Section 29-4217. REIMBURSEMENT RATES:ENVIRONMENTAL ACCESSIBILITY ADAPTION

 

4217.1A case management service provider shall conduct all case management services for waiver recipients.

 

4217.2Case management services are ongoing activities and shall include the following:

 

(a)Conducting direct observation of the recipient;

 

(b)Conducting financial and functional eligibility screening, contact, or interaction with the recipient's authorized representative;

 

(c)Conducting a comprehensive assessment of the recipient's medical, social, and functional status to include obtainment of level of care determination and financial eligibility documentation;

 

(d)Assisting the recipient with identification and selection of approved and enrolled service providers subject to the recipient's choice;

 

(e)Assisting the recipient with securing necessary physician orders when required for the initiation of any service;

 

(f)Determining and developing the recipient's ISP in collaboration with an interdisciplinary team of professionals and including the recipient or authorized representative, family members, friends, providers of health related services, recipient's physician, and legal guardian, where appropriate, in establishment of the service plan;

 

(g)Presenting the ISP (including goals, service providers, frequency, and duration of services) to the recipient or representative for acceptance;

 

(h)Submitting the ISP to MAA for review and approval;

 

(i)Assisting the recipient with initiating service provision, confidentiality, and measuring the recipient's progress against the ISP; and providing telephone reassurance and friendly visiting to recipients as part of the case management program;

 

(j)Conducting a periodic (at least quarterly) review of the recipient's ISP;

 

(k)Assisting the recipient in gaining access to needed Medicaid-financed services and all other needed supports (for example, medical, financial, counseling, housing, adult day care, and personal assistance) that are necessary to maintain the recipient in the community;

 

(l)Coordinating all waiver services for the recipients so that services provided to recipients are delivered in a safe, timely, and cost effective manner; providing supportive counseling to the recipient and family as appropriate; and addressing and resolving identified problems;

 

(m)Coordinating and monitoring necessary and appropriate services in a timely manner (including twenty-four (24) hour crisis coverage) for the waiver recipient as specified in the recipient's ISP;

 

(n)Providing information about non-Medicaid programs and services for which the recipient might be eligible; referring the recipient to the proper service as necessary; and providing assistance to the recipient in gaining public benefits and linkages to community resources;

 

(o)Documenting monthly in-home visits and telephone contacts;

 

(p)Reviewing and approving the ISP of the direct care and other service providers in a timely manner, and maintaining copies in the recipient's record;

 

(q)Ensuring the provision of supplies and equipment for use in the recipient's care;

 

(r)Providing supportive counseling to the recipient and family, as appropriate;

 

(s)Ensuring the cost-effectiveness of the recommended waiver services;

 

(t)Coordinating multiple services or providers; and providing on-going assessment of the recipient's continued appropriateness for participation in the waiver;

 

(u)On-going monitoring of the implementation of ISP to ensure quality of care and service provisions;

 

(v)Ensuring that the recipient obtains annual (and as needed) level of care certification, and ensuring that the information is forwarded to MAA prior to the expiration of the current certification period;

 

(w)Documenting quarterly reviews that provide a synopsis of the recipient's care and outcomes within a defined period; and

 

(y)Maintaining records necessary to provide supportive documentation of all case management services provided.

 

4217.3When conducting quarterly reviews, the case manager shall also include the following documentation as part of the complete synopsis of the recipient's care and outcomes for a defined period:

 

(a)Utilization of services;

 

(b)Communication with other providers regarding the recipient's goals and progress;

 

(c)Identification and resolution of problems; and

 

(d)Referrals or linkages to community resources.

 

4217.4A case management aide shall assist the case manager in the implementation of the recipient's ISP.

 

4217.5A case management aide shall conduct the following duties:

 

(a)Provide clerical support to the case manager; and

 

(b)Assist the case manager with contacting service providers and arranging for the provision of recipient services consistent with the approved ISP.

 

4217.6Case management aides shall not conduct the following activities:

 

(a)Recipient's assessment;

 

(b)Development of the recipient's ISP; and

 

(c)In-home visitations.

 

4217.7A unit of case management services for the recipient's initial assessment, ISP development, and service implementation shall be all activities that include the following:

 

(a)Obtaining a level of care determination;

 

(b)Obtaining the recipient's (or representative) agreement to participate in the waiver by completion of the Beneficiary Freedom of Choice form;

 

(c)Completing the comprehensive recipient assessment by completing and authenticating the Recipient Health History form;

 

(d)Developing the comprehensive ISP utilizing interdisciplinary team members, recipient or designee, family members, or a legal guardian;

 

(e)Presenting the completed ISP to the recipient or designee for acceptance of services;

 

(f)Submitting the ISP to the MAA for review and approval;

 

(g)Completing the Medicaid application and obtaining supporting documents;

 

(h)Assisting the recipient in the selection of service providers; and

 

(i)Ensuring the proper implementation and utilization of services.

 

4217.8A unit of case management services for an annual re-assessment of the recipient shall be all activities associated with the initial assessment of the recipient in order to continue waiver and other needed services. The annual re-assessment shall occur prior to the expiration of the certification period in order to continue waiver services. Re-assessment activities shall also include the following:

 

(a)Re-determining eligibility and level of care of the recipient;

 

(b)Performing a re-assessment of the recipient's needs and goals; and

 

(c)Assessing progress in meeting established goals, as established in the ISP;

 

4217.9A unit of case management services for recipient for monthly service coordination activities shall be all activities associated with general oversight of the recipient and all services being provided to the recipient. Included in this service unit are the following activities:

 

(a)Monthly (within thirty (30) days) in-home visits;

 

(b)Communicating and coordinating with service providers, as needed;

 

(c)Documenting all case management activities;

 

(d)Identifying and resolving problems or needs;

 

(e)Communicating with the District of Columbia MAA personnel, as needed; and

 

(f)Conducting all other activities related to the efficient administration of the waiver and maintaining the recipient in the community.

 

source

Final Rulemaking published at 50 DCR 9025(October 24, 2003).