DD Waiver Services

1. Department of Medical Assistance Services DD Waiver Services Division of Long-Term Care Department of Medical Assistance Services 2013 http://dmasva.dmas.virginia.gov 1

2. Objectives of Training • Train in-home and day support providers on the associated requirements for Individual and Family Developmental Disabilities Support (DD) Waiver.

3. Development of the DD waiver

4. Development of the (DD) Waiver • DMAS was directed by the 1999 General Assembly session to develop a new waiver for persons with developmental disabilities. • DMAS formed a work group consisting of consumers, advocates, providers and state agencies that met nine times from May 10, 1999 through May 18, 2000 to discuss waiver development issues.

5. Work Group Goals • Option to institutionalization • Consumer-directed whenever possible • Services in the workplace when possible • Individually tailored services • Coordinate with schools and other training areas • Maximize other financial resources • Minimize duplication of resources

6. Development of the (DD) Waiver • DMAS submitted a report to the 2000 General Assembly session proposing the development of a new waiver. • DMAS requested and received approval from the Centers for Medicare and Medicaid services (CMS) in May 2000 to begin implementation of the DD waiver on July 1, 2000. • This waiver would be more consumer-driven and provide additional supports to families.

7. Development of DD Waiver • In order to get waiver approval from CMS, there must be an alternative institutional placement. • For the DD waiver the alternative placement must be an Intermediate Care Facility for the Mentally Retarded (ICF/MR).

8. Eligible for (DD) Waiver • The individual must be 6 years of age and older and meet the “related conditions” requirements of C.F.R. § 435.1009, including autism; • May not have a diagnosis of intellectual disability (ID) as defined by the American Association on Developmental Disabilities (AAIDD)

9. Individual and Family Developmental Disabilities Support (DD) Waiver • Meet the level of care for admission to an Intermediate Care Facility for the Mentally Retarded (ICF/MR).

10. Adult Companion Services Assistive Technology Crisis Stabilization Crisis Supervision Environmental Modifications In-home Residential Support Day Support Skilled Nursing Supported Employment Therapeutic Consultation Personal Emergency Response System Family/Caregiver Training Respite Care Personal Attendant Services Prevocational Services Transition services- MFP Case Management (State Plan Option) Covered Services

11. In-home Residential Support Services Service Definition

12. Training and assistance or specialized supervision Most training occurs in an individual’s home or residence considered to be his/her home In-home support does not include room and board Enables an individual to acquire, improve, or maintain: Activities of daily living (ADLs) Access community resources Adapt to the community/daily environment Safety skills and health status In-home Residential Support Service Definition

13. In-home Residential Support Services • Supplemental to the care provided by a parent or similar caregiver • May support an individual whose level of independence does not require a primary caregiver

14. May not be provided for a continuous 24-hour period Training is provided in the home or community Supports are delivered on a 1:1 staff to individual ratio In-home Residential Support Service Definition

15. Person Centered Approach • This service should provide empowerment and support to the individual so that he or she may develop his or her own individual lifestyle

16. In-home Residential Support Training and Assistance Activities

17. Functional skills training in personal care activities such as: Toileting, Bathing, Grooming, Dressing, Eating, Mobility, Communication, Household Chores, Food Preparation, Money Management, Shopping etc. Functional skills training in use of community resources such as: Transportation, Shopping, Social/Recreational Activities Training to help the individual adapt his behavior to home and community environments In-home Residential Support Activities

18. Assistance with personal care tasks, e.g. ADLs and community resources, if the individual is physically unable to learn these tasks Monitoring health, physical condition and medical needs Ensure completion of hygiene, nutrition and other tasks essential to health and welfare. Support with shopping, banking, laundry, arranging transportation etc. There must be documentation on the schedule for the type of assistance being provided. In-home Residential Support Activities Continued

19. In-home Residential Support Criteria • May not be provided simultaneously with personal care, respite care, attendant care or CD respite care services • Must be prior-authorized • Should be provided at frequency allowing for systematic training and maintenance of functional supports • Individual must be present

20. In-home Residential Support Criteria • Functional Assessment must be conducted by the provider to evaluate each individual in his home environment and community settings. • 12VAC30-120-750 (B) (2)

21. Total billing can not exceed total hours approved by DMAS on the individual’s POC Documentation of dates, times, and services provided Any circumstances that prevented the individual from receiving all scheduled hours If fewer than all the hours scheduled on the POC are delivered on a regular basis, over a 60-day period, the provider should determine if there is a need to request a revised POC reducing the hours In-home Residential Support hours and limitations

22. In-home Residential Support hours and limitations • General Supervision is non-billable • Examples of General Supervision: • Awake staff coverage at night if the individual generally sleeps throughout the night • Oversight of leisure activities • Routine bed checks • Asleep staff at night on the premises for security and/or safety reasons • Staff “on call” during the day while the individual is participates in work/day support/school activities

23. In-home Residential Support • Specialized Supervision

24. Provides staff presence for ongoing or intermittent intervention to ensure the individual’s health and safety. DMAS 457 must clearly document the individual’s need for this support. Provider DMAS 457 form must contain a specialized supervision objective outlining the staff’s activities and specific times that these activities will occur Activities must relate to the assessed health and safety needs of the individual In-home Residential Support Specialized Supervision

25. In-home Residential Support Specialized Supervision • May include hours throughout the entire night, but only if documentation supports the request • Ongoing need for this service should be documented in semi-annual reviews • If, over a 60-day period, the hours of Specialized Supervision actually provided are consistently less than the scheduled-upon, approved, and determined amount, the provider is expected to revise the DMAS-457 form, the weekly schedule, and amount to reflect this reduction.

26. In-home Residential Restrictions With Other Services • In-Home Residential Support services will not be authorized for the primary purpose of supervision or personal care.

27. In-home Residential Support Documentation

28. In-home Residential Support Documentation Supporting Documentation (457) indicates: • Need for the service • Amount and type of activities (objectives and goals) Schedule of services • Total hours per day • Total hours per week

29. In-home may not necessarily be required daily, but POC must reflect needs and appropriate allowable activities to be provided on a periodic basis Additional hours when clearly justified need to be requested through the case manager Reimbursed for hours of direct staff time with individual only In-home Residential Support Documentation

30. In-home Residential Support Documentation • Must be authorized by DMAS • Services explicitly detailed in Supporting Documentation

31. In-home Residential Support Documentation • A formal, written behavioral program is required to address behaviors, including self-injury, aggression or self stimulation. 12 VAC30-120-150(B)(4)

32. In-home Residential Support Documentation • Semi-annual Reviews: • Must be reviewed with individual • General status of individual • Significant events • Individual/family satisfaction with services • Any revision to Plan of Care (POC) and supporting documentation • Submitted to case manager

33. In-home Residential Support Documentation Supervision of direct care staff: • Monthly contacts/Semi-annual home visits • Signature of responsible supervisor • Date of contact/observation • Person contacted/observed • Staff performance and service delivery • Problems, concerns, individual satisfaction with services • Actions planned/taken to correct problems

34. In home Residential Support Documentation • Provider must maintain documentation of the date, times the services that were provided, and specific circumstances preventing the provision of any scheduled services. 12VAC30-120-750 ( C )

35. In-home Supporting Documentation Overview

36. Day Support Services

37. Variety of training Assistance Support Specialized supervision (other than home or individual residence) Peer Interactions Specialized supervision for the acquisition Retention Improvement of self help Socialization Adaptive skills Day Support Service Definitions

38. Day Support Service Definition Continued • Providers are reimbursed only for the amount and type of day support services included in the individual’s approved Plan of Care. This does not include prevocational services. 12VAC30-120-752(A)

39. Day Support Activities Functional training in: • Self, social & environmental awareness • Sensory, gross and fine motor skills • Communication • Personal care • Problem-solving skills • Using community resources • Community safety • Peer interactions

40. Day Support Criteria • Must have demonstrated need for training, assistance and supervision • in settings outside of home • to access in-home residential services • to increase current level of independence • to sustain skills • Individuals cannot benefit from Supported Employment

41. Day Support Criteria • Functional Assessment must be conducted by the provider to evaluate each individual in his home environment and community settings.

42. Day Support Types and Levels • Types: • Center-Based • Non Center-Based • Levels: • Regular • Intensive

43. Day Support Intensive Level Criteria • Must meet at least one of the following criteria: • Need for physical assistance for caring for personal needs • Extensive disability-related difficulties, requiring additional staff support • Extensive constant supervision to reduce or eliminate behaviors that preclude full participation in the program. Formal behavioral plan is required to address behaviors (Withdrawal, self injury, aggression or self stimulation)

44. Day Support Services Documentation

45. Day Support Services Documentation Supporting Documentation (457) indicates: • Need for the service • Amount and type of activities (objectives and goals) Schedule of services • Total hours per day • Total hours per week • Maximum not to exceed 780 units per plan year

46. Day Support Services Documentation • Services and documentation must be separate and distinguishable from In-Home Residential Support or Personal Care • Service cannot be provided in individual’s home without prior authorization from Kepro

47. Documentation must confirm the following: Attendance Amount of individual’s time in service Specific information regarding individual’s response to various settings Day Support Services Documentation

48. Day Support Services Documentation • Supports as agreed to in the supporting documentation objectives • Assessment results must be available in at least a daily note or weekly summary

49. Day Support Services Documentation • Provider must review the supporting documentation with the individual or family/caregiver for annual review and revisions • Submit to case manager at least semiannually

50. Attendance log or similar document must be maintained indicating the following: Date Type of services rendered Number of Hours or Units provided (including specific time frame) Center-based or non center-based Regular or intensive level Day Support Services Documentation