Application for 1915(c) HCBS Waiver: CA.0431.R02.00

The Medicaid Home and Community-Based Services (HCBS) waiver program is authorized in 1915(c) of the Social Security Act. The program permits a State to furnish an array of home and community-based services that assist Medicaid beneficiaries to live in the community and avoid institutionalization. The State has broad discretion to design its waiver program to

Application for 1915(c) HCBS Waiver: CA.0431.R02.00 - Mar 01, 2014

PURPOSE OF THE HCBS WAIVER PROGRAM

The Medicaid Home and Community-Based Services (HCBS) waiver program is authorized in 1915(c) of the Social Security Act. The program permits a State to furnish an array of home and community-based services that assist Medicaid beneficiaries to live in the community and avoid institutionalization. The State has broad discretion to design its waiver program to address the needs of the waivers target population. Waiver services complement and/or supplement the services that are available to participants through the Medicaid State plan and other federal, state and local public programs as well as the supports that families and communities provide.

The Centers for Medicare & Medicaid Services (CMS) recognizes that the design and operational features of a waiver program will vary depending on the specific needs of the target population, the resources available to the State, service delivery system structure, State goals and objectives, and other factors. A State has the latitude to design a waiver program that is cost-effective and employs a variety of service delivery approaches, including participant direction of services.

1. Major Changes

Describe any significant changes to the approved waiver that are being made in this renewal application:

Character Count: out of 12000

The significant changes to the approved waiver being made in the renewal application: Expansion into three additional counties: Orange, San Mateo and Santa Clara. The addition of these counties will make the Assisted Living Waiver (ALW) available in all counties included in California's Coordinated Care Initiative (CCI). The removal of Environmental Accessibility Adaptions as an ALW service due to non-use. Consolidating the Assisted Living Service and the Assisted Care Service into one service with the provider being either a Residential Care Facility (RCF) or Home Health Agency (HHA) based on the participant's choice of setting. There are no other major changes planned for the Assisted Living Waiver (ALW) at this time.

1. Request Information (1 of 3)

  • The State of Californiarequests approval for a Medicaid home and community-based services (HCBS) waiver under theauthority of 1915(c) of the Social Security Act (the Act).

  • Program Title (optional - this title will be used to locate this waiver in the finder):

    California Assisted Living Waiver
  • Type of Request: renewal

    Requested Approval Period:(For new waivers requesting five year approval periods, the waiver must serve individuals who are dually eligible for Medicaid and Medicare.)

    Original Base Waiver Number: CA.0431

    Waiver Number:CA.0431.R02.00

    Draft ID:CA.10.02.00

  • Type of Waiver (select only one):

  • Proposed Effective Date: (mm/dd/yy)

    Approved Effective Date: 03/01/14

  • 1. Request Information (2of 3)

  • Level(s) of Care. This waiver is requested in order to providehome and community-based waiver services to individuals who, but forthe provision of such services, would require the following level(s) ofcare, the costs of which would be reimbursed under the approved MedicaidState plan (check each that applies):

    Hospital

    Nursing Facility

    Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF/IID) (as defined in 42 CFR §440.150)

  • 1. Request Information (3 of 3)

  • Concurrent Operation with Other Programs. This waiver operates concurrently with another program (or programs)approved under the following authorities

    Select one:

     Not applicable

     Applicable

     not selected

  • Dual Eligiblity for Medicaid and Medicare.

    Check if applicable:

    This waiver provides services for individuals who are eligible for both Medicare and Medicaid.
  • 2. Brief Waiver Description

    Brief Waiver Description. In one page or less, briefly describe the purposeof the waiver, including its goals, objectives, organizational structure(e.g., the roles of state, local and other entities), and service delivery methods.

    Character Count: out of 6000

    The Assisted Living Waiver (ALW) offers Medi-Cal eligible beneficiaries the choice of residing in an assisted living setting as an alternative to long-term placement in a nursing facility. The goal of the ALW is to facilitate nursing facility transition back into a homelike and community setting or prevent skilled nursing admissions for beneficiaries with an imminent need for nursing facility placement. Assisted Living services from Tier one to five are provided to eligible participants who live in Residential Care Facilities (RCF) or Public Subsidized Housing (PSH) sites. Services are delivered by either the RCF staff or licensed Home Health Agency staff based on the participant’s choice of residential setting. Tier Five was added in an amendment just prior to this renewal. Tier Five is a community residential option for participants who have physical and mental disabilities that make being in other facilities, such as skilled nursing facilities, or in Tiers one through four of the ALW, inappropriate. Participants eligible for Tier Five services will require Nursing Facility Level of Care but will also exhibit severe mental/cognitive disabilities as a result of a traumatic brain injury. They will also have demonstrated one or more failed placements in the past. Residential Habilitation is a new service that was added to the ALW as part of an amendment just prior to this renewal. This service, which is available to all tiers, requires prior approval from DHCS Nurse Evaluators and provides for additional, appropriate staff to assist in acquiring, retaining and improving the self-help, socialization and adaptive skills as needed by the participant. This may be one-to-one or some other ratio of staff-to-participant depending on need. Augmented Plan of Care Development and Follow-up is a new service that was added to the ALW as part of an amendment just prior to this renewal. This service is comprised of two parts: • A behavior assessment or systematic assessment of a participant’s behavior that includes a description of their functional and dysfunctional behaviors, the circumstances under which identified behaviors are exhibited and the factors that should be taken into account when developing a programmatic response to the behavior(s). This assessment is followed by the development of a written behavior plan; training personnel to implement the behavior plan; monitoring the effectiveness of the behavior plan; and modifying the plan as necessary. The written behavior plan shall identify those participants who need more structured approaches to address challenging behaviors (such as Residential Habilitation Services). • Those care coordination activities described under “Care Coordination” plus additional assessment and determination of possible mental health and psychiatric service needs of the participant, including the prescription and management of psychiatric medications. The Care Coordination Agencies (CCA) shall work closely with the County Mental Health plans to coordinate mental health services and ongoing medication management. The increased level of contact with the participant and coordination with County Mental Health is expected to require approximately twice the contact and assistance as persons who receive the routine Care Coordination services. Every waiver participant receives Care Coordination from an independent CCA. A Registered Nurse (RN) with the CCA administers a semiannual (every six months) assessment for level of care determination. The CCA develops the Individualized Service Plan (ISP) to identify the participant's needs and the methodology to meet those needs. The assisted living provider is either the RCF or a Home Health Agency (HHA) in the PSH setting. The assisted living provider is responsible for meeting the needs of the participant, including Activities of Daily Living (ADLs) Instrumental ADLs (IADLs), meals, transportation, medication administration and skilled nursing as needed. The RCFs are licensed and regulated by the California Department of Social Services, Community Care Licensing (CCL) Division. The HHA renders assisted living services in the PSH setting. The HHA is responsible for meeting the needs of the participant analogous to the RCF. Meal preparation may be provided individually in each participant's apartment, or in a common dining area depending on the availability of common space at the PSH site. The HHAs are licensed and regulated by the California Department of Public Health, Licensing and Certification Division (L&C).

    3. Components of the Waiver Request

    The waiver application consists of the following components.Note: Item 3-E must be completed.

  • Waiver Administration and Operation. Appendix A specifies the administrative and operational structure of this waiver.

  • Participant Access and Eligibility. Appendix B specifies the target group(s) of individuals who are served in this waiver, the number of participants that the State expects to serve during each year that the waiver is in effect, applicable Medicaid eligibility and post-eligibility (if applicable) requirements, and procedures for the evaluation and reevaluation of level of care.

  • Participant Services. Appendix C specifies the home and community-based waiver services that are furnished through the waiver, including applicable limitations on such services.

  • Participant-Centered Service Planning and Delivery. Appendix D specifies the procedures and methods that the State uses to develop, implement and monitor the participant-centered service plan (of care).

  • Participant-Direction of Services. When the State provides for participant direction of services, Appendix E specifies the participant direction opportunities that are offered in the waiver and the supports that are available to participants who direct their services. (Select one):

  • Participant Rights. Appendix F specifies how the State informs participants of their Medicaid Fair Hearing rights and other procedures to address participant grievances and complaints.

  • Participant Safeguards. Appendix G describes the safeguards that the State has established to assure the health and welfare of waiver participants in specified areas.

  • Quality Improvement Strategy. Appendix H contains the Quality Improvement Strategy for this waiver.

  • Financial Accountability. Appendix I describes the methods by which the State makes payments for waiver services, ensures the integrity of these payments, and complies with applicable federal requirements concerning payments and federal financial participation.

  • Cost-Neutrality Demonstration. Appendix J contains the State's demonstration that the waiver is cost-neutral.

  • 4. Waiver(s) Requested

  • Comparability. The State requests a waiver of the requirements containedin 1902(a)(10)(B) of the Act in order to provide the services specified in Appendix C that are not otherwise available under the approved Medicaid Stateplan to individuals who: (a) require the level(s) of care specified in Item 1.Fand (b) meet the target group criteria specified in Appendix B.

  • Income and Resources for the Medically Needy.Indicate whether the Staterequests a waiver of 1902(a)(10)(C)(i)(III) of the Act in order to useinstitutional income and resource rules for the medically needy (select one):

  • Statewideness.Indicate whether the State requests a waiver of thestatewideness requirements in 1902(a)(1) of the Act (select one):

    If yes, specify the waiver of statewideness that is requested (check each that applies):

    Geographic Limitation. A waiver of statewideness is requested in order tofurnish services under this waiver only to individuals who reside in the followinggeographic areas or political subdivisions of the State.

    Specify the areas to which this waiver applies and, as applicable, the phase-in schedule of the waiver by geographic area:

    Character Count: out of 6000

    The ALW is currently implemented in the following counties: Alameda, Contra Costa, Fresno, Kern, Los Angeles, Riverside, Sacramento, San Bernardino, San Diego, San Joaquin, and Sonoma Counties. This renewal will include expansion into Orange, San Mateo and Santa Clara counties. Additional Counties may be added in the future through an Amendment to this waiver.

    Limited Implementation of Participant-Direction. A waiver of statewideness isrequested in order to make participant-direction of services as specified in Appendix E available only to individuals who reside in the following geographicareas or political subdivisions of the State. Participants who reside in theseareas may elect to direct their services as provided by the State or receivecomparable services through the service delivery methods that are in effect elsewherein the State.

  • 5. Assurances

    In accordance with 42 CFR 441.302, the State provides the following assurances to CMS:

  • Health & Welfare: The State assures that necessary safeguards have been taken to protect the health andwelfare of persons receiving services under this waiver. These safeguards include:

  • As specified in Appendix C, adequate standards for all types of providersthat provide services under this waiver;

  • Assurance that the standards of any State licensure or certificationrequirements specified in Appendix C are met for services or for individualsfurnishing services that are provided under the waiver. The State assuresthat these requirements are met on the date that the services are furnished;and,

  • Assurance that all facilities subject to 1616(e) of the Act where home andcommunity-based waiver services are provided comply with the applicable Statestandards for board and care facilities as specified in Appendix C.

  • Financial Accountability. The State assures financial accountability for fundsexpended for home and community-based services and maintains and makes availableto the Department of Health and Human Services (including the Office of theInspector General), the Comptroller General, or other designees, appropriatefinancial records documenting the cost of services provided under the waiver.Methods of financial accountability are specified in Appendix I.

  • Evaluation of Need: The State assures that it provides for an initial evaluation (and periodicreevaluations, at least annually) of the need for a level of care specifiedfor this waiver, when there is a reasonable indication that an individual mightneed such services in the near future (one month or less) but for the receiptof home and community-based services under this waiver. The procedures forevaluation and reevaluation of level of care are specified in Appendix B.

  • Choice of Alternatives: The State assures that when an individual is determined to be likely to require the level of care specified for this waiver and is in a target group specified in Appendix B, the individual (or, legal representative, if applicable) is:

  • Informed of any feasible alternatives under the waiver; and,

  • Given the choice of either institutional or home and community-based waiverservices. Appendix B specifies the procedures that the State employs toensure that individuals are informed of feasible alternatives under thewaiver and given the choice of institutional or home and community-basedwaiver services.

  • Average Per Capita Expenditures: The State assures that, for any year that the waiver is in effect, the average per capita expenditures under the waiver will not exceed 100 percent of the average per capita expenditures that would have been made under the Medicaid State plan for the level(s) of care specified for this waiver had the waiver not been granted. Cost-neutrality is demonstrated in Appendix J.

  • Actual Total Expenditures: The State assures that the actual total expenditures for home and community-based waiver and other Medicaid services and its claim for FFP in expenditures for the services provided to individuals under the waiver will not, in any year of the waiver period, exceed 100 percent of the amount that would be incurred in the absence of the waiver by the State's Medicaid program for these individuals in the institutional setting(s) specified for this waiver.

  • Institutionalization Absent Waiver: The State assures that, absent the waiver, individuals served in the waiver would receive the appropriate type of Medicaid-funded institutional care for the level of care specified for this waiver.

  • Reporting: The State assures that annually it will provide CMS with information concerning the impact of the waiver on the type, amount and cost of services provided under the Medicaid State plan and on the health and welfare of waiver participants. This information will be consistent with a data collection plan designed by CMS.

  • Habilitation Services. The State assures that prevocational, educational, or supported employment services, or a combination of these services, if provided as habilitation services under the waiver are: (1) not otherwise available to the individual through a local educational agency under the Individuals with Disabilities Education Act (IDEA) or the Rehabilitation Act of 1973; and, (2) furnished as part of expanded habilitation services.

  • Services for Individuals with Chronic Mental Illness. The State assures that federal financial participation (FFP) will not be claimed in expenditures for waiver services including, but not limited to, day treatment or partial hospitalization, psychosocial rehabilitation services, and clinic services provided as home and community-based services to individuals with chronic mental illnesses if these individuals, in the absence of a waiver, would be placed in an IMD and are: (1) age 22 to 64; (2) age 65 and older and the State has not included the optional Medicaid benefit cited in 42 CFR 440.140; or (3) age 21 and under and the State has not included the optional Medicaid benefit cited in 42 CFR 440.160.

  • 6. Additional Requirements

    Note: Item 6-I must be completed.

  • Service Plan.In accordance with 42 CFR 441.301(b)(1)(i), a participant-centeredservice plan (of care) is developed for each participant employing the proceduresspecified in Appendix D. All waiver services are furnished pursuant to the serviceplan. The service plan describes: (a) the waiver services that are furnished to theparticipant, their projected frequency and the type of provider that furnishes eachservice and (b) the other services (regardless of funding source, including State planservices) and informal supports that complement waiver services in meeting the needsof the participant. The service plan is subject to the approval of the Medicaid agency.Federal financial participation (FFP) is not claimed for waiver services furnishedprior to the development of the service plan or for services that are not included inthe service plan.

  • Inpatients.In accordance with 42 CFR 441.301(b)(1)(ii), waiver services are not furnishedto individuals who are in-patients of a hospital, nursing facility or ICF/IID.

  • Room and Board.In accordance with 42 CFR 441.310(a)(2), FFP is not claimedfor the cost of room and board except when: (a) provided as part of respite servicesin a facility approved by the State that is not a private residence or (b) claimed asa portion of the rent and food that may be reasonably attributed to an unrelatedcaregiver who resides in the same household as the participant, as provided in Appendix I.

  • Access to Services.The State does not limit or restrict participant access to waiver services except as provided in Appendix C.

  • Free Choice of Provider.In accordance with 42 CFR 431.151, a participant may selectany willing and qualified provider to furnish waiver services included in the serviceplan unless the State has received approval to limit the number of providers under theprovisions of 1915(b) or another provision of the Act.

  • FFP Limitation.In accordance with 42 CFR 433 Subpart D, FFP is not claimed forservices when another third-party (e.g., another third party health insurer or otherfederal or state program) is legally liable and responsible for the provision andpayment of the service. FFP also may not be claimed for services that are available without charge, or as free care to the community. Services will not be considered to be without charge, or free care, when (1) the provider establishes a fee schedule for each service available and (2) collects insurance information from all those served (Medicaid, and non-Medicaid), and bills other legally liable third party insurers. Alternatively, if a provider certifies that a particular legally liable third party insurer does not pay for the service(s), the provider may not generate further bills for that insurer for that annual period.

  • Fair Hearing:The State provides the opportunity to request a Fair Hearing under 42 CFR 431Subpart E, to individuals: (a) who are not given the choice of home and community-basedwaiver services as an alternative to institutional level of care specifiedfor this waiver; (b) who are denied the service(s) of their choice or the provider(s)of their choice; or (c) whose services are denied, suspended, reduced orterminated. Appendix F specifies the State's procedures to provide individualsthe opportunity to request a Fair Hearing, including providing notice of action as required in 42 CFR 431.210.

  • Quality Improvement.The State operates a formal, comprehensive system to ensure that the waiver meetsthe assurances and other requirements contained in this application. Through anongoing process of discovery, remediation and improvement, the State assures thehealth and welfare of participants by monitoring: (a) level of care determinations;(b) individual plans and services delivery; (c) provider qualifications; (d)participant health and welfare; (e) financial oversight and (f) administrativeoversight of the waiver. The State further assures that all problems identifiedthrough its discovery processes are addressed in an appropriate and timely manner,consistent with the severity and nature of the problem. During the period that thewaiver is in effect, the State will implement the Quality Improvement Strategy specifiedin Appendix H.

  • Public Input. Describe how the State secures public input into the development of the waiver:

    Character Count: out of 6000

    The August 29, 2013 Stakeholder Teleconference was promoted via the ALW website: http://www.dhcs.ca.gov/services/ltc/Pages/ALWPP.aspx and via e-mails to interested parties. Comments and suggestions were received by the California Assisted Living Association and other vested groups and were considered and as appropriate, incorporated into this waiver renewal. An additional Stakeholder Teleconference was held on Novemenber 14, 2013. Additional comments and suggenstion were received and will be considered for future amendments.

  • Notice to Tribal Governments.The State assures that it has notified in writing all federally-recognized TribalGovernments that maintain a primary office and/or majority population within theState of the State's intent to submit a Medicaid waiver request or renewal requestto CMS at least 60 days before the anticipated submission date is provided by PresidentialExecutive Order 13175 of November 6, 2000. Evidence of the applicable notice isavailable through the Medicaid Agency.

  • Limited English Proficient Persons.The State assures that it provides meaningful access to waiver services byLimited English Proficient persons in accordance with: (a) Presidential ExecutiveOrder 13166 of August 11, 2000 (65 FR 50121) and (b) Department of Health and HumanServices "Guidance to Federal Financial Assistance Recipients Regarding Title VIProhibition Against National Origin Discrimination Affecting Limited EnglishProficient Persons" (68 FR 47311 - August 8, 2003). Appendix B describeshow the State assures meaningful access to waiver services by Limited EnglishProficient persons.

  • 7. Contact Person(s)

  • The Medicaid agency representative with whom CMS should communicate regarding the waiver is:

  • If applicable, the State operating agency representative with whom CMS should communicate regarding the waiver is:

  • 8. Authorizing Signature

    This document, together with Appendices A through J, constitutes the State'srequest for a waiver under §1915(c) of the Social Security Act. The State assuresthat all materials referenced in this waiver application (including standards,licensure and certification requirements) are readily available in print or electronic form upon request to CMS through the Medicaid agency or,if applicable, from the operating agency specified in Appendix A. Any proposed changesto the waiver will be submitted by the Medicaid agency to CMS in the form of waiver amendments.

    Upon approval by CMS, the waiver application serves as the State'sauthority to provide home and community-based waiver services tothe specified target groups. The State attests that it will abideby all provisions of the approved waiver and will continuouslyoperate the waiver in accordance with the assurances specifiedin Section 5 and the additional requirements specified in Section 6of the request.

    Attachments

    Attachment #1: Transition Plan

    Specify the transition plan for the waiver:

    Character Count: out of 12000

    Attachment #2: Home and Community-Based Settings Waiver Transition Plan

    Specify the state's process to bring this waiver into compliance with federal homeand community-based (HCB) settings requirements at 42 CFR 441.301(c)(4)-(5), andassociated CMS guidance.

    Consult with CMS for instructions before completing this item. This field describesthe status of a transition process at the point in time of submission. Relevantinformation in the planning phase will differ from information required to describeattainment of milestones.

    To the extent that the state has submitted a statewide HCB settings transition planto CMS, the description in this field may reference that statewide plan. The narrativein this field must include enough information to demonstrate that this waiver complieswith federal HCB settings requirements, including the compliance and transitionrequirements at 42 CFR 441.301(c)(6), and that this submission is consistent with theportions of the statewide HCB settings transition plan that are germane to this waiver.Quote or summarize germane portions of the statewide HCB settings transition plan asrequired.

    Note that Appendix C-5 HCB Settings describes settings that do not require transition;the settings listed there meet federal HCB setting requirements as of the date of submission.Do not duplicate that information here.

    Update this field and Appendix C-5 when submitting a renewal or amendment to this waiver forother purposes. It is not necessary for the state to amend the waiver solely for the purposeof updating this field and Appendix C-5. At the end of the state's HCB settings transitionprocess for this waiver, when all waiver settings meet federal HCB setting requirements,enter "Completed" in this field, and include in Section C-5 the information on all HCBsettings in the waiver.

    Character Count: out of 60000

    The State submitted to CMS a request to renew this waiver on November 27, 2013, prior to release of CMS-2249-F and CMS-2296-F. The California Statewide Transition Plan, to be submitted to CMS on or before December 20, 2014, will include plans to ensure HCBS settings in this waiver are compliant with the new rules.

    Additional Needed Information (Optional)

    Provide additional needed information for the waiver (optional):

    Character Count: out of 60000

    Appendix A: Waiver Administration and Operation

  • State Line of Authority for Waiver Operation.Specify the state line of authority for the operation of the waiver (select one):

     The waiver is operated by the State Medicaid agency.

     The waiver is operated by a separate agency of the State that is not a division/unit of the Medicaid agency.

    Specify the division/unit name:

    In accordance with 42 CFR 431.10, the Medicaid agency exercises administrative discretion in the administration and supervision of the waiver and issues policies, rules and regulations related to the waiver. The interagency agreement or memorandum of understanding that sets forth the authority and arrangements for this policy is available through the Medicaid agency to CMS upon request. (Complete item A-2-b).

     not selected

  • Appendix A: Waiver Administration and Operation

  • Oversight of Performance.

  • Medicaid Director Oversight of Performance When the Waiver is Operated by another Division/Unit within the State Medicaid Agency. When the waiver is operated by another division/administration within the umbrella agency designated as the Single State Medicaid Agency. Specify (a) the functions performed by that division/administration (i.e., the Developmental Disabilities Administration within the Single State Medicaid Agency), (b) the document utilized to outline the roles and responsibilities related to waiver operation, and (c) the methods that are employed by the designated State Medicaid Director (in some instances, the head of umbrella agency) in the oversight of these activities:

    As indicated in section 1 of this appendix, the waiver is not operated by another division/unit within the State Medicaid agency. Thus this section does not need to be completed.

    Character Count: out of 12000

  • Medicaid Agency Oversight of Operating Agency Performance. When the waiver is not operated by the Medicaid agency, specify the functions that are expressly delegated through a memorandum of understanding (MOU) or other written document, and indicate the frequency of review and update for that document. Specify the methods that the Medicaid agency uses to ensure that the operating agency performs its assigned waiver operational and administrative functions in accordance with waiver requirements. Also specify the frequency of Medicaid agency assessment of operating agency performance:

    As indicated in section 1 of this appendix, the waiver is not operated by a separate agency of the State. Thus this section does not need to be completed.

    Character Count: out of 12000

  • Appendix A: Waiver Administration and Operation

  • Use of Contracted Entities.Specify whether contracted entities perform waiver operational and administrative functions on behalf of the Medicaid agency and/or the operating agency (if applicable) (select one):

     Yes. Contracted entities perform waiver operational and administrative functions on behalf of the Medicaid agency and/or operating agency (if applicable).

     No. Contracted entities do not perform waiver operational and administrative functions on behalf of the Medicaid agency and/or the operating agency (if applicable).

     not selected

  • Appendix A: Waiver Administration and Operation

  • Role of Local/Regional Non-State Entities. Indicate whether local or regional non-state entities perform waiver operational and administrative functions and, if so, specify the type of entity (Select One):

     not selected

     Not applicable

     Applicable - Local/regional non-state agencies perform waiver operational and administrative functions.

  • Appendix A: Waiver Administration and Operation

  • Responsibility for Assessment of Performance of Contracted and/or Local/Regional Non-State Entities. Specify the state agency or agencies responsible for assessing the performance of contracted and/or local/regional non-state entities in conducting waiver operational and administrative functions:

    Character Count: out of 6000

  • Appendix A: Waiver Administration and Operation

  • Assessment Methods and Frequency. Describe the methods that are used to assess the performance of contracted and/or local/regional non-state entities to ensure that they perform assigned waiver operational and administrative functions in accordance with waiver requirements. Also specify how frequently the performance of contracted and/or local/regional non-state entities is assessed:

    Character Count: out of 12000

  • Appendix A: Waiver Administration and Operation

  • Distribution of Waiver Operational and Administrative Functions. In the following table, specify the entity or entities that have responsibility forconducting each of the waiver operational and administrative functions listed (check each that applies):

    In accordance with 42 CFR 431.10, when the Medicaid agency does not directly conduct a function, it supervises the performanceof the function and establishes and/or approves policies that affect the function. All functions not performed directly by the Medicaid agency must be delegated in writing and monitored by the Medicaid Agency. Note: More than one box may be checked per item. Ensure that Medicaid is checked when the Single State Medicaid Agency (1) conducts the function directly; (2) supervises the delegated function; and/or (3) establishes and/or approves policies related to the function.

  • Appendix A: Waiver Administration and Operation

    Quality Improvement: Administrative Authority of the Single State Medicaid Agency

    As a distinct component of the States quality improvement strategy,provide information in the following fields to detail the Statesmethods for discovery and remediation.

  • Methods for Discovery: Administrative Authority

    The Medicaid Agency retains ultimate administrative authority and responsibility for the operation of the waiver program by exercising oversight of the performance of waiver functions by other state and local/regional non-state agencies (if appropriate) and contracted entities.

  • Performance Measures

    For each performance measure the State will use to assess compliance with the statutory assurance, complete the following. Performance measures for administrative authority should not duplicate measures found in other appendices of the waiver application. As necessary and applicable, performance measures should focus on:
    • Uniformity of development/execution of provider agreements throughout all geographic areas covered by the waiver
    • Equitable distribution of waiver openings in all geographic areas covered by the waiver
    • Compliance with HCB settings requirements and other new regulatory components (for waiver actions submitted on or after March 17, 2014)

    Where possible, include numerator/denominator.

    For each performance measure, provide information on the aggregated data that will enable the State to analyze and assess progress toward the performance measure. In this section provide information on the method by which each source of data is analyzed statistically/deductively or inductively, how themes are identified or conclusions drawn, and how recommendations are formulated, where appropriate.

    Performance Measure:

    Administrative Authority, Oversight, and Assessments from the CCAs The number/percent of assessments received from CCAs that receive approval by DHCS and result in enrollment in the ALW. • Numerator: number of assessments received from CCAs that receive DHCS approval and resulted in enrollment in the ALW. • Denominator: number of assessments received from CCAs

    Data Source (Select one):Provider performance monitoring If 'Other' is selected, specify:
    Data Source (Select one):Record reviews, on-site If 'Other' is selected, specify:

    Data Aggregation and Analysis:

  • If applicable, in the textbox below provide any necessary additional information on the strategies employed by the State to discover/identify problems/issues within the waiver program, including frequency and parties responsible.

    Character Count: out of 6000

    The DHCS conducts continuous and on-going review of the assessments as submitted by the CCAs. The DHCS conducts annual quality assurance visits to the providers to verify that the assessments as completed by the CCAs match the needs of the participant and are fully implemented.

  • Methods for Remediation/Fixing Individual Problems

  • Describe the States method for addressing individual problems as they are discovered. Include information regarding responsible parties and GENERAL methods for problem correction. In addition, provide information on the methods used by the State to document these items.

    Character Count: out of 6000

    Remediation: Any non-compliance will result in the DHCS contacting the CCA to: *review the LOC data *determine etiology of non-compliance *develop Corrective Action Plan (CAP) and timeline as appropriate. Resolution Follow-up: The DHCS will: *follow up in writing to determine if the CAP was completed with a successful outcome *monitor the change(s) for continuing compliance The DHCS will conduct an annual QA audit and generate a report summarizing the data and the findings regarding the LOC determinations. The DHCS is responsible for the identification and prioritization of the problems as presented. The CCAs are responsible for the remediation of the problems and the efficacy of this process is to document in the subsequent assessment submission period. The DHCS will provide further Technical Assistance (TA) to the CCAs as required to assure that the remediation occurs and is continuous.

  • Remediation Data Aggregation

    Remediation-related Data Aggregation and Analysis (including trend identification)
  • Timelines

    When the State does not have all elements of the Quality Improvement Strategy in place, provide timelines to design methods for discovery and remediation related to the assurance of Administrative Authority that are currently non-operational.
  • Appendix B: Participant Access and Eligibility

    B-1: Specification of the Waiver Target Group(s)

  • Target Group(s).Under the waiver of Section 1902(a)(10)(B) of the Act, the State limits waiver services to one or more groups or subgroups of individuals. Please see the instruction manual for specifics regarding age limits.In accordance with 42 CFR 441.301(b)(6), select one or more waiver target groups, check each of the subgroups in the selected target group(s) that may receive services under the waiver, and specify the minimum and maximum (if any) age of individuals served in each subgroup:

  • Additional Criteria. The State further specifies its target group(s) as follows:

    Character Count: out of 12000

    Eligible participants for Tiers one through five are determined to be at the Nursing Facility Level A or Nursing Facility Level B Level of Care as per the California Code of Regulations (CCR) Sections 51120 (Intermediate Care Services, NF-A) and 51124 (Skilled Nursing Services NF-B).

  • Transition of Individuals Affected by Maximum Age Limitation. When there is a maximum age limit that applies to individuals who may be served in the waiver, describe the transition planning procedures that are undertaken on behalf of participants affected by the age limit (select one):

    Specify:

    Character Count: out of 12000

    When a participant in the Disabled (Physical) or Disabled (Other) target group reaches age 64, a transition plan will be developed by the Case Coordinator to move them into the Aged target group. The transition will be seamless to the participant.

  • Appendix B: Participant Access and Eligibility

    B-2: Individual Cost Limit (1 of 2)

  • Individual Cost Limit.The following individual cost limit applies when determining whether to deny home and community-based services or entrance to the waiver to an otherwise eligible individual (select one).Please note that a State may have only ONE individual cost limit for the purposes of determining eligibility for the waiver:

     No Cost Limit. The State does not apply an individual cost limit. Do not complete Item B-2-b or item B-2-c.

     Cost Limit in Excess of Institutional Costs. The State refuses entrance to the waiver to any otherwise eligible individual when the State reasonably expects that the cost of the home and community-based services furnished to that individual would exceed the cost of a level of care specified for the waiver up to an amount specified by the State. Complete Items B-2-b and B-2-c.

     Institutional Cost Limit. Pursuant to 42 CFR 441.301(a)(3), the State refuses entrance to the waiver to any otherwise eligible individual when the State reasonably expects that the cost of the home and community-based services furnished to that individual would exceed 100% of the cost of the level of care specified for the waiver. Complete Items B-2-b and B-2-c.

     Cost Limit Lower Than Institutional Costs. The State refuses entrance to the waiver to any otherwise qualified individual when the State reasonably expects that the cost of home and community-based services furnished to that individual would exceed the following amount specified by the State that is less than the cost of a level of care specified for the waiver.

     not selected

  • Appendix B: Participant Access and Eligibility

    B-2: Individual Cost Limit (2 of 2)

  • Method of Implementation of the Individual Cost Limit. When an individual cost limit is specified in Item B-2-a, specify the proceduresthat are followed to determine in advance of waiver entrance that the individual's healthand welfare can be assured within the cost limit:

    Character Count: out of 12000

    The costs for the ALW services are designed not to exceed the annual sum of the Nursing Facility (NF) rate of $51,804.00 plus the estimated state plan costs for persons in the NF setting of $5,258.00. The rates for the five tiers of service, plus the cost of care coordination with the other waiver services, combined, are set to maintain cost neutrality. Participants are notified of their right to request a Fair Hearing if enrollment is denied due to the cost limit.

  • Participant Safeguards.When the State specifies an individual cost limit in Item B-2-a and there is a changein the participant's condition or circumstances post-entrance to the waiver that requiresthe provision of services in an amount that exceeds the cost limit in order to assure theparticipant's health and welfare, the State has established the following safeguards to avoidan adverse impact on the participant (check each that applies):

    The participant is referred to another waiver that can accommodate the individual's needs.

    Additional services in excess of the individual cost limit may be authorized.

    Specify the procedures for authorizing additional services, including the amount that may be authorized:

    Character Count: out of 12000

    Only the DHCS RN may authorize additional services for individuals with traumatic brain injury or those participants who meet all of the following specific criteria: • Meets NF-A or NF-B Level of Care with severe mental/cognitive disabilities usually as consequence of a traumatic brain injury ; • Demonstrates, has a history of or has the potential of wandering or flight behavior; • Demonstrates or has a history of an inconsistent ability to provide self-care, potential of injury to self or others, or potential of behavior outbursts that negatively affect others; • Demonstrates or has a history of unsuccessful attempt(s) of placement in other community settings; • Requires potential 24-hours/seven days per week hands-on or physical presence supervision and management; can be left alone for short periods of time; and, • Only able to reside in a community setting licensed to provide 24-hour services, supervision and supports, demonstrated by at least one failed placement in a less restrictive setting. CCA must document the need for additional services in an Individual Service Plan. Additional services will be authorized at the time DHCS RN reviews and approves each participant's ISP, and DHCS' approval will be documented in the ISP. Note: Diagnostic criteria will not be used as a determinant of need. Each individual will be assessed according to their needs, not their diagnosis.

    Other safeguard(s)

    Specify:

    Character Count: out of 12000

    Should a participant develop needs with associated costs that exceed the individual cost limit, the DHCS in conjunction with the CCA, would work cooperatively with the participant to achieve cost neutrality. The DHCS will assist to determine if there are choices that the participant may exercise to alleviate the excessive costs. The expected goal is to enable the participant to remain enrolled in the waiver. In the event that the participant is not able to remain within cost neutrality, is being non-compliante with their ISP, refuses to pay rent, or jeopardizes the health and well being of other participants, the DHCS, in conjunction with the CCA, would assist to determine alternative placement that would enable the participant to receive the needed care in the least restrictive environment. The decision to relocate would be in conjunction with the participant's wishes, consistent with the prescribing physician's orders, and will preserve the health, safety and well-being of the participant in the least restrictive setting. Primary consideration would be given to another waiver program or to independent living with IHSS and/or other supportive care. If all avenues of community placement have been exhausted the participant has the choice of nursing facility placement or remaining in community housing without waiver services.

  • Appendix B: Participant Access and Eligibility

    B-3: Number of Individuals Served (1 of 4)

  • Unduplicated Number of Participants.The following table specifies the maximum number of unduplicated participantswho are served in each year that the waiver is in effect. The State will submita waiver amendment to CMS to modify the number of participants specified for anyyear(s), including when a modification is necessary due to legislative appropriationor another reason. The number of unduplicated participants specified in this tableis basis for the cost-neutrality calculations in Appendix J:

  • Limitation on the Number of Participants Served at Any Point in Time.Consistent with the unduplicated number of participants specified in Item B-3-a, theState may limit to a lesser number the number of participants who will be served atany point in time during a waiver year. Indicate whether the State limits the numberof participants in this way: (select one):

    The limit that applies to each year of the waiver period is specified in the following table:

  • Appendix B: Participant Access and Eligibility

    B-3: Number of Individuals Served (2 of 4)

  • Reserved Waiver Capacity.The State may reserve a portion of the participant capacity of the waiverfor specified purposes (e.g., provide for the community transition ofinstitutionalized persons or furnish waiver services to individualsexperiencing a crisis) subject to CMS review and approval. The State(select one):

  • Appendix B: Participant Access and Eligibility

    B-3: Number of Individuals Served (3 of 4)

  • Scheduled Phase-In or Phase-Out.Within a waiver year, the State may make the number of participants who are served subject to a phase-in or phase-out schedule (select one):

  • Allocation of Waiver Capacity.

    Select one:

    Specify: (a) the entities to which waiver capacity is allocated;(b) the methodology that is used to allocate capacity and how often themethodology is reevaluated; and, (c) policies for the reallocation of unusedcapacity among local/regional non-state entities:

    Character Count: out of 12000

    Slots are allotted to the counties included in this waiver. All slots are available to all counties on an equal basis. The goal is that two thirds of all participant placements be NF transitions. At no time will waiting lists exist for the lack of slots when there are slots not being utilized in other counties.

  • Selection of Entrants to the Waiver. Specify the policies that apply to the selection of individuals for entrance to the waiver:

    Character Count: out of 12000

    Each waiver participant is determined to be at the NF LOC by the electronically scored Assessment Tool as administered by the CCA. The participant is determined to be at one of the five tiers by the Assessment Tool. Tier One approximating the NF-A LOC, and Tiers Two through Five being gradations of the NF-B LOC.

  • Appendix B: Participant Access and Eligibility

    B-3: Number of Individuals Served - Attachment #1 (4 of 4)

    Answers provided in Appendix B-3-d indicate that you do not need to complete this section.

    Appendix B: Participant Access and Eligibility

    B-4: Eligibility Groups Served in the Waiver

  • Medicaid Eligibility Groups Served in the Waiver.Individuals who receive services under this waiver are eligible under thefollowing eligibility groups contained in the State plan. The State appliesall applicable federal financial participation limits under the plan.Check all that apply:

    Eligibility Groups Served in the Waiver (excluding the special home and community-based waiver group under 42 CFR 435.217)

    Low income families with children as provided in §1931 of the Act

    SSI recipients

    Aged, blind or disabled in 209(b) states who are eligible under 42 CFR §435.121

    Optional State supplement recipients

    Optional categorically needy aged and/or disabled individuals who have income at:

    Working individuals with disabilities who buy into Medicaid (BBA working disabled group as provided in §1902(a)(10)(A)(ii)(XIII)) of the Act)

    Working individuals with disabilities who buy into Medicaid (TWWIIA Basic Coverage Group as provided in §1902(a)(10)(A)(ii)(XV) of the Act)

    Working individuals with disabilities who buy into Medicaid (TWWIIA Medical Improvement Coverage Group as provided in §1902(a)(10)(A)(ii)(XVI) of the Act)

    Disabled individuals age 18 or younger who would require an institutional level of care (TEFRA 134 eligibility group as provided in §1902(e)(3) of the Act)

    Medically needy

    Medically needy in 209(b) States (42 CFR §435.330)

    Medically needy in 1634 States and SSI Criteria States (42 CFR §435.320, §435.322 and §435.324)

    Other specified groups (include only statutory/regulatory reference to reflect the additional groups in the State plan that may receive services under this waiver)

    Specify:

    Character Count: out of 6000

    All other mandatory and optional groups under the plan.

    Special home and community-based waiver group under 42 CFR 435.217) Note: When the special home and community-based waiver group under 42 CFR 435.217 is included, Appendix B-5 must be completed

  • Appendix B: Participant Access and Eligibility

    B-5: Post-Eligibility Treatment of Income (1 of 4)

    In accordance with 42 CFR 441.303(e), Appendix B-5 must be completed when the State furnishes waiver services to individuals in the special home and community-based waiver group under 42 CFR 435.217, as indicated in Appendix B-4. Post-eligibility applies only to the 42 CFR 435.217 group. A State that uses spousal impoverishment rules under 1924 of the Act to determine the eligibility of individuals with a community spouse may elect to use spousal post-eligibility rules under 1924 of the Act to protect a personal needs allowance for a participant with a community spouse.

  • Use of Spousal Impoverishment Rules.Indicate whether spousal impoverishment rules are used to determine eligibility for the special home and community-based waiver group under 42 CFR 435.217(select one):

  • Appendix B: Participant Access and Eligibility

    B-5: Post-Eligibility Treatment of Income (2 of 4)

  • Regular Post-Eligibility Treatment of Income: SSI State.

    The State uses the post-eligibility rules at 42 CFR 435.726 for individuals who do not have a spouse or have a spouse who is not a community spouse as specified in 1924 of the Act. Payment for home and community-based waiver services is reduced by the amount remaining after deducting the following allowances and expenses from the waiver participant's income:

  • Allowance for the needs of the waiver participant (select one):

     The following standard included under the State plan

     The following dollar amount

     The following formula is used to determine the needs allowance:

    Specify:

    Character Count: out of 6000

    Total Income, including any income disregarded during the Section 1902(a)(10)(A)(ii)(VI) eligibility determination.

     Other

     not selected

  • Allowance for the spouse only (select one):

     Not Applicable

     The state provides an allowance for a spouse who does not meet the definition of a community spouse in §1924 of the Act. Describe the circumstances under which this allowance is provided:

     not selected

  • Allowance for the family (select one):

     Not Applicable (see instructions)

     AFDC need standard

     Medically needy income standard

     The following dollar amount:

     The amount is determined using the following formula:

     Other

     not selected

  • Amounts for incurred medical or remedial care expenses not subject to payment by a third party, specified in 42 CFR 435.726:

  • Health insurance premiums, deductibles and co-insurance charges
  • Necessary medical or remedial care expenses recognized under State law but not covered under the State's Medicaid plan, subject to reasonable limits that the State may establish on the amounts of these expenses.
  • Select one:

     Not Applicable (see instructions)Note: If the State protects the maximum amount for the waiver participant, not applicable must be selected.

     The State does not establish reasonable limits.

     The State establishes the following reasonable limits

     not selected

    Appendix B: Participant Access and Eligibility

    B-5: Post-Eligibility Treatment of Income (3 of 4)

  • Regular Post-Eligibility Treatment of Income: 209(B) State.

    Answers provided in Appendix B-4 indicate that you do not need to complete this section and therefore this section is not visible.

  • Appendix B: Participant Access and Eligibility

    B-5: Post-Eligibility Treatment of Income (4 of 4)

  • Post-Eligibility Treatment of Income Using Spousal Impoverishment Rules

    The State uses the post-eligibility rules of §1924(d) of the Act(spousal impoverishment protection) to determine the contribution of a participantwith a community spouse toward the cost of home and community-based care if itdetermines the individual's eligibility under §1924 of the Act. There is deductedfrom the participant's monthly income a personal needs allowance (as specified below),a community spouse's allowance and a family allowance as specified in the State Medicaid Plan.The State must also protect amounts for incurred expenses for medical or remedial care(as specified below).

  • Allowance for the personal needs of the waiver participant

    (select one):

     SSI standard

     Optional State supplement standard

     Medically needy income standard

     The special income level for institutionalized persons

     A percentage of the Federal poverty level

     The following dollar amount:

     The following formula is used to determine the needs allowance:

    Specify formula:

    Character Count: out of 4000

    Total Income, including any income disregarded during the Section 1902(a)(10)(A)(ii)(VI) eligibility determination.

     Other

     not selected

  • If the allowance for the personal needs of a waiver participant with a community spouse is different from the amount used for the individual's maintenance allowance under 42 CFR 435.726 or42 CFR 435.735, explain why this amount is reasonable to meet the individual's maintenance needs in the community.

    Select one:

     Allowance is the same

     Allowance is different.

     not selected

  • Amounts for incurred medical or remedial care expenses not subject to payment by a third party, specified in 42 CFR 435.726:

  • Health insurance premiums, deductibles and co-insurance charges
  • Necessary medical or remedial care expenses recognized under State law but not covered under the State's Medicaid plan, subject to reasonable limits that the State may establish on the amounts of these expenses.
  • Select one:

     Not Applicable (see instructions)Note: If the State protects the maximum amount for the waiver participant, not applicable must be selected.

     The State does not establish reasonable limits.

     The State uses the same reasonable limits as are used for regular (non-spousal) post-eligibility.

     not selected

    Appendix B: Participant Access and Eligibility

    B-6: Evaluation/Reevaluation of Level of Care

    As specified in 42 CFR 441.302(c), the State provides for an evaluation (and periodic reevaluations)of the need for the level(s) of care specified for this waiver, when there is a reasonable indicationthat an individual may need such services in the near future (one month or less), but for theavailability of home and community-based waiver services.

  • Reasonable Indication of Need for Services.In order for an individual to be determined to need waiver services, an individual must require:(a) the provision of at least one waiver service, as documented in the service plan, and(b) the provision of waiver services at least monthly or, if the need for services is less than monthly,the participant requires regular monthly monitoring which must be documented in the service plan.Specify the State's policies concerning the reasonable indication of the need for services:

  • Minimum number of services.

    The minimum number of waiver services (one or more) that an individual must require in order to be determined to need waiver services is:
  • Frequency of services. The State requires (select one):

     The provision of waiver services at least monthly

     Monthly monitoring of the individual when services are furnished on a less than monthly basis

     not selected

  • Responsibility for Performing Evaluations and Reevaluations.Level of care evaluations and reevaluations are performed (select one):

     Directly by the Medicaid agency

     By the operating agency specified in Appendix A

     By an entity under contract with the Medicaid agency.

    Specify the entity:

    Character Count: out of 4000

    The CCA

     Other

     not selected

  • Qualifications of Individuals Performing Initial Evaluation: Per 42 CFR §441.303(c)(1), specify the educational/professional qualifications ofindividuals who perform the initial evaluation of level of care for waiver applicants:

    Character Count: out of 6000

    The CCA must employ a Registered Nurse (RN) to administer the Assessment Tool as developed for the ALW and shall be authorized to provide Care Coordination or the additional Service Assessment/Plan of Care Development services only when he/she meets the requirements specified below. A. Have and maintain a current, unsuspended, un-revoked license to practice as a R.N. in the State of California. B. Have work experience that includes at least one of the following: 1) A minimum of 1000 hours of experience in an acute care setting providing nursing care to patients with similar care need(s). 2) A minimum of 2000 hours of experience in a home setting(s) providing nursing care to patients with the similar care need(s). Complete training on use of the ALW Assessment Tool, the ALW ISP, and training on the Care Coordination Procedures Manual as provided by the DHCS.

  • Level of Care Criteria. Fully specify the level of care criteria that are used to evaluateand reevaluate whether an individual needs services through thewaiver and that serve as the basis of the State's level of careinstrument/tool. Specify the level of care instrument/tool that isemployed. State laws, regulations, and policies concerning level ofcare criteria and the level of care instrument/tool are available to CMS upon request through the Medicaid agency or theoperating agency (if applicable), including the instrument/toolutilized.

    Character Count: out of 12000

    The LOC criteria are based on the CCR Sections 51120 (Intermediate Care Services, NF-A) and 51124 (Skilled Nursing Services NF-B). Persons eligible for the ALW are determined to meet the LOC by the electronically scored Assessment Tool.

  • Level of Care Instrument(s).Per 42 CFR 441.303(c)(2), indicate whether the instrument/toolused to evaluate level of care for the waiver differs from theinstrument/tool used to evaluate institutional level of care(select one):

     The same instrument is used in determining the level of care for the waiver and for institutional care under the State Plan.

     A different instrument is used to determine the level of care for the waiver than for institutional care under the State plan.

    Describe how and why this instrument differs from the form used to evaluate institutional level of care and explain how the outcome of the determination is reliable, valid, and fully comparable.

    Character Count: out of 12000

    The Assessment Tool is based on the Minimum Data Set (MDS) and is designed to facilitate the assessment and determination of waiver eligibility by the CCA RN. The Assessment Tool is electronically scored in an Excel spreadsheet format. The CCA RN enters the data and the Assessment Tool automatically specifies the tier(s) of service for an eligible participant. The Assessment Tool was alpha and beta tested prior to implementation and was updated to strengthen the validity of the tool. The Assessment Tool provides a consistent determination of waiver eligibility and has demonstrated consistency from user to user. The Assessment Tool used by ALW is different from the tools used to determine institutional LOC because it is designed to determine not only LOC but also a specific tier level exclusive to ALW services and the daily rate that will be paid to the RCFE or HHA to provide the necessary daily care. These tier levels are based on the waiver participants care needs. As care needs change the participant's tier level will change.

     not selected

  • Process for Level of Care Evaluation/Reevaluation: Per 42 CFR §441.303(c)(1), describe the process for evaluating waiverapplicants for their need for the level of care under the waiver. Ifthe reevaluation process differs from the evaluation process, describethe differences:

    Character Count: out of 12000

    Waiver participants are reassessed every six months. The assessment is the same. The DHCS reviews 100% of all assessments and reassessments.

  • Reevaluation Schedule.Per 42 CFR 441.303(c)(4), reevaluations of the level of carerequired by a participant are conducted no less frequently thanannually according to the following schedule(select one):

     Every three months

     Every six months

     Every twelve months

     Other schedule

     not selected

  • Qualifications of Individuals Who Perform Reevaluations.Specify the qualifications of individuals who perform reevaluations(select one):

     The qualifications of individuals who perform reevaluations are the same as individuals who perform initial evaluations.

     The qualifications are different.

     not selected

  • Procedures to Ensure Timely Reevaluations. Per 42 CFR §441.303(c)(4), specify the procedures that the Stateemploys to ensure timely reevaluations of level of care (specify):

    Character Count: out of 6000

    The CCA RN performs the reassessments. They are allowed 30 days before or after the due date to complete the reassessment, and an additional seven days to complete the ISP (commonly referred to as a plan of care) and submit all documents to the DHCS.

  • Maintenance of Evaluation/Reevaluation Records. Per 42 CFR §441.303(c)(3), the State assures that written and/orelectronically retrievable documentation of all evaluations andreevaluations are maintained for a minimum period of 3 years asrequired in 45 CFR §92.42. Specify the location(s) where recordsof evaluations and reevaluations of level of care are maintained:

    Character Count: out of 6000

    All original records are maintained by the CCA for a minimum of three years. Copies are retained by the DHCS and the RCF/HHA providers.

  • Appendix B: Evaluation/Reevaluation of Level of Care

    Quality Improvement: Level of Care

    As a distinct component of the States quality improvement strategy,provide information in the following fields to detail the Statesmethods for discovery and remediation.

  • Methods for Discovery: Level of Care Assurance/Sub-assurances

    The state demonstrates that it implements the processes and instrument(s) specified in its approved waiver for evaluating/reevaluating an applicant's/waiver participant's level of care consistent with level of care provided in a hospital, NF or ICF/IID.

  • Sub-Assurances:

  • Sub-assurance: An evaluation for LOC is provided to all applicants for whom there is reasonable indication that services may be needed in the future.

    Performance Measures

    For each performance measure the State will use to assess compliance with the statutory assurance (or sub-assurance), complete the following. Where possible, include numerator/denominator.

    For each performance measure, provide information on the aggregated data that will enable the State to analyze and assess progress toward the performance measure. In this section provide information on the method by which each source of data is analyzed statistically/deductively or inductively, how themes are identified or conclusions drawn, and how recommendations are formulated, where appropriate.

    Performance Measure:

    Initial Level of Care The number/percent of new enrollees that received an initial LOC determination prior to receiving waiver services. • Numerator: number of new enrollees with an initial LOC completed prior to the onset of waiver services. • Denominator: number of new enrollees.

    Data Source (Select one):Record reviews, on-site If 'Other' is selected, specify:

    Data Aggregation and Analysis:

  • Sub-assurance: The levels of care of enrolled participants are reevaluated at least annually or as specified in the approved waiver.

    Performance Measures

    For each performance measure the State will use to assess compliance with the statutory assurance (or sub-assurance), complete the following. Where possible, include numerator/denominator.

    For each performance measure, provide information on the aggregated data that will enable the State to analyze and assess progress toward the performance measure. In this section provide information on the method by which each source of data is analyzed statistically/deductively or inductively, how themes are identified or conclusions drawn, and how recommendations are formulated, where appropriate.

    Performance Measure:

    Level of Care Redetermination the number of participants that received timely reassessments.Numerator: number of participants whose reassessment was completed within six months of the previous assessment, plus or minus 30 days.Denominator: A representative sample of participants.

    Data Source (Select one):Record reviews, on-site If 'Other' is selected, specify:

    Data Aggregation and Analysis:

  • Sub-assurance: The processes and instruments described in the approved waiver are applied appropriately and according to the approved description to determine participant level of care.

    Performance Measures

    For each performance measure the State will use to assess compliance with the statutory assurance (or sub-assurance), complete the following. Where possible, include numerator/denominator.

    For each performance measure, provide information on the aggregated data that will enable the State to analyze and assess progress toward the performance measure. In this section provide information on the method by which each source of data is analyzed statistically/deductively or inductively, how themes are identified or conclusions drawn, and how recommendations are formulated, where appropriate.

    Performance Measure:

    LOC Process/ Forms the number/percent of participants with an LOC assessment completed by a qualified evaluator.Numerator: number of participants with an LOC completed by a CCA RNDenominator: a representative sample of participants.

    Data Source (Select one):Record reviews, on-site If 'Other' is selected, specify:

    Data Aggregation and Analysis:

  • If applicable, in the textbox below provide any necessary additional information on the strategies employed by the State to discover/identify problems/issues within the waiver program, including frequency and parties responsible.

    Character Count: out of 6000

    Discovery: Initial - The DHCS reviews 100% of the assessments as submitted to ensure that the LOC determination was made. The DHCS will conduct annual Quality Assurance audits. The DCHS will visit a random sample of enrolled participants and review the charts in both the CCA offices and in the RCFE/PSH settings. In the event that an irregularity or inconsistency is detected with the Assessment Tool, it will be modified and corrected and the Assessment Tool Handbook will be updated to reflect the changes and improvements to the Assessment Tool, and the CCAs will be provided with training and TA to adopt and implement the revised Tool.

  • Methods for Remediation/Fixing Individual Problems

  • Describe the States method for addressing individual problems as they are discovered. Include information regarding responsible parties and GENERAL methods for problem correction. In addition, provide information on the methods used by the State to document these items.

    Character Count: out of 6000

    Remediation: Within 60 days of discovery, any non-compliance will result in the DHCS contacting the provider to: 1. review the data 2. determine etiology of non-compliance 3. develop the Corrective Action Plan (CAP) with timeline Resolution Follow-up: The DHCS will: 1. follow up to determine if the CAP was completed with successful outcome 2. monitor the change(s) for continuing compliance

  • Remediation Data Aggregation

    Remediation-related Data Aggregation and Analysis (including trend identification)
  • Timelines

    When the State does not have all elements of the Quality Improvement Strategy in place, provide timelines to design methods for discovery and remediation related to the assurance of Level of Care that are currently non-operational.
  • Appendix B: Participant Access and Eligibility

    B-7: Freedom of Choice

    Freedom of Choice.As provided in 42 CFR 441.302(d), when an individual is determined to be likely to require a level ofcare for this waiver, the individual or his or her legal representative is:
  • informed of any feasible alternatives under the waiver; and
  • given the choice of either institutional or home and community-based services.
  • Procedures. Specify the State's procedures for informingeligible individuals (or their legal representatives) of the feasiblealternatives available under the waiver and allowing these individualsto choose either institutional or waiver services. Identify the form(s)that are employed to document freedom of choice. The form or forms areavailable to CMS upon request through the Medicaid agency or the operatingagency (if applicable).

    Character Count: out of 12000

    The participant has the right to choose the provider they prefer. This applies to the CCA, the RCF and where to the extent that options are available, the HHA in PSH. Participants are provided with information regarding the available providers in the county of interest upon request, and via the DHCS website: http://www.dhcs.ca.gov/services/ltc/Pages/ALWPP.aspx The CCA provide the participant with the choices available to them in lieu of the ALW. The participant signs the Freedom of Choice document indicating his or her choice of the ALW as the preferred option for the delivery of services. The participant has the right to decline the waiver services at any time.

  • Maintenance of Forms. Per 45 CFR §92.42, written copies or electronically retrievablefacsimiles of Freedom of Choice forms are maintained for a minimumof three years. Specify the locations where copies of theseforms are maintained.

    Character Count: out of 4000

    The original is maintained by the CCA and the DHCS is provided with a copy at the time of initial authorization of services.

  • Appendix B: Participant Access and Eligibility

    B-8: Access to Services by Limited English Proficiency Persons

    Access to Services by Limited English Proficient Persons. Specify the methods that the State uses to provide meaningful access tothe waiver by Limited English Proficient persons in accordance with theDepartment of Health and Human Services "Guidance to Federal FinancialAssistance Recipients Regarding Title VI Prohibition Against NationalOrigin Discrimination Affecting Limited English Proficient Persons" (68 FR 47311 - August 8, 2003):

    Character Count: out of 12000

    DHCS employs several methods to ensure meaningful access to waiver services by Limited English Proficient (LEP) individuals, in accordance with §50514 of the Health and Safety Code and §10746 of the Welfare and Institution (W&I) Code. Participating waiver providers are required to provide both interpreter and translation services for applicants and participants in the Medi-Cal threshold languages most commonly encountered in that county. Threshold languages are: Armenian, Cambodian, Chinese, Farsi, Hmong, Korean, Russian, Spanish, and Vietnamese. A threshold is defined as 3,000 beneficiaries or 5% of the Medi-Cal population within a county (whichever is lower) whose primary language is other than English. Language services include, as a first preference, the availability of bilingual staff who can communicate directly with applicants and participants in their preferred language. When such staff members are not available, face-to-face interpretation provided by trained staff, or contract or volunteer interpreters, will be the next preference. For languages where there is no staff on site, translation will be covered by aligning with a specific language or ethnic center such as Asian Health Services or by utilizing telephone interpreter services such as the AT&T Language Line. DHCS will furnish participating counties and waiver providers with translated written materials in English and Spanish, as well as threshold languages most commonly encountered in the county.

    Appendix C: Participant Services

    C-1: Summary of Services Covered (1 of 2)

  • Waiver Services Summary. List the services that are furnished under the waiver in the following table. If case management is not a service under the waiver, complete items C-1-b and C-1-c:

  • Appendix C: Participant Services

    C-1/C-3: Service Specification

    State laws, regulations and policies referenced in the specification are readily available to CMS upon request through the Medicaid agency or the operating agency (if applicable).

    Service Type:

    Service:

    Alternate Service Title (if any):

    Assisted Living Services - Homemaker; Home Health Aide; Personal Care

    HCBS Taxonomy:

    Complete this part for a renewal application or a new waiver that replaces anexisting waiver. Select one :


    Service Definition (Scope):

    The following is a list of services provided or coordinated by either the RCF waiver provider or HHA waiver provider for participants residing in Public Subsidized Housing (PSH): • 24-hour awake staff to provide oversight and meet the scheduled and unscheduled needs (Provision of awake staff at night is waived in 6-bed RCFs as per CCL); • Provision and oversight of personal and supportive services including assistance with ADLs and IADLs; • Assistance with self-administration of medications and/or administration by licensed nursing staff as needed; • Recreational activities (Referral to recreational activities in a PSH setting); • Provision of three meals per day plus snacks in the RCF setting; or, • Coordination of three meals and snacks in a PSH setting; • Housekeeping and laundry (Participant provides cleaning products and coins for laundry equipment); • Licensed nursing staff, as necessary, to meet the skilled nursing needs of the participants. This does not include 24-hour skilled nursing care or continuous skilled nursing supervision. • Transportation, or arrangement of transportation, to medically necessary appointments and to other needed services as identified on the ISP. The use of public transportation, when safe and appropriate, is an option. • An IRS is required in the PSH setting. An IRS is a 24-hour call system that enables participants to secure immediate assistance in the event of an emotional, physical or environmental emergency. The IRS is designed to meet the needs and abilities of participants. The IRS may be a 24-hour response system, paging or intercom system. Accommodations that must be available in ALW settings include: • Private or semi-private bedroom with lockable door in an RCF or private occupancy in PSH with doors that lock, unless sharing is the participant's preference. (The choice of a housemate or roommate is independent of the ALW); • Private or semi-private bathroom (shared by not more than two participants) in an RCF or private full bathroom in PSH; There must be adequate bathroom space for the privacy and dignity of the participants when bathrooms are semi-private; • Shared common space, such as a dining room or common activities center that may also serve as a dining room; • Kitchenette, equipped with a refrigerator, a microwave (or cooking appliance in PSH) and storage space for utensils and supplies if participants do not have access to a common kitchen area at all times. • PSH sites must have space sufficient for an HHA to operate an office with lockable doors and a telephone line; • PSH sites must allow building access to identified employees for the purpose of rendering the ALW benefit. • Note: These services do NOT include the cost of rent or the purchase of food. Assisted Living Services will be delivered to participants in one of five possible "tiers" of service. Participants will be assigned an ALW tier as determined by the Care Coordination Agency RN. ALW Assessment Tool is administered by the CCA RN to potential, new participants to the waiver, and repeated at each reassessment. The tool measures the need for assistance with ADLs, IADLs and the need for assistance in one or more of the seven (7) functional categories: Cognitive Patterns, Behavioral Symptoms, Continence, Communications, Medications, Skin Conditions, or Other Treatments. Based on the combined need for assistance in these areas, the tool calculates a LOC eligibility and tier of service for the participant. • Tier one services will be assigned to participants with the lowest level of support need; • Tier two, tier three, and tier four services will be assigned to participants with more significant support needs, respectively; and; • Tier five services will be assigned to participants who require intense, focused attention to ADLs and IADLs as a result of a severe traumatic brain injury. These participants will have a need for assistance beyond that provided in Tiers one through four along with the additional residential habilitation services to successfully manage their care needs while residing in either an RCF or PSH. Tier five is designed to provide a community residential alternative for participants whose physical, mental and cognitive disabilities make placement in other facilities, such as SNFs, IMDs, ICF/DDs or in Tiers one through four of the ALW inappropriate or unmanageable. To be eligible for Tier five, participants must demonstrate one or more failed placements in the past, and demonstrate that they can successfully reside in a supervised community setting. Tier five provides extensive physical, behavioral, cognitive, communicative, social and psychosocial treatments and supervision for those ALW-eligible participants with care needs typical of severe traumatic brain injury. To be eligible for Tier five services a participant must have suffered a traumatic brain injury and meet all of the following specific criteria: • Meets NF-A or NF-B LOC with severe mental/cognitive disabilities; • Demonstrates, has a history of or has the potential of wandering or flight behavior; • Demonstrates or has a history of an inconsistent ability to provide self-care, potential or injury to self or others, or potential of behavior outbursts that negatively affect others; • Demonstrates or has a history of unsuccessful attempts(s) of placement in other community settings; • Requires potential 24-hours/seven days per week hands-on or physical presence supervision and management; can be left alone for short periods of time; and, • Only able to reside in a community setting licensed to provide 24-hour services, supervision and supports, demonstrated by at least one failed placement in a less restrictive setting. Assisted Living Services, as all ALW benefits, will be delivered in accordance with an ISP. The ISP is based on the needs identified by the CCA RN via the ALW Assessment Tool, clinical records, professional assessments and the personal preferences of the participant. The participant takes part in the development of the ISP to the full extent possible. Participants who are unable to participate in the development of their own ISP may be assisted by a family member or other responsible party, such as a legal conservator. The person(s) responsible for a participant's health care decisions may fill the lead role in plan development and oversight in collaboration with the provider and the CCA as necessary. Assisted Living Services includes personal care services (including assistance with ADLs and IADLs as needed), chore services, companion services, medication oversight, and therapeutic social and recreational programming provided in a home-like environment. This service includes 24-hour on-site direct care staff to meet scheduled or unpredictable needs in a way that promotes maximum dignity and independence, and to provide supervision, safety, and security. Assisted Living Services include personalized care, available 24-hours per day rendered by onsite staff. Direct care staff will be awake and available at all times. An exception to the requirement of awake staff at night is granted to RCFs with a licensed capacity of fewer than seven beds. In RCFs with a licensed capacity of fewer than seven beds, direct care staff must be available on the immediate premises but are not required to remain awake throughout the night. Assisted Living Services are furnished to participants who reside in private or semi-private residency units which may be shared at the participant's request but not as a requirement of program participation. The ISP will reflect the choice of the participant to share a residence. The participant has a right to privacy. Residences may be locked at the discretion of the participant, except when a physician or mental health professional has certified in writing that the participant is sufficiently cognitively impaired as to be a danger to self or others if given the opportunity to lock the door. (This requirement does not apply where it conflicts with fire code). Each residence is separate and distinct from the other.

    Specify applicable (if any) limits on the amount, frequency, or duration of this service:

    Service Delivery Method (check each that applies):

    Specify whether the service may be provided by (check each that applies):

    Provider Specifications:

    Appendix C: Participant Services

    C-1/C-3: Provider Specifications for Service

    Service Type: Statutory Service

    Service Name: Assisted Living Services - Homemaker; Home Health Aide; Personal Care

    Provider Category:

    Provider Type:

    Home Health Agencies (HHAs) in Publicly Subsidized Housing (PSH) Settings

    Provider Qualifications

    License (specify):

    HHA Title 22, §§74659 et seq.

    Certificate (specify):

    CHHA BPC §§1736.1-1736.6

    Other Standard (specify):

    In PSH residences, Assisted Living Services are provided by Medi-Cal licensed Home Health Agencies (HHAs). \ All HHAs must: 1. Possess a State of California business license, be licensed as a Home Health Agency in California, and be certified as a Medi-Cal provider of home health services. 2. Be in substantial compliance with all licensing regulations and in good standing with the licensing agency.

    Verification of Provider Qualifications

    Entity Responsible for Verification:

    DPH Licensing and Certification

    Frequency of Verification:

    Annually

    Appendix C: Participant Services

    C-1/C-3: Provider Specifications for Service

    Service Type: Statutory Service

    Service Name: Assisted Living Services - Homemaker; Home Health Aide; Personal Care

    Provider Category:

    Provider Type:

    Residential Care Facility (RCF)

    Provider Qualifications

    License (specify):

    RCFs must meet licensure and certification requirements set forth by the CCL. Participating RCFs must be in substantial compliance and good standing with licensing regulations (Ref: Title 22, § 87101(s)(9)). RCFs that are on probation with and/or have pending accusation against the licensee are not in substantial compliance for the purpose of the ALW. (Ref. H&S § 1569.33).

    Certificate (specify):

    Other Standard (specify):

    DHCS maintains an active list of RCF applicants and providers that is provided to CCL for review and consideration of facility status. CCL notifies the DHCS of any change in provider status for waiver providers. Individual RNs and social workers are not provider types that are authorized directly through the ALW but, a qualified RN or social worker may be contracted or hired by the RCF to provide necessary services to participants based on the participant’s individual service plan. Individual RNs and social workers may decide to operate as a business to provide ALW services as a CCA provider.

    Verification of Provider Qualifications

    Entity Responsible for Verification:

    CDSS CCL

    Frequency of Verification:

    5 Years

    Appendix C: Participant Services

    C-1/C-3: Service Specification

    State laws, regulations and policies referenced in the specification are readily available to CMS upon request through the Medicaid agency or the operating agency (if applicable).

    Service Type:

    Service:

    Alternate Service Title (if any):

    Care Coordination

    HCBS Taxonomy:

    Complete this part for a renewal application or a new waiver that replaces anexisting waiver. Select one :


    Service Definition (Scope):

    Care Coordinators assist participants in gaining access to needed waiver and other state plan services. In collaboration with participants and/or their families, the Care Coordinators will complete the assessment and reassessment of waiver participants using the ALW Assessment Tool, at least every six months, and more frequently, as indicated by a change in the condition of the participant. A CCA RN must conduct the assessment and complete the Assessment Tool. Care Coordinators must also verify Medi-Cal eligibility. Care Coordinators will assist participants in the direct development, implementation, and modification of their ISP to the extent that the participant desires to be involved. Participants who are unable to direct the development of their own ISP and participate in the oversight of their own services may be assisted by a family member or other responsible party, such as a legal conservator. The person(s) responsible for a participant's health care decisions may fill the lead role in plan development and oversight in collaboration with the Care Coordinator as necessary. The ISP is a plan describing the services rendered to the participant, the manner in which the services are delivered, and the desired outcome for each service. The ISP must include specification of the type of provider performing each service and the frequency and duration of each service. Participants may choose to be involved in all aspects of the design, delivery, and modification of their services. They have the right to decide when services are delivered, where services are delivered and how services are delivered. The Care Coordinator will ensure that the ISP is completed during the initial meeting and reviewed (and updated as needed) every six months. On an ongoing basis, Care Coordinators, in collaboration with participants, will also be responsible for ensuring the appropriate, timely delivery of needed services. This will be achieved through face-to-face meetings with the participant and/or responsible parties every month, and a review of participant records at each six-month reassessment. Participants may request a review of their ISP at any time. The Care Coordinator assessments and determinations of Medi-Cal eligibility are subject to verification by the DHCS. Every six months a Care Coordinator RN will reassess participants and determine with the participant what, if any, updates need to be made to the ISP. The Care Coordinator will assess the participants for health and safety. Any signs of abuse or neglect will be reported immediately to Adult Protective Services (APS), and the DHCS. Depending on whether the participant is residing in an RCF or PSH, CCL or DPH L&C will also be notified. Participants will be enrolled into the ALW upon completion of the Assessment, verification of eligibility and completion of the Freedom of Choice Document. The Care Coordinator is eligible to submit bills for Care Coordination once the participant is enrolled. A participant can only be enrolled into the waiver after having been transitioned into an assisted living community residence.

    Specify applicable (if any) limits on the amount, frequency, or duration of this service:

    Care Coordination is on-going for the duration of time the participant is enrolled in the waiver. If a participant leaves the assisted living setting due to hospitalization, etc…the CCA will continue to advocate for the participant for up to thirty days for the purpose of coordinating the participant returning to the assisted living setting. If the participant is unable to return after 30 days, the participant will be disenrolled from the ALW. The participant retains the unduplicated slot for 60 days to facilitate subsequent return to the ALW. After 60 days, the slot is available to another participant. The emphasis of the ALW is the successful transition of persons from skilled nursing into assisted living based on freedom of choice. The goal is for the CCAs to coordinate at least one NF transition for every one community placement they coordinate. The CCAs will work in conjunction with the Money Follows the Person (MFP) program, known in California as California Community Transitions (CCT) to assist with the successful placement of persons identified by CCT who choose the ALW. The CCAs will consider the placement of a CCT individual as a qualifying NF transition. The CCT Operational Protocol recognizes the PSH sites as an appropriate placement. Should a participant in the CCT demonstration choose to reside in an RCF, the CCT demonstration would refer the participant to a CCA for enrollment in the ALW.

    Service Delivery Method (check each that applies):

    Specify whether the service may be provided by (check each that applies):

    Provider Specifications:

    Appendix C: Participant Services

    C-1/C-3: Provider Specifications for Service

    Service Type: Statutory Service

    Service Name: Care Coordination

    Provider Category:

    Provider Type:

    Care Coordinator Agency (CCA)

    Provider Qualifications

    License (specify):

    Business License

    Certificate (specify):

    Other Standard (specify):

    Care Coordination Agency Minimum Requirements for Care Coordination Agency (CCA) Agency Experience and Staff Requirements A Care Coordination Agency must employ the following staff with the required years of experience providing care coordination, which includes the following activities: conducting assessments, developing care plans, arranging for and monitoring service delivery, maintaining progress notes and case records, conducting quality assurance reviews, and collecting data. Registered Nurse (RN): A RN must have and maintain a current, unsuspended, un-revoked license to practice as an RN in California and have work experience that includes either a minimum of 10,000 hours in an acute care hospital or a minimum of 2,000 hours of experience in a home health setting. Individual RNs and social workers are not provider types that are authorized directly through the ALW but, a qualified RN or social worker may be contracted or hired by the RCF to provide necessary services to participants based on the participant’s individual service plan. Individual RNs and social workers may decide to operate as a business to provide ALW services as a CCA provider. A Social Worker must have either a bachelor or master degree in social work, psychology, counseling, rehabilitation, gerontology, or sociology plus one year of related work experience. Agencies must have mandatory in-service training programs for their staff. Agencies must have a process for soliciting and/or obtaining feedback from clients regarding their satisfaction with service. Agencies must have a quality assurance program to track client complaints and incident reports. Agencies must maintain a service record for each client. At a minimum, the record must contain all required forms, completed assessments, signed care plans (ISPs), and progress notes. Agencies must agree to make these records available to DHCS for audit. Agencies must have contingency plans to deliver services in the event of a disaster or emergency. Staff must agree to collect data as specified.

    Verification of Provider Qualifications

    Entity Responsible for Verification:

    DHCS upon application as an ALW provider and during annual review

    Frequency of Verification:

    Annually

    Appendix C: Participant Services

    C-1/C-3: Service Specification

    State laws, regulations and policies referenced in the specification are readily available to CMS upon request through the Medicaid agency or the operating agency (if applicable).

    Service Type:

    Service:

    Alternate Service Title (if any):

    Residential Habilitation

    HCBS Taxonomy:

    Complete this part for a renewal application or a new waiver that replaces anexisting waiver. Select one :


    Service Definition (Scope):

    Residential habilitation provides for additional staff with additional training to deliver a more constant and concentrated effort, on a one to one staff ratio, involving the addition of specialized behavior modification techniques. The focus is more toward a participant’s safety and well-being when interacting with participants who “act out,” or display violent or self-destructive behaviors, and destructive behaviors toward other individuals. The residential habilitation service includes assistance with ADLs, but with the focus of overseeing the behavioral issues requiring a constant and concentrated effort for up to 24 hours per day, 7 days a week involving the addition of the specialized behavior modification techniques related to such issues as TBI. Provision of this service requires prior approval from DHCS Registered Nurses to allow additional, appropriate staff to focus individual attention on one participant to assist in acquiring, retaining and improving the self-help, socialization and adaptive skills while concentrating on helping them to control their behavior issues that would otherwise preclude them from living in a community setting. Providers will be reimbursed for supplying additional, appropriate staff to oversee a participant, depending on an individual’s unique needs. Staff may be licensed medical staff, personal or nursing aides, security personnel, or other specialties as appropriate to the specific participant. Staff must have had a minimum of two hours of documented approved education, specific to TBI and a minimum of two hours of documented approved continuing education per year thereafter. Specific services are an intensive form of those specified under the Assisted Living Services and specifically aimed at those participants who require more staff and more intense focus on the activity and the participant's safety and well-being than that anticipated for the participant receiving routine assisted living services. Services may include: •Hands-on assistance with ADLs such that the participant is guided to become more self-reliant; such enhanced assistance is anticipated to take up to twice as long as that provided to those participants receiving routine assisted living services. •In-person, eyes-on supervision/protective supervision to redirect the participant away from wandering, acting out behaviors, violent behaviors, self-destructive or other person-destructive behaviors. •Such oversight is expected to require staff that is assigned a limited number of participants for an extended time. Residential habilitation services are available to participants residing in both an RCF and a PSH. Residential Habilitation Services will be provided by the home health agency in addition to regular Assisted Living Services to participants residing in PSH settings.

    Specify applicable (if any) limits on the amount, frequency, or duration of this service:

    Reimbursed per 15 minute increments, based on prior authorization as outlined on the ISP for the amount of time needed for the specific participant. Providers may bill a maximum of 24 hours per day (96 units).

    Service Delivery Method (check each that applies):

    Specify whether the service may be provided by (check each that applies):

    Provider Specifications:

    Appendix C: Participant Services

    C-1/C-3: Provider Specifications for Service

    Service Type: Statutory Service

    Service Name: Residential Habilitation

    Provider Category:

    Provider Type:

    RCF

    Provider Qualifications

    License (specify):

    CDSS CCL issued RCF license.

    Certificate (specify):

    Other Standard (specify):

    RCFs must meet licensure and certification requirements set forth by the CCL. Participating RCFs must be in substantial compliance and good standing with licensing regulations (Ref: Title 22, § 87101(s)(9)). RCFs that are on probation with and/or have pending accusation against the licensee are not in substantial compliance for the purpose of the ALW. (Ref. H&S § 1569.33). The DHCS maintains an active list of RCF applicants and providers that is provided to CCL for review and consideration of facility status. CCL notifies the DHCS of any change in provider status for waiver providers.

    Verification of Provider Qualifications

    Entity Responsible for Verification:

    CDSS CCL

    Frequency of Verification:

    5 years

    Appendix C: Participant Services

    C-1/C-3: Provider Specifications for Service

    Service Type: Statutory Service

    Service Name: Residential Habilitation

    Provider Category:

    Provider Type:

    PSH - HHA

    Provider Qualifications

    License (specify):

    CA Dept. of Public Health (CDPH) issued HHA license.

    Certificate (specify):

    Medi-Cal certified provider.

    Other Standard (specify):

    In PSH residences, Assisted Living Services are provided by Medi-Cal licensed Home Health Agencies (HHAs). A PSH-HHA must: 1. Possess a State of California business license, be licensed as a Home Health Agency in California, and be certified as a Medi-Cal provider of home health and ALW services. 2.Be in substantial compliance with all licensing regulations and in good standing with the licensing agency.

    Verification of Provider Qualifications

    Entity Responsible for Verification:

    CDPH L&C

    Frequency of Verification:

    Annually

    Appendix C: Participant Services

    C-1/C-3: Service Specification

    State laws, regulations and policies referenced in the specification are readily available to CMS upon request through the Medicaid agency or the operating agency (if applicable).

    Service Type:

    As provided in 42 CFR 440.180(b)(9), the State requests the authority to provide the following additional service not specified in statute.

    Service Title:

    Augmented Plan of Care Development and Follow-up

    HCBS Taxonomy:

    Complete this part for a renewal application or a new waiver that replaces anexisting waiver. Select one :


    Service Definition (Scope):

    The Care Coordination Agencies (CCA) will be required to perform a systematic assessment of a participant's behavior that includes a description of their functional and dysfunctional behaviors, the circumstances under which identified behaviors are exhibited and the factors that should be taken into account when developing a programmatic response to the behavior(s) in addition to Care Management services. This assessment is followed by a behavior plan that includes developing a written behavior plan including the prescription and management of psychiatric medications; training personnel to implement the behavior plan; monitoring the effectiveness of the behavior plan; and modifying the plan as necessary. The written behavior plan shall identify those participants who need more structured approaches to address challenging behaviors (such as Residential Habilitation Services). CCAs shall develop the behavior plan and monitor the effectiveness of the plan through periodic observation and assessment, and modify the plan as needed. The CCA shall work closely with the County Mental Health plans and services to coordinate mental health services and ongoing medication management. The increased level of contact with the participant and coordination with County Mental Health is expected to require approximately twice the contact and assistance as persons who receive routine care coordination.

    Specify applicable (if any) limits on the amount, frequency, or duration of this service:

    Service Assessment/Plan of Care Development ($200) may be billed in addition to "Care Coordination" for those participants that require the services as listed above. This service will be reimbursed per month, based on prior authorization as outlined on the ISP.

    Service Delivery Method (check each that applies):

    Specify whether the service may be provided by (check each that applies):

    Provider Specifications:

    Appendix C: Participant Services

    C-1/C-3: Provider Specifications for Service

    Service Type: Other Service

    Service Name: Augmented Plan of Care Development and Follow-up

    Provider Category:

    Provider Type:

    Care Coordination Agency (CCA)

    Provider Qualifications

    License (specify):

    Business License

    Certificate (specify):

    Other Standard (specify):

    Care Coordination Agency Minimum Requirements for Care Coordination Agency (CCA) Agency Experience and Staff Requirements A Care Coordination Agency must employ the following staff with the required years of experience providing care coordination, which includes the following activities: conducting assessments, developing care plans, arranging for and monitoring service delivery, maintaining progress notes and case records, conducting quality assurance reviews, and collecting data. Registered Nurse (RN): A RN must have and maintain a current, unsuspended, un-revoked license to practice as an RN in California and have work experience that includes either a minimum of 10,000 hours in an acute care hospital or a minimum of 2,000 hours of experience in a home health setting. A Social Worker must have either a bachelor or master degree in social work, psychology, counseling, rehabilitation, gerontology, or sociology plus one year of related work experience. Agencies must have mandatory in-service training programs for their staff. Agencies must have a process for soliciting and/or obtaining feedback from clients regarding their satisfaction with service. Agencies must have a quality assurance program to track client complaints and incident reports. Agencies must maintain a service record for each client. At a minimum, the record must contain all required forms, completed assessments, signed care plans (ISPs), and progress notes. Agencies must agree to make these records available to DHCS for audit. Agencies must have contingency plans to deliver services in the event of a disaster or emergency. Staff must agree to collect data as specified.

    Verification of Provider Qualifications

    Entity Responsible for Verification:

    DHCS upon application as an ALW provider and during annual review

    Frequency of Verification:

    Annually

    Appendix C: Participant Services

    C-1/C-3: Service Specification

    State laws, regulations and policies referenced in the specification are readily available to CMS upon request through the Medicaid agency or the operating agency (if applicable).

    Service Type:

    As provided in 42 CFR 440.180(b)(9), the State requests the authority to provide the following additional service not specified in statute.

    Service Title:

    NF Transition Care Coordination

    HCBS Taxonomy:

    Complete this part for a renewal application or a new waiver that replaces anexisting waiver. Select one :


    Service Definition (Scope):

    This benefit is designed to address the increased need for Care Coordination prior to the successful transition of an individual from a nursing facility (NF) into an assisted living setting. The Care Coordinator may claim the NF Transition Care Coordination reimbursement after the successful transition of the participant from a NF, NF subacute or acute facility into the ALW and establishment of residence in an assisted living setting. The services must be rendered in the timeframe not to exceed 180 consecutive days prior to transition, and the services rendered by the Care Coordination Agency (CCA) must be consistent with the definition of transition services. This one time reimbursement is intended to provide the sufficient hours for this transition to occur. It is a one-time benefit per participant with a calculation of the service rate being the equivalent of 5 months of care coordination. The goal is for one-half of all waiver enrollees to transfer from a NF, NF subacute or acute facility in to the ALW. However, any individual who qualifies for the waiver may be admitted provided enrollment capacity is available. • The specific services rendered prior to NF transition are as followed: • Explanation of the ALW and alternative choices available to the participant • Determination of Medi-Cal eligibility • Administration of the Assessment Tool to determine tier at level of care • Provision of information regarding available facilities • Development of the ISP • Submission of all documents to the DHCS for approval • Upon confirmation of approval, coordination of transition of participant into chosen facility

    Specify applicable (if any) limits on the amount, frequency, or duration of this service:

    This ALW benefit may be incurred once in the lifetime of the participant.

    Service Delivery Method (check each that applies):

    Specify whether the service may be provided by (check each that applies):

    Provider Specifications:

    Appendix C: Participant Services

    C-1/C-3: Provider Specifications for Service

    Service Type: Other Service

    Service Name: NF Transition Care Coordination

    Provider Category:

    Provider Type:

    Care Coordination Agency

    Provider Qualifications

    License (specify):

    Business License

    Certificate (specify):

    Other Standard (specify):

    Care Coordination Agency Minimum Requirements for Care Coordination Agency (CCA) Agency Experience and Staff Requirements A Care Coordination Agency must employ the following staff with the required years of experience providing care coordination, which includes the following activities: conducting assessments, developing care plans, arranging for and monitoring service delivery, maintaining progress notes and case records, conducting quality assurance reviews, and collecting data. Registered Nurse (RN): A RN must have and maintain a current, unsuspended, un-revoked license to practice as an RN in California and have work experience that includes either a minimum of 10,000 hours in an acute care hospital or a minimum of 2,000 hours of experience in a home health setting. A Social Worker must have a either bachelor or master degree in social work, psychology, counseling, rehabilitation, gerontology, or sociology plus one year of related work experience. Agencies must have mandatory in-service training programs for their staff. Agencies must have a process for soliciting and/or obtaining feedback from clients regarding their satisfaction with service. Agencies must have a quality assurance program to track client complaints and incident reports. Agencies must maintain a service record for each client. At a minimum, the record must contain all required forms, completed assessments, signed care plans (ISPs), and progress notes. Agencies must agree to make these records available to DHCS for audit. Agencies must have contingency plans to deliver services in the event of a disaster or emergency. Staff must agree to collect data as specified.

    Verification of Provider Qualifications

    Entity Responsible for Verification:

    DHCS

    Frequency of Verification:

    Annually

    Appendix C: Participant Services

    C-1: Summary of Services Covered (2 of 2)

  • Provision of Case Management Services to Waiver Participants. Indicate how case management is furnished to waiver participants (select one):

     not selected

     Not applicable - Case management is not furnished as a distinct activity to waiver participants.

     Applicable - Case management is furnished as a distinct activity to waiver participants.

     None of the above apply - Case management is furnished as a waiver service (Do not complete item C-1-c).

  • Delivery of Case Management Services. Specify the entity or entities that conduct case management functions on behalf of waiver participants:

    Character Count: out of 4000

    Care Coordination Agency RN staff

  • Appendix C: Participant Services

    C-2: General Service Specifications (1 of 3)

  • Criminal History and/or Background Investigations. Specify the State's policies concerning the conduct of criminal history and/or background investigations of individuals who provide waiver services (select one):

    Specify: (a) the types of positions (e.g., personal assistants, attendants) for which such investigations must be conducted; (b) the scope of such investigations (e.g., state, national); and, (c) the process for ensuring that mandatory investigations have been conducted. State laws, regulations and policies referenced in this description are available to CMS upon request through the Medicaid or the operating agency (if applicable):

    Character Count: out of 12000

    Prior to issuing a license the Department of Social Services (DSS), Community Care Licensing (CCL) is responsible for conducting a criminal record review of the applicant, administrator or any other adult involved in the operations of a licensed facility including all individuals working, residing or volunteering in a that facility and has the authority to approve or deny a facility license, or employment, residence, or presence in an RCF, based upon the results of such a review. As part of the criminal records review DSS requires all individuals to submit fingerprints that are submitted to both the California Department of Justice and the FBI. All staff must be cleared prior to initiating participant/patient contact. Documentation of criminal record clearances and fingerprinting must be maintained by the facility and be available for inspection by DSS. DSS may seek verification from a law enforcement agency or court if it is deemed necessary.

  • Abuse Registry Screening. Specify whether the State requires the screening of individuals who provide waiver servicesthrough a State-maintained abuse registry (select one):

  • Appendix C: Participant Services

    C-2: General Service Specifications (2 of 3)

  • Services in Facilities Subject to §1616(e) of the Social Security Act. Select one:

  • Types of Facilities Subject to §1616(e). Complete the following table for each type of facility subject to §1616(e) of the Act:

    Facility Type
    RCF
  • Larger Facilities: In the case of residential facilities subject to §1616(e) that serve four or more individuals unrelated to the proprietor, describe how a home and community character is maintained in these settings.

    Character Count: out of 12000

    The RCFs participating in the ALW vary in size from five beds to over 200. The RCFs are licensed and regulated by the CDSS CCL. These facilities are not regarded as healthcare facilities, but social-based facilities. The RCF is the participant's home, akin to an apartment complex, providing non-medical services as necessary. The residents are regarded as living in their own home; albeit a licensed facility, not in a healthcare setting. Larger RCFs typically subdivide the building to create small communities within the building. Participants may be grouped by special needs, such as a memory care unit. ALW participants are not distinguished from others in the RCF in any fashion. The larger RCFs typically provide alternative meal times to offer choice and to reduce the number of persons in the dining area at any one time. Many RCFs provide additional smaller, homelike dining areas to offer the experience of a family style meal. The care providers in all RCFs tend to care for the same individuals every day. This enables the care provider to gain familiarity with the particular needs of each individual and for the individual to develop a trusting relationship with the care provider. RCFs with delayed egress or secured perimeters will not be considered a Home and Community-Based setting for this waiver. Facilities participating as ALW HCBS settings are required to have the following qualities: a. The setting is integrated in, and facilitates the individual’s full access 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, in the same manner as individuals without disabilities. b. The setting is selected by the individual from among all available alternatives and is identified in the person-centered service plan. c. An individual’s essential personal rights of privacy, dignity and respect, and freedom from coercion and restraint are protected. d.Individual initiative, autonomy, and independence in making life choices, including but not limited to, daily activities, physical environment, and with whom to interact are optimized and not regimented. e. Individual choice regarding services and supports, and who provides them, is facilitated. Please also indicate in this section of the application how the facilities meet the following requirements: f. The unit or room is a specific physical place that can be owned, rented or occupied under another legally enforceable agreement by the individual receiving services, and the individual has, at a minimum, the same responsibilities and protections from eviction that tenants have under the State’s landlord tenant law; g. Each individual has privacy in their sleeping or living unit: (1) Units have lockable entrance doors, with appropriate staff having keys to doors; (2) Individuals share units only at the individual’s choice; and (3) Individuals have the freedom to furnish and decorate their sleeping or living units. h. Individuals have the freedom and support to control their own schedules and activities, and have access to food at any time; i. Individuals are able to have visitors of their choosing at any time; and j. Receipt of any particular service or support cannot be a condition for living in the unit.

  • Appendix C: Participant Services

    C-2: Facility Specifications

    Facility Type:

    RCF

    Waiver Service(s) Provided in Facility:

    Facility Capacity Limit:

    N/A

    Scope of Facility Sandards. For this facility type, please specify whether the State's standards address the following topics (check each that applies):

    When facility standards do not address one or more of the topics listed, explain why the standard is not included or is not relevant to the facility type or population. Explain how the health and welfare of participants is assured in the standard area(s) not addressed:

    All RCF's are licensed by the State. Per this license 'the licensee shall employ staff as necessary to ensure provision of care and supervision to meet client health and safety needs. The DHCS requires the RCFs and the HHAs to submit their Significant Incident Reports (SIRs)to both the licensing entities and to the CCAs. The CCAs submit the SIRs to the DHCS. DHCS quantifies, tracks, and monitors the trends in the SIR activity. In the event that a trend or pattern of SIRs is detected, the provider(s) are given the appropriate TA with clear timelines for improvement. Monitoring continues to ensure that remediation occurs. In the event that remediation is not achieved or is insufficient, the DHCS issues a CAP to the provider. The DHCS may restrict the provider from continuing to enroll further participants until they demonstrate the ability to provide for the health and safety of all participants appropriately.

    Appendix C: Participant Services

    C-2: General Service Specifications (3 of 3)

  • Provision of Personal Care or Similar Services by Legally Responsible Individuals. Alegally responsible individual is any person who has a duty under State law to care for another person and typically includes:(a) the parent (biological or adoptive) of a minor child or the guardian of a minor child who must provide care to the child or(b) a spouse of a waiver participant. Except at the option of the State and under extraordinary circumstances specified by the State,payment may not be made to a legally responsible individual for the provision of personal care or similar services that the legallyresponsible individual would ordinarily perform or be responsible to perform on behalf of a waiver participant.Select one:

     No. The State does not make payment to legally responsible individuals for furnishing personal care or similar services.

     Yes. The State makes payment to legally responsible individuals for furnishing personal care or similar services when they are qualified to provide the services.

     not selected

  • Other State Policies Concerning Payment for Waiver Services Furnished by Relatives/Legal Guardians.Specify State policies concerning making payment to relatives/legal guardians for the provision of waiver services over and above the policies addressed in Item C-2-d. Select one:

     The State does not make payment to relatives/legal guardians for furnishing waiver services.

     The State makes payment to relatives/legal guardians under specific circumstances and only when the relative/guardian is qualified to furnish services.

     Relatives/legal guardians may be paid for providing waiver services whenever the relative/legal guardian is qualified to provide services as specified in Appendix C-1/C-3.

     Other policy.

     not selected

  • Open Enrollment of Providers. Specify the processes that are employed to assure that all willing and qualified providers have the opportunity to enroll as waiver service providers as provided in 42 CFR §431.51:

    Character Count: out of 12000

    All RCFs in the catchment area (county boundaries) are eligible to apply to be a waiver provider. The RCFs complete a two-page application and submit it to the DHCS. The DHCS submits the facility information to the CCL to ascertain if the facility is regarded to be in substantial compliance and good standing in all licensing and certification requirements. If CCL recommends the facility, the facility is notified in writing. The letter advises the facility of the next steps to applying to be a Medi-Cal provider. All HHAs wishing to work in the catchment area are eligible to apply. The HHA completes a two-page application and submits it to the DHCS. The DHCS submits the HHA information to L&C for a recommendation on the status of the HHA. The DHCS issues a letter advising the HHA of the next steps for applying to be a Medi-Cal provider. The DHCS works cooperatively with the local housing authorities in each county to identify and partner with an HHA to implement the PSH portion of the ALW. HHAs, Non-profit organization, individuals or other case management business may apply to ALW to become a Care Coordination Agency.

  • Appendix C: Participant Services

    Quality Improvement: Qualified Providers

    As a distinct component of the States quality improvement strategy,provide information in the following fields to detail the Statesmethods for discovery and remediation.

  • Methods for Discovery: Qualified Providers

    The state demonstrates that it has designed and implemented an adequate system for assuring that all waiver services are provided by qualified providers.

  • Sub-Assurances:

  • Sub-Assurance: The State verifies that providers initially and continually meet required licensure and/or certification standards and adhere to other standards prior to their furnishing waiver services.

    Performance Measures

    For each performance measure the State will use to assess compliance with the statutory assurance, complete the following. Where possible, include numerator/denominator.

    For each performance measure, provide information on the aggregated data that will enable the State to analyze and assess progress toward the performance measure. In this section provide information on the method by which each source of data is analyzed statistically/deductively or inductively, how themes are identified or conclusions drawn, and how recommendations are formulated, where appropriate.

    Performance Measure:

    Qualified Providers Number/ percent of enrolled Care Coordinator Agency (CCA) providers who continuously meet the CCA provider qualifications. Numerator: number of CCA providers who continuously meet the specific provider qualifications Denominator: the number of CCA providers

    Data Source (Select one):Record reviews, off-site If 'Other' is selected, specify:

    Data Aggregation and Analysis:

    Performance Measure:

    Qualified Providers Number/ percent of enrolled HHA providers who continuously meet the HHA provider qualifications. Numerator: number of HHA providers who continuously meet the specific provider qualifications of meeting the participantsADL and IADL needs. Denominator: the number of HHA providers

    Data Source (Select one):Record reviews, on-site If 'Other' is selected, specify:

    Data Aggregation and Analysis:

    Performance Measure:

    Qualified Providers Number/ percent of enrolled RCF providers who continuously meet the RCF provider qualifications. Numerator: number of RCF providers who continuously meet the specific provider qualifications of offering a private room and meeting the participants ADL and IADL needs Denominator: the number of RCF providers surveyed

    Data Source (Select one):Record reviews, on-site If 'Other' is selected, specify:

    Data Aggregation and Analysis:

    Performance Measure:

    The number/percent of Residential Habilitation Services claims received from CCAs that were pre-approved by DHCS RNs. Numerator: number of participants with paid claims for Residential Habilitation Services. Denominator: number of participants who were pre-determined by a DHCS RN, after review of a completed supplemental assessment, to require Residential Habilitation Services.

    Data Source (Select one):Financial records (including expenditures) If 'Other' is selected, specify:

    Data Aggregation and Analysis:

  • Sub-Assurance: The State monitors non-licensed/non-certified providers to assure adherence to waiver requirements.

    For each performance measure the State will use to assess compliance with the statutory assurance, complete the following. Where possible, include numerator/denominator.

    For each performance measure, provide information on the aggregated data that will enable the State to analyze and assess progress toward the performance measure. In this section provide information on the method by which each source of data is analyzed statistically/deductively or inductively, how themes are identified or conclusions drawn, and how recommendations are formulated, where appropriate.

  • Sub-Assurance: The State implements its policies and procedures for verifying that provider training is conducted in accordance with state requirements and the approved waiver.

    For each performance measure the State will use to assess compliance with the statutory assurance, complete the following. Where possible, include numerator/denominator.

    For each performance measure, provide information on the aggregated data that will enable the State to analyze and assess progress toward the performance measure. In this section provide information on the method by which each source of data is analyzed statistically/deductively or inductively, how themes are identified or conclusions drawn, and how recommendations are formulated, where appropriate.

    Performance Measure:

    Provider Training Number/percent of enrolled providers who meet the training requirements Numerator: number of providers who attend annual training Denominator: total number of providers

    Data Source (Select one):Training verification records If 'Other' is selected, specify:

    Data Aggregation and Analysis:

  • If applicable, in the textbox below provide any necessary additional information on the strategies employed by the State to discover/identify problems/issues within the waiver program, including frequency and parties responsible.

    Character Count: out of 6000

    The DHCS provides continuous and ongoing TA to all waiver providers. This assistance includes clinical input, provider requirements, assistance with billing and significant issue documentation. The DHCS provides extensive training for new waiver providers including a manual specific to provider type. The DHCS conducts an annual QA audit and review. The data from the review are aggregated and presented back to the providers in the format of TA. New strategies for improving waiver implementation are fostered by this process.

  • Methods for Remediation/Fixing Individual Problems

  • Describe the States method for addressing individual problems as they are discovered. Include information regarding responsible parties and GENERAL methods for problem correction. In addition, provide information on the methods used by the State to document these items.

    Character Count: out of 6000

    The DHCS identifies individual problems that are specific or unique to a single provider and addresses the problems directly with the provider. The nature of the issue and the severity of the problem are identified and discussed with the provider by the DHCS. A Corrective Action Plan (CAP) or remediation process is developed by DHCS in conjunction with the provider to respond to the issue. The DHCS then monitors the provider with supportive TA to assure that resolution occurs. If the issue continues, further TA with a more stringent CAP is developed. Providers may be placed in suspension from admitting and retaining additional waiver participants until the issue is resolved. The initial CAP period is either 90 days or 180 days depending on the nature and severity of the problem. The length of the CAP period assigned is at the discretion of the DHCS. In the event that the issue continues, or grows in proportion, the provider is disenrolled as a waiver provider and participants are moved to another provider site for continuity of care. The participants are provided with a list of participating facilities within the county from which to choose. The CCA responsible for the participants would be the lead agency for assuring that the participant's freedom of choice is respected.

  • Remediation Data Aggregation

    Remediation-related Data Aggregation and Analysis (including trend identification)
  • Timelines

    When the State does not have all elements of the Quality Improvement Strategy in place, provide timelines to design methods for discovery and remediation related to the assurance of Qualified Providers that are currently non-operational.
  • Appendix C: Participant Services

    C-3: Waiver Services Specifications

    Section C-3 'Service Specifications' is incorporated into Section C-1 'Waiver Services.'

    Appendix C: Participant Services

    C-4: Additional Limits on Amount of Waiver Services

  • Additional Limits on Amount of Waiver Services.Indicate whether the waiver employs any of the following additional limits on the amount of waiver services (select one).

     not selected

     Not applicable- The State does not impose a limit on the amount of waiver services except as provided in Appendix C-3.

     Applicable - The State imposes additional limits on the amount of waiver services.

    When a limit is employed, specify: (a) the waiver services to which the limit applies; (b) the basis of the limit, including its basis in historical expenditure/utilization patterns and, as applicable, the processes and methodologies that are used to determine the amount of the limit to which a participant's services are subject; (c) how the limit will be adjusted over the course of the waiver period; (d) provisions for adjusting or making exceptions to the limit based on participant health and welfare needs or other factors specified by the state; (e) the safeguards that are in effect when the amount of the limit is insufficient to meet a participant's needs; (f) how participants are notified of the amount of the limit.(check each that applies)

    Limit(s) on Set(s) of Services. There is a limit on the maximum dollar amount of waiver services that is authorized for one or more sets of services offered under the waiver.

    Prospective Individual Budget Amount. There is a limit on the maximum dollar amount of waiver services authorized for each specific participant.

    Furnish the information specified above.

    Character Count: out of 24000

    The costs for the ALW services are designed not to exceed the sum of the NF rate of $51,830.00 annually plus the estimated state plan costs for persons in the NF setting of $5,258.00 (Ref: NF A/H waiver, Appendix J-1 2). The rates for the five tiers of service, plus the cost of Care Coordination, with the other wavier services, combined, are set to maintain cost neutrality. The CCAs explain the waiver benefits and choices prior to having the participant sign the Freedom of Choice Document. If a participant has a short-term need for additional state plan services that exceed individual cost neutrality, but the participant is otherwise stable in the assisted living community-based setting, those services are available to the participant and the waiver remains cost neutral in the aggregate. Should the participant require long-term, on-going care that fails to meet cost neutrality that will not be restored in the immediate future, the participant will be disenrolled from the ALW and offered other Medi-Cal long-term care options as available. A short-term need for additional services is limited to 60 days.

    Budget Limits by Level of Support. Based on an assessment process and/or other factors, participants are assigned to funding levels that are limits on the maximum dollar amount of waiver services.

    Other Type of Limit. The State employs another type of limit.

    Not applicable. The State does not impose a limit on the amount of waiver services except as provided in Appendix C-3.

  • Appendix C: Participant Services

    C-5: Home and Community-Based Settings

    Explain how residential and non-residential settings in this waiver comply with federal HCB Settings requirements at 42 CFR 441.301(c)(4)-(5) and associated CMS guidance. Include:
  • Description of the settings and how they meet federal HCB Settings requirements, atthe time of submission and in the future.

  • Description of the means by which the state Medicaid agency ascertains that all waiversettings meet federal HCB Setting requirements, at the time of this submission and ongoing.

  • Note instructions at Module 1, Attachment #2, HCB Settings Waiver Transition Plan fordescription of settings that do not meet requirements at the time of submission. Do not duplicatethat information here.

    Character Count: out of 60000

    Appendix D: Participant-Centered Planning and Service Delivery

    D-1: Service Plan Development (1 of 8)

    State Participant-Centered Service Plan Title:Individual Service Plan (ISP)

  • Responsibility for Service Plan Development.Per 42 CFR 441.301(b)(2), specify who is responsible for thedevelopment of the service plan and the qualifications of theseindividuals (select each that applies):

    Registered nurse, licensed to practice in the State

    Licensed practical or vocational nurse, acting within the scope of practice under State law

    Licensed physician (M.D. or D.O)

    Case Manager (qualifications specified in Appendix C-1/C-3)

    Case Manager (qualifications not specified in Appendix C-1/C-3).

    Social Worker

    Other

  • Appendix D: Participant-Centered Planning and Service Delivery

    D-1: Service Plan Development (2 of 8)

  • Service Plan Development Safeguards.Select one:
  • Appendix D: Participant-Centered Planning and Service Delivery

    D-1: Service Plan Development (3 of 8)

  • Supporting the Participant in Service Plan Development. Specify: (a) the supports and information that are made available tothe participant (and/or family or legal representative, asappropriate) to direct and be actively engaged in the service plandevelopment process and (b) the participant's authority to determinewho is included in the process.

    Character Count: out of 12000

    The Individualized Service Plan (ISP) is a participant-directed plan that identifies the services needed by the participant to assure health and safety in the assisted living or the assisted care settings. A participant has the authority to include individuals of his/her choice to participate in the service plan development process. The participant has the freedom of choice to select providers, including the CCA. During development of the ISP, individuals of the participant’s choice, representatives from the residential care facility or the home health agency, and the care coordination agency can offer support and guidance to the participant. Each of these individuals and/or entities can offer a unique perspective to ensure the participant’s plan for long-term services and supports is personalized to his or her specific needs. The participant signs the ISP and indicates he/she was active in the development of the ISP and agrees or disagrees with any portion of the ISP as developed. The goals of the ISP are based on the 6-month interval until the subsequent reassessment. The ISP also identifies any known issue, intervention and outcome of identified issues. The issues are defined in nursing/health care language and are not medical diagnoses. The intent of identifying issues for the participant is to lead to a timely resolution of those issues by setting goals for remediation. An accurate goal is measureable and definitive, not vague as to time and manner of resolution. The intervention is the specific action that will be taken to achieve the goal. The outcome is the result of the intervention. If the outcome is not the resolution of the issue, then the issue continues to be an active issue on the ISP. When issues are resolved, the resolution is documented as the outcome, and the issue is subsequently inactive on the ISP. The ISP reflects the current needs of the participant and includes short-term goals that are resolved in the first six months, as well as long-term goals that persist on the ISP until eventual resolution. The advocates for the participants involved in the ALW have stated a strong preference for the ISP to reflect the individualized needs of the participant. CCAs are to refrain from the use of repetitive language common to all ISPs but rather ensure that the ISP accurately reflects the current needs of each participant.

  • Appendix D: Participant-Centered Planning and Service Delivery

    D-1: Service Plan Development (4 of 8)

  • Service Plan Development Process. In four pages or less, describe the process that is used to develop the participant-centered service plan, including: (a) who develops the plan, who participates in the process, and the timing of the plan; (b) the types of assessments that are conducted to support the service plan development process, including securing information about participant needs, preferences and goals, and health status; (c) how the participant is informed of the services that are available under the waiver; (d) how the plan development process ensures that the service plan addresses participant goals, needs (including health care needs), and preferences; (e) how waiver and other services are coordinated; (f) how the plan development process provides for the assignment of responsibilities to implement and monitor the plan; and, (g) how and when the plan is updated, including when the participant's needs change.State laws, regulations, and policies cited that affect the serviceplan development process are available to CMS upon request through the Medicaid agencyor the operating agency (if applicable):

    Character Count: out of 24000

    The ISP is based on the needs identified by the ALW Assessment Tool, clinical records, professional assessments and the personal preferences of the participant. The CCA administers the Assessment Tool which determines participant eligibility for the waiver. The tool measures the need for assistance with ADLs and the need for assistance in one or more of the seven functional categories: Cognitive Patterns, Behavioral Symptoms, Continence, Communications, Medications, Skin Conditions, or Other Treatments. Based on the combined need for assistance in these areas, the tool calculates a level of care eligibility and tier of service for the participant. The ISP is a plan describing the services rendered to the participant, the manner in which the services are delivered, and the desired outcome for each service. The ISP must include specification of the type of provider performing each service and the frequency and duration of each service. Participants may choose to be involved in all aspects of the design, delivery, and modification of their services. They have the right to decide when services are delivered, where services are delivered and how services are delivered. The CCA will ensure that the ISP is completed during the initial meeting and reviewed (and updated as needed) every six months. On an ongoing basis, the CCAs, in collaboration with the participants, will also be responsible for ensuring the appropriate, timely delivery of needed services. This will be achieved through face-to-face meetings with the participant and/or responsible parties every month, and a review of participant records at each six-month reassessment. Participants may request a review of their ISP at any time. The CCA assessments and determinations of Medi-Cal eligibility are subject to verification by the DHCS. Every six months the CCA RN will reassess participants and determine with the participant what, if any, updates need to be made to the ISP. The CCA will assess the participant for health and safety issues. Any signs of abuse or neglect will be reported immediately to Adult Protective Services (APS), the DHCS, and, if the participant is residing in an RCFE, CCL. If the participant is residing in PSH, L&C shall be notified.

  • Appendix D: Participant-Centered Planning and Service Delivery

    D-1: Service Plan Development (5 of 8)

  • Risk Assessment and Mitigation. Specify how potential risks to the participant are assessed during theservice plan development process and how strategies to mitigate risk areincorporated into the service plan, subject to participant needs andpreferences. In addition, describe how the service plan developmentprocess addresses backup plans and the arrangements that are used forbackup.

    Character Count: out of 12000

    The ISP identifies potential risks to the participants that could compromise the participant's health and safety or well-being in the assisted living or assisted care setting. These risks may be identified by the CCA, the participant, the participant's representative, or by the direct provider of the assisted living or assisted care services. The CCA, in conjunction with the participant, representatives and providers, details a plan to mitigate or minimize the risks as described. The participant has the right and obligation to express his/her concerns with both the identification of risk factors and the proposed strategies to address those risks. The ISP shall also include a long-term plan for accessing emergency services in the event of catastrophic or wide spread emergency occurrences. The ISP plan shall reflect the mobility limitations specific to each participant. RCFs and Home Health Agencies must have current, written emergency disaster plans which must include the following: contain a plan for evacuation, address elements of sheltering in place, identify temporary relocation sites, and identify detailed staff assignments in the event of a disaster or an emergency. The emergency disaster plan must be posted prominently in the facility and be available to emergency responders. California Government Code sections 8550-8551 provide the authority for the State to develop the framework and processes to establish statewide emergency programs. In licensed residential care settings, the California Department of Social Services regulates processes for accessing emergency services; in public subsidized housing settings, processes for provision of emergency services conform to the federal Housing and Urban Development requirements.

  • Appendix D: Participant-Centered Planning and Service Delivery

    D-1: Service Plan Development (6 of 8)

  • Informed Choice of Providers. Describe how participants are assisted in obtaining informationabout and selecting from among qualified providers of the waiverservices in the service plan.

    Character Count: out of 6000

    Participants have the choice of waiver providers before they are enrolled in the ALW. Individuals and/or family members interested in learning about the choice of waiver providers are directed to the Department of Health Care Services’ website which lists “Long-Term Care Alternatives” for home and community-based service options where ALW providers are identified by location and service area. The initial contact with potential participants includes a discussion of the CCAs available in the county of choice. The CCA presents the individual with a list and description of the RCFs/PSHs in the county of choice with a discussion of the similarities and distinctions among them. As an example, some participants prefer the larger RCFs with more apartment-like units and a greater variety of residents, while some participants prefer the smaller, six-bed style RCFs with a more homelike atmosphere. The CCAs are responsible for providing the participants with the information they require to make informed choices.

  • Appendix D: Participant-Centered Planning and Service Delivery

    D-1: Service Plan Development (7 of 8)

  • Process for Making Service Plan Subject to the Approval of the Medicaid Agency. Describe the process by which the service plan is made subjectto the approval of the Medicaid agency in accordance with 42 CFR§441.301(b)(1)(i):

    Character Count: out of 6000

    Every ISP is submitted to the DHCS every six months accompanied by the assessment for review and approval. The CCA retains the original and provides the DHCS (as well as the direct service provider) a copy of the ISP.

  • Appendix D: Participant-Centered Planning and Service Delivery

    D-1: Service Plan Development (8 of 8)

  • Service Plan Review and Update.The service plan is subject to at least annual periodic review andupdate to assess the appropriateness and adequacy of the services asparticipant needs change. Specify the minimum schedule for the review and update of the service plan:
  • Maintenance of Service Plan Forms.Written copies or electronic facsimiles of service plans aremaintained for a minimum period of 3 years as required by 45 CFR 92.42.Service plans are maintained by the following(check each that applies):

    Medicaid agency

    Operating agency

    Case manager

    Other

  • Appendix D: Participant-Centered Planning and Service Delivery

    D-2: Service Plan Implementation and Monitoring

  • Service Plan Implementation and Monitoring. Specify: (a) the entity (entities) responsible for monitoring theimplementation of the service plan and participant health and welfare; (b)the monitoring and follow-up method(s) that are used; and, (c) the frequencywith which monitoring is performed.

    Character Count: out of 24000

    The CCA is responsible for the development of the ISP with approval from the DHCS. The ISP is implemented by the direct service provider as well as any additional supportive entities as identified. As an example, the participant may have a need to attend church services. The provider may be a volunteer from the church to provide a ride to and from services. The CCA is responsible for the primary monitoring of the ISP implementation. The CCA is required to meet with the particpants at least monthly and review the ISP. The CCA RN meets with the participant at least every six (6) months to reassess the participant and update the ISP. The DHCS provides additional monitoring and oversight through regular contact with all providers as well as annual QA reviews. The annual reviews require that DHCS staff visit the CCA offices as well as the RCF and the PSH sites. The annual QA audits include the Participant Experience Survey (PES) to ensure that the participants are satisfied with their overall delivery of waiver services. `

  • Monitoring Safeguards.Select one:
  • Appendix D: Participant-Centered Planning and Service Delivery

    Quality Improvement: Service Plan

    As a distinct component of the States quality improvement strategy,provide information in the following fields to detail the Statesmethods for discovery and remediation.

  • Methods for Discovery: Service Plan Assurance/Sub-assurances

    The state demonstrates it has designed and implemented an effective system for reviewing the adequacy of service plans for waiver participants.

  • Sub-Assurances:

  • Sub-assurance: Service plans address all participants assessed needs (including health and safety risk factors) and personal goals, either by the provision of waiver services or through other means.

    Performance Measures

    For each performance measure the State will use to assess compliance with the statutory assurance (or sub-assurance), complete the following. Where possible, include numerator/denominator.

    For each performance measure, provide information on the aggregated data that will enable the State to analyze and assess progress toward the performance measure. In this section provide information on the method by which each source of data is analyzed statistically/deductively or inductively, how themes are identified or conclusions drawn, and how recommendations are formulated, where appropriate.

    Performance Measure:

    Service Plan Number/percentage of participants with an ISP that reflects the participants's needs as identified. Numerator: the number of participants whose ISPs reflect the needs identified by the assessment, clinical records, professional assessments and the personal preferences of the participant. Denominator: a representative sample of participants.

    Data Source (Select one):Record reviews, on-site If 'Other' is selected, specify:

    Data Aggregation and Analysis:

  • Sub-assurance: The State monitors service plan development in accordance with its policies and procedures.

    Performance Measures

    For each performance measure the State will use to assess compliance with the statutory assurance (or sub-assurance), complete the following. Where possible, include numerator/denominator.

    For each performance measure, provide information on the aggregated data that will enable the State to analyze and assess progress toward the performance measure. In this section provide information on the method by which each source of data is analyzed statistically/deductively or inductively, how themes are identified or conclusions drawn, and how recommendations are formulated, where appropriate.

    Performance Measure:

    Timeliness of the Service Plan Number/percent of participants with an ISP submitted within 10 days after the completion of the assessment Numerator: number of participants with an ISP submitted timely Denominator: a representative sample of participants

    Data Source (Select one):Record reviews, on-site If 'Other' is selected, specify:

    Data Aggregation and Analysis:

  • Sub-assurance: Service plans are updated/revised at least annually or when warranted by changes in the waiver participants needs.

    Performance Measures

    For each performance measure the State will use to assess compliance with the statutory assurance (or sub-assurance), complete the following. Where possible, include numerator/denominator.

    For each performance measure, provide information on the aggregated data that will enable the State to analyze and assess progress toward the performance measure. In this section provide information on the method by which each source of data is analyzed statistically/deductively or inductively, how themes are identified or conclusions drawn, and how recommendations are formulated, where appropriate.

    Performance Measure:

    Timeliness of the Service Plan Number/ percent of participants with an ISP submitted within 30 days before or after the 6-month interval from the previous ISP. Numerator: number of participants with an ISP submitted timely Denominator: a representative sample of participants

    Data Source (Select one):Record reviews, on-site If 'Other' is selected, specify:

    Data Aggregation and Analysis:

  • Sub-assurance: Services are delivered in accordance with the service plan, including the type, scope, amount, duration and frequency specified in the service plan.

    Performance Measures

    For each performance measure the State will use to assess compliance with the statutory assurance (or sub-assurance), complete the following. Where possible, include numerator/denominator.

    For each performance measure, provide information on the aggregated data that will enable the State to analyze and assess progress toward the performance measure. In this section provide information on the method by which each source of data is analyzed statistically/deductively or inductively, how themes are identified or conclusions drawn, and how recommendations are formulated, where appropriate.

    Performance Measure:

    Services are delivered according to ISP Number/percent of participants with services delivered in accordance to the ISP Numerator: Number of participants with services delivered in accordance with the ISP. Denominator: a representative sample of participants.

    Data Source (Select one):Record reviews, on-site If 'Other' is selected, specify:

    Data Aggregation and Analysis:

  • Sub-assurance: Participants are afforded choice: Between waiver services and institutional care; and between/among waiver services and providers.

    Performance Measures

    For each performance measure the State will use to assess compliance with the statutory assurance (or sub-assurance), complete the following. Where possible, include numerator/denominator.

    For each performance measure, provide information on the aggregated data that will enable the State to analyze and assess progress toward the performance measure. In this section provide information on the method by which each source of data is analyzed statistically/deductively or inductively, how themes are identified or conclusions drawn, and how recommendations are formulated, where appropriate.

    Performance Measure:

    Participants are offered a choice between waiver services and institutional care Number/ percent of participants with a documented choice between waiver services and institutional care Numerator: number of participants whose Freedom of Choice document is signed, dated and in the CCA chart. Denominator: a representative number of participants.

    Data Source (Select one):Record reviews, on-site If 'Other' is selected, specify:

    Data Aggregation and Analysis:

  • If applicable, in the textbox below provide any necessary additional information on the strategies employed by the State to discover/identify problems/issues within the waiver program, including frequency and parties responsible.

    Character Count: out of 6000

    The DHCS will compile an annual QA Audit and Report summarizing the data and the findings regarding the LOC determinations. These findings are presented to the CCAs (also to the RCF and HHA providers) by the DHCS. The DHCS is responsible for the identification and prioritization of issues as presented. The CCAs are responsible for remediation of those issues, and the efficacy of this process by the documentation of all findings and their remediation in the subsequent assessment submission period.

  • Methods for Remediation/Fixing Individual Problems

  • Describe the States method for addressing individual problems as they are discovered. Include information regarding responsible parties and GENERAL methods for problem correction. In addition, provide information on the methods used by the State to document these items.

    Character Count: out of 6000

    If and when it is determined that the quality assurances are not being met, the DHCS will collect the data, aggregate the data, and present the findings to the providers with systems design change to correct and remediate the identified issues. The DHCS will provide these data and changes in a TA format for all concerned providers. The DHCS will also continue to provide direct TA to providers on a continuous basis as requested and when it is identified that there is a specific need for a given provider. Remediation: Within 60 days of discovery, any non-compliance will result in the DHCS contacting the provider to: • review the data; • determine etiology of non-compliance; • develop CAP with timeline; Resolution Follow-up: The DHCS will: • follow up to determine if the CAP was completed with successful outcome; • monitor the change(s) for continuing compliance; • determine etiology of non-compliance; • develop CAP with timeline.

  • Remediation Data Aggregation

    Remediation-related Data Aggregation and Analysis (including trend identification)
  • Timelines

    When the State does not have all elements of the Quality Improvement Strategy in place, provide timelines to design methods for discovery and remediation related to the assurance of Service Plans that are currently non-operational.
  • Appendix E: Participant Direction of Services

    Applicability (from Application Section 3, Components of the Waiver Request):

    CMS urges states to afford all waiver participants the opportunity to direct their services. Participant direction of services includes the participant exercising decision-making authority over workers who provide services, a participant-managed budget or both. CMS will confer the Independence Plus designation when the waiver evidences a strong commitment to participant direction.

    Indicate whether Independence Plus designation is requested (select one):

    Appendix E: Participant Direction of Services

    E-1: Overview (1 of 13)

    Answers provided in Appendix E-0 indicate that you do not need to submit Appendix E.

    Appendix E: Participant Direction of Services

    E-1: Overview (2 of 13)

    Answers provided in Appendix E-0 indicate that you do not need to submit Appendix E.

    Appendix E: Participant Direction of Services

    E-1: Overview (3 of 13)

    Answers provided in Appendix E-0 indicate that you do not need to submit Appendix E.

    Appendix E: Participant Direction of Services

    E-1: Overview (4 of 13)

    Answers provided in Appendix E-0 indicate that you do not need to submit Appendix E.

    Appendix E: Participant Direction of Services

    E-1: Overview (5 of 13)

    Answers provided in Appendix E-0 indicate that you do not need to submit Appendix E.

    Appendix E: Participant Direction of Services

    E-1: Overview (6 of 13)

    Answers provided in Appendix E-0 indicate that you do not need to submit Appendix E.

    Appendix E: Participant Direction of Services

    E-1: Overview (7 of 13)

    Answers provided in Appendix E-0 indicate that you do not need to submit Appendix E.

    Appendix E: Participant Direction of Services

    E-1: Overview (8 of 13)

    Answers provided in Appendix E-0 indicate that you do not need to submit Appendix E.

    Appendix E: Participant Direction of Services

    E-1: Overview (9 of 13)

    Answers provided in Appendix E-0 indicate that you do not need to submit Appendix E.

    Appendix E: Participant Direction of Services

    E-1: Overview (10 of 13)

    Answers provided in Appendix E-0 indicate that you do not need to submit Appendix E.

    Appendix E: Participant Direction of Services

    E-1: Overview (11 of 13)

    Answers provided in Appendix E-0 indicate that you do not need to submit Appendix E.

    Appendix E: Participant Direction of Services

    E-1: Overview (12 of 13)

    Answers provided in Appendix E-0 indicate that you do not need to submit Appendix E.

    Appendix E: Participant Direction of Services

    E-1: Overview (13 of 13)

    Answers provided in Appendix E-0 indicate that you do not need to submit Appendix E.

    Appendix E: Participant Direction of Services

    E-2: Opportunities for Participant Direction (1 of 6)

    Answers provided in Appendix E-0 indicate that you do not need to submit Appendix E.

    Appendix E: Participant Direction of Services

    E-2: Opportunities for Participant-Direction (2 of 6)

    Answers provided in Appendix E-0 indicate that you do not need to submit Appendix E.

    Appendix E: Participant Direction of Services

    E-2: Opportunities for Participant-Direction (3 of 6)

    Answers provided in Appendix E-0 indicate that you do not need to submit Appendix E.

    Appendix E: Participant Direction of Services

    E-2: Opportunities for Participant-Direction (4 of 6)

    Answers provided in Appendix E-0 indicate that you do not need to submit Appendix E.

    Appendix E: Participant Direction of Services

    E-2: Opportunities for Participant-Direction (5 of 6)

    Answers provided in Appendix E-0 indicate that you do not need to submit Appendix E.

    Appendix E: Participant Direction of Services

    E-2: Opportunities for Participant-Direction (6 of 6)

    Answers provided in Appendix E-0 indicate that you do not need to submit Appendix E.

    Appendix F: Participant Rights

    Appendix F-1: Opportunity to Request a Fair Hearing

    The State provides an opportunity to request a Fair Hearingunder 42 CFR Part 431, Subpart E to individuals: (a) who arenot given the choice of home and community-based services as analternative to the institutional care specified in Item 1-F ofthe request; (b) are denied the service(s) of their choice orthe provider(s) of their choice; or, (c) whose services aredenied, suspended, reduced or terminated. The State provides notice of action as required in 42 CFR 431.210.

    Procedures for Offering Opportunity to Request a Fair Hearing. Describe how the individual (or his/her legal representative) isinformed of the opportunity to request a fair hearing under 42CFR Part 431, Subpart E. Specify the notice(s) that are used to offer individuals the opportunity to request a Fair Hearing. State laws, regulations, policies and noticesreferenced in the description are available to CMS upon request through the operatingor Medicaid agency.

    Character Count: out of 12000

    The CCA is responsible for explaining to individuals, or their legal representative, the services offered through the waiver. CCAs can help individuals make decisions about their choices of living arrangements by explaining the differences between receiving long-term services and supports in a nursing facility and in an RCF or public subsidized housing setting. The CCA is also responsible for informing individuals about resources available to them to determine financial eligibility for long-term services and supports. The Care Coordination Agency Provider Handbook is available to download from the Department of Health Services’ ALW internet home page. The handbook provides guidance to ensure that: • Potential participants, their legal representatives, relatives, or involved persons are informed of the choice of either participating or not participating in the ALW program, if the beneficiary is determined to be eligible for the ALW. • Individuals are informed regarding the ALW’s informal grievance procedures and formal appeal rights, termination procedures, and rights to refuse or discontinue services. • There is an understanding that it is the Department of Health Care Services’ responsibility, when an individual is denied waiver services, or when waiver services are reduced or terminated, to forward a Notice of Action (NOA) to the individual, or his/her legal representative. The NOA contains an explanation for the reason the State is denying, reducing, or terminating services, and provides information on how to ask for a State Hearing, and how to get questions answered, including telephone numbers for free legal aid. • The individual’s choice is documented on the Freedom of Choice document. State Hearings are coordinated and conducted by the California Department of Social Services. Final authority for the adoption of decisions rests with the Director of the Department of Health Care Services, as per Delegation Order #94-151. California will fully comply with the requirements of 42 CFR Part 431, Subpart E. Fair hearings will be conducted through the Medicaid Fair Hearing process. Notices of Action are issued in compliance with the CCR §51014.1 (Fair Hearing Related to Denial, Termination or Reduction in Medical Services).

    Appendix F: Participant-Rights

    Appendix F-2: Additional Dispute Resolution Process

  • Availability of Additional Dispute Resolution Process.Indicate whether the State operates another dispute resolutionprocess that offers participants the opportunity to appealdecisions that adversely affect their services while preservingtheir right to a Fair Hearing. Select one:

     No. This Appendix does not apply

     Yes. The State operates an additional dispute resolution process

     not selected

  • Description of Additional Dispute Resolution Process. Describe the additional dispute resolution process,including: (a) the State agency that operates the process; (b)the nature of the process (i.e., procedures and timeframes),including the types of disputes addressed through the process;and, (c) how the right to a Medicaid Fair Hearing is preservedwhen a participant elects to make use of the process: Statelaws, regulations, and policies referenced in the description areavailable to CMS upon request through the operating or Medicaid agency.

    Character Count: out of 12000

  • Appendix F: Participant-Rights

    Appendix F-3: State Grievance/Complaint System

  • Operation of Grievance/Complaint System.Select one:

     No. This Appendix does not apply

     Yes. The State operates a grievance/complaint system that affords participants the opportunity to register grievances or complaints concerning the provision of services under this waiver

     not selected

  • Operational Responsibility. Specify the State agency that is responsible for the operationof the grievance/complaint system:

    Character Count: out of 4000

  • Description of System. Describe the grievance/complaint system, including: (a) the typesof grievances/complaints that participants may register; (b) theprocess and timelines for addressing grievances/complaints; and,(c) the mechanisms that are used to resolve grievances/complaints.State laws, regulations, and policies referenced in thedescription are available to CMS upon request through the Medicaid agency or theoperating agency (if applicable).

    Character Count: out of 12000

  • Appendix G: Participant Safeguards

    Appendix G-1: Response to Critical Events or Incidents

  • Critical Event or Incident Reporting and Management Process. Indicate whether the State operates Critical Event or Incident Reporting andManagement Process that enables the State to collect information on sentinel eventsoccurring in the waiver program.Select one:

     not selected

     Yes. The State operates a Critical Event or Incident Reporting and Management Process (complete Items b through e)

     No. This Appendix does not apply (do not complete Items b through e)

  • State Critical Event or Incident Reporting Requirements. Specify the types of critical events or incidents (including allegedabuse, neglect and exploitation) that the State requires to bereported for review and follow-up action by an appropriateauthority, the individuals and/or entities that are required toreport such events and incidents and the timelines for reporting.State laws, regulations, and policies that are referencedare available to CMS upon request through the Medicaid agency or the operating agency(if applicable).

    Character Count: out of 24000

    The RCFs and are required to submit Serious Incident Reports (SIR) to CCL as per Title 22. For the purposes of the ALW, the RCF and HHA providers are required to submit a SIR to the CCA and DHCS within 24 hours of occurrence. A routine SIR may be submitted within 72 hours. CCR Title 22§ 87211 a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: 1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. (A) Death of any resident from any cause regardless of where the death occurred, including but not limited to a day program, a hospital, en route to or from a hospital, or visiting away from the facility. (B) Any serious injury as determined by the attending physician and occurring while the resident is under facility supervision. C) The use of an Automated External Defibrillator. (D) Any incident which threatens the welfare, safety or health of any resident, such as physical or psychological abuse of a resident by staff or other residents, or unexplained absence of any resident. (2) Occurrences, such as epidemic outbreaks, poisonings, catastrophes or major accidents which threaten the welfare, safety or health of residents, personnel or visitors, shall be reported within 24 hours either by telephone or facsimile to the licensing agency and to the local health officer when appropriate. (3) Fires or explosions, which occur in or on the premises shall be reported immediately to the local fire authority; in areas not having organized fire services, within 24 hours to the State Fire Marshal; and no later than the next working day to the licensing agency. DHCS requires RCFs and HHAs to submit incident reports to the CCA and DHCS within 24 hours of occurrence for serious incidents or issues, or 72 hours for less serious issues. 1.CCAs e-mail incident reports to the state via a dedicated e-mail box (ALWP.IR@dhcs.ca.gov) which can only be accessed by the ALW Unit staff. 2.Incident reports are reviewed by ALW RN staff. 3.ALW RNs follow up with CCAs as needed. 4.The ALW team informs the California Department of Social Services Community Care Licensing Division when it has been determined that an RCF is restricted from enrolling additional waiver participants. 5.Incident report data is entered into a spreadsheet for tracking purposes and analyzed for trends on an annual basis. DHCS tracks incident reporting activity in the ALW database. The date, type and disposition of the incidents are tracked on a continuous basis.

  • Participant Training and Education. Describe how training and/or information is provided to participants(and/or families or legal representatives, as appropriate) concerningprotections from abuse, neglect, and exploitation, including how participants(and/or families or legal representatives, as appropriate) can notifyappropriate authorities or entities when the participant may haveexperienced abuse, neglect or exploitation.

    Character Count: out of 12000

    The CCA will be responsible for participant training and education. The CCA will discuss with and provide the participant with information regarding abuse, neglect, or exploitation; how to recognize if any of these occur; and whom to contact to report such events/incidents. The CCA will provide additional training as necessary. The CCA is a mandated Adult Protective Services (APS) reporter. The RCF is mandated to post the contact information for the Ombudsman in the facility. The CCA conducts an independent quality assurance visit monthly with the participant and completes a reassessment every six months.

  • Responsibility for Review of and Response to Critical Events or Incidents. Specify the entity (or entities) that receives reports of criticalevents or incidents specified in item G-1-a, the methods that areemployed to evaluate such reports, and the processes and time-framesfor responding to critical events or incidents, including conductinginvestigations.

    Character Count: out of 12000

    The RCF and HHA are required to send a SIR to CCL or L&C within 24 hours respectively. The CCA forwards the SIR to the DHCS. DHCS will investigate when the waiver provider fails to: • Report abuse or neglect of a waiver participant; • Notify the physician of a change in the participant’s condition, if the participant is harmed by the failure of this action; • Inform the participant of their rights; • Provide waiver services as described in the participant's ISP; • Provide adequate notification to the participant when services are changed or terminated; • Act within their professional scope of practice (if verified, L&C will re-direct to licensing entity); • Report suspected or verified medication misuse. Within 30 days of the identification of a trend or pattern of critical events, the provider will be given TA as the nature and severity of the issue. The DHCS will follow up within the next 30 days to assure that the issue is ameliorated. In the event that the problem persists, the DHCS will issue a CAP with a 60-90 day timeframe for remediation. In the event that the provider is unable to fulfill the conditions of the CAP, the provider will be suspended from further waiver enrollment and disallowed from enrolling additional waiver participants. In the event that the provider continues to fail to assure the health and safety of the participants, the DHCS will work in conjunction with CCL, L&C or Medi-Cal Provider Enrollment in the consideration of suspension of the RCF, HHA license or suspension of a CCAs Medi-Cal billing privileges. DHCS will notify the participant, their family or representative of any investigative results within 24 hours of completion of any investigation.

  • Responsibility for Oversight of Critical Incidents and Events. Identify the State agency (or agencies) responsible for overseeingthe reporting of and response to critical incidents or events thataffect waiver participants, how this oversight is conducted, and how frequently.

    Character Count: out of 12000

    The CCA is the first line of quality assurance and is responsible for intervening in the behalf of the participant in the event of a significant event. The SIR is submitted to L&C (HHAs) or CCL (RCFs). The DHCS follows up with the CCA to monitor remediation and prevention of further similar events for the participantas indicated above. In the event that the provider continues to demonstrate the inability to meet the requirements of a waiver provider, the provider shall be disenrolled as a waiver provider and the participants transferred to another locale within 30 days as per CCL.

  • Appendix G: Participant Safeguards

    Appendix G-2: Safeguards Concerning Restraints and Restrictive Interventions (1 of 3)

  • Use of Restraints.(Select one): (For waiver actions submitted before March 2014, responses in Appendix G-2-a will displayinformation for both restraints and seclusion. For most waiver actions submitted afterMarch 2014, responses regarding seclusion appear in Appendix G-2-c.)

     The State does not permit or prohibits the use of restraints

    Specify the State agency (or agencies) responsible for detecting the unauthorizeduse of restraints and how this oversight is conducted and its frequency:

    Character Count: out of 12000

    CCL for the RCFs and L&C for the HHAs

     The use of restraints is permitted during the course of the delivery of waiver services. Complete Items G-2-a-i and G-2-a-ii.

     not selected

  • Appendix G: Participant Safeguards

    Appendix G-2: Safeguards Concerning Restraints and Restrictive Interventions (2 of 3)

  • Use of Restrictive Interventions.(Select one):

     The State does not permit or prohibits the use of restrictive interventions

    Specify the State agency (or agencies) responsible for detecting the unauthorizeduse of restrictive interventions and how this oversight is conducted and its frequency:

    Character Count: out of 12000

    CCL is the licensing and regulatory authority for the RCF. CCL enforces the regulatory language prohibiting unlawful restraints. L&C is responsible for the regulatory management and oversight of the HHA. L&C enforces the regulatory language regarding unlawful restraints.

     The use of restrictive interventions is permitted during the course of the delivery of waiver services Complete Items G-2-b-i and G-2-b-ii.

     not selected

  • Appendix G: Participant Safeguards

    Appendix G-2: Safeguards Concerning Restraints and Restrictive Interventions (3 of 3)

  • Use of Seclusion.(Select one): (This section will be blank for waivers submitted before Appendix G-2-c was added to WMS in March 2014, andresponses for seclusion will display in Appendix G-2-a combined with information on restraints.)

     The State does not permit or prohibits the use of seclusion

     The use of seclusion is permitted during the course of the delivery of waiver services. Complete Items G-2-c-i and G-2-c-ii.

     not selected

  • Appendix G: Participant Safeguards

    Appendix G-3: Medication Management and Administration (1 of 2)

    This Appendix must be completed when waiver services are furnished to participants who are served in licensed or unlicensed living arrangements where a provider has round-the-clock responsibility for the health and welfare of residents. The Appendix does not need to be completed when waiver participants are served exclusively in their own personal residences or in the home of a family member.

  • Applicability.Select one:

     No. This Appendix is not applicable (do not complete the remaining items)

     Yes. This Appendix applies (complete the remaining items)

     not selected

  • Medication Management and Follow-Up

  • Responsibility. Specify the entity (or entities) that have ongoing responsibility formonitoring participant medication regimens, the methods for conducting monitoring,and the frequency of monitoring.

    Character Count: out of 12000

    The RCF is responsible for medication management for the participants unless the participant has a physician order to self-manage his/her medication(s). Medications are maintained in the Medication Room of the RCF and accessed only by the designated staff. The oversight and management of medications is under the auspices of the CCL. In the PSH setting, the participant has responsibility for the maintenance and safeguards of his/her medication. The HHA will assist or administer medications by licensed staff as necessary.

  • Methods of State Oversight and Follow-Up. Describe: (a) the method(s) that the State uses to ensure that participantmedications are managed appropriately, including: (a) the identification of potentiallyharmful practices (e.g., the concurrent use of contraindicated medications); (b) the method(s)for following up on potentially harmful practices; and, (c) the State agency (or agencies) thatis responsible for follow-up and oversight.

    Character Count: out of 12000

    In the RCF setting, the state oversight is provided by the CCA staff. The CCA provides a QA component with the CCA RN review of medications during the semi-annual assessment. CCL employs Licensing Program Analysts (LPAs) to inspect and regulate the RCF. The LPAs inspect the medication room and ensure that the providers are compliant with the regulations governing the storage, administration and documentation of medications. The CCA monitors to ensure that the participants are receiving their medications as per the physician's orders.

  • Appendix G: Participant Safeguards

    Appendix G-3: Medication Management and Administration (2 of 2)

  • Medication Administration by Waiver Providers

  • Provider Administration of Medications.Select one:

     Not applicable. (do not complete the remaining items)

     Waiver providers are responsible for the administration of medications to waiver participants who cannot self-administer and/or have responsibility to oversee participant self-administration of medications. (complete the remaining items)

     not selected

  • State Policy. Summarize the State policies that apply to the administration of medications bywaiver providers or waiver provider responsibilities when participants self-administermedications, including (if applicable) policies concerning medication administration bynon-medical waiver provider personnel. State laws, regulations, and policies referencedin the specification are available to CMS upon request through the Medicaid agency or theoperating agency (if applicable).

    Character Count: out of 12000

    The RCF utilizes medication technicians to assist participants with medications, but the technicians may not administer medications. Under California law, only a licensed nurse (or physician) may administer a medication. The RCF has the ability to assist participants to the extent of passing medications or opening syringes and handing them to the participant, but the participant must have the ability to self-administer the medication or the services of a licensed nurse are required. This requirement is enforced by CCL. Under the ALW, both RCF and HHA providers are required to have skilled nursing staff sufficient to meet the skilled nursing needs of the participant. If the participant is unable to take medication with assistance, the RCF or the HHA is responsible for providing the licensed nurse as needed.

  • Medication Error Reporting.Select one of the following:

     Providers that are responsible for medication administration are required to both record and report medication errors to a State agency (or agencies).

    Complete the following three items:

    (a) Specify State agency (or agencies) to which errors are reported:

    Character Count: out of 12000

    The RCF reports to the CCL and the HHA reports to the L&C.

    (b) Specify the types of medication errors that providers are required to record:

    Character Count: out of 12000

    All medication errors are recorded.

    (c) Specify the types of medication errors that providers must report to the State:

    Character Count: out of 12000

    All medication errors are reported.

     Providers responsible for medication administration are required to record medication errors but make information about medication errors available only when requested by the State.

     not selected

  • State Oversight Responsibility. Specify the State agency (or agencies) responsible for monitoring the performance ofwaiver providers in the administration of medications to waiver participants and how monitoringis performed and its frequency.

    Character Count: out of 12000

    The RCF reports to the CCL and the HHA reports to the L&C. CCL visits all of the RCFs participating in the ALW once every 5 years. DHCS visits the RCF annually. The HHA is visited annually by L&C.

  • Appendix G: Participant Safeguards

    Quality Improvement: Health and Welfare

    As a distinct component of the States quality improvement strategy,provide information in the following fields to detail the Statesmethods for discovery and remediation.

  • Methods for Discovery: Health and Welfare

    The state demonstrates it has designed and implemented an effective system for assuring waiver participant health and welfare. (For waiver actions submitted before June 1, 2014, this assurance read "The State, on an ongoing basis, identifies, addresses, and seeks to prevent the occurrence of abuse, neglect and exploitation.")

  • Sub-Assurances:

  • Sub-assurance: The state demonstrates on an ongoing basis that it identifies, addresses and seeks to prevent instancesof abuse, neglect, exploitation and unexplained death. (Performance measures in this sub-assurance include all Appendix G performance measures for waiver actions submitted before June 1, 2014.)

    Performance Measures

    For each performance measure the State will use to assess compliance with the statutory assurance (or sub-assurance), complete the following. Where possible, include numerator/denominator.

    For each performance measure, provide information on the aggregated data that will enable the State to analyze and assess progress toward the performance measure. In this section provide information on the method by which each source of data is analyzed statistically/deductively or inductively, how themes are identified or conclusions drawn, and how recommendations are formulated, where appropriate.

    Performance Measure:

    Health and Welfare Number and percent of SIRs, specifically occurrences of abuse, neglect and exploitation, reported within the required timeframe. Numerator: number of critical incidents reported in timeframe Denominator: number of critical incidents reported

    Data Source (Select one):Critical events and incident reports If 'Other' is selected, specify:

    Data Aggregation and Analysis:

    Performance Measure:

    Percent of cases reviewed with documentation the CCA has discussed recognizing instances of abuse, neglect or exploitation with the participant or other responsible person. Numerator: number of cases reviewed with documentation CCA discussed recognizing instances of abuse, neglect or exploitation with the participant or other responsible person. Denominator: number of cases reviewed

    Data Source (Select one):Record reviews, off-site If 'Other' is selected, specify:

    Data Aggregation and Analysis:

    Performance Measure:

    Percent of cases reviewed with documentation that the participant or other responsible person are aware of how to report instances of abuse, neglect or exploitation. Numerator: number of cases reviewed with documentation CCA discussed how to report instances of abuse, neglect or exploitation with the participant or other responsible person. Denominator: number of cases reviewed

    Data Source (Select one):Record reviews, off-site If 'Other' is selected, specify:

    Data Aggregation and Analysis:

  • Sub-assurance: The state demonstrates that an incident management system is in place that effectively resolves those incidents and prevents further similar incidents to the extent possible.

    Performance Measures

    For each performance measure the State will use to assess compliance with the statutory assurance (or sub-assurance), complete the following. Where possible, include numerator/denominator.

    For each performance measure, provide information on the aggregated data that will enable the State to analyze and assess progress toward the performance measure. In this section provide information on the method by which each source of data is analyzed statistically/deductively or inductively, how themes are identified or conclusions drawn, and how recommendations are formulated, where appropriate.

  • Sub-assurance: The state policies and procedures for the use or prohibition of restrictive interventions (including restraints and seclusion) are followed.

    Performance Measures

    For each performance measure the State will use to assess compliance with the statutory assurance (or sub-assurance), complete the following. Where possible, include numerator/denominator.

    For each performance measure, provide information on the aggregated data that will enable the State to analyze and assess progress toward the performance measure. In this section provide information on the method by which each source of data is analyzed statistically/deductively or inductively, how themes are identified or conclusions drawn, and how recommendations are formulated, where appropriate.

  • Sub-assurance: The state establishes overall health care standards and monitors those standards based on the responsibility of the service provider as stated in the approved waiver.

    Performance Measures

    For each performance measure the State will use to assess compliance with the statutory assurance (or sub-assurance), complete the following. Where possible, include numerator/denominator.

    For each performance measure, provide information on the aggregated data that will enable the State to analyze and assess progress toward the performance measure. In this section provide information on the method by which each source of data is analyzed statistically/deductively or inductively, how themes are identified or conclusions drawn, and how recommendations are formulated, where appropriate.

  • If applicable, in the textbox below provide any necessary additional information on the strategies employed by the State to discover/identify problems/issues within the waiver program, including frequency and parties responsible.

    Character Count: out of 6000

    The direct providers of the assisted living services are held accountable to assure the health and safety of all participants in their care. The CCA provides the framework for that assurance within the ISP. The CCA also conducts the monthly visit and reassessment every six months to assure that the needs of the participant are being met. The DHCS conducts a 100% review of the documents submitted and an annual QA audit to assure that the health and safety of the participants is not jeopardized. The DHCS retains the authority to restrict enrollment to by any provider of whom there is a question or concern in this regard. The DHCS retains the authority to disenroll any provider who fails to respond to remediation and TA in this regard. Discovery: Monitoring/Prevention The DHCS will annually review a random sample of CCA, HHA and RCF files to verify documentation of continuous monitoring of: • participant risk and risk management, preventative measures to assure health and safety as indicated by the ISP • information provided regarding abuse, neglect and exploitation. Abuse/Neglect The DHCS will review the SIRs as submitted by the providers to verify that suspicion of or observed acts of abuse, neglect and exploitation were identified and immediate appropriate action was taken. Incidents/Complaints The DHCS will review the SIRs with L&C and CCL as appropriate.

  • Methods for Remediation/Fixing Individual Problems

  • Describe the States method for addressing individual problems as they are discovered. Include information regarding responsible parties and GENERAL methods for problem correction. In addition, provide information on the methods used by the State to document these items.

    Character Count: out of 6000

    Remediation: Monitoring/Prevention • The DHCS will notify the provider upon discovery of failure to meet requirements for continuous monitoring and develop a corrective action plan. Abuse/Neglect, Incidents/Complaints • Immediately upon discovery of inappropriate or untimely action in response to a report, the DHCS will notify the responsible party to develop a corrective action plan. Resolution Follow-up: The DHCS will: • Follow up to determine if the corrective action was completed • Monitor the change(s) for continuing compliance.

  • Remediation Data Aggregation

    Remediation-related Data Aggregation and Analysis (including trend identification)
  • Timelines

    When the State does not have all elements of the Quality Improvement Strategy in place, provide timelines to design methods for discovery and remediation related to the assurance of Health and Welfare that are currently non-operational.
  • Appendix H: Quality Improvement Strategy (1 of 2)

    Under 1915(c) of the Social Security Act and 42 CFR 441.302, the approval of an HCBS waiver requires that CMS determine that the State has made satisfactory assurances concerning the protection of participant health and welfare, financial accountability and other elements of waiver operations. Renewal of an existing waiver is contingent upon review by CMS and a finding by CMS that the assurances have been met. By completing the HCBS waiver application, the State specifies how it has designed the waiver’s critical processes, structures and operational features in order to meet these assurances.

    • Quality Improvement is a critical operational feature that an organization employs to continually determine whether it operates in accordance with the approved design of its program, meets statutory and regulatory assurances and requirements, achieves desired outcomes, and identifies opportunities for improvement.

    CMS recognizes that a state’s waiver Quality Improvement Strategy may vary depending on the nature of the waiver target population, the services offered, and the waiver’s relationship to other public programs, and will extend beyond regulatory requirements. However, for the purpose of this application, the State is expected to have, at the minimum, systems in place to measure and improve its own performance in meeting six specific waiver assurances and requirements.

    It may be more efficient and effective for a Quality Improvement Strategy to span multiple waivers and other long-term care services. CMS recognizes the value of this approach and will ask the state to identify other waiver programs and long-term care services that are addressed in the Quality Improvement Strategy.

    Quality Improvement Strategy: Minimum Components

    The Quality Improvement Strategy that will be in effect during the period of the approved waiver is described throughout the waiver in the appendices corresponding to the statutory assurances and sub-assurances. Other documents cited must be available to CMS upon request through the Medicaid agency or the operating agency (if appropriate).

    In the QIS discovery and remediation sections throughout the application (located in Appendices A, B, C, D, G, and I) , a state spells out:

    • The evidence based discovery activities that will be conducted for each of the six major waiver assurances;
    • The remediation activities followed to correct individual problems identified in the implementation of each of the assurances;

    In Appendix H of the application, a State describes (1) the system improvement activities followed in response to aggregated, analyzed discovery and remediation information collected on each of the assurances; (2) the correspondent roles/responsibilities of those conducting assessing and prioritizing improving system corrections and improvements; and (3) the processes the state will follow to continuously assess the effectiveness of the OIS and revise it as necessary and appropriate.

    If the State's Quality Improvement Strategy is not fully developed at the time the waiver application is submitted, the state may provide a work plan to fully develop its Quality Improvement Strategy, including the specific tasks the State plans to undertake during the period the waiver is in effect, the major milestones associated with these tasks, and the entity (or entities) responsible for the completion of these tasks.

    When the Quality Improvement Strategy spans more than one waiver and/or other types of long-term care services under the Medicaid State plan, specify the control numbers for the other waiver programs and/or identify the other long-term services that are addressed in the Quality Improvement Strategy. In instances when the QIS spans more than one waiver, the State must be able to stratify information that is related to each approved waiver program. Unless the State has requested and received approval from CMS for the consolidation of multiple waivers for the purpose of reporting, then the State must stratify information that is related to each approved waiver program, i.e., employ a representative sample for each waiver.

    Appendix H: Quality Improvement Strategy (2 of 2)

    H-1: Systems Improvement

  • System Improvements

  • Describe the process(es) for trending, prioritizing, and implementing system improvements(i.e., design changes) prompted as a result of an analysis of discovery andremediation information.

    Character Count: out of 12000

    The ALW Quality Improvement Strategy (QIS) is designed to provide meaningful performance measures through the review of participant ISPs to identify all health care needs and develop prevention strategies through trend analysis, prioritization of assessed participant risks, and development of specific goals and objectives resulting in the implementation of system improvements. The State assures quality of participant health and welfare by setting proactive quality improvement strategies with participation and collaboration of the CCA in tandem with participants and/or their families, providers, consumer/participant advocates, and local and state agencies. Agreed upon quality improvement goals are set on an annual basis with specified objectives. The State uses reported data to set ad hoc improvement goals as the data and circumstances suggest. This approach is focused on the expectation that through comprehensive development of a participant’s ISP, (which includes all measures of the ALW Assessment Tool - assistance with ADLs, IADLs as they relate to coordinated physical health and community-based supports and services, as well as the seven (7) functional categories of cognitive patterns, behavioral symptoms, continence, communications, medications, skin conditions and other treatments). Each ALW participant will have a greater likelihood of improved health status and quality of life. Concurrently, this process allows early identification and prevention of deterioration of the participant's intake health status while supporting the assurances of 42 CFR §441.301 and §441.302. The ALW uses the participant’s ISP as a gauge to measure all health care needs and develop prevention strategies through qualitative analysis of the services delivered. The ISP focused preventions allow the ALW participants and providers to have a direct role in the quality assessment and quality improvement processes allowing timely interventions to assure early identification of health and welfare needs. Access The CCA is responsible for assessment of the participant for admission into the ALW. The CCA is responsible for the following: • Prior to the participant’s enrollment into the ALW, complete the initial ALW Assessment and develop the initial ISP documenting the participant’s initial health care needs. • As stated in Appendix C-3, the ISP will include specified services to be provided with measureable outcomes for each service. • The ISP will be updated as needed (at a minimum of every 6 months). • The service performance measures are addressed by a regular review of the desired outcome of each health care need with the development of specific action plans if needed to improve or review the participant’s health care needs. • Each ISP review will assess the participant for health and safety needs, including any signs of abuse or neglect that will be immediately reported to APS, DHCS and the L&C. Trending • The DHCS tracks and monitors the following data sources: • ISPs and SIRs from the RCF and the HHA • ISP updates to measure the effectiveness of updated and/or revised service plans • Complaints or concerns voiced by the participants • Concerns identified by the CCAs • The ISPs and SIRs are tracked in a log and trended by provider and type of action. Prioritizing The ALW recognizes the following hierarchy of concerns: 1. Any ISP change, (as detailed in Appendix D) change in presenting health condition(s), altered care delivery goals, intervention needs, and measured outcomes to quantify compliance with waiver health and welfare assurances. 2. All SIRs, specifically; a. Events resulting in participant injury or accident; b. Events resulting in hospitalization or treatment; c. Immediate threats to health and safety; d. Potential threats to health and safety; e. Other health care concerns that may manifest under certain conditions. Implementing 1. The DHCS annual QA audits provides the data for TA to all ALW provider(s). 2. Identified ISP and SIR trends are closely monitored by the DHCS to support the assurances of 42 CFR §441.301 and §441.302. 3. For all assurance problems with providers the DHCS reviews the nature and severity of the problem and, if needed, develops a CAP as indicated for the provider in question. 4. The DHCS continues to monitor and follow up with the provider to ensure that the conditions of the CAP are met and the health and safety needs of the participant are met. 5. If the conditions of the CAP are not addressed, then probationary action is initiated. The DHCS primary systems improvement objective for the QIS is to assure participant health and welfare through the following measures: 1. To identify, quickly and reliably, positive or undesirable trends that will allow for necessary adjustments to enhance overall performance of the system, and act on opportunities for improvement; 2. Assure data undergoes rigorous reliability and validity testing that is used to drive policy and procedure decisions to increase performance; and, 3. Ensure timely discovery and remediation that allows the DHCS to take swift action to improve meaningful outcomes for the participants in the ALW. The QIS process is designed to review all participant reports, assessments, reassessments, special incident reports, critical incidents reports, etc. The following details how the ALW performs trend analysis and prioritizes areas in need of remediation. The ALW Trending/Prioritizing/System Improvement Process: The QIS will determine to what extent each waiver assurance has been met during the reporting period, measure it against ALW goals, and assess and prioritize trends towards the goal of implementing system improvements. 1. Aggregate data is collected for each performance measure. Measures include: participant assessments; reassessments; ISPs and SIRs from the RCFs and the HHAs; complaints or concerns voiced by the participants and concerns as identified by the CCAs. 2. The ALW methodology is to coordinate the analysis of each performance measure, and track data by: participant, frequency, provider type, action, remediation, and systemic issues. Additional data review includes identification of health care needs based on enrollment primary diagnosis and reassessed changes in participant health service tier. 3. The participant’s LOC is reevaluated every 6 months. Trending of these data sources measures the provider's compliance with quality assurance and promotes identification of needed remedial or corrective actions. A combination of audit tools is used to support analysis of the performance measures. 4. CAPs are prioritized based on risk assessment and health and welfare needs of participants. Interventions include a continuum of actions from staff training to removal of provider from the ALW. All CAPs are monitored for efficacy of remedial action. The remedy/improvement may be more appropriately targeted to specific situations. The DHCS primary systems improvement objective for the QIS is to assure participant health and welfare through the following measures: • Identify, quickly and reliably, positive and adverse trends that will allow for necessary adjustments to enhance overall performance of the system, and act on opportunities for improvement; • Assure data that is used to drive policy and procedure decisions undergoes rigorous reliability and validity testing to increase performance; and • Ensure timely discovery and remediation that allows the DHCS to take swift action to improve meaningful outcomes for the participants in the ALW. • Performance Measure Indicator: – All SIRs are followed up within 24 hours by the State and specific licensing agencies as provided in state regulations. Identified ISP and SIR trends are closely monitored by the DHCS to support the assurances of 42 CFR §441.301 and §441.302.

  • System Improvement Activities
  • System Design Changes

  • Describe the process for monitoring and analyzing the effectivenessof system design changes. Include a description of the various roles andresponsibilities involved in the processes for monitoring & assessing systemdesign changes. If applicable, include the State's targeted standards forsystems improvement.

    Character Count: out of 12000

    The Medicaid agency retains the ultimate authority for the assurance of quality and quality improvement in the ALW. The QIS uses a multi-level approach. Each level is designed to promote discovery, identify trends and capture timely remediation information that promote system improvements. Level One: Level of Care Evaluation/Reevaluation • LOC determination as detailed in Appendix B-6 is generated by the CCA prior to initial enrollment and reviewed by the DHCS • Each waiver participant is reassessed for LOC at least every six months or upon significant change by the CCA. All reassessments are reviewed by the DHCS. • The ISP, jointly developed by the participant and the CCA, is used to guide all plan services and safeguards as detailed in the waiver guidance. Level Two: Service Plan • As detailed in Appendix C, the CCA reviews the ISPs monthly with the participant to assure that the participant’s needs are addressed and considered. • The ISPs are developed in accordance to the waiver requirements to identify all health care needs and address health and safety risks of participants, with monthly review by the CCAs and annual review by the DHCS. • The ISPs are revised as needed and at least every six months by the CCAs and reviewed by the DHCS. • Services outlined by the ISP are implemented by staff of the RCFs and HHA, and reviewed monthly by the CCA and annually by the DHCS. • Providers are held accountable for the health and safety of the participants. ISPs are reviewed for completeness and the appropriateness of the interventions for addressing the healthcare needs of the participant as identified in the assessment. Level Three: Coordination of the Qualified Providers • CDSS CCL is responsible for ensuring RCFs meet licensing and certification requirements of the CDSS. • CDPH L&C is responsible for ensuring that HHAs meet the licensing and certification requirements of the CDPH. • DHCS is responsible for annual monitoring to assure provider adherence to waiver requirements, and follow up when providers have not met specified standards. • DHCS is responsible for annually compiling and reviewing data collected from waiver providers and waiver participants for quality assurance. • Providers are responsible for the health and safety of the participants. The CCAs monitor the RCFs and HHAs and the DHCS monitors the CCAs (as well as the RCFs and the HHAs). Level Four: Prevention of instances of abuse, neglect and exploitation • Through the ALW Provider Manual and annual training, the State provides TA to the CCAs and all providers on the identification of abuse, neglect and exploitation, timelines for the notification of specified authorities, and remediation information. • The State reviews all SIRs, with linkages to the State Licensing Agencies. • The State analyzes a statistically significant percentage of SIRs for trends to allow development of risk prevention strategies. Data is reviewed continuously and analyzed annually by the DHCS. • Systemic issues are addressed through CAPs and TA by the DHCS. The DHCS continues to monitor the providers after the deliverance of the TA to assure that the practices are changed according to the CAP and that the issues are remediated. In the event that the systemic issues persist, the DHCS will revisit the provider, offer additional TA and impose sanctions as indicated and as described in H.1.a.i. TA is offered to the providers on a global basis for program-wide systemic issues and on an individual basis for issues pertaining to a particular provider. Level Five: Administrative Authority provided by the DHCS • DHCS is the administrative authority for the ALW that monitor actions of other State agencies and of all providers. • The annual review of provider records and of participant records followed by monitoring and analysis produces the recommended changes brought to the QMS for discussion and action. • The Olmstead Advisory Group and the ALW Stakeholders’ Group provide input to the ALW quality management system. These advisory groups are comprised of primary customers and family members, providers, and advocacy organizations that meet quarterly.

  • Describe the process to periodically evaluate, as appropriate,the Quality Improvement Strategy.

    Character Count: out of 12000

    The Medicaid agency retains the ultimate responsibility for the assurance of quality improvement through the implementation of the QIS. The process for periodic evaluation of the QIS is embedded in the annual QA audit. The audits are based on the performance measures and are held to the standard of the confidence interval. The QIS has a process that separates the programs measures into, 1) required actions taken, indicating that the provider has followed protocols and all corrective measures have been resolved, and 2) corrective actions taken by provider and reported to the QIS prior to audits and/or review of trend analysis. Individual provider problems are based on review of State regulations and policies governing actions specified in licensing guidelines. As required by corrective action findings individual providers will complete specified staff trainings to update staff competencies based on ALW participant's needs. The QIS documents all oversight activities through program letters, coordination of provider continued eligibility as a Medi-Cal contracted provider of ALW services, noted in all provider records, maintained in a running record in the providers files, and update reports to CMS as required.

  • Appendix I: Financial Accountability

    I-1: Financial Integrity and Accountability

    Financial Integrity. Describe the methods that are employed to ensure the integrity of payments thathave been made for waiver services, including: (a) requirements concerning the independentaudit of provider agencies; (b) the financial audit program that the state conducts toensure the integrity of provider billings for Medicaid payment of waiver services,including the methods, scope and frequency of audits; and, (c) the agency (or agencies)responsible for conducting the financial audit program. State laws, regulations, and policiesreferenced in the description are available to CMS upon request through the Medicaid agency orthe operating agency (if applicable).

    Character Count: out of 12000

    The Health Insurance Portability and Accountability Act (HIPAA) Compliant HCPCS Codes are unique to each waiver service. Each provider type is only eligible to bill for the wavier service(s)they render. The billing is via a standardized billing form,the UB-04. Claims are submitted to the fiscal intermediary for payment. Only recognized Medi-Cal billers may be paid for waiver services. ALW Alpha Provider Category of HIPPA Rate Restrictions Service Prefix Type Services Compliant for billing Provider HCPCS Codes Care Coordination CCA 93118 G9002 $200 Once per client, per month NF Transition Care Coordination (Care Coordinator) CCA 93 118 G9001 $1,000 Once per client, per lifetime Assisted Living Services RCF 92119 T2031 U1 $52One tier per client HHA 14 119 T2031 U2 $62per day,in the T2031 U3 $71RCF or PSH setting. T2031 U4 $82 T2031 U5 $200 Residential habilitation services are available to participants residing in both an RCF and a PSH. Residential Habilitation Services will be provided by the home health agency in addition to regular Assisted Living Services to participants residing in PSH settings. Residential Habilitation RCF 92 119 T2017 U4 $4.50 Per 15 minutes HHA 14 119 Service Assessment/ Plan of Care Development CCA 93 118 T2024 $200 Enhanced care coordination; may be billed in addition to Care Coordination for participants requiring additional services. Per month Audits are conducted at three levels: 1) The DHCS examines the provider records and contrasts and compares the records with the authorized services; 2) The Audits and Investigations Division (A&I) is available to conduct a more detailed financial analysis in the event of suspicious billing practices; and 3) The state conducts routine, random audits of all Medi-Cal billers to ensure competency and accuracy in the paid claims. A&I is responsible for ensuring the fiscal integrity and medical necessity of Medi-Cal program services. All claims submitted by waiver and state plan providers are subject to random review regardless of provider type, specialty, or service rendered. A&I verifies that claims selected have sufficient documentation to approve the claim for payment. Providers are notified if a claim requires additional documentation before approval for payment. Failure to comply with the request for additional documentation may result in suspension from the Medi-Cal program, pursuant to W&I §14124.2. A&I has three branches that conduct reviews using various methodologies to ensure program integrity and the validity of claims for reimbursement. The A&I Medical Review Branch (MRB) performs essential medical reviews of non-institutional providers. Providers may also be subject to a more comprehensive review on a weekly basis known as a pre-checkwrite review. This review is based on a set of criteria, such as irregular billing patterns, designed to identify potential fraud or abuse. Providers selected for this more comprehensive review may receive an on-site visit by A&I staff. Many of these reviews result in program removal, monetary penalties, or less intrusive sanctions and utilization controls. The MRB also conducts Medi-Cal provider anti-fraud activities that include performing field reviews on new Medi-Cal providers and providers undergoing re-enrollment. MRB is charged with bringing closure to sanctioned providers through audits designed to quantify the abuse, settlement agreement, or permissive suspensions (exclusions) from the Medi-Cal program. Failure to comply with any request by A&I staff for documentation may result in administrative sanctions, including suspension from the Medi-Cal program, pursuant to W&I §14124.2. MRB staff work closely with the fiscal intermediary in data mining and extracting processes as well as the performance of the annual Medi-Cal Payment Error Study. The A&I Financial Audits Branch performs cost settlement and rate setting audits of institutional providers, i.e. hospitals, nursing facilities, and certain clinics. The A&I Investigations Branch (IB) conducts investigations of suspected Medi-Cal beneficiary fraud as well as preliminary investigations of provider fraud. IB is also responsible for coordinating provider fraud referrals to the state Department of Justice (DOJ) and Federal Bureau of Investigations. Suspected fraud or abuse identified through any audit or investigation process is referred to the DOJ via the IB. IB and MRB coordinate the placing of administrative sanctions on providers with substantiated evidence of fraud. IB serves as DHCS' principal liaison with outside law enforcement and prosecutorial entities on Medi-Cal fraud.

    Appendix I: Financial Accountability

    Quality Improvement: Financial Accountability

    As a distinct component of the States quality improvement strategy,provide information in the following fields to detail the Statesmethods for discovery and remediation.

  • Methods for Discovery: Financial Accountability

    State financial oversight exists to assure that claims are coded and paid for in accordance with the reimbursement methodology specified in the approved waiver. (For waiver actions submitted before June 1, 2014, this assurance read "State financial oversight exists to assure that claims are coded and paid for in accordance with the reimbursement methodology specified in the approved waiver.")

  • Sub-Assurances:

  • Sub-assurance: The State provides evidence that claims are coded and paid for in accordance with the reimbursement methodology specified in the approved waiver and only for services rendered. (Performance measures in this sub-assurance include all Appendix I performance measures for waiver actions submitted before June 1, 2014.)

    Performance Measures

    For each performance measure the State will use to assess compliance with the statutory assurance (or sub-assurance), complete the following. Where possible, include numerator/denominator.

    For each performance measure, provide information on the aggregated data that will enable the State to analyze and assess progress toward the performance measure. In this section provide information on the method by which each source of data is analyzed statistically/deductively or inductively, how themes are identified or conclusions drawn, and how recommendations are formulated, where appropriate.

    Performance Measure:

    Financial Accountability Number/percent of remediation actions necessitated by the continuous quality monitoring of the CCAs Numerator: number of remediation actions taken against CCAs Denominator: number of CCAs

    Data Source (Select one):Other If 'Other' is selected, specify:

    1. DHCS Audits-provider records, contracts of authorized services 2. A&I conducts detailed financial analysis on all suspicious biling 3. State Medicaid Agency conducts random audits

    Data Aggregation and Analysis:

    Performance Measure:

    Financial Accountability Number/percent of remediation actions necessitated by the continuous quality monitoring of the HHAs Numerator: number of remediation actions taken against HHA Denominator: number of HHAs

    Data Source (Select one):Other If 'Other' is selected, specify:

    1. DHCS Audits-provider records, contracts of authorized services 2. A&I conducts detailed financial analysis on all suspicious biling 3. State Medicaid Agency conducts random audits

    Data Aggregation and Analysis:

    Performance Measure:

    Financial Accountability Number/percent of remediation actions necessitated by the continuous quality monitoring of the RCFs. Numerator: number of remediation actions taken against RCFs Denominator: number of RCFs

    Data Source (Select one):Other If 'Other' is selected, specify:

    1. DHCS Audits-provider records, contracts of authorized services 2. A&I conducts detailed financial analysis on all suspicious biling 3. State Medicaid Agency conducts random audits

    Data Aggregation and Analysis:

  • Sub-assurance: The state provides evidence that rates remain consistent with the approved rate methodology throughout the five year waiver cycle.

    Performance Measures

    For each performance measure the State will use to assess compliance with the statutory assurance (or sub-assurance), complete the following. Where possible, include numerator/denominator.

    For each performance measure, provide information on the aggregated data that will enable the State to analyze and assess progress toward the performance measure. In this section provide information on the method by which each source of data is analyzed statistically/deductively or inductively, how themes are identified or conclusions drawn, and how recommendations are formulated, where appropriate.

  • If applicable, in the textbox below provide any necessary additional information on the strategies employed by the State to discover/identify problems/issues within the waiver program, including frequency and parties responsible.

    Character Count: out of 6000

    Discovery: The DHCS will annually review a random sample of paid claims data to assure that claims are coded and paid for in accordance with the reimbursement methodology specified in Appendix I-3 of the approved waiver.

  • Methods for Remediation/Fixing Individual Problems

  • Describe the States method for addressing individual problems as they are discovered. Include information regarding responsible parties and GENERAL methods for problem correction. In addition, provide information on the methods used by the State to document these items.

    Character Count: out of 6000

    In the event that a discrepancy is discovered, the provider would be given a plan for remediation, a timeframe in which to implement the changes in their billing practices as described in the plan to achieve the indicated improvement and then perfect design changes to ensure continuance of enhanced practice.

  • Remediation Data Aggregation

    Remediation-related Data Aggregation and Analysis (including trend identification)
  • Timelines

    When the State does not have all elements of the Quality Improvement Strategy in place, provide timelines to design methods for discovery and remediation related to the assurance of Financial Accountability that are currently non-operational.
  • Appendix I: Financial Accountability

    I-2: Rates, Billing and Claims (1 of 3)

  • Rate Determination Methods. In two pages or less, describe the methods that are employed to establish providerpayment rates for waiver services and the entity or entities that are responsible for ratedetermination. Indicate any opportunity for public comment in the process. If differentmethods are employed for various types of services, the description may group services forwhich the same method is employed. State laws, regulations, and policies referenced in thedescription are available upon request to CMS through the Medicaid agency or the operatingagency (if applicable).

    Character Count: out of 12000

    DHCS released the design and reimbursement structure of the ALW in a series of public stakeholder meetings in the summer of 2005. The original four tiers of service and the Care Coordination service remain cost neutral with the assumption that ALW participant use of state plan services does not generally exceed the predicted annual average of $5,300. The estimate of the Assisted Living bundled services was preliminarily calculated by developing a comprehensive provider business model. Additional information for the development of the rates came from researching the cost of providing similar services in waiver programs in other states including Oregon, Washington, and Vermont. For all services except the Assisted Living bundled service, costs were developed by the State from estimates of unit price and utilization. The State developed unit price estimates by benchmarking these services against services in California’s MSSP and NF A/B waiver programs. The new reimbursement structure, which includes the addition of Tier five has been publicly presented through a stakeholder meeting held August 29, 2013 and reflects the severity of the physical, mental and cognitive condition of an individual with traumatic brain injury as an ALW participant. The increase rate for Assisted Living Services and the addition of Residential Habilitation and Augmented Plan of Care Development and Follow-Up(both services available to participants in all tiers) will ensure appropriate care and supervision of all ALW participants. The State arrived at the rate of $1,000 for NF Transition by estimating the amount of work necessary to transition an individual from a SNF into the waiver, within the limitations of cost effectiveness standards and yet still offering a financial incentive to Care Coordinators to actively pursue the NF transition. The increased reimbursement rate for Tier five, Assisted Living Services is based upon the statewide weighted average NF-B rate. The rate for Residential Habilitation is based upon conversations with private facilities that provide Tier five LOC that have informed DHCS of their costs for providing these services. $4.50 per 15 minutes is at the low end of a range of costs obtained by DHCS and has been chosen to protect the expenditure of state and federal dollars. The rate for Augmented Plan of Care Development and Follow-Up is based upon the assumption that many participants will require approximately 11 hours per month of this type of service that would be reimbursed at the Medi-Cal home and community-based services waiver, home health agency case management rate of $11.36 per 15 minutes or an additional $200 per month. Tier five will continue to provide cost neutrality in the aggregate with the assumption that the use of State Plan services will not generally exceed the predicted annual average of $5,300. All waiver participants will continue to receive the services they are entitled to through the waiver and the State Plan. This waiver will not violate the Medicaid comparability requirement that services must be comparable, and are based on medical necessity, not enrollment in another Medicaid program. The Long-Term Care Division holds direct responsibility for determining rates and for oversight of the rate determination process. A list of all reimbursement rates are posted on the ALW website at: http://www.dhcs.ca.gov/services/ltc/Pages/ALWPP.aspx and is reviewed at stakeholder meetings prior to implementation.

  • Flow of Billings. Describe the flow of billings for waiver services, specifying whether provider billingsflow directly from providers to the State's claims payment system or whether billings are routedthrough other intermediary entities. If billings flow through other intermediary entities,specify the entities:

    Character Count: out of 6000

    The providers bill the fiscal intermediary directly using the UB-04 standardized billing form.

  • Appendix I: Financial Accountability

    I-2: Rates, Billing and Claims (2 of 3)

  • Certifying Public Expenditures(select one):

  • Appendix I: Financial Accountability

    I-2: Rates, Billing and Claims (3 of 3)

  • Billing Validation Process. Describe the process for validating provider billings to produce the claimfor federal financial participation, including the mechanism(s) to assure that allclaims for payment are made only: (a) when the individual was eligible for Medicaidwaiver payment on the date of service; (b) when the service was included in the participant'sapproved service plan; and, (c) the services were provided:

    Character Count: out of 6000

    All ALW participants have full-scope Medi-Cal eligibility. The CCA confirms eligibility at the time a participant is enrolled by obtaining a Medi-Cal eligibility printout. The CCA continues to verify Medi-Cal eligibility monthly. The CCA completes the Assessment Tool and verifies the NF LOC status of a potential participant. To enroll a participant into the ALW, the CCA forwards the enrollment forms for processing to the DHCS. Claims submitted for each participant are processed through the California Medi-Cal Management Information System to check for Medi-Cal eligibility prior to payment. DHCS will regularly review a random sample of paid claims to assure that claims are coded and paid for in accordance with services included in the participant’s service plan and verified by monthly visits conducted by the CCA.

  • Billing and Claims Record Maintenance Requirement.Records documenting the audit trail of adjudicated claims (including supporting documentation) aremaintained by the Medicaid agency, the operating agency (if applicable), and providers of waiver servicesfor a minimum period of 3 years as required in 45 CFR 92.42.

  • Appendix I: Financial Accountability

    I-3: Payment (1 of 7)

  • Method of payments -- MMIS(select one):

     Payments for all waiver services are made through an approved Medicaid Management Information System (MMIS).

     Payments for some, but not all, waiver services are made through an approved MMIS.

     Payments for waiver services are not made through an approved MMIS.

     Payments for waiver services are made by a managed care entity or entities. The managed care entity is paid a monthly capitated payment per eligible enrollee through an approved MMIS.

     not selected

  • Appendix I: Financial Accountability

    I-3: Payment (2 of 7)

  • Direct payment.In addition to providing that the Medicaid agency makes payments directly to providers of waiver services, payments for waiver services are made utilizing one or more of the following arrangements (select at least one):

    The Medicaid agency makes payments directly and does not use a fiscal agent (comprehensive or limited) or a managed care entity or entities.

    The Medicaid agency pays providers through the same fiscal agent used for the rest of the Medicaid program.

    The Medicaid agency pays providers of some or all waiver services through the use of a limited fiscal agent.

    Providers are paid by a managed care entity or entities for services that are included in the State's contract with the entity.

  • Appendix I: Financial Accountability

    I-3: Payment (3 of 7)

  • Supplemental or Enhanced Payments.Section 1902(a)(30) requires that payments for services be consistent with efficiency, economy, and quality of care. Section 1903(a)(1) provides for Federal financial participation to States for expenditures for services under an approved State plan/waiver.Specify whether supplemental or enhanced payments are made. Select one:

  • Appendix I: Financial Accountability

    I-3: Payment (4 of 7)

  • Payments to State or Local Government Providers.Specify whether State or local government providers receive payment for the provision of waiver services.

     No. State or local government providers do not receive payment for waiver services. Do not complete Item I-3-e.

     Yes. State or local government providers receive payment for waiver services. Complete Item I-3-e.

     not selected

  • Appendix I: Financial Accountability

    I-3: Payment (5 of 7)

  • Amount of Payment to State or Local Government Providers.

    Specify whether any State or local government provider receives payments(including regular and any supplemental payments) that in the aggregateexceed its reasonable costs of providing waiver services and, if so,whether and how the State recoups the excess and returns the Federalshare of the excess to CMS on the quarterly expenditure report.Select one:

    Answers provided in Appendix I-3-d indicate that you do not need to complete this section.

  • Appendix I: Financial Accountability

    I-3: Payment (6 of 7)

  • Provider Retention of Payments.Section 1903(a)(1) provides that Federal matching funds are only available for expenditures made by statesfor services under the approved waiver. Select one:

     Providers receive and retain 100 percent of the amount claimed to CMS for waiver services.

     Providers do not receive and retain 100 percent of the amount claimed to CMS for waiver services.

     Providers are paid by a managed care entity (or entities) that is paid a monthly capitated payment.

     not selected

  • Appendix I: Financial Accountability

    I-3: Payment (7 of 7)

  • Additional Payment Arrangements

  • Voluntary Reassignment of Payments to a Governmental Agency.Select one:

  • Organized Health Care Delivery System.Select one:

  • Contracts with MCOs, PIHPs or PAHPs.Select one:

     The State does not contract with MCOs, PIHPs or PAHPs for the provision of waiver services.

     The State contracts with a Managed Care Organization(s) (MCOs) and/or prepaid inpatient health plan(s) (PIHP) or prepaid ambulatory health plan(s) (PAHP) under the provisions of §1915(a)(1) of the Act for the delivery of waiver and other services. Participants may voluntarily elect to receive waiver and other services through such MCOs or prepaid health plans. Contracts with these health plans are on file at the State Medicaid agency.

     This waiver is a part of a concurrent §1915(b)/§1915(c) waiver. Participants are required to obtain waiver and other services through a MCO and/or prepaid inpatient health plan (PIHP) or a prepaid ambulatory health plan (PAHP). The §1915(b) waiver specifies the types of health plans that are used and how payments to these plans are made.

     not selected

  • Appendix I: Financial Accountability

    I-4: Non-Federal Matching Funds (1 of 3)

  • State Level Source(s) of the Non-Federal Share of Computable Waiver Costs.Specify the State source or sources of the non-federal share of computable waiver costs. Select at least one:

    Appropriation of State Tax Revenues to the State Medicaid agency

    Appropriation of State Tax Revenues to a State Agency other than the Medicaid Agency.

    Other State Level Source(s) of Funds.

  • Appendix I: Financial Accountability

    I-4: Non-Federal Matching Funds (2 of 3)

  • Local Government or Other Source(s) of the Non-Federal Share of Computable Waiver Costs.Specify the source or sources of the non-federal share of computable waiver costs that are not from state sources. Select One:

     Not Applicable. There are no local government level sources of funds utilized as the non-federal share.

     Applicable

     not selected

  • Appendix I: Financial Accountability

    I-4: Non-Federal Matching Funds (3 of 3)

  • Information Concerning Certain Sources of Funds.Indicate whether any of the funds listed in Items I-4-a or I-4-b that make upthe non-federal share of computable waiver costs come from the following sources:(a) health care-related taxes or fees;(b) provider-related donations; and/or,(c) federal funds.Select one:

     None of the specified sources of funds contribute to the non-federal share of computable waiver costs

     The following source(s) are used

     not selected

  • Appendix I: Financial Accountability

    I-5: Exclusion of Medicaid Payment for Room and Board

  • Services Furnished in Residential Settings.Select one:

     No services under this waiver are furnished in residential settings other than the private residence of the individual.

     As specified in Appendix C, the State furnishes waiver services in residential settings other than the personal home of the individual.

     not selected

  • Method for Excluding the Cost of Room and Board Furnished in Residential Settings. The following describes the methodology that the State uses to exclude Medicaid payment for room and board in residential settings:

    Character Count: out of 12000

    In the RCF setting, the participant pays the facility directly for the provision of room and board at the beginning of the month from his/her SSI/SSP income, retaining the Personal Needs Allowance as governed by regulation. The facility bills the Medi-Cal program for the care rendered at the end of the month, only billing for the days in which the participant was enrolled in the waiver. In the PSH setting, the participant pays their rent directly to the housing authority. The HHA is responsible for the preparation of food, but not the purchase of bulk food items

  • Appendix I: Financial Accountability

    I-6: Payment for Rent and Food Expenses of an Unrelated Live-In Caregiver

    Reimbursement for the Rent and Food Expenses of an Unrelated Live-In Personal Caregiver.Select one:

    Appendix I: Financial Accountability

    I-7: Participant Co-Payments for Waiver Services and Other Cost Sharing (1 of 5)

  • Co-Payment Requirements.Specify whether the State imposes a co-payment or similar charge upon waiver participants forwaiver services. These charges are calculated per service andhave the effect of reducing the total computable claim for federal financial participation.Select one:

     No. The State does not impose a co-payment or similar charge upon participants for waiver services.

     Yes. The State imposes a co-payment or similar charge upon participants for one or more waiver services.

     not selected

  • Appendix I: Financial Accountability

    I-7: Participant Co-Payments for Waiver Services and Other Cost Sharing (2 of 5)

  • Co-Payment Requirements.

  • Participants Subject to Co-pay Charges for Waiver Services.

    Answers provided in Appendix I-7-a indicate that you do not need to complete this section.

  • Appendix I: Financial Accountability

    I-7: Participant Co-Payments for WaiverServices and Other Cost Sharing (3 of 5)

  • Co-Payment Requirements.

  • Amount of Co-Pay Charges forWaiver Services.

    Answers provided in Appendix I-7-a indicate that you do not need to complete this section.

  • Appendix I: Financial Accountability

    I-7: Participant Co-Payments for Waiver Services and Other Cost Sharing (4 of 5)

  • Co-Payment Requirements.

  • Cumulative Maximum Charges.

    Answers provided in Appendix I-7-a indicate that you do not need to complete this section.

  • Appendix I: Financial Accountability

    I-7: Participant Co-Payments for Waiver Services and Other Cost Sharing (5 of 5)

  • Other State Requirement for Cost Sharing.Specify whether the State imposes a premium, enrollment fee or similar cost sharing onwaiver participants. Select one:

  • Appendix J: Cost Neutrality Demonstration

    J-1: Composite Overview and Demonstration of Cost-Neutrality Formula

    Composite Overview. Complete the fields in Cols. 3, 5 and 6 in the following table for each waiver year. The fieldsin Cols. 4, 7 and 8 are auto-calculated based on entries in Cols 3, 5, and 6. The fields in Col. 2 areauto-calculated using the Factor D data from the J-2-d Estimate of Factor D tables.Col. 2 fields will be populated ONLY when the Estimate of Factor D tables in J-2-d have been completed.

    Level(s) of Care: Nursing Facility

    Appendix J: Cost Neutrality Demonstration

    J-2: Derivation of Estimates (1 of 9)

  • Number Of Unduplicated Participants Served. Enter the total number of unduplicated participants from Item B-3-a who will be served each year that the waiver is in operation. When the waiver serves individuals under more than one level of care, specify the number of unduplicated participants for each level of care:

  • Appendix J: Cost Neutrality Demonstration

    J-2: Derivation of Estimates (2 of 9)

  • Average Length of Stay. Describe the basis of the estimate of the average length of stay on the waiver by participants in item J-2-a.

    Character Count: out of 6000

    The Average Length of Stay (ALOS) for waiver participants is 247 days. The ALOS is based on the most recent available 372 data. ALW enrollment experience shows that participants enrolled in the waiver will maintain continuous enrollment until forced to leave due to illness or death. The ALOS is expected to remain constant each waiver year.

  • Appendix J: Cost Neutrality Demonstration

    J-2: Derivation of Estimates (3 of 9)

  • Derivation of Estimates for Each Factor. Provide a narrative description for the derivation of the estimates of the following factors.

  • Factor D Derivation. The estimates of Factor D for each waiver year are located in Item J-2-d. The basis for these estimates is as follows:

    Character Count: out of 12000

    The last five years of the ALW there has been a consistent enrollment at the different Tier levels: Tier 1 33% Tier 2 17% Tier 3 28% Tier 4 22% It is anticipated that Tier 5 will be <1% of waiver enrollment. Factor D is calculated as the average cost for waiver services per year based on paid claims data for the past three years. It is anticipated that NF Transition Services will be rendered to one-third of new enrollees. The figure of $1,000 is derived from the estimation that NF transition is the equivalent of 5 months of Care Coordination. The ALW is working closely with the CCT program and it is anticipated that all additional NF transitions will be in conjunction with CCT. It is anticipanted that Service Assessment/Plan of Care Development will be utilized by 10% of enrollees in this waiver. It is anticipated that Residential Habilitation will be utilized by 10% of enrollees in this waiver. For the estimate of Factor D costs it is assumed that the average usage of this service will be 12 hours per day for every day the participant is enrolled.

  • Factor D' Derivation. The estimates of Factor D' for each waiver year are included in Item J-1. The basis of these estimates is as follows:

    Character Count: out of 12000

    Factor D'is the average cost for utilization of state plan Medicaid services per year based on the actual paid claims data over the last three years. There is no projected increase in these costs. This is attributed to the steady utilization of State Plan services and an effective educational program to reduce the use of emergency room care in favor of physician visits. Increases in access to and the cost of Medicaid services are not anticipated to increase. Medicare Part D drug costs are not included in the Factor D estimates.

  • Factor G Derivation. The estimates of Factor G for each waiver year are included in Item J-1. The basis of these estimates is as follows:

    Character Count: out of 12000

    The values for G and G' in the waiver renewal application are based on the average Medi-Cal nursing facility and State Plan costs of individuals in California. The values for G and G'are weighted to a 365 day year. This is based on the assumption that the relative peer group in the institutional setting remains in place for a time period of greater than one year. The values for the ALW are static. The Factor G estimates for inpatient NF A/B costs are from weighted daily facility rate for NF-A and NF-B facilities of $142.00 per day. It is assumed that if a participant were to reside in a NF facility rather than accessing ALW services, the participant would remain in place for the full year. The weighted average is calculated at 365 days. There is no anticipated increase in NF reimbursement.

  • Factor G' Derivation. The estimates of Factor G' for each waiver year are included in Item J-1. The basis of these estimates is as follows:

    Character Count: out of 12000

    The Factor G' estimates the state plan services utilization during inpatient NF A/B hospitalization. There is no anticipated increase in state plan services reimbursement. The Factor G estimate reflects actual utilization during inpatient NF A/B hospitalization. This figure ($5,395) is based on the average reported in the following CMS 372 Reports: WY 3 (January 1, 2008 - December 31, 2008) WY 1 (March 1, 2009 - February 28, 2010) WY 2 (March 1, 2010 - February 28, 2011) Factor G' is not projected to increase. Medicare Part D drug costs are not included in the Factor G' estimates

  • Appendix J: Cost Neutrality Demonstration

    J-2: Derivation of Estimates (4 of 9)

    Component management for waiver services. If the service(s) below includes two or more discrete services that arereimbursed separately, or is a bundled service, each component of the service must be listed.Select “manage components” toadd these components.

    Waiver Services
    Assisted Living Services - Homemaker; Home Health Aide; Personal Care
    Care Coordination
    Residential Habilitation
    Augmented Plan of Care Development and Follow-up
    NF Transition Care Coordination

    Appendix J: Cost Neutrality Demonstration

    J-2: Derivation of Estimates (5 of 9)

  • Estimate of Factor D.

    i. Non-Concurrent Waiver. Complete the following table for each waiver year.Enter data into the Unit, # Users, Avg. Units Per User, and Avg. Cost/Unit fieldsfor all the Waiver Service/Component items.Select Save and Calculate to automatically calculate and populate the Component Costs and Total Costs fields.All fields in this table must be completed in order to populate the Factor D fields in the J-1 Composite Overview table.

  • Waiver Year: Year 1

    Appendix J: Cost Neutrality Demonstration

    J-2: Derivation of Estimates (6 of 9)

  • Estimate of Factor D.

    i. Non-Concurrent Waiver. Complete the following table for each waiver year.Enter data into the Unit, # Users, Avg. Units Per User, and Avg. Cost/Unit fieldsfor all the Waiver Service/Component items.Select Save and Calculate to automatically calculate and populate the Component Costs and Total Costs fields.All fields in this table must be completed in order to populate the Factor D fields in the J-1 Composite Overview table.

  • Waiver Year: Year 2

    Appendix J: Cost Neutrality Demonstration

    J-2: Derivation of Estimates (7 of 9)

  • Estimate of Factor D.

    i. Non-Concurrent Waiver. Complete the following table for each waiver year.Enter data into the Unit, # Users, Avg. Units Per User, and Avg. Cost/Unit fieldsfor all the Waiver Service/Component items.Select Save and Calculate to automatically calculate and populate the Component Costs and Total Costs fields.All fields in this table must be completed in order to populate the Factor D fields in the J-1 Composite Overview table.

  • Waiver Year: Year 3

    Appendix J: Cost Neutrality Demonstration

    J-2: Derivation of Estimates (8 of 9)

  • Estimate of Factor D.

    i. Non-Concurrent Waiver. Complete the following table for each waiver year.Enter data into the Unit, # Users, Avg. Units Per User, and Avg. Cost/Unit fieldsfor all the Waiver Service/Component items.Select Save and Calculate to automatically calculate and populate the Component Costs and Total Costs fields.All fields in this table must be completed in order to populate the Factor D fields in the J-1 Composite Overview table.

  • Waiver Year: Year 4

    Appendix J: Cost Neutrality Demonstration

    J-2: Derivation of Estimates (9 of 9)

  • Estimate of Factor D.

    i. Non-Concurrent Waiver. Complete the following table for each waiver year.Enter data into the Unit, # Users, Avg. Units Per User, and Avg. Cost/Unit fieldsfor all the Waiver Service/Component items.Select Save and Calculate to automatically calculate and populate the Component Costs and Total Costs fields.All fields in this table must be completed in order to populate the Factor D fields in the J-1 Composite Overview table.

  • Waiver Year: Year 5

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