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Intent of New HCBS Rules
Effective 3/2014:
• Better align HCBS Medicaid funding and program requirements with civil rights protections afforded under ADA
• Address concerns that in some states HCBS used to fund “institutional-style” settings lacking opportunities for people to engage meaningfully in their communities
• Ensure that individuals have full access to the benefits of community living and the opportunity to receive services in the most integrated setting appropriate to their needs
2
Key Points to keep in mind:
• Outcome oriented – focuses on nature and quality of individuals’ experience in the setting
• The regulations focus on whether individuals supported have the “same degree of access” as others in the community
• 4 Years Left until CMS requires full compliance in March 2019
• Person Centered Planning and Process Requirements effective now — not subject to five year phase in
10/25/2016 3
NYS’s Transition Plan
• Originally submitted March 2015
• CMS Letter September 2015---requiring more detail, timelines, milestones, etc.
• Amended and published July 2016 for public input through September 9th 2016
https://www.health.ny.gov/health_care/medicaid/redesign/home_community_based_settings.htm
• Anticipated To be resubmitted to CMS Fall/Winter 2016
10/25/2016 4
Highlights of OPWDD’s
Transition Plan • New policy decision reflected: “OPWDD has
decided to limit the size of group homes for new development to no more than 4 persons by the end of 2019” (unless an exception is approved by the Commissioner)
• Sheltered Work Shop Conversions to Integrated Settings
• ICF Conversions to Waiver Settings
• Assessment Results and Lessons Learned
10/25/2016 5
What is “Heightened Scrutiny”?
• Process for submitting evidence to the CMS
Secretary for settings that CMS “presumes not to
be HCBS” where the state finds that the setting can
meet HCBS under a “heightened scrutiny”
threshold.
• State must overcome the presumption and prove
that such settings are not institutional in nature
and do not isolate people with disabilities from
the broader community.
7
Which settings trigger Heightened
Scrutiny?
8
1 • Located in a building on grounds of public institution;
2
• Located in a building that is also publically or privately operated facility providing inpatient institutional treatment;
3 • Immediately adjacent to public institution;
4 • Converted from an ICF on or after March 17, 2014;
5
• Multiple settings collocated and operationally related that isolate and/or inhibit interactions with the broader community
6
• Settings that isolate people that receive HCBS from the broader community of people who do not receive HCBS
Why Heightened Scrutiny?
10/25/2016 9
Exam
ple
s:
1. Gated communities for people with disabilities
2. Farmsteads or disability specific farm communities
3. Residential schools
4. Private campus settings/ Multiple settings co-located and operationally related
Wh
y?
Little ability to access the broader community
People served only interact with others receiving services or paid staff
All activities/services provided on-site so people don’t have to leave
People don’t typically leave to access the community as part of their day to day lives
”Thus, the setting typically does not afford individuals the opportunity to fully engage in community ...”
What we look for when designating a
setting Heightened Scrutiny
“Settings That Isolate”
Does the setting have the effect of isolating
individuals? Practices and operations—what is the
experience of the people in the setting?
and
Does the setting have institutional qualities instead
of HCBS qualities? Again, what is the experience of
people in the setting?
10
Heightened Scrutiny Settings
Identified by DQI as of 10/17/16
11
Total Settings
Reviewed to
Date
Total Triggered
for Heightened
Scrutiny
%
All Settings 6,430 217 3.4%
Residential 5,654 146 2.6%
Day Program 775 71 9.2%
Residential Heightened Scrutiny - Issues
(out of 146 Settings)
26%
24%
22%
15%
12%
0%
5%
10%
15%
20%
25%
30%
Access to Community Rights Protections SiteOperations/Practices
Individualized HabPlanning
Environmental
Percent Not Met by Protocol Section
Percent Not Met
12
At CMS level, North Dakota - only HS
determination to date
10/25/2016 13
Each had his/her own room
Homes and rooms reflected individual choice, interests, hobbies
People interacted with broader community on a daily basis, including many community activities
All 10 people engaged in wide variety of employment or education activities including entrepreneurial
Residential (on grounds
of ICF campus)
APPROVED
Majority of participants spend majority of their day on-site
Activities take place on ICF campus alongside ICF residents under the direct supervision of ICF staff
CMS finds that the Day Program does not meet characteristics of HCBS because the majority of individuals receive most of their services at the facility-based program and are not integrated into the greater community.
Day Setting on Grounds of ICF—NOT APPROVED
Remember:
All HCBS waiver services/settings must meet HCBS
standards by 10/1/2018
Only settings triggering “heightened scrutiny,” (HS) according to the criteria (HS), undergo HS process if OPWDD
believes the setting can meet HCBS
characteristics and requirements
10/25/2016 14
Heightened Scrutiny process is
setting/site specific but all settings
need to meet HCBS rules
What Does a Heightened Scrutiny
Designation Mean for the Setting
and its Provider?
• It does not mean that the setting has to close and/or
that it can no longer be funded by HCBS. However,
the setting must be able to adhere to HCBS
regulations to remain a HCBS waiver service.
• It does mean the setting is subject to a higher burden
of proof that it meets or can meet community
standards and is not isolating/institutional.
– i.e.: Public Input and CMS Submission of Evidence
10/25/2016 15
Person Centered Planning Includes
Habilitation Planning
10/25/2016 17
PCP is at the center of the HCBS settings rule. This is not just about creating a nice PC plan!
If you don’t know what the person’s interests, likes, dislikes, dreams and aspirations are, or, if the person doesn’t know either – you can’t meet the essence of the rules
On-going discovery and learning has to be part of the service delivery model and practice - making the PCP a living “document”
Requires a transition from a “service life” model to a “community life” model - but this takes learning
Requires training for the entire organization on what person-centered thinking means
10/25/2016 18
Facilitate Meaningful Community Access
Provide and post information about community events and happenings for residents and facilitate information sharing and informed choice making
1 Incorporate priorities/preferences for meaningful community activities into the Hab Planning process including supports needed for the person to participate
2
Consider adjustments to staff schedules/creative scheduling during peak hours when community events would be occurring even just a day or two a week
3
Encourage people to use natural supports, neighborhood folks, co-workers, etc for community participation when possible. 4
Review and discuss which individuals can participate in a community event without requiring staff support, update the Individual Plans of Protective oversight (IPOP) accordingly and begin allowing alone time in the community when appropriate
5
Facilitate Meaningful Community Access:
10/25/2016 19
Encourage settings to coordinate access to transportation with each other when possible. Encourage people with similar interests to participate in an activity with each other, when desired.
6
Incorporate travel training into routine habilitation activities for increased access to public transportation. Where available, encourage use of public transportation
7
Post taxi information, bus lines, etc in a visible location and train people to utilize these services 8
Through person-centered planning meetings, determine what natural support resources are available to assist in carrying out specific community interests. Incorporate this discussion into routine person-centered reviews as a topic of further discussion.
9
Heightened Scrutiny Evidence
Needs to Document That:
• Setting is integrated in the community to the extent that a person
without a disability in the same community would consider it a part
of their community and would not associate it with the provision of
services
• Individuals participate regularly in typical community life activities
outside of the setting to the extent the individual desires
• Community activities foster relationships with community members
• Services to the individual, and activities in which the individual
participates are engaged with the broader community
10/25/2016 20
Services Provided Reflect and
Document:
10/25/2016 21
Access
• to community based on individual desires
Variety
•of activities/ offerings —both individualized and small group activities
Quality
•cultural competency, measures to increase community access and decrease social isolation (e.g., CQL POMs)
Services Provided Reflect and
Document:
10/25/2016 22
Choice
Autonomy
Self-direction
Control over
Personal Resources
Individual Rights
Documentation
10/25/2016 23
• Incorporate “learning logs/ discovery” documentation in
every day progress notes or data collection formats
• Set up easy charting that allow selection from choice of
activities and preferences from PCP assessments’
established list of activities and preferences
• Establish concurrent documentation formats/procedures that
actively engage staff and individuals with documenting
experience and reaction to community/inclusive activities
• Ensure facility-based service activities/programming is
emphasizing self-direction, personal growth and control, has
choice for personal preferences and interests etc.
Considerations 10/25/2016 24
Invest time and resources into effective practices.
Build your social capital at all levels.
Explore traditional and non-traditional revenue
sources.
Do it one person at a time, and do it a lot of times
until you’re done. You’ll get better at what you do.
Start small – clear the path. Don't get stuck in planning, processing and waiting for
the right “time” for change.
Hire for who you want to become, not for who you
are.
Our buildings should be places for people to come
and go – not to stay.
We shouldn’t provide things here that exist
naturally in the community.
General Tips: • Look at existing policies & procedures to determine
whether they are compliant with HCBS settings
requirements. Revise and retrain staff accordingly
based on revisions.
• Provide ongoing staff trainings on HCBS rights,
respectful interactions, privacy, and providing support to
explore individualized personal interests. Explain that
blanket assumptions about capabilities (such as access
to keys) cannot be arbitrarily decided by staff without
informed consent and due process. Remind staff that
blanket schedules and general house rules are
institutional, restrictive, and discouraged.
10/25/2016 25
• Look at residential physical plant areas to ensure
locks are available, access to typical areas is
present, and overtly institutional appearances are
minimized when possible.
• Train and educate residents on community access,
choice, and overall HCBS rights of individuals
• Incorporate person-centered discussions on
interests, rights, satisfaction, availability of natural
supports, etc into ISP review/Hab Plan expectations
10/25/2016 26
General Tips:
Where to Get More Information?
OPWDD HCBS Settings Toolkit: http://www.opwdd.ny.gov/opwdd_services_supports/HCBS/hcb
s-settings-toolkit
www.hcbsadvocacy.org
CMS Toolkit: www.medicaid.gov/hcbs
27
Site Review Activities – What Remains
Required Routine Activities:
• IRMA and RIA review
• Entrance conference (information gathering)
• Request documentation
• Observe individuals in their environment & during their
activities including mealtime (with historical exceptions)
• Converse with individuals, DSPs, and as needed
clinicians and other agency staff
• Review for compliance with regulatory standards
included in Protocol
• Validate effective correction of previous deficiencies
• Exit conference/Exit Conference Form (ECF)
• OFPC Activities
Site Review – What’s New • Consistent gathering of information the site and the
people receiving supports (Info Gathering/Entrance)
• Track documentation requested and agency timely
response
• Integrates routine assessment of HCBS Settings
Requirements
• Includes quality standards in some environments
• Required Conditional Activities: “Qualifier Questions”
(QQs) determine need to review some of the protocol standards
Review that a sample of people with a specific high risk
needs are appropriately supported regarding that need.
Site Review
Site Protocol Sections
• Heightened Scrutiny Triggers (New? Changes?)
• Health Support and Medication
• Personal Funds
• General Operations for: Individualized Choice, Autonomy & Satisfaction
• Delivery of Safeguards, Services and Supports
• Rights and Protections
• Site and Safety
• Fire Safety
• Site Specific Requirements
• Special Risk Factors
Section 1:
Heightened Scrutiny Triggers
• Applies to certified sites where HCBS
waiver services are delivered
• Same 6 standards currently included
on the Heightened Scrutiny/HCBS
Settings Protocol
10/25/2016 33
Section 4: Individualized Choice, Autonomy & Satisfaction
• Includes HCBS settings expectations
• Mechanism to assess satisfaction with service/service setting; agency response to dissatisfaction
• Autonomy fostered, independent access
• Privacy in physical space
• Access to community activities
• Meaningful activities
• Cultural, Religious, Lifestyle choices supported
10/25/2016 34
Section 6:
Rights and Protections
• Includes HCBS settings rights
• Respectful Interactions
• Rights assured and protected
• Access to facility not limited
• Privacy of personal information
• Personal control/choice regarding eating
• Incident reporting, protection, prevention
10/25/2016 35
Section 7: Site and Safety
• Residences: “home-like”
• Site allows visitors a time of choosing
• No surveillance cameras
• Site appropriate to individuals
• Supplies/equipment to meet needs
• Site cleanliness, maintenance and safety
• Time Out Room Requirements
10/25/2016 36
Site Protocol – Examples of Application of HCBS Standards to Other Settings
Current Protocol Requirement Source New, Reviewing also in these settings:
Are (consumers) afforded all rights guaranteed by regulation?
• Universal 633 rights mesh with HCBS requirements to move the whole service system forward
Encouraged to have full access to the community; Sufficient transportation and sufficient staff allocation for individualized choices of activities and schedules (3 items)
• Heightened Scrutiny (now)
• HCBS Settings Assessments
(2014-2015)
All day programs: Day Treatments, Day Trainings
Private Schools Free Standing Respite
Mechanism to assess living arrangement and roommate choice
• Same as above All sites where individuals reside
Mechanism to assess satisfaction and timely action to address
• Same as above All certified sites
Mechanism for increased independence/access to home, access to environment and control privacy of space and info
• Same as above
Private Schools
Site Protocol – Examples of Application of HCBS Standards to Other Settings
Current Protocol Requirement Source New, Reviewing also in these settings:
Schedules/routines personally determined per needs, interests, and preferences (rather than per staff or agency operations).
• Heightened Scrutiny (now)
• HCBS Settings Assessments
(2014-2015)
All sites where individuals reside
Individuals are supported to exercise control and choice in lives, including cultural, religious and lifestyle choices (2 items)
• Same as above All certified sites
Site absent of rules/policies that limit rights, independence, choice, autonomy. Visitors as preferred. (2 items)
• Same as above All certified sites
Access and choice of food and when to eat.
• Same as above Private Schools
Person Centered Review
• Review of any and all services a person receives from all provider agencies providing their services
• Implemented for provided sample (earlier slide)
• Applicable no matter how or where individual receives services/supports
• Includes service and site specific requirements related to: Person Centered service planning
Person Centered service delivery
HCBS requirements if supported in certified site
Safeguards: minimize risks
Rights, health, safeguards, behavioral supports, protections
Quality of life - Outcomes
PCR Activities • Conversation with individual regarding:
– Services they receive, options they were provided, how they came to decide, planning process to get them there
– What they do, what they want to do, where they see their life going
– Satisfaction… are services meeting expectations, getting them to goals, service delivery, service effectiveness?
• Conversation with relevant service developers, service implementers
• Review of each service the person receives in a manner similar to current practices
• Review of service planning and effectiveness of risk identification and planning
• Verify Desired Outcomes are occurring
Agency Review
• Regulatory and quality expectations designed, implemented and managed at the agency level
• Sample (based on agency size) verification of compliance for selected regulatory requirements: hiring, training, personal allowance, incident management.
• Agency practices and strategies that influence quality outcomes: – Attention to Outcomes for individuals
– Community connections
– Workforce
– Quality improvement planning and strategies
– Agency management
3 Routine Review Types and Protocols
Type-
Name
Start
Date
Purpose of
Activity
Scope of
Activity
Site
Review
10.03.16 Health, safety,
well-being and
HCBS
compliance
≈ 7,300 sites:
100% certified non-ICF sites
Person-
Centered
Review
12.2016 Individual’s
needs, goals &
outcomes are
met through
comprehensive
service planning
& delivery
400 DOH ISP
1100 Statewide
1500 Individuals - Full PCR
+ ≈ 250 Individuals in HS Sites (Partial PCR)
+ ≈1500 WB Individuals in IRAs (Partial PCR)
Agency
Review
01.2017 Verify effective
systems and
quality oversight
700+ agencies
Questions on HCBS Settings
• Maryellen Moeser
518-473-2599 for Transition Plan, timelines, policy, etc.
• [email protected] for DQI site review and heightened scrutiny designations and notifications
43