Comment 45
Appendix C: Participant Services, Quality Improvement: Qualified Providers, Methods for Discovery: Qualified Providers; 1. Sub-Assurances, Performance Measures, page 177
DMAS and others have raised concerns about LRIs providing personal assistance services through consumer-direction. There are also concerns about other models of service delivery. To address concerns about some other FIS Waiver services, DMAS uses Performance Measures to identify problems and methods to remediate problems.
RECOMMENDATION: Add a Performance Measure regarding the number of individuals using LRIs for personal assistance services who have written documentation regarding some of the factors identified in comment 44 above.
Comment 46
Appendix C: Participant Services, Quality Improvement: Qualified Providers, Methods for Remediation/Fixing Individual Problems, page 178
The sub-assurance addressing the provision of consumer-directed personal assistance services may identify problems with the development of objective written documentation and description of the extraordinary care to be provided by the LRI as a paid provider.
RECOMMENDATION: If DMAS identifies problems with this sub-assurance, the case manager/support coordinator and services facilitator will be required to develop and implement a corrective action plan.
Comment 47
Appendix D: Participant-Centered Planning and Service Delivery, D-1: Service Plan Development (2 of 8), b. Service Plan Development Safeguards, narrative, 3rd paragraph, 1st sentence, page 195
This item requires the support coordinator/case manager to “offer choice among all providers serving the area in which the individual desires services”. This is not offered; there is no reliably current and usable database or document for the case manager/support coordinator to obtain this information. DMAS currently requires use of the Virginia Informed Choice form to document that choice has been given. The form is inadequate for this and other purposes.
RECOMMENDATION: Develop a database of FIS Waiver service providers listed by service that includes the name of the provider agency, contact information for the agency, geographical area the agency will provide services, and for licensed agencies, if the agency has a provisional license.
Comment 48
Appendix D: Participant-Centered Planning and Service Delivery, D-1: Service Plan Development (2 of 8), Service Plan Development Safeguards, narrative, page 195
Appendix D: Participant-Centered Planning and Service Delivery, D-2: Service Plan Implementation and Monitoring, b. Monitoring Safeguards, narrative, page 203
There appears to be an assumption that DD case managers are with private organizations, and as such, the draft Application proposes that the private entity would be prohibited from providing waiver services other than services facilitation. The majority of case managers (the term used for the service provided to people with developmental disabilities who do not have a diagnosis of intellectual disability) are not private providers. Most DD case management is now provided by CSBs directly with CSB employees. Historically, DD case management was provided almost exclusively by private providers. The availability of private DD case management has eroded since 2017 when changes were made to the administration of DD case management. Currently, the remaining private entities providing DD case management are permitted to provide waiver services so long as the private entity maintains separation of case management and direct service provision (same requirement applies to CSBs). The draft Application appears to end this practice and only allow CSBs to provide both case management/support coordination and other waiver services.
RECOMMENDATION: Continue to allow private DD case management entities to provide other waiver services so long as they maintain the current requirements for separation of direct services and case management.
Comment 49
Appendix D: Participant-Centered Planning and Service Delivery, D-1: Service Plan Development (4 of 8), d. Service Plan Development Process, narrative, 7th paragraph, page 197
Use of the Virginia Informed Choice (VIC) form to document choice of services and providers would continue. The VIC is inadequate. The VIC and all parts of the plan are not typically shown to the individual during the course of their meeting, thereby limiting their ability to participate fully in the meeting and to have reinforcement of what is being discussed and how it is relevant to their plan.
RECOMMENDATION: Redesign the VIC to include a better description of the available service choices, including available providers. When services are added, removed or providers changed, use of the VIC should be required.
RECOMMENDATION: Add that to the VIC a statement that the individual was provided a copy of the entire plan. If the plan cannot be provided at the meeting, the VIC should indicate how and when the entire plan would be provided to the individual.
RECOMMENDATION: Add telehealth options to the VIC, when available for a specific service, so that the individual can choose which, if any, telehealth option they want.
RECOMMENDATION: Before the meeting, all forms and parts of the plan should be provided as partially completed or incomplete documents to the individual so that they are aware before the meeting of the questions that will be asked and items they may want to discuss during the meeting. This will also improve their ability to follow along with completion of the forms and plan during the meeting.
Comment 50
Appendix D: Participant-Centered Planning and Service Delivery, D-1: Service Plan Development (4 of 8), d. Service Plan Development Process, narrative, 6th paragraph, page 198
Some FIS Waiver providers are not required to produce reviews/reports.
RECOMMENDATION: Clarify which service providers are required to provide quarterly reviews. List FIS Waiver services that do not require quarterly reviews and how the case manager/service coordinator monitors these services in absence of quarterly provider reviews.
Comment 51
Appendix D: Participant-Centered Planning and Service Delivery, D-1: Service Plan Development (5 of 8), e. Risk Assessment and Mitigation, narrative, 5th paragraph, 8th line, page 199
For individuals who select consumer-directed supports, but who do not want services facilitation, they will need to access the Employee Management Manual.
RECOMMENDATION: Include details about how the individual may access the Employee Management Manual, the fiscal agent, and other items needed to initiate or continue employer of record responsibilities without services facilitation.
Comment 52
Appendix D: Participant-Centered Planning and Service Delivery, D-1: Service Plan Development (5 of 8), e. Risk Assessment and Mitigation, 7th paragraph, page 199
Individuals who have been receiving FIS Waiver services, may lose their back-up supports when their parents or other unpaid caregivers move, die, or otherwise no longer available. The draft Application states the following: “Individuals unable to identify adequate safeguards for back-up supports are not approved for waiver services.” The language does state that referrals to other providers are considered. However, it is often a fact that other providers are not available.
RECOMMENDATION: Modify the language in this item to require further action by the case manager/support coordinator to avoid the loss of a waiver, especially for individuals who may be in traumatic situations after the loss of natural support and/or unpaid caregivers who had been their back-up support.
Comment 53
Appendix D: Participant-Centered Planning and Service Delivery, D-1: Service Plan Development (6 of 8), f. Informed Choice of Providers, narrative, page 200
The provider lists referenced in this section are outdated, incomplete, nonexistent, and/or often not usable.
RECOMMENDATION: Individuals should be given choice of providers and provider lists before initial plan development, annual reviews and when requested by the individual. Provider lists should be current, include geographical availability of provider, and indicate if providers have conditional licensure.
Comment 54
Appendix D: Participant-Centered Planning and Service Delivery, D-2: Service Plan Implementation and Monitoring, b. Monitoring Safeguards, narrative, page 203
The draft Application states, “individuals who are dissatisfied with their case manager may choose another” from other another CSB or for DD case management, from a private case management provider. DMAS should determine if private case management is a choice individuals can make based on the availability of private providers under contract with CSBs or if this is no longer a choice the majority of individuals with DD are able to realize.
RECOMMENDATION: Include language that will address the lack of choice of case management to ensure choice is once again an option for individuals.
Comment 55
Appendix E: Participant Direction of Services, E-1: Overview (1 of 13), a. Description of Participant Direction, narrative, 1st paragraph, page 228
The Description of participant direction (consumer-direction) is unnecessarily negative in tone and approach. Individuals should not be required to “express dissatisfaction with agency-directed services” in order to initiate agency-directed services. The draft Application does not reflect why or how individuals may come to the decision to change from agency-directed to consumer-directed services. Often individuals are not made aware during the initial planning meeting that consumer-direction is an option. Case managers/support coordinators who often have limited knowledge of the consumer-directed model are not able to adequately described the model or explain how consumer-directed services are used in conjunction with other waiver services to support an individual living in an integrated environment.
RECOMMENDATION: Modify descriptive language of why an individually may initially or subsequently choose to use consumer-directed services.
Comment 56
Appendix E: Participant Direction of Services, E-1: Overview (1 of 13), a. Description of Participant Direction, narrative, 2nd paragraph, page 228
The draft Application states that individuals who elect to use consumer-directed services may choose a services facilitator to provide training and guidance. When an individual chooses to use consumer-directed services, and chooses not to receive services facilitation as a service, services facilitation is not required.
RECOMMENDATION: Include the process for the individual to initiate and continue consumer-directed services in the absence of services facilitation. This process should include a description of the role of the employer of record and role of the case manager/support coordinator.
Comment 57
Appendix E: Participant Direction of Services, E-1: Overview (1 of 13), a. Description of Participant Direction, narrative, 2nd paragraph, 5th line, page 228
Appendix E: Participant Direction of Services, E-1: Overview (5 of 13), f. Participant Direction by a Representative, narrative, page 231
If the individual is unable or opts not to be the employer of record, they should not be limited to only their family members or caregivers as the employer of record. A friend, neighbor or other may service as the employer of record.
RECOMMENDATION: Clarify that family members and caregivers are not the only persons who can be the employer of record for the individual.
Comment 58
Appendix E: Participant Direction of Services, E-1: Overview (1 of 13), a. Description of Participant Direction, narrative, 3rd paragraph, 2nd line, page 228
The services facilitator maintains documentation of services provided by the services facilitator, not by the consumer-directed personal care assistant, respite provider or the companion.
RECOMMENDATION: Clarify that the services facilitator documents the services they provide; not services provided by the consumer-directed personal care assistant, respite provider or the companion.
Comment 59
Appendix E: Participant Direction of Services, E-1: Overview (3 of 13), d. Election of Participant Direction, narrative, item (c), page 229
Individuals may use consumer-direction for a skilled service, if the service is provided with nurse delegation (54.1-3000). In addition, individuals may use consumer-direction for a skilled service as described in 54.1-3001 A.12.
RECOMMENDATION: Include language that allows for nurse delegation following provisions in State Regulation 18VAC 90-19-240.
RECOMMENDATION: Include language that allows consumer-direction for a skilled service as described in 54.1-3001 A.12.
Comment 60
Appendix E: Participant Direction of Services, E-1: Overview (4 of 13), e. Information Furnished to Participant, narrative, page 230
Appendix E: Participant Direction of Services, E-1: Overview (5 of 13), f. Participant Direction by a Representative, narrative, 1st paragraph, page 231
Individuals are not always adequately informed about the consumer-direction model of services. Case management/support coordination is often the initial and only source of information provided to the individual about consumer-direction. Case managers/support coordinators often have limited knowledge of the consumer-directed model. This includes knowledge about how consumer-directed services can be used in combination with other FIS Waiver services to support an individual living in an integrated environment.
Case managers/support coordinators must have knowledge about consumer-direction, especially since the case manager/support coordinator will perform some of the tasks that would have been the responsibility of services facilitation, if the individual choses to use consumer-directed services without services facilitation.
The Employer of Record Manual does not provide information about how the employer of record performs their required tasks, if they select not to use services facilitation.
RECOMMENDATION: Include a description of the process for the individual to initiate and continue consumer-directed services in the absence of services facilitation. This process should include descriptions of the distinct roles of the employer of record, case manager/support coordinator, and fiscal agent.
Comment 61
Appendix E: Participant Direction of Services, E-1: Overview (5 of 13), f. Participant Direction by a Representative, narrative, 2nd paragraph, 3rd sentence, page 231
The draft Application states that the services facilitator conducts a face-to-face meeting at least every three months. This is accurate if the individual is using personal assistance services. However, less frequent meetings are required if the individual is only using respite and/or companion services.
RECOMMENDATION: Clarify the required frequency of services facilitation face-to-face visits.
RECOMMENDATION: Add language about the role of the case manager/support coordinator for the monitoring described in this item, if the individual chooses not to use services facilitation.
Comment 62
Appendix E: Participant Direction of Services, E-1: Overview (5 of 13), f. Participant Direction by a Representative, narrative, 2nd paragraph, last two sentences, page 231
The draft Application would require the services facilitator to “review timesheets during the face-to-face visits” to ensure the approved hours are not exceeded. This is a provision that existed prior to the use of electronic visit verification and electronic time records. This services facilitation task is no longer practical or needed. The fiscal agent software prevents payment of services above the approved hours.
RECOMMENDATION: Remove language requiring the services facilitator to “review timesheets during the face-to-face visits”. If DMAS decides to maintain this requirement, add language about the role of the case manager/support coordinator to review timesheets, including how they will access the timesheets in the fiscal agent’s system during the face-to-face visits.
Comment 63
Appendix E: Participant Direction of Services, E-1: Overview (9 of 13), j. Information and Assistance in Support of Participant Direction, narrative, 1st paragraph, page 233
Informing individuals about the consumer-directed model and non-medical transportation services is the responsibility of the case manager/support coordinator. Case managers/support coordinators who have limited knowledge of the consumer-directed model are not able to adequately describe the model or explain how consumer-directed services can be used in combination with other FIS Waiver services.
RECOMMENDATION: Add language describing how case managers/support coordinators are provided training about consumer-directed assistant, companion, respite and non-medical transportation.
Comment 64
Appendix E: Participant Direction of Services, E-1: Overview (9 of 13), j. Information and Assistance in Support of Participant Direction, narrative, 2nd paragraph, 2nd line, page 233
The services facilitator does not conduct and submit quarterly reviews if only companion and/or respite services are used, unless there is documentation indicating why more frequent services facilitation visits are needed and agreed to by the individual.
RECOMMENDATION: Revise the language to describe that quarterly reviews are submitted for personal assistance services. If the individual is only receiving companion and/or respite, the reviews will typically be on a different schedule.