9. Respite Services, Service Definition: The Board recommends including information about nurse delegation (VA Code 18VAC90-19-240).
As mentioned in the recommendations above, the delegation of nursing tasks and procedures is an option for people receiving CD respite services under specific circumstances. Nurse delegation allows for greater autonomy and control by the individual receiving services and should be included here.
10. Respite Services, Specify Applicable Limits on the Amount, Frequency or Duration of the Service: The Board recommends that clarification regarding the parameters of the 480-hour limit, e.g., per calendar year, state fiscal year, be included in the renewal application.
11. Respite Services, Specify Applicable Limits on the Amount, Frequency or Duration of the Service: The Board recommends clarification that if a legally responsible person is the provider of consumer-directed services, and there is an identified primary caregiver who is not the person providing services, respite services are available.
The limitation described in the waiver application is not accurate: “Individuals who receive personal care from a legally responsible individual shall not be authorized for the respite service, as the legally responsible individual, as primary caregiver, is paid.”
An individual can have a legally responsible person as a provider of consumer-directed services, and also have an identified primary caregiver in need of respite services. This should be clarified in the application.
12. Respite Services, Specify Applicable Limits on the Amount, Frequency or Duration of the Service: The Board recommends that Legal Guardian be checked as an authorized provider of respite services.
We believe this omission was an oversight.
13. Companion Services, Specify Applicable Limits on the Amount, Frequency or Duration of the Service: The Board recommends that Legal Guardian be checked as an authorized provider of companion services.
We believe this omission was an oversight.
14. Services Facilitation: The Board recommends re-examining the role of the consumer-directed services facilitator to eliminate unnecessary duplication of functions and more clearly delineate the roles of services facilitators, support coordinators, and CCC Plus care coordinators.
Service facilitators, support coordinators, and CCC Plus care coordinators are all responsible for monitoring services. This can result in duplication of effort, diffusion of responsibility, confusion, and reduced individual ownership of responsibility. It can also unduly burden individuals who must accommodate multiple home visits and assessments.
When various parties have overlapping roles, DMAS should either distinguish how each party’s contribution to the overall role differs from the others’ contributions or, if the contributions do not differ, consolidate the role under fewer parties. The cost of this service should be analyzed in relation to the benefit achieved for the funding agency and the consumer.
15. Assistive Technology, Service Definition, Specify Applicable Limits on the Amount, Frequency or Duration of this Service: The Board recommends that DMAS clarify that if assistive technology is denied under EPSDT, in some circumstances, the technology can be assessed under DD waiver Assistive Technology rules.
The Board was a member of the HB 990 workgroup which required DMAS to continue to study and develop recommendations for the permanent use of virtual supports and increase access to virtual supports. EPSDT was discussed extensively by this workgroup. In particular, denials for assistive technology (AT) under EPSDT rules. DMAS reported confirmation from CMS that if AT is denied under EPSDT rules, the AT can be reviewed under waiver rules to determine if the AT is allowable. This should be included in the application.
16. Assistive Technology: Service Definition: The Board recommends clarification in the AT service definition that criteria for AT includes the ability to “actively participate in other waiver services that are part of their plan for supports.“ In addition, expand the service definition to also focus on functional abilities versus just “remedial or direct medical benefit”.
The CMS definition focuses on functional abilities and not only medical needs, which would include the ability to actively participate in other waiver services that are part of a person’s plan for supports.
17. Peer Mentor Supports: The Board recommends clarifying what “Prior to accessing funding for this waiver service, all other available and appropriate funding sources must be explored and exhausted” means in the context of eligibility for this service.
18. Peer Mentor Supports: The Board recommends clarifying what it means to have “lived independently in the community” as this phrase is used in the Waiver application to describe the individuals who may provide peer mentor supports.
The application states: “Peer Mentor Supports are provided by an individual with a developmental disability who has lived independently in the community for at least one year and is or has been a recipient of services, including but not limited to, publicly-funded housing, Medicaid waiver services, work incentives, and supported employment.” It is unclear what it means to have “lived independently in the community” for the purposes of determining one’s qualifications to provide peer mentor supports. The Board is concerned that the phrase is susceptible to interpretations that would exclude a number of people with developmental disabilities who would be well-suited to delivering the allowable activities defined in the application. The phrase could be interpreted, for instance, to mean that an individual must live in his or her own apartment or home, which could exclude individuals in other types of residential settings, such as supported living, who could prove very capable of acting as peer mentors. The Board recommends that DMAS reconsider and/or clarify the standard.
19. Environmental Modifications, Service Specification, Service Definition : The Board recommends that DMAS allow authorization for environmental modifications needed to transition from an institutional setting to the community up to 180 consecutive days in advance of the community transition.
The inability to access environmental modifications prior to transitioning from an institutional setting to a community setting has been a long-standing barrier for many people. CMS allows the needed environmental modification to be authorized and begun while the individual is still in the institution. This allowance is described on page 174 of the CMS, “Instructions, Technical Guide and Review Criteria” for 1915(c) waivers.
Appendix D: Participant-Centered Planning and Service Delivery - Quality Improvement: Service Plan
20. “Sub-assurance: Service plans address all participants assessed needs (including health and safety risk factors) and personal goals, either by provision of waiver services or through other means” Section: The Board recommends adding performance measures that speak to the satisfaction of the individual and/or their chosen team members with their service plan.
The proposed performance measures focus on whether the service plans address individuals’ assessed risks, but do not appear to speak to whether the service plans address participants’ personal goals. Absent standard documentation of individuals’ goals against which to compare the service plans, one source of relevant information is the individuals’ and/or chosen team members’ satisfaction level with the service plans. The waiver application indicates that some form of satisfaction information is obtained during and following service plan development. According to the “Service Plan Development Process” section under Appendix D-1, “An evaluation of how the plan achieves the desired outcomes, from the individual’s and responsible partners’ perspectives, is completed prior to final agreements.” The waiver application should include a performance measure that speaks to this information collected regarding satisfaction with the service plan.
Appendix E: Participant Direction of Services
21. “Election of Participant Direction” Specify the Criteria: The Board recommends changing the first sentence from “Individuals assessed as having an intellectual disability that may limit or prevent…” to “Individuals assessed as having a developmental disability that may limit or prevent…”
Appendix F-1: Participant Rights - Opportunity to Request a Fair Hearing
22. “Procedures for Offering Opportunity to Request a Fair Hearing” Section: The Board recommends reconsideration of two of the items (#6 and #7) in the exception list for advance notification of adverse action.
With respect to #6, the individual's physician prescribes a change in the level of care, the individual may not agree with the recommendation of his physician and may seek a second opinion on the appropriateness of care or services. The 10-day advance notice should be afforded to individuals so that they have an opportunity to seek additional information or clarification from their or another physician prior to service termination.
With respect to #7. When the individual's request for admission into a Medicaid-covered service or when the individual's request for an increase in a Medicaid-covered service is denied or not acted upon promptly for any reason, i.e., diagnostic or functional eligibility, funding, no provider¸ there is also no reason that advance notice should not be provided to the individual so that she can seek assistance, particularly with respect to locating a provider.
Unless the situation is an emergency, advance notice of adverse action should always be provided.
Appendix G-1: Response to Critical Events or Incidents
23. “State Critical Event or Incident Reporting Requirements” Section: The Board recommends updating the language regarding required reporting of deaths and serious injuries to account for new requirements added to 12 VAC 35-105-160.
Reporting requirements for DBHDS-licensed providers in 12 VAC 35-105-160 have changed. Previously, providers were required to collect, maintain, and report each death or serious injury. Now, providers are required to collect, maintain, and report Levels II and III serious incidents. Providers are also required to collect, maintain, and review at least quarterly (but not report) all Level I serious incidents. Definitions of Levels I, II, and III serious incidents should be included in the application. References to “serious injuries or deaths” throughout Appendix G should be changed to “serious incidents” for consistency.
24. “State Critical Event or Incident Reporting Requirements” and “Responsibility for Review of and Response to Critical Events or Incidents” Sections: The Board recommends adding references, where appropriate, to the roles of the state’s protection and advocacy entity.
The state’s protection and advocacy entity receive and review complaints, which may or may not involve critical incidents pertaining to waiver recipients. The Code of Virginia §37.2-709 also requires reporting of all critical incidents and deaths in facilities and in the community to the state’s protection and advocacy entity, as well as allegations of abuse or neglect that are required to be reported pursuant to regulations adopted by the Board pursuant to Chapter 4 (§ 37.2-400 et seq.). The protection and advocacy entity, along with various other entities including the State Long-Term Care Ombudsman, are also entitled to receive Adult Protective Services information per 22 VAC 30-100-50.
25. C. Participant Training and Education: The Board recommends that DMAS remove the reference to the Guide to Long Term Care Services in Virginia contained on the Virginia Health Information website from the application.
The guide referenced pertains to nursing facilities, assisted living facilities, adult day care centers, etc. It does not pertain the HCBS waiver services and does not address the reporting of abuse, neglect and exploitation as inferred in the waiver application.