Section 29-4218. REIMBURSEMENT RATES:ADULT DAY HEALTH

 

A case manager shall establish a specific written ISP for each recipient of waiver services and shall ensure, at a minimum, that the ISP is in accordance with the requirements of subsections §§ 4201 through 4204 of this chapter.

 

4218.1Each case manager shall not have a recipient caseload greater than forty-five (45) persons (inclusive of Medicaid and non-Medicaid recipients) when the service provision is not supported by the services of a case management aide. In cases where the provision of case management services are supported by the services of a case management aide, the case management service provider shall not have a recipient caseload greater than fifty (50) persons (inclusive of Medicaid and non-Medicaid recipients).

 

4218.2The case manager shall utilize uniform documentation forms as provided and directed by the MAA.

 

4218.3The case manager shall ensure that all of the documents listed in § 4216.8 are submitted to the MAA for review and approval of services. The MAA shall approve or disapprove the ISP within seven (7) working days of its receipt.

 

4218.4The case manager shall conduct a comprehensive reassessment of the recipient and ensure completion of all waiver documents listed in § 4216.8 on an annual basis prior to expiration of the current certification period and submitting the waiver package to the MAA for review and approval.

 

4218.5Following the approval of service from the MAA, the case manager shall follow-up promptly with the selected providers of services to ensure that all services are in place, and that the quantity and quality of services are sufficient to meet the identified needs of the recipient.

 

4218.6The case manager shall ensure that the recipient is given free choice of all qualified providers of each service included in his or her written ISP.

 

4218.7Each case manager who provides direct case management services is required to assist the recipient in accessing all necessary services that are available to the recipient and that are necessary to maintaining the recipient in the community whether they are Medicaid (State Plan) services, Medicaid (waiver) services, or non-Medicaid financed services.

 

4218.8Each case manager shall attend training sessions as scheduled and required by the MAA in order to promote the efficient and effective delivery of Medicaid-financed services.

 

4218.9Each case manager shall develop and implement a utilization review plan to ensure non-duplication of services being provided to the recipient. The utilization review plan shall also evaluate the appropriateness, efficiency, adequacy, and coordination of services with the objective of achieving the least costly, yet most appropriate delivery of waiver services.

 

4218.10When 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.

 

4218.11The case manager shall ensure that a home assessment is conducted (by a licensed physician or a licensed physical therapist) prior to ordering EAA service(s) on the ISP. The signed assessment form shall be submitted to the MAA with the ISP.

 

4218.12Prior to initiating EAA services, the case manager shall obtain an evaluation from a Construction Analyst or Housing Inspector. The evaluation must substantiate that the home is in a condition that is structurally sound to accommodate each ordered service(s) and include any stipulation(s) or recommendation(s) on how the service(s) should be implemented.

 

4218.13Each case manager shall develop (and be prepared to implement) twenty-four (24) hour emergency service(s), should the recipient so require.

 

4218.14Each case manager shall approve requests for changes, additions, or termination of services utilizing the "Request for Change in Services" form, amending the ISP to reflect the requested changes, and submitting the change request and amended ISP to MAA for review and approval. Only the case manager shall admit, request a change in services, or discharge a recipient from the waiver program.

 

4218.15The case manager may terminate waiver services when at least one (1) of the following conditions exist:

 

(a)The recipient no longer meets the financial eligibility criteria;

 

(b)The recipient expires;

 

(c)The recipient has moved out of the District of Columbia;

 

(d)The recipient's condition has improved, and the recipient no longer requires assistance with activities of daily living (ADL) and instrumental activities of daily living (IADL) as per the level of care criteria;

 

(e)The recipient (if competent to make decisions) requests termination of services;

 

(f)The recipient has been permanently placed in an institution;

 

(g)The recipient's certification period has ended and the recipient remains institutionalized;

 

(h)The recipient is unwilling to use available services and the multidisciplinary team is unable to propose a plan that is acceptable to the recipient; and

 

(i)The recipient's behavior poses a risk to the safety and well being of the provider staff.

 

4218.16If the termination of services is based on §§ 4218.15(h) or 4218.15(i), the case manager shall provide the recipient or authorized representative with a written thirty (30) day notice in advance of the date of termination that shall include but is not limited to the following:

 

(a)Decision to terminate the services;

 

(b)Reason for termination of services;

 

(c)Copy of waiver standards supporting the termination decision;

 

(d)Copy of the directory of other waiver providers; and

 

(e)Information on the recipient's right to a Fair Hearing and instructions for obtaining a Fair Hearing.

 

4218.17If a recipient desires to transfer to another provider of services, the case manager shall assist the recipient or authorized representative in the selection of a new provider(s) and ensure a smooth and complete transfer of the recipient to the selected provider(s).

 

4218.18If the behavior of a resident poses an immediate threat to the safety and well being of the provider staff, the case manager shall immediately suspend or terminate the recipient's services. Suspension of services shall not exceed thirty (30) days.

 

4218.19Within seventy-two (72) hours of suspension, the case manager shall notify the recipient or authorized representative in writing of the following:

 

(a)Grounds for suspension; and

 

(b)The recipient's right to appeal the suspension.

 

4218.20At the end of the suspension period, the case manager may re-instate or terminate the recipient's services.

 

4218.21The recipient shall be provided with a notice of termination at least fifteen (15) days before the effective date of termination, if the decision is made to terminate the services.

 

4218.22The case manager shall document monthly (within thirty (30) days) in-home visits and telephone contacts within the recipient's record.

 

source

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