HELPFUL STRATEGIES & REMINDERS
For People transitioning from facilities (including NF, incarceration, MHA facility, SRC, SETT)
MA eligibility can be determined up to 6 months prior to discharge
Waiver Advisory Opinion Determination Advisory as to eligibility post transition can be
made
174
FACILITIES TRANSITIONS HELPFUL STRATEGIES & REMINDERS
Complete MA application, Cover Sheet, and send with supporting documentation to RO Waiver Coordinator
No additional waiver paperwork is needed at this time
If Medicaid eligible (financial eligibility) then DEWS will send “Waiver Advisory Opinion Letter”
Person has to find community residence (typically six months from date of application)
If community residence is not established by due date, a new MA application is required
*People transitioning from Facilities (including NF, incarceration, MHA facility, SRC, SETT)
175
FACILITIES TRANSITIONS HELPFUL STRATEGIES & REMINDERS
Once community residence is finalized complete remaining waiver paperwork including: Waiver Enrollment Checklist Initial Certificate of Need Freedom of Choice Waiver Application Verification Form Provisional or IP
Send all items to RO Waiver Coordinator
*People transitioning from Facilities (including NF, incarceration, MHA facility, SRC, SETT)
176
Waiver Re-enrollmentHelpful Strategies &
Reminders People can re-enroll/re-enter their waiver slot
during the same fiscal year (i.e. July 2012 to June 2013)
People can re-enroll/re-enter from a long-term care stay (nursing home, SRC)
If the person will tentatively be discharged within six months, then submit the MA cover sheet, supporting documentation, and application to DDA
Advise DDA of discharge date so DDA can authorize effective waiver enrollment date
177
NEW DIRECTIONS WAIVER
UPDATESHELPFUL STRATEGIES
& REMINDERS
178
ROLES AND RESPONSIBILITIES
Resource Coordinators, Support Brokers, and Fiscal Management Services all have unique roles
Roles and responsibilities can be supported but shall not be duplicated as per federal assurances
• Referral and Related Activities• Plan Development• Monitoring and Follow Up
Resource Coordinator
• Human Resource Department• Recruitment, Interviews, and
Supervision• Timesheet review and approval• Budget monitoring
Support Broker
• Accounting & Payroll Department• Management Approved Budget • IRS Fiscal Agent• Pay service providers
Fiscal Management
Services
179
NEW DIRECTIONS & SUPPORT BROKERS
TRAININGOrientation
*Stories*Group Exercises
*VideosAudio Clips
• People, Families, Independent Contractors, and Agencies
• Resource Coordinators
Initial Support Broker Training
• People, Families, Independent Contractors, and Agencies
• Resource Coordinators
Individualized Budgets
• People, Families, Independent Contractors, and Agencies
• Resource Coordinators
Recertification
• Update on policies & procedures
• Refresher course
*New Directions participants and self advocates will share personal stories and advice.
New in
FY 13
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SUPPORT BROKERSSeveral Support Broker Options (certified independent contractor, agency, or family member)Support Brokers can not provider other services to the same waiver participant Family members as Support Brokers
*You must continually evaluate whether the decisions made are the person’s choice or the family member’s choice
Person’s Wants
Family Wants
*New Person to spend time with
*Community Integration
*Family Member as paid staff
*Respite
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NEW DIRECTIONS HELPFUL
STRATEGIES & REMINDERSResource coordinators must review and certify IP & B Helpful questions to review: Is the plan holistic (all needs and all resources)? Are the goals clear or vague? What is the plan of action to meet the goals? Do the services identified support the person’s
goals? Does it support health and safety? Are the services covered under the waiver? Does the plan and budget match? Does the budget add up?
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NEW DIRECTIONS HELPFUL
STRATEGIES & REMINDERSResource coordinators Plan and Budget Responsibilities Plan, Assess, and Monitor throughout the year Recommend service (holistic, various resources) and
budget change (+) and (-) to meet needs, goals, etc. Evaluate budget modification against person’s
choice and health and safety Avoid end of the year mass spending of unused
budget Note: Annual budget is not based on previous year’s actual expenditures.
Note: ND Participants will receive notice of 2% COLA for FY 2013
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NEW DIRECTIONS HELPFUL
STRATEGIES & REMINDERSMedications section should include: Over the counter medications Drug name, dosage, and prescribing physician What the medication is being taken for Who is administering the medication
For participants who cannot self medicate:
All paid staff dispensing medication need to have Medication Technician training
IP & B must include nursing delegation services
Support brokers who are nurses cannot perform nurse delegating services.
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NEW DIRECTIONS HELPFUL
STRATEGIES & REMINDERS
The IP & B must contain a two level back-up system including:
Name Addresses Phone numbers Responsibilities
Note: Support broker and primary staff cannot be listed as back-up staff.
Primary Staff
Back-Up #1 Back-Up #2
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SELF DIRECTION MYTHS
RUMORS, AND MISUNDERSTANDING
You must have family involvement for ND? Community of Practice is the only way someone
can self direct? PATH are person centered planning tool only
allowed with Community of Practice? DDA is moving away from New Directions – it is
not their focus – it’s a flash in the pan? People will loose RC as a service if they use ND? You must go into the CP waiver prior to using the
ND Waiver? Waivers are open? Closed? People are not ready to self-direct?
REQUEST FOR SERVICE CHANGE AND SERVICE FUNDING PLAN PROCESS
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REQUEST FOR SERVICES CHANGE
Any time after the receipt of services, an eligible person may:
(1) Apply for or request a change in intensity of services or support, or apply for additional services;
(2) Request a less intensive form of that service, and may receive the less intensive service if it is available.
Reference: COMAR 10.22.12.11
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REQUEST FOR SERVICES CHANGE
Complete and accurate information assist with
review and determining approval status as well
as eliminates the need for follow up questions from the regional office.
Background and summary information should include information relevant to the person and requested need
The IP Services Summary Addendum form can assist reviewers with a clear and concise picture of the services currently provided (DDA and/or other services) and services that are being requested
Full disclosure of resource exploration provides an overall understanding of what has been tried
A comprehensive description of any potential health and safety risks allows for an accurate assessment of need
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REQUEST FOR SERVICES CHANGE
Including all relevant information in a legible format provides ease of review.
Site to Site Transfers
• Cost Neutral-One person or Complete site• Verify staffing ratios• Accessibility• Health and safety• Team agreement
• Cost Increase or Decrease• Rationale for increase or decrease in funding
Legibility and Print Size
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WHAT’S THE IMPACT?
Emergency Request Provides ability for
immediate approval/denial
Allows for a service start date from the date of the initial verbal emergency request and prior to the submission of the RFSC from
Is flagged by the regional office for expedited review and approval
Standard Request Is reviewed
chronologically as received by the regional office
Service start date can only be authorized back to the date that the RFSC form is submitted
The type of request affects the potential start date for service authorization and may affect the time to
process the request.
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WHAT’S THE IMPACT?
DD Eligible• May be eligible for
full residential and/or vocational services
Supports Only Eligible• Not eligible for full
residential and vocational services
• Only eligible for services described in regulations as support services
Waiver Eligible Waiver covered
services with a demonstrated need are approved
State Only Funded Additional services
are only considered when health and safety are the emergent needs
Eligibility status and the type funding the person receives plays a role in the final approval decision.
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ONE TO ONE STAFFING
This type of support can be supportive or restrictive. DDA wants to be sure that people get what they need in the least intrusive manner.
Be sure that the Request for Service Change packet includes the following:
1. The role of the one to one staff person2. Length of time the 1:1 supports are requested3. Data and information to support the need for the
request (e.g. data summaries, incident reports, professional recommendations, etc.)
4. The work that will be completed during the time that one to one supports are in place
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1:1 STAFFING FOR BEHAVIOR SUPPORTS
Guidelines for Approval Periods Up to One Year
• New patterns of behavior that indicate a need for a plan (no current plan)
• Person changes service provider• Time for acclimation to new surroundings, assessment of
behavior, plan development and approval, and staff training
• Person currently exhibits life threatening behavior (i.e. PICA, Lesch Nyhan, Prader Willi), that may require on-going support-• Annual review of training, environmental changes and
other supports to minimize intrusive intervention
Up to Six Month Approvals• Person has need for plan modification
Up to Three Months• To train staff in the implementation of the plan• To stabilize medications that are a part of the overall
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1:1 STAFFING FOR MEDICAL NEEDSApprovals for this type of request are based on:
1. The type of need2. Prognosis for health status
improvement3. Specific time frames indicated in
supporting documentation (medical reports, physicians orders, etc.)
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AWAKE OVERNIGHT (AON) STAFFING
Be sure that the Request for Service Change packet includes the following:
1. The role of the one to one staff person2. Length of time the AON supports are requested3. Data and information to support the need for the
request (e.g. sleep or behavioral data summaries, incident reports, professional recommendations, etc.)
4. Other measures that have been attempted (technology, behavior support services, etc.) and been unsuccessful
POLICY ON REPORTABLE INCIDENTS AND INVESTIGATIONS(PORII)
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EVIDENCE AND DOCUMENTATION
PORIIIPRC
Monitoring
Health
Welfare
&
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PORII FEDERAL ASSURANCE
Federal Requirements include: Participants’ health and welfare are
safeguarded and monitored
Adequate system for identification and documentation of Reportable Events to ensure people are adequately protected from abuse, neglect, financial exploitation, rights violation, and to ensure that waiver services appropriately meet their needs.
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PARTICIPANTS’ HEALTH AND WELFARE ARE SAFEGUARDED AND MONITORED
People receive medical services needed
People are free from mistreatment Abuse, neglect, and exploitation Unauthorized or inappropriate use of restraints
Plan and plan modifications continually support the person’s health and safety
Critical Event or Incident Reporting and Management Process
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PERFORMANCE MEASURES#1- Number of people who receive medical services as recommended by their physician(s)
#2- Number of people reporting they are free from mistreatment
#3- Number of incidents involving unauthorized or inappropriate use of restraints
#4-Percent of deaths based on population count vs. percent of deaths of Maryland population and US population
*Performance Measures for both Community Pathways and New Directions Waivers unless otherwise indicated.
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PERFORMANCE MEASURES#5 - Number of budget modifications reviewed by resource coordinators (New Directions Only)
#6- Number of people with 2 level back up plans in their IP&B (New Directions Only)
#7- Number of critical incidents reported (New Directions Only)
#8 -Number of reportable incidents that are reported within required timeframes (New Directions Only)
*Performance Measures for both Community Pathways and New Directions Waivers unless otherwise indicated.
PORII
UPDATES HELPFUL STRATEGIESREMINDERS
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PORII – HELPFUL STRATEGIES
AND REMINDERSThe police do not always understand that
people with developmental disabilities have the same rights other citizens.
If the person in services alleges abuse and the police are not investigating then: The RC should follow up with the person who was
the victim and help him/her file charges against the aggressor.
Often the agency is focusing on linking the person in services to supportive services (e.g.: counseling) or conducting "damage control."
The RC can empower the person by helping him/her seek justice.
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PORII – HELPFUL STRATEGIES
AND REMINDERSPeople in services also should have the
opportunity to file charges in instances where theft has occurred.
There have been many cases where agencies learn an employee has stolen funds from a person in services.
The agency reimburses the person, but does not offer the person the opportunity to file charges against the person who stole from them.
The person who was the victim of theft should have the opportunity to press charges.
In doing so, action may be taken against the staff...preventing future employment at other DDA licensed providers.
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PORII – HELPFUL STRATEGIES
AND REMINDERS
Regulations require a team meeting within 5 days of an unauthorized restraint.
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PORII – HELPFUL STRATEGIES
AND REMINDERSOften there is question re: whether or not the
Incident Report must be disclosed to the resource coordinator.....
Under Maryland Code Health General Title 7- Developmental Disabilities Law, Subtitle 10 - Rights of Individuals, Section 7-1010 - Records - Consent to disclosure; Disclosure of the Appendix 4 (initial report) to the Resource Coordinator is required.
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PORII – HELPFUL STRATEGIES
AND REMINDERSMedical Review Committee (“MRC”) The Appendix 7 includes information pertaining
to the agency's internal investigation and may be protected under the protection given to a Medical Review Committee (“MRC”).
Some agencies have concerns about confidentiality or sharing information from Appendix 7’s, the agency investigation, or Standing Committee discussions.
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PORII – HELPFUL STRATEGIES
AND REMINDERSMedical Review Committee (“MRC”) This information may remain confidential if the
agency operates its Standing Committee within the context of a Medical Review Committee (“MRC”).
The bylaws or policies governing the actions of one’s Standing Committee need to be consistent with those governing a MRC, in order to have the expected protections.
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PORII – HELPFUL STRATEGIES
AND REMINDERSMedical Review Committee (“MRC”)
Md. Code Health Occ. (“HO”) §1-401 establishes the rules governing Medical Review Committees (“MRC”) also known as Peer Review Committees (“PRCs”).
It is a somewhat confusing statute; however, for the following reasons, it permits alternative health care systems to establish MRCs.
Licensed providers probably have MRCs, even if they are not called that.
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PORII – HELPFUL STRATEGIES
AND REMINDERSWhat Does A Medical Review Committee
(“MRC”) Do?
The short answer is that it “EVALUATES.”
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PORII – HELPFUL STRATEGIES
AND REMINDERSA MRC does one (or all) of the functions listed in HO
§1-401(c):
Evaluates and seeks to improve the quality of health care provided by the providers of health care;
Evaluates the need for and the level of performance of health care provided by providers of health care;
Evaluates the qualifications, competence, and performance of providers of health care; or
Evaluates and acts on matters that relate to the discipline of any provider of health care.
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PORII – HELPFUL STRATEGIES
AND REMINDERS
As you will note that a MRC may perform far more duties for the agency than risk management, utilization review and credentialing.
A committee could be established to evaluate the quality of care generally provided in the facility and be a MRC.
Some agencies have several such committees, i.e.: the Standing Committee.
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PORII – HELPFUL STRATEGIES
AND REMINDERSThe thought to remember is that confidentiality is
given because the balance of improving healthcare delivery systems through evaluation and subsequent reforms, outweighs the normal ability of parties to obtain information and documents for civil cases and for the public to obtain documents through the Public Information Act.
Thus, a committee set up with procedures to evaluate which does that and acts in accordance with the recommendation, is probably a MRC, even if it has not been named as such.
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PORII – FY 2013 POLICY REVISIONS
In addition to meeting CMS requirements, the policy is being revised with the goals of: Making the policy less cumbersome for the
providers Define the roles and responsibilities of key
staff at DDA, OHCQ and Medicaid
DDA
OHCQMedicaid
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PORII –PROPOSED POLICY REVISIONS
1. Integrated IT System
By 07/2012 DDA, Medicaid and OHCQ will have a draft plan for implementation of the PCIS2 web-based incident reporting module.
The PCIS2 module allows:
OHCQ, DDA and Medicaid real-time access to reports,
The state and the providers using the system to analyze data trends
PCIS2 has safeguards in place that assisted providers in submitting complete & acceptable incident reports and investigations.
OHCQ
DDA
RC
Provider
Medicaid
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PORII –PROPOSED POLICY REVISIONS
2. Neglect & Police Notification
The current PORII requires police notification every time an allegation of neglect is made.
There is concern that these notifications are watering down the system and resulting in desensitization of the police department.
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PORII –PROPOSED POLICY REVISIONS
2. Neglect & Police NotificationCurrent ExamplesPolice do not take serious allegations seriously
because they come out to the sites all the time for instances where there was a report of neglect:
1:3 staffing vs. 2:3 staffing (lack of supervision), or
Person shows up for the day program without his coat
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PORII –PROPOSED POLICY REVISIONS
2. Neglect & Police Notification Proposed Revision:
All allegations of neglect will continue to be reportable, but the requirement of police notification will apply to only incidents involving substantial risk of life-threatening harm.
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PORII –PROPOSED POLICY REVISIONS
3. Resource Coordination Notification
The revised policy will require agencies to send the Appendix 4 (not the Appendix 7) to the Resource Coordinator.
Q: Under what authority are agencies required to disclose Appendix 4s to Resource Coordinators
A: Disclosure of the Appendix 4 is required under Maryland Code Health General Title 7- Developmental Disabilities Law, Subtitle 10 - Rights of Individuals, Section 7-1010 - Records - Consent to disclosure.
A4
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PORII –PROPOSED POLICY REVISIONS
3. Resource Coordination Notification
Q: Does the policy require agencies send the Appendix 7 to the Resource Coordinator who works with the individual identified in the incident report?
A: No. agencies are not required to provide the Resource Coordinator with the Appendix 7, Agency Investigation Report. Agencies are required to collaborate with Resource Coordinators to make sure that appropriate action is taken to protect the participant from harm. The agency is required to advise the Resource Coordinator of the interventions taken and follow-up plan that will prevent future recurrence.
A 7
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PORII –PROPOSED POLICY REVISIONS
4. More User-Friendly
A Frequently Asked Questions (FAQ)/Technical Assistance section was added to the policy.
Prompts to ensure the provider documents the immediate response to the incident for health and safety assurances are included in the PCIS-2 module.
PCIS
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PORII –PROPOSED POLICY REVISIONS
5. Agency Investigation Timeframe
CMS has stated that the current timeframe for investigation of reportable incidents (21 days) needs to be revised
The proposed change to PORII shortens this timeframe to 10 days.
2013
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PORII –PROPOSED POLICY REVISIONS
6. Incidents Have Been Broken Down Into "Tier I" And "Tier II."
All “Tier I“ incidents will be sent to OHCQ Some incidents ("Tier II") will be sent only to
DDA and Resource Coordination (not to OHCQ). DDA will conduct the initial follow up. The DDA regional office can make a referral to
OHCQ & request follow up on any of the Tier II incidents where DDA has concerns.
OHCQ
DDA
Tier II
Tier IConcer
n
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PORII –PROPOSED POLICY REVISIONS
7. The New Category "Choking" has been added to PORII
8. Roles Defined
The PORII describes the roles in incident reporting for
Resource Coordinators Support Brokers
PORII
SB
RC
LOW INTENSITY SUPPORT SERVICES
UPDATES
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FY 12 - LISS $1.25 MILLION FUNDING EXPANSION
Effective May 29, 2012 until June 30, 2012 or until all funds are allocated.
First-come, first-serve basis for eligible people
People eligible for the DDA’s Service of Short Duration (SSD) funding shall have their needs addressed under the Waiting List Initiative and not through LISS.
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LISS FY 2013
Funding allocation for Fiscal Year 2013
Includes 2% COLA
LISS regulations to be published soon
LISS form and FAQ printed in Spanish
User Guide to be developed based on regulations and program experience
Request not processed by June 30, 2012 will be processed under FY 13 funds
FISCAL UPDATES
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FISCAL UPDATES2 % Fiscal Year 2013 Cost of Living
Allowances (COLA)
Providers Resource Coordination Agencies Low Intensity Support Services Specialized Services New Directions Participants
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FISCAL UPDATESFiscal Year 2013 Expansion
Transitioning Youth Emergency Forensic Waiting List Equity Fund
Budget Reconciliation and Financing Act Bill (BRFA) (SB1301) -includes a provision allowing DDA to carry-over up to $5 million from this fiscal year (FY2012) to next fiscal year (FY2013).
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