Home and Community Based Services Settings Rule

June 24, 2015

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HCBS Settings Rule

• Title: Medicaid Program; State Plan Home and Community-Based Services, 5-Year Period for Waivers, Provider Payment Reassignment, and Home and Community-Based Setting Requirements for Community First Choice (Section 1915(k) of the Act) and Home and Community-Based Services (HCBS) Waivers (Section 1915(c) of the Act) or “The Settings Rule”

• Published in the Federal Register on 01/16/2014• Effective March 17, 2014• www.hcbsadvocacy.org • http://

dds.dc.gov/page/waiver-amendment-information

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HCBS Settings Rule

• Describes traits of HCBS settings. (Our focus today.)

• Establishes guidelines for person-centered plans of care.

• Adds public input requirements for changes in services or rate.

• Allows states to group waiver populations together.

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HCBS Settings Rule – Intent

• To ensure that people receiving long-term services and supports through home and community-based service (HCBS) programs are actually community-based, with full access to the benefits of community living and the opportunity to receive services in the most integrated setting appropriate.

• Focus on:• Integration with the community• Choice• Rights• Independence

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Standards for all HCBS Settings

Integration with the community

• The setting must support full access by the person to the greater community, “including opportunities to seek employment and work in competitive integrated settings, engage in community life, control personal resources, and receive services in the community, to the same degree of access as [people] not receiving Medicaid HCBS.”

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CMS Exploratory Questions: Integration

• Is the person aware of or have access to materials to become aware of activities occurring outside the HCBS setting?

• Does the person shop, attend religious services, schedule appointments, have lunch with family and friends in the community, as the person chooses?

• Are people moving about inside and outside the setting, as opposed to sitting by the front door?

• Do people in the setting have access to public transportation?

• Does the person have a checking or savings account or other means to control his or her funds?

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Standards for all HCBS Settings

Choice • People must have a choice among setting

options, including settings that are not disability-specific.

• CMS Exploratory Question: Can the person identify other providers who render the services he or she receives?

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Standards for all HCBS Settings

Rights

• The setting must ensure people’s rights to privacy, dignity and respect, and freedom from coercion and restraint.

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CMS Exploratory Questions: Rights• Does staff talk to other staff about the person as if the

person was not present or within earshot of other people living in the setting?

• Does staff address people in the manner in which the person would like to be addressed as opposed to routinely addressing people as “hon” or “sweetie”?

• Do people in the setting have different haircuts/ styles and color?

• Are people prohibited from engaging in legal activities?• Is health information about people kept private?• Are people’s schedules for PT, OT, medications, diet,

etc. posted in a general area for all to view?

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Standards for all HCBS Settings

Independence

• The setting must optimize a person’s ability to make life choices, including choices related to daily activities, the physical environment, and with whom to interact.

• Similarly, the setting must facilitate choice regarding services and supports and who provides them.

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CMS Exploratory Questions: Independence

• Does the person’s schedule vary from other people’s in the same setting?

• Does the person work in an integrated community setting?

• Does the person regularly participate in meaningful non-work activities in the community for the period of time the person desires.

• Is individual choice facilitated in a manner that leaves the person feeling empowered to make decisions?

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Standards for Residential HCBS Settings• People must have:

• Landlord-tenant protections.• Lockable doors.• Choice of roommates.• Freedom to furnish and decorate their unit.• Control of their own schedule.• Access to food anytime.• Visitors anytime.• Physical accessibility.

• Any change to the above rules must be due to a specific need and explained in the person-centered plan.

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CMS Exploratory Questions: Residential

• Can the person request an alternative meal if desired?• Is the person required to sit at an assigned seat in a dining

area?• Does the person have access to such things as a tv, radio, and

leisure activities that interest him or her and can he or she schedule such activities at his or her convenience?

• Does the person know he or she can request a change in roommate?

• Does the person have a lease or written residency agreement?• Can the person close and lock his or her bedroom door?

Bathroom door? • Does the person have full access to typical facilities in a home

such as a kitchen with cooking facilities, dining area, laundry and comfortable seating in the shared areas?

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Settings That Are Not HCBS

• Nursing facilities• Institutions for mental diseases (IMD)• Intermediate care facilities for

individuals with intellectual disabilities (ICF/IID)

• Hospitals

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Settings That Are PresumedNot HCBS

• Settings in a publicly or privately-owned facility providing inpatient treatment.

• Settings on grounds of, or adjacent to, a public institution.

• Settings with the effect of isolating individuals from the broader community of individuals not receiving Medicaid HCBS.

HCBS Waiver Transition PlanWe must modify service settings within a little less than 4 years to meet new HCBS rules to ensure continued flow of Medicaid funding.

• All states must develop an HCBS transition plan, that provides a comprehensive assessment of potential gaps in compliance with the new regulation, as well as strategies, timelines, and milestones for becoming compliant with the rule’s requirements.

• DDS submitted its Statewide Transition Plan on March 17, 2015 and is working with stakeholders on our state self-assessment.

• Providers will be conducting self-assessments and writing transition plans for their own organizations.

• Service coordinators will also be talking to every person who receives HCBS services about their experiences to inform our assessment.

State Self-Assessment

• Work with HCBS Settings Advisory Group to review and make recommendations for remediation, where needed, on:

• All HCBS waiver service definitions and provider requirements. (Completed)

• All regulations governing HCBS. (Completed) • DDS/DDA Provider Certification Review (PCR) process. (In

progress)• DOH licensing requirements and regulations. • All relevant DDS/DDA policies, procedures, and protocols,

including Quality Management practices and tools. (In progress)

• Provider training requirements. (In progress)• Human Care Agreements and rate methodologies. (In

progress)• Information systems. (Not started)

Draft Changes to General Provisions • 1938 HOME AND COMMUNITY BASED SETTING

REQUIREMENTS

1938.1 All Supported Living, Supported Living with Transportation, Host Home, Respite Daily, Residential Habilitation, Day Habilitation, Small Group Day Habilitation, Individualized Day Supports, Supported Employment, Small Group Supported Employment and Employment Readiness settings must: • be chosen by the person;• ensure people’s right to privacy, dignity, and respect, and freedom

from coercion and restraint;• be physically accessible to the person and allow the person access

to all common areas; • support the person’s community integration and inclusion,

including relationship-building and maintenance, support for self-determination and self-advocacy, and opportunities for employment and meaningful non-work activities in the community;

• provide information on individual rights; and• allow visitors at any time, with any exception based on the

person’s assessed need and justified in his or her person-centered plan.

Draft Changes to General Provisions 

1938 HOME AND COMMUNITY BASED SETTING REQUIREMENTS

1938.2 All Supported Living, Supported Living with Transportation, Host Home, Residential Habilitation, and Respite Daily, settings must:

• Be integrated in the community and support access to the greater community;

• Provide opportunities for the person to engage in community life;

• Allow full access to the greater community;

• Be leased in the names of the people who are being supported. If this is not possible, then the provider must ensure that each person has a legally enforceable residency agreement or other written agreement that, at a minimum, provides the same responsibilities and protections from eviction that tenants have under relevant landlord/tenant law. This applies equally to leased and provider owned properties.

Draft Changes to General Provisions1938 HOME AND COMMUNITY BASED SETTING REQUIREMENTS

1938.2(e) All Supported Living, Supported Living with Transportation, Host Home, Residential Habilitation, and Respite Daily, settings must:

• Develop and adhere to policies which ensure that each person receiving services has the right to the following:

• Privacy in his or her personal space, including entrances that are lockable by the person (with staff having keys as needed);

• Freedom to furnish and decorate his or her personal space (with the exception of Respite Daily);

• Control over his or her personal funds and bank accounts;

• Privacy for telephone calls, texts and/or emails; and

• Access to food at any time.

Draft Changes to General Provisions

1938 HOME AND COMMUNITY BASED SETTING REQUIREMENTS

1938.3 Any deviations from the requirements in § 1938.2(e) must be supported by a specific assessed need, justified in the person’s person-centered Individualized Support Plan, and reviewed and approved as a restriction by the Provider’s Human Rights Committee.

Draft Changes to General Provisions 1911 INDIVIDUAL RIGHTS (New Additions)

Each Waiver provider shall develop and adhere to policies which ensure that each person receiving services has the right to the following: • Be informed orally and in writing of the following:

• Complaint and referral procedures including how to file an anonymous complaint;

 •  How to report an allegation of abuse, neglect and

exploitation; 

• For people receiving residential supports, the person’s rights as a tenant, and information about how to relocate and request new housing.

Draft Changes to General Provisions 

New Provider Requirements (1904.4)

• Complete mandatory training in Person-Centered Thinking, Supported Decision-Making, Supporting Community Integration, and any other topics as determined by DDS.

• Develop and implement a continuous quality assurance and improvement system, that includes person-centered thinking, community integration, and compliance with the HCBS Settings Rule, to evaluate the effectiveness of services provided.

Draft Changes to General Provisions 

1907 INDIVIDUAL SUPPORT PLAN (ISP) (Changes)

• The ISP is the plan that identifies the supports and services to be provided to the person and the evaluation of the person’s progress on an on-going basis to assure that the person’s needs and desired outcomes are being met, based on what is important to and for the person, specifically including identifying the person’s interest in employment, identifying goals for community integration and inclusion, and determining the most integrated setting available to meet the person’s needs.

• The ISP shall be developed by the person and his or her support team using Person-Centered Thinking and Discovery tools and skills.

Draft Changes to Day/ Voc Regs 

• Ban payment of stipends for attendance or participation at day or vocational programs.

• Require development of PPP & JS/CPPP.

• Emphasis on community integration.

• Day Habilitation must include activities to support community integration and inclusion. These must occur in the community in groups not to exceed 4 participants and must be based on people’s interests and preferences as reflected in their Individualized Support Plan and Person-Centered Thinking and Discovery tools.

• Employment Readiness must include community-based employment preparation experiences that are related to the person’s employment goals.

Person Centered Approach

Required by the HCBS Settings Rule.

… grounded in demonstrating respect for the dignity of all involved…seek to discover, understand and clearly describe the unique characteristics of the person, so that the person:

• Has positive control over the life he/she desires and finds satisfying;

• Is recognized and valued for their contributions to their communities (past, current and potential); and

• Is supported in a web of relationships, both natural and paid, within the desired community/neighborhood

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Important To & Important ForImportant To

What is important to a person includes what results in feeling satisfied, content, comforted, fulfilled, and happy.

• Relationships

• Status and control

• Rituals & routines

• Rhythm or pace of life

• Things to do and places to go Things to have

Important For

What others see as necessary to help the person • Be valued• Be a contributing member of

their communityIssues of health• Prevention & Treatment of

illness/medical conditions• Promotion of wellnessIssues of safety & well being (physical and emotional)

Importantto

Importantfor

Health & Safety Dictate Lifestyle

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Person Centered Thinking

Importantto

Importantfor

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How health and well being fits into the desired life – not either/or, but both/and.

Person Centered ThinkingTraining for Attorneys and Guardians

July 16, 2015Facilitated by: Michael SmullTime: 2:00pm – 4:30pmLocation: Conference Room 2B (HR Suite) To register please contact Fikicia Guy and Erica Gross in the DDS Training Departmentdds.providertraining@dc.gov 

Integrated Approach to Health

Technology• Wii Fit• Timer• TV: music videos

Personal Strengths

• Likes fruits and veggies• Enjoys looking good• Loves being outside Relationship

Based• Sister helps

with medical decisions.

• Roommate to go on walks with.

Eligibility Specific• Nutrition• Fitness• Dental• Nursing (HCMP)• Staffing supports

Community Based

• Senior center• Health clinic• Paved path in

the park

For More Information

Erin LevetonState Office of Disability AdministrationDC Department on Disability Services(202) 730-1754Erin.Leveton@dc.gov