1 Department of Medical Assistance Services 1 Department of Medical Assistance Services

http://dmasva.dmas.virginia.gov/ 1

Department of Medical Assistance Services

Division of Long-Term CareDepartment of Medical Assistance Services

http://dmasva.dmas.virginia.gov 1

DD Waiver Services

Objectives of Training

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

Development of the DD waiver

Development of the (DD) Waiver• DMAS was directed by the 1999 General

Assembly session to develop a new waiver for persons with developmental disabilities.

• DMAS formed a work group consisting of consumers, advocates, providers and state agencies that met nine times from May 10, 1999 through May 18, 2000 to discuss waiver development issues.

Work Group Goals• Option to institutionalization• Consumer-directed whenever possible• Services in the workplace when possible• Individually tailored services• Coordinate with schools and other training

• Maximize other financial resources• Minimize duplication of resources

Development of the (DD) Waiver• DMAS submitted a report to the 2000

General Assembly session proposing the development of a new waiver.

• DMAS requested and received approval from the Centers for Medicare and Medicaid services (CMS) in May 2000 to begin implementation of the DD waiver on July 1, 2000.

• This waiver would be more consumer-driven and provide additional supports to families.

Development of DD Waiver• In order to get waiver approval from CMS,

there must be an alternative institutional placement.

• For the DD waiver the alternative placement must be an Intermediate Care Facility for the Mentally Retarded (ICF/MR).

Eligible for (DD) Waiver• The individual must be 6 years of age and

older and meet the “related conditions” requirements of C.F.R. § 435.1009, including autism;

• May not have a diagnosis of intellectual disability (ID) as defined by the American Association on Developmental Disabilities (AAIDD)

Individual and Family Developmental Disabilities Support (DD) Waiver• Meet the level of care for admission to an

Intermediate Care Facility for the Mentally Retarded (ICF/MR).

Covered Services

• Adult Companion Services

• Assistive Technology

• Crisis Stabilization

• Crisis Supervision

• Environmental Modifications

• In-home Residential Support• Day Support• Skilled Nursing

• Supported Employment• Therapeutic Consultation• Personal Emergency Response System• Family/Caregiver Training• Respite Care • Personal Attendant Services • Prevocational Services• Transition services- MFP

• Case Management (State Plan Option)

In-home Residential Support Services Service Definition

In-home Residential Support Service Definition• Training and assistance or specialized

supervision• Most training occurs in an individual’s home

or residence considered to be his/her home• In-home support does not include room and

• Enables an individual to acquire, improve, or maintain: – Activities of daily living (ADLs)– Access community resources– Adapt to the community/daily environment – Safety skills and health status

In-home Residential Support Services

• Supplemental to the care provided by a parent or similar caregiver

• May support an individual whose level of independence does not require a primary

caregiver

In-home Residential Support Service Definition• May not be provided for a continuous 24-

hour period

• Training is provided in the home or community

• Supports are delivered on a 1:1 staff to individual ratio

Person Centered Approach

This service should provide empowerment and support to the individual so that he or she may develop his or her own individual lifestyle

In-home Residential Support Training and Assistance Activities

In-home Residential Support Activities• Functional skills training in personal care

activities such as: – Toileting, Bathing, Grooming, Dressing, Eating,

Mobility, Communication, Household Chores, Food Preparation, Money Management, Shopping etc.

• Functional skills training in use of community resources such as:– Transportation, Shopping, Social/Recreational

Activities• Training to help the individual adapt his

behavior to home and community environments

In-home Residential Support Activities Continued• Assistance with personal care tasks, e.g. ADLs

and community resources, if the individual is physically unable to learn these tasks

• Monitoring health, physical condition and medical needs

• Ensure completion of hygiene, nutrition and other tasks essential to health and welfare.

• Support with shopping, banking, laundry, arranging transportation etc.

• There must be documentation on the schedule for the type of assistance being provided.

In-home Residential Support Criteria• May not be provided simultaneously with

personal care, respite care, attendant care or CD respite care services

• Must be prior-authorized• Should be provided at frequency allowing

for systematic training and maintenance of functional supports

• Individual must be present

In-home Residential Support Criteria

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

• 12VAC30-120-750 (B) (2)

In-home Residential Support hours and limitations• Total billing can not exceed total hours

approved by DMAS on the individual’s POC• Documentation of dates, times, and services

provided • Any circumstances that prevented the

individual from receiving all scheduled hours

• If fewer than all the hours scheduled on the POC are delivered on a regular basis, over a 60-day period, the provider should determine if there is a need to request a revised POC reducing the hours

In-home Residential Support hours and limitations• General Supervision is non-billable

• Examples of General Supervision:– Awake staff coverage at night if the

individual generally sleeps throughout the night

– Oversight of leisure activities– Routine bed checks– Asleep staff at night on the premises for

security and/or safety reasons– Staff “on call” during the day while the

individual is participates in work/day support/school activities

In-home Residential Support

•Specialized Supervision

In-home Residential Support Specialized Supervision Provides staff

presence for ongoing or intermittent intervention to ensure the individual’s health and safety.

DMAS 457 must clearly document the individual’s need for this support.

Provider DMAS 457 form must contain a specialized supervision objective outlining the staff’s activities and specific times that these activities will occur

Activities must relate to the assessed health and safety needs of the individual

In-home Residential Support Specialized Supervision• May include hours throughout the entire

night, but only if documentation supports the request

• Ongoing need for this service should be documented in semi-annual reviews– If, over a 60-day period, the hours of

Specialized Supervision actually provided are consistently less than the scheduled-upon, approved, and determined amount, the provider is expected to revise the DMAS-457 form, the weekly schedule, and amount to reflect this reduction.

In-home Residential Restrictions With Other Services• In-Home

Residential Support services will not be authorized for the primary purpose of supervision or personal care.

In-home Residential Support Documentation

Supporting Documentation (457) indicates:–Need for the service–Amount and type of activities

(objectives and goals)Schedule of services–Total hours per day–Total hours per week

• In-home may not necessarily be required daily, but POC must reflect needs and appropriate allowable activities to be provided on a periodic basis

• Additional hours when clearly justified need to be requested through the case manager

• Reimbursed for hours of direct staff time with individual only

• Must be authorized by DMAS

• Services explicitly detailed in Supporting Documentation

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

In-home Residential Support Documentation• Semi-annual Reviews:

– Must be reviewed with individual• General status of individual• Significant events• Individual/family satisfaction with services

• Any revision to Plan of Care (POC) and supporting documentation

• Submitted to case manager

In-home Residential Support DocumentationSupervision of direct care staff:

– Monthly contacts/Semi-annual home visits– Signature of responsible supervisor– Date of contact/observation– Person contacted/observed– Staff performance and service delivery– Problems, concerns, individual satisfaction with

services– Actions planned/taken to correct problems

In home Residential Support Documentation

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

In-home Supporting Documentation Overview

Day Support Services

Day Support Service Definitions• Variety of training• Assistance• Support• Specialized supervision (other than home

or individual residence)• Peer Interactions

• Specialized supervision for the acquisition

• Retention • Improvement of self help• Socialization• Adaptive skills

Day Support Service Definition Continued• Providers are

reimbursed only for the amount and type of day support services included in the individual’s approved Plan of Care. This does not include prevocational services. 12VAC30-120-752(A)

Day Support ActivitiesFunctional training in:

– Self, social & environmental awareness– Sensory, gross and fine motor skills– Communication – Personal care– Problem-solving skills– Using community resources– Community safety– Peer interactions

Day Support Criteria• Must have demonstrated need for training,

assistance and supervision– in settings outside of home– to access in-home residential services– to increase current level of independence– to sustain skills

• Individuals cannot benefit from Supported Employment

Day Support Criteria• Functional

Assessment must be conducted by the provider to evaluate each individual in his home environment and community settings.

Day Support Types and Levels• Types:

– Center-Based– Non Center-Based

• Levels:– Regular– Intensive

Day Support Intensive Level Criteria• Must meet at least one of the following

criteria:– Need for physical assistance for caring for

personal needs– Extensive disability-related difficulties,

requiring additional staff support– Extensive constant supervision to reduce or

eliminate behaviors that preclude full participation in the program.

Formal behavioral plan is required to address behaviors

(Withdrawal, self injury, aggression or self stimulation)

Day Support Services Documentation

Day Support Services DocumentationSupporting Documentation (457) indicates:

– Need for the service– Amount and type of activities (objectives and

goals)

Schedule of services– Total hours per day– Total hours per week– Maximum not to exceed 780 units per plan

Day Support Services Documentation• Services and documentation must be

separate and distinguishable from In-Home Residential Support or Personal Care

• Service cannot be provided in individual’s home without prior authorization from Kepro

Day Support Services Documentation • Documentation must confirm the

following:

• Attendance

• Amount of individual’s time in service

• Specific information regarding individual’s response to various settings

Day Support Services Documentation• Supports as agreed

to in the supporting documentation objectives

• Assessment results must be available in at least a daily note or weekly summary

Day Support Services Documentation• Provider must

review the supporting documentation with the individual or family/caregiver for annual review and revisions

• Submit to case manager at least semiannually

Day Support Services Documentation• Attendance log or

similar document must be maintained indicating the following:

• Date• Type of services

rendered

• Number of Hours or Units provided (including specific time frame)

• Center-based or non center-based

• Regular or intensive level

Day Support Service Blocks• 1 - 3.99 hours =1 block

• 4 - 6.99 hours = 2 block

• 7 or more hours = 3 block

Day Support Supporting Documentation Overview

Questions

Quality Management Review (QMR)

Contact InformationLong-Term Care Division

Division of Long-Term Care Telephone

804-225-4222 Fax 804-612-0050

www.dmas.virginia.gov

Supported Employment Services

Supported Employment Service Description• Paid employment• Community

worksites with people without disabilities

• Specialized supervision and training

• Ongoing support

Supported EmploymentActivities• Training in specific job and related skills• Ongoing or intermittent assistance• Specialized supervision to ensure health

and safety• Contacts with employer, family members,

other support services needed for initiating, maintaining and evaluating employment

Supported EmploymentCriteria• Service cannot be available from DRS or

school system (must be documented)• Generally follows DRS time-limited

services• Assessment must clearly reflect need for

ongoing supports on the job• Reimbursed only for services included in

Supported EmploymentIndividual Model

– Regular community job– Job coach services– Usually one to one– Intermittent support– Reimbursement for specific interventions only,

including collateral contacts, not time on the job

Supported EmploymentGroup Model

– 8 or fewer people with disabilities– Integration with people without disabilities– Enclave– Work Crew– Entrepreneurial– Benchwork/Electronics Assembly

Supported Employment Service Limitations• Transportation not included in service

• Case manager must determine and document supported employment services not available from DRS or school

Supported Employment DocumentationSupporting Documentation (457) indicates:

– Need for the service– Amount and type of activities (objectives and

goals)

Schedule of services– Total hours per day– Total hours per week– Maximum not to exceed 780 units per plan

year for SE enclave

Supported Employment Documentation• Attendance log or

similar document must be maintained indicating the following:

• Date• Type of services

rendered

• Number of Hours or Units provided (including specific time frame)

• Center-based or non center-based

• Regular or intensive level

Supported EmploymentService Units• Individual Supported Employment (SE)

billed hourly

• Group Supported Employment billed at unit rate:1 - 3.99 hours = 1 blocks 4 - 6.99 hours = 2 blocks7 or more hours = 3 blocks

Supported Employment Supporting Documentation Overview

Therapeutic Consultation Services

Therapeutic Consultation Service DefinitionTherapeutic consultation provides expertise,

training, and technical assistance in any of the following specialty areas to assist family members, caregivers, and other service providers in supporting the individual.

Specialty Areas for Therapeutic Consultation are:

Psychology Rehabilitation Occupational Therapy

Behavioral Consultation

Psychiatry Social Work

Therapeutic Recreation

Psychiatric Clinical Nursing

Therapeutic Consultation Activities1. Interviewing the individual and relevant

family members, caregivers, and other service providers to identify issues to be addressed and desired outcomes of consultation;

2. Observing the individual in natural and structured settings, or both;

3. Developing data collection mechanisms and direct collection of baseline data;

Therapeutic Consultation Activities Continued4. Assessing the individual’s present and

potential level of functioning, including the use of instruments to measure areas of adaptation or skills (but not to measure intelligence);

5. Observing and assessing current intervention or support strategies being used with the consumer;

6. Design and develop supporting documentation detailing interventions and support strategies to address identified issues and desired outcomes;

Therapeutic Consultation Activities Continued7. Demonstrate specialized, therapeutic

interventions or supports;8. Train relevant persons to implement

specific interventions or support techniques;

9. Train relevant persons to observe individual, record data, and monitor implementation of therapeutic interventions or support strategies;

10. Review documentation and evaluate activities conducted by family members, caregivers, or program staff; and

Therapeutic Consultation Activities Continued11. Train and provide technical assistance to

family members, caregivers and other individual primarily responsible for carrying out the Individual’s Service Plan

Therapeutic Consultation Criteria Continued• The Plan of Care (POC) must clearly reflect

individual’s needs, for specialized consultation provided to caregivers in order to implement the plan of care effectively.

Therapeutic Consultation Criteria Continued

• Therapeutic Consultation services may not include direct therapy, nor duplicate the activities of other services available to the individual through the State Plan for Medical Assistance.

Therapeutic ConsultationCriteria Continued• Behavioral Consultation may be

provided in absence of other DD Waiver services when consultation provided to informal caregivers is necessary to prevent institutionalization

• TC services, other than behavior consultation, may be provided in In-Home Residential or Day Support settings or in office settings in conjunction with another Waiver service.

Therapeutic Consultation Documentation• The following information is required in the

supporting documentation:• Identifying information• Targeted objectives, timeframes, expected

outcomes• Specific consultation activities• Written support plan detailing

interventions or support strategies

Therapeutic Consultation Documentation continued

• Summary of consultative activities for the month

• Dates, locations, times of service delivery

• Supporting documentation objectives addressed

• Specific details of the activities conducted

• Services delivered as planned or modified

• Effectiveness of the strategies and satisfaction of services

Monthly and contact notes:

Therapeutic Consultation Documentation continued• Semi-annual Reviews

are required if provider extends three months longer should be forwarded to case manager

• Activities related to therapeutic consultation supporting documentation

• Individual status and satisfaction with services

• Consultation outcomes and effectiveness

Therapeutic Consultation Documentation continued• If consultation

services extend less than three months:

• Forward a copy of monthly contact notes or a summary to case manager for semi annual review

Therapeutic Consultation Documentation continued• A final disposition summary must be

forwarded to the case manager within 30 days following the end of this service must include:

• Strategies utilized• Objectives met• Unresolved issues• Consultant recommendations

12VAC30-120-756 (6)

Service Units and Limitations• Unit of service is one hour • Services must be explicitly detailed in

supporting documentation

• Case managers must submit prior authorization to Kepro

Therapeutic Consultation Supporting Documentation

Questions?• This is your time to ask questions. How

may we help you?

Contact InformationLong-Term Care Division

Division of Long-Term Care Telephone

804-225-4222 Fax 804-612-0050

www.dmas.virginia.gov

1 Department of Medical Assistance Services 1 Department of Medical Assistance Services

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