5977545 Health Care Finance, Department of - Notice of Final Rulemaking - Governing Supportive Living Services for Participants in the Home and Community Based Services Waiver for Individuals with Intellectual and Developmental Disabilities
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DEPARTMENT OF HEALTH CARE FINANCE
NOTICE OF FINAL RULEMAKING
The Director of the Department of Health Care Finance (DHCF), pursuant to the authority set forth in An Act to enable the District of Columbia to receive federal financial assistance under Title XIX of the Social Security Act for a medical assistance program, and for other purposes, approved December 27, 1967 (81 Stat. 744; D.C. Official Code § 1-307.02 (2014 Repl. & 2015 Supp.)), and the Department of Health Care Finance Establishment Act of 2007, effective February 27, 2008 (D.C. Law 17-109; D.C. Official Code § 7-771.05(6) (2012 Repl.)), hereby gives notice of the adoption of an amendment to Section 1934, entitled “Supported Living Services,” of Chapter 19 (Home and Community-Based Services Waiver for Individuals with Intellectual and Developmental Disabilities) of Title 29 (Public Welfare) of the District of Columbia Municipal Regulations (DCMR).
These final rules establish standards governing reimbursement of supported living services provided to participants in the Home and Community-Based Services Waiver for Individuals with Intellectual and Developmental Disabilities (ID/DD Waiver) and conditions of participation for providers.
The ID/DD Waiver was approved by the Council of the District of Columbia (Council) and renewed by the U.S. Department of Health and Human Services, Centers for Medicare and Medicaid Services, for a five (5) year period beginning November 20, 2012. An amendment to the ID/DD Waiver was approved by the Council through the Medicaid Assistance Program Amendment Act of 2014, effective February 26, 2015 (D.C. Law 20-155; D.C. Official Code § 1-307.02(a)(8)(E) (2014 Repl. & 2015 Supp.)). CMS approved the amendment to the ID/DD Waiver effective September 24, 2015.
Supported living services are provided to persons with an assessed need for assistance with acquisition, retention, or improvement in skills related to activities of daily living, and the social and adaptive skills necessary to enable persons enrolled in the Waiver to reside and successfully participate in the community. The most recent Notice of Final Rulemaking for 29 DCMR § 1934 (Supported Living Services) was published in the D.C. Register on August 28, 2015, at 62 DCR 011872. A Notice of Emergency and Proposed Rulemaking, which was published in the D.C. Register on February 12, 2016, at 63 DCR 001719, was adopted and became effective on February 4, 2016, and remains in effect until June 3, 2016, or publication of this final rulemaking in the D.C. Register, whichever occurs first. The emergency and proposed rules amended the previously published final rules by: (1) clarifying words and/or phrases to reflect more person-centered language and to simplify interpretation of the rule; (2) requiring the use of DDS approved person-centered thinking and discovery tools; (3) clarifying requirements to require that daily progress notes include any health or behavioral events of change in status that are typical for the person; (4) modifying rates to reflect increased costs of providing services; (5) requiring that supports are aimed at skill building and include opportunities for community integration and competitive integrated employment; (6) adding Wellness to the list of professional services; (7) clarifying requirements around maintenance, repair and acquisition of adaptive equipment; (8) creating flexibility in the times that are considered awake and asleep hours for the purposes of staffing and the rate reimbursement; (9) changing the vacancy factor to ninety five (95%); and (10) allowing authority to reimburse at a specialized rate, as necessary, for court-ordered intensive staffing to support persons with complex behaviors. DHCF received no public comments on the emergency and proposed rules and no substantive changes have been made.
The Director of DHCF adopted these rules as final on April 13, 2016, and they shall become effective on the date of publication of this notice in the D.C. Register.
Chapter 19, HOME AND COMMUNITY-BASED SERVICES WAIVER FOR INDIVIDUALS WITH INTELLECTUAL AND DEVELOPMENTAL DISABILITIES, of Title 29 DCMR, PUBLIC WELFARE, is amended as follows:
Section 1934, SUPPORTED LIVING SERVICES, is amended to read as follows:
1934 SUPPORTED LIVING SERVICES
1934.1 The purpose of this section is to establish standards governing Medicaid eligibility for supported living services under the Home and Community-Based Services Waiver for Individuals with Intellectual and Developmental Disabilities (Waiver) and to establish conditions of participation for providers of supported living services for Medicaid reimbursement.
1934.2 Supported living services are provided to persons enrolled in the Waiver who have limited informal supports and have an assessed need for assistance with acquisition, retention, or improvement in skills related to activities of daily living, and who require assistance with the development of social and adaptive skills that are necessary to enable the person to reside in the community and successfully participate in community activities based upon what is important to and for the person as documented in his or her Individual Support Plan (ISP) and reflected in his or her Person-Centered Thinking and Discovery tools.
1934.3 To be eligible for all Medicaid reimbursable supported living services, each person shall:
(a) Have a documented need for assistance with acquisition, retention or improvement in skills related to activities of daily living:
(b) Require assistance with the development of social and adaptive skills necessary to enable the person to reside and integrate in the community and successfully participate in community activities; and
(c) Have an ISP and Plan of Care that identifies the need for supported living services.
1934.4 To be eligible for Medicaid reimbursement, twenty-four (24) hour one-to-one supported living services in a single occupancy supported living residence (SLR), each person shall:
(a) Have a history of challenging behaviors that may put others at risk;
(b) Require intensive supports as determined by a psychological assessment which is updated annually or pursuant to a court order; and
(c) Have a behavior support plan (BSP) that identifies the challenging behaviors and the need for one-to-one supervision that was approved by the Department on Disability Services (DDS).
1934.5 Persons eligible for Medicaid reimbursable twenty-four (24) hour supported living services with skilled nursing must have a circulatory, respiratory, gastro-intestinal, or neurological condition or any other serious medical condition that requires frequent monitoring or at least hourly care. The following documents are required for reimbursement for this service:
(a) A physician’s order or an advanced practice registered nurse’s (APRN) order documenting the scope, frequency, and duration of skilled nursing services; and
(b) A concise statement which sets forth the presenting problem that requires supported living with skilled nursing services and includes the responsibilities of the nurse.
1934.6 In order to be eligible for Medicaid reimbursable supported living periodic services in an SLR, each person shall:
(a) Demonstrate a need for the acquisition, and improvement of skills related to activities of daily living and the social and adaptive skills necessary for community residence, as indicated in the ISP; and
(b) Have an assessed need requiring less than twenty-four (24) hour supports and supervision.
1934.7 Medicaid reimbursable supported living services shall be provided in one of the following types of residences:
(a) An SLR owned or leased by a Waiver provider; or
(b) A home owned or leased by the person receiving supported living services.
1934.8 When Medicaid reimbursable supported living services are provided in an SLR, the SLR shall serve one (1) to three (3) related or unrelated persons. With the exception of couples who chose to share a bedroom, the number of persons in the SLR shall not exceed the number of bedrooms in the residence unless written approval from DDS is obtained.
1934.9 In order to receive Medicaid reimbursement, the Waiver provider shall include the person living in the residence in the lease, when the SLR is owned or leased by the Waiver provider, unless the person does not meet the leasing eligibility criteria, in which case, the provider shall enter into a written residency agreement with the person. The lease or other written residency agreement shall include all of the responsibilities and protections from eviction that apply under the jurisdiction’s landlord-tenant laws.
1934.10 In order to be eligible for Medicaid reimbursement, each SLR located out-of-state shall be licensed or certified in accordance with the host state’s laws and regulations and must adhere to the terms and conditions set forth in an agreement between the District of Columbia and the host state.
1934.11 In order to be eligible for Medicaid reimbursement, each provider, including an out-of-state provider of supported living services, shall be a Waiver provider agency and meet the following requirements:
(a) Comply with Section 1904 (Provider Qualifications) and Section 1905 (Provider Enrollment Process) of Chapter 19 of Title 29 DCMR;
(b) Provide verification of passing the DDS Provider Certification Review (PCR) for in-home supports, supported living or respite services for the last three (3) years. For providers with less than three (3) years of PCR certification, provide verification of a minimum of three (3) years of experience providing residential or respite services to the ID/DD population, evidence of certification or licensure from the jurisdiction in which the service was delivered, and evidence of PCR certification for each year that the provider was enrolled as a waiver provider in the District of Columbia, if applicable; and
(c) Have an executed, signed, current Human Care Agreement with DDS, if required by DDS.
1934.12 In addition to the requirements described under § 1934.9, each out-of-state provider shall comply with the following additional requirements to receive Medicaid reimbursement:
(a) Remain in good standing in the jurisdiction where the program is located, if licensed or certified by the host state;
(b) Submit a copy of the current certification, licensing and/or survey performed by the host state and provider’s corrective action, if applicable, to DDS; and
(c) Allow authorized agents of the District of Columbia government, federal government, and governmental officials of the host state full access to all sites and records for audits and other reviews.
1934.13 Medicaid reimbursable supported living services may be provided with or without transportation. Each Medicaid provider shall comply with the requirements set forth in Subsection 1904.5 of Title 29 DCMR, if transportation services are provided to enable persons to gain access to Waiver services and other community services and activities in a safe and efficient manner.
1934.14 If transportation services are provided by the Direct Support Professional (DSP), such that the DSP drives the person in the vehicle provided by the provider, the DSP shall meet the requirements governing transportation services set forth in Subsections 1904.5(j) and (k) (Provider Qualifications) of Chapter 19 of Title 29 DCMR.
1934.15 Each DSP shall meet all of the requirements set forth in Section 1906 (Requirements for Persons Providing Direct Services) of Chapter 19 of Title 29 DCMR.
1934.16 Services shall only be authorized for Medicaid reimbursement in accordance with the following provider requirement procedures:
(a) DDS shall provide a written service authorization before the commencement of services;
(b) The service name and Waiver provider delivering services must be identified in the ISP and Plan of Care;
(c) The ISP, Plan of Care, and Summary of Supports and Services must document the amount and frequency of services to be received; and
(d) The services to be provided shall not conflict with the service limitations described under Subsection 1934.25.
1934.17 Each provider of Medicaid reimbursable supported living services shall assist persons in the acquisition, retention, and improvement of skills related to activities of daily living, and other social and adaptive skills necessary to enable the person to become a fully integrated member of their community. To accomplish these goals, the provider shall:
(a) Use the DDS-approved Person-Centered Thinking tools, the person’s Positive Personal Profile, and the Job Search and Community Participation Plan to develop a functional assessment that includes what is important to and for the person, within the first month of providing services. This assessment shall be reviewed and revised annually or more frequently as needed;
(b) Participate as a member of the person’s support team, at his or her preference, including making recommendations for the development of the ISP and Plan of Care;
(c) Review the person’s ISP and Plan of Care goals, DDS- approved person centered thinking tools, Positive Person Profiles and Job Search and Community Participation plan, objectives, and activities at least quarterly and more often, as necessary, and submit quarterly reports to the person, family, as appropriate, guardian, and DDS Service Coordinator no later than seven (7) business days after the end of the first quarter or each subsequent quarter thereafter and in accordance with the requirements described, under Section 1908 (Reporting Requirements) and Section 1909 (Records and Confidentiality of Information) of Chapter 19 of Title 29 DCMR;
(d) Provide access and information as requested for service coordination, visits and reviews;
(e) Assist in the coordination of all services that a person may receive; and
(f) Develop and implement the person’s Health Care Management Plan, in accordance with the DDS Health and Wellness Standards.
1934.18 Each provider of Medicaid reimbursable supported living services shall ensure that each person receives the level of support he/she needs for skill development, habilitation and other supports, when appropriate, which shall include, but not be limited to, support for the following categories, unless the person has demonstrated independence and capacity in any of the following areas. Supports provided shall be aimed at teaching the person to increase his or her skills and self-reliance:
(a) Eating and food preparation, including learning about healthy eating choices;
(b) Personal hygiene;
(c) Dressing;
(d) Monitoring medication administration and healthcare needs;
(e) Communications;
(f) Interpersonal and social skills;
(g) Household chores;
(h) Mobility;
(i) Financial management;
(j) Motor and perceptual skills;
(k) Problem-solving and decision-making;
(l) Human sexuality;
(m) Opportunities to engage in community life, including but not limited to social, recreational, and religious activities utilizing community resources based on the person’s interests, beliefs, culture, and preferences, and building and maintaining relationships;
(n) Ensuring that adaptive equipment is appropriate, functioning and well maintained;
(o) Opportunities for the person to seek employment and vocational supports to work in the community in a competitive and integrated setting, and
(p) Other supports that are identified as important to or for the person receiving supports as identified in the person’s ISP.
1934.19 Each provider of Medicaid reimbursable supported living services shall ensure that staff delivering day habilitation, individualized day supports, companion, employment readiness, or supported employment services shall receive training about the person’s health care needs as identified by the nurse, and are informed about those needs that are relevant to the person in those settings and that are identified in the person’s Health Care Management Plan and BSP.
1934.20 Each provider of Medicaid reimbursable supported living services shall ensure that each person enrolled in the Waiver receives the professional services required to meet his or her goals as identified in the person's ISP and Plan of Care. Professional services may include, but are not limited to, the following disciplines:
(a) Medicine;
(b) Dentistry;
(c) Education;
(d) Nutrition;
(e) Nursing;
(f) Occupational therapy;
(g) Physical therapy;
(h) Psychology, including behavior supports;
(i) Social work;
(j) Speech, hearing, and language therapy; and
(k) Wellness.
1934.21 Each provider of Medicaid reimbursable supported living services shall maintain the records as prescribed under Section 1909 of Title 29 DCMR for monitoring and auditing purposes for each person receiving services and shall also maintain the following documents:
(a) If providing twenty-four (24) hour supported living services in a single occupancy or one-to-one supports, a copy of the annual BSP or court order;
(b) Progress notes that describe the person’s leisure and recreation activities, in accordance with his or her interests as identified in the ISP or Person-Centered Thinking and Discovery tools, and a schedule of when the person is in his or her home;
(c) The records of any nursing care, procedures, and other supports related to the development and management of the Health Care Management Plan; and
(d) A record of monitoring and maintenance of adaptive equipment, if applicable;
1934.22 Each provider of Medicaid reimbursable supported living services shall meet the requirements described under Section 1908 (Reporting Requirements), Section 1911 (Individual Rights), and Section 1938 (Home and Community-Based Setting Requirements) of Chapter 19 of Title 29 DCMR.
1934.23 Reimbursement for Medicaid reimbursable supported living services shall not include:
(a) Cost of room and board;
(b) Cost of facility maintenance, upkeep and improvement, modifications or adaptations to an SLR or home to meet the requirements of the applicable life safety code;
(c) Safety monitoring as a stand-alone task;
(d) Activities for which payment is made by a source other than Medicaid;
(e) Time when the person is in school or employed; and
(f) Time when the person is hospitalized, on vacation independently, or any other time in which the person is not receiving direct care staff support from a provider.
1934.24 Medicaid reimbursable supported living services shall not include services delivered by the person’s relative, legal guardian, or legally responsible person.
1934.25 Medicaid reimbursable supported living services shall not be authorized concurrently with the following Waiver services:
(a) Residential Habilitation;
(b) Respite;
(c) Host Home;
(d) In-Home Supports; and
(e) Transportation, when the provider chooses to provide supported living services with transportation services.
1934.26 The reimbursement rate for Medicaid reimbursable supported living services shall be calculated based on the staff on duty and shall include:
(a) All supervision of the DSP;
(b) All nursing provided in the residence for medication administration, physician ordered protocols and procedures, charting, other supports as per physician's orders, oversight, coordination, and maintenance of a Health Care Management Plan, and training for residential staff and day and/ or vocational supervisory staff on a person’s health care needs, as applicable;
(c) All transportation, if applicable;
(d) Programmatic supplies and fees;
(e) Ongoing maintenance and coordination of the acquisition or repair of adaptive equipment;
(f) Quality assurance costs, such as incident management systems and staff development; and
(g) General administrative fees for Waiver services.
1934.27 Each provider of Medicaid reimbursable twenty-four (24) hour supported living services with skilled nursing shall:
(a) Provide skilled nursing services and supports to the person living in the SLR;
(b) Complete any skilled nursing assessment and document hourly nursing interventions and treatments; and
(c) Provide as appropriate, all of the supported living activities listed in Subsections 1934.18 and 1934.19, and Subsection 1934.20.
1934.28 For twenty-four (24) hour supported living services with skilled nursing, in order to be eligible for Medicaid reimbursement, the duties of a registered nurse shall be consistent with the scope of practice standards for registered nurses set forth in Section 5414 of Title 17 DCMR. At a minimum, they shall include the following duties:
(a) Prepare an initial routine physical assessment, including an individualized service nursing plan and evaluation;
(b) Assist in the development of the Health Care Management Plan;
(c) Coordinate the person’s care and referrals;
(d) Administer medications and treatment as prescribed by a legally authorized healthcare professional licensed in the District of Columbia, or consistent with the requirements of the appropriate jurisdiction;
(e) Provide oversight of non-licensed medication administration personnel;
(f) Provide wound care, tube feeding, diabetic care, and other treatment regimens prescribed by the physician, as needed;
(g) Provide oversight and supervision to a licensed practical nurse, when delegating and assigning nursing interventions;
(h) Record progress notes during each visit and complete quarterly reports; and
(i) Provide competency training to the day habilitation, employment readiness, individualized day support, companion, and/or supported employment nursing or supervisory staff, as applicable, on the person’s healthcare needs by the nurse, including needs identified in the Health Care Management Plan.
1934.29 In order to be eligible for Medicaid reimbursement, the duties of a licensed practical nurse delivering twenty-four (24) hour supported living services with skilled nursing, shall be consistent with the scope of practice standards for a licensed practical nurse set forth in Chapter 55 of Title 17 DCMR. At a minimum, they shall include the following duties:
(a) Record progress notes during each visit and on quarterly reports;
(b) Report immediately, any changes in the person's condition, to the supervising registered nurse;
(c) Provide wound care, tube feeding, diabetic care, and other treatment regimens prescribed by the physician; and
(d) Administer medications and treatment as prescribed by a legally authorized healthcare professional licensed in the District of Columbia or consistent with the requirements of the jurisdiction in which the healthcare professional is licensed.
1934.30 In addition to the requirements at § 1934.21, each provider of Medicaid reimbursable supported living services with skilled nursing shall also maintain the following documents:
(a) A copy of the physician’s order or an APRN’s order specifying the type, frequency, scope, and duration of the skilled nursing services, if applicable;
(b) A copy of the job description detailing the duties of the nurse delivering the service, if applicable; and
(c) A copy of each assessment that the nurse has conducted and documentation of the hourly nursing interventions and treatments, if applicable.
1934.31 Medicaid reimbursable supported living skilled nursing services shall not include custodial care.
1934.32 Medicaid reimbursable supported living one-to-one services in a single occupancy means services provided to one person exclusively by a supported living service provider who has been trained in all general requirements and possesses all training required to implement the person’s specific behavioral and/or clinical protocols and support plans for a pre-authorized length of time.
1934.33 Medicaid reimbursable supported living one-to-one services in a single-occupancy SLR shall only be permitted with prior annual approval by the DDS Restrictive Control Review Committee, or a medical treatment plan signed by the person’s physician. Providers delivering one-to-one services shall require the person to have a BSP or DDS approved medical treatment plan that reflects the need for one-to-one supervision.
(a) The BSP shall be developed according to the requirements set forth in the DDA/DDS Behavioral Supports Policy and Procedure available at the DDS website at http://dds.dc.gov/page/policies-and-procedures-dda.
(b) If providers of Medicaid reimbursable supported living services are delivering one-to-one supported living services pursuant to a BSP, the assessment shall be updated on an annual basis to determine if the services are necessary.
1934.34 If one-to-one supported living services are delivered pursuant to a court order, the order shall be verified on an annual basis, to determine if the services are necessary.
1934.35 Supported living services shall be Medicaid reimbursable for emergency situations when the person is not physically residing at the SLR or home, but is temporarily residing in a hotel or other facility and continues to receive support from the provider.
1934.36 An acuity evaluation to set levels of support shall be determined by the Support Team and approved by the DDS Waiver Unit through review of current staffing levels; available health and behavioral records; and the results of the Level of Need Assessment and Screening Tool, or its successor, to determine if a person has a health, behavioral and/or functional acuity that requires increased supports. A person may be assessed at a support level that is consistent with their current staffing level if other acuity indicators are not in place.
1934.37 The Medicaid reimbursement rate for supported living services without transportation shall be as follows:
(a) Basic Support Level 1: Provides asleep overnight support for a home with three (3) residents and a direct care staff support ratio of 1:3 during all hours when individuals are awake and receiving services. The reimbursement rate shall be two hundred thirty one dollars and eleven cents ($231.11) per day;
(b) Basic Support Level 2: Provides awake overnight support for a home with three (3) residents and a direct care staff support ratio of 1:3 for staff awake overnight and 1:3 during all awake hours when the residents are receiving services. The reimbursement rate shall be two hundred forty-one dollars and thirty-nine cents ($241.39) per day;
(c) Moderate Support Level 1: Provides asleep overnight support for a home with three (3) residents and a direct care staff support ratio of 2:3 for eight (8) hours a day, 1:3 during the remaining awake hours, and 1:3 staff asleep overnight coverage. The reimbursement rate shall be three hundred twenty six dollars and twenty-two cents ($326.22) per day;
(d) Moderate Support Level 2: Provides awake overnight support for a home with three (3) residents and a direct care staff support ratio of 2:3 for eight (8) hours a day, 1:3 during remaining awake hours, and 1:3 staff awake coverage overnight. The reimbursement rate shall be three hundred thirty-six dollars and fifty cents ($336.50) per day;
(e) Intensive Support Level 1: Provides support for a home with three (3) residents and a direct care staff support ratio of 1:3 for staff awake overnight and 2:3 during all awake hours when the residents are receiving services and adjusted for increased absenteeism from day and employment programs. The reimbursement rate shall be three hundred seventy-five dollars and sixty-eight ($375.68) per day;
(f) Intensive Support Level 2: Provides support for a home with three (3) residents and a direct care staff support ratio of 2:3 for staff awake overnight and 2:3 during all awake hours when the residents are receiving services and adjusted for increased absenteeism from day and employment programs. The reimbursement rate shall be four hundred twenty-four dollars and ninety-eight cents ($424.98) per day;
(g) Basic Support Level 1: Provides asleep overnight support for a home with two (2) residents and a direct care staff support ratio of 1:2 during all hours when individuals are awake and receiving services. The reimbursement rate shall be three hundred fifteen dollars and fifty-nine cents ($315.59) per day;
(h) Basic Support Level 2: Provides awake overnight support for a home with two (2) residents and a direct care staff support ratio of 1:2 for staff awake overnight and 1:2 during all awake hours when the residents are receiving services. The reimbursement rate shall be three hundred twenty-eight dollars and thirty-four cents ($328.34) per day;
(i) Moderate Support Level 1: Provides awake overnight support for a home with two (2) residents and a direct care staff support ratio of 2:2 for four (4) hours a day, 1:2 during remaining awake hours and 1:2 staff awake coverage overnight. The reimbursement rate shall be three hundred ninety-two dollars and twenty-nine cents ($392.29) per day;
(j) Moderate Support Level 2: Provides support in a SLR with two (2) residents and a direct care staff support ratio of 1:2 for staff awake overnight and 2:2 for eight (8) hours a day, 1:2 during remaining awake hours when residents are in the home and adjusted for increased absenteeism. The rate shall be four hundred forty dollars and twenty-one cents ($440.21) per day;
(k) Intensive Support Level 1: Provides support in a home with two (2) residents and a direct care staff support ratio of 1:2 for staff awake overnight and 2:2 for all awake hours when residents are in the home and adjusted for increased absenteeism. The rate shall be five hundred fifteen dollars and forty-three cents ($515.43) per day;
(l) Supported living periodic services, as described under Subsection 1934.6, shall be authorized up to sixteen (16) hours per day without transportation. The hourly rate shall be twenty-three dollars and ninety-six cents ($23.96) billable in quarter hour units (fifteen minutes) of five dollars and ninety-nine cents ($5.99) per billable unit;
(m) There shall be a specialized service rate for supported living with skilled nursing services, described under Subsection 1934.5. The rate shall be five hundred three dollars and fifty-three cents ($503.53) per day without transportation, when there are at least three (3) people living in the SLR and residing in a home that requires skilled nursing services and demonstrates extraordinary medical needs; and
(n) There shall be a specialized service rate for twenty-four hour one-to-one supported living service for a person living in a single occupancy SLR, described under Subsection 1934.4. The rate shall be six hundred eight dollars and seven cents ($608.07) for asleep overnight staff and six hundred twenty-seven dollars and fifteen cents ($627.15) for one-to-one awake overnight staff.
1934.38 The Medicaid reimbursement rate for supported living services with transportation shall be as follows:
(a) Basic Support Level 1: Provides asleep overnight support for a home with three (3) residents and a direct care staff support ratio of 1:3 during all hours. The reimbursement rate shall be three hundred thirteen dollars and nine cents ($313.09) per day;
(b) Basic Support Level 2: Provides awake overnight support for a home with three (3) residents and a direct care staff support ratio of 1:3 for staff awake overnight and 1:3 during all awake hours. The reimbursement rate shall be three hundred twenty three dollars and thirty-seven cents ($323.37) per day;
(c) Moderate Support Level 1: Provides asleep overnight support for a home with three (3) residents and a direct care staff support ratio of 2:3 for eight (8) hours a day, 1:3 during the remaining awake hours, and 1:3 staff asleep overnight coverage. The reimbursement rate shall be four hundred eight dollars and nineteen cents ($408.19) per day;
(d) Moderate Support Level 2: Provides awake overnight support for a home with three (3) residents and a direct care staff support ratio of 2:3 for eight (8) hours a day, 1:3 during remaining awake hours, and 1:3 staff awake coverage overnight. The reimbursement rate shall be four hundred eighteen dollars and forty-seven cents($418.47) per day;
(e) Intensive Support Level 1: Provides support for a home with three (3) residents and a direct care staff support ratio of 1:3 for staff awake overnight and 2:3 during all awake hours when the residents are receiving services and adjusted for increased absenteeism from day and employment programs. The reimbursement rate shall be four hundred fifty-seven dollars and sixty-six cents ($457.66) per day;
(f) Intensive Support Level 2: Provides support for a home with three (3) residents and a direct care staff support ratio of 2:3 for staff awake overnight and 2:3 during all awake hours when the residents are receiving services and adjusted for increased absenteeism from day and employment programs. The reimbursement rate shall be five hundred six dollars and ninety-five cents ($506.95) per day;
(g) Basic Support Level 1: Provides asleep overnight support for a home with two (2) residents and a direct care staff support ratio of 1:2 staff asleep overnight coverage and 1:2 staff awake coverage when residents are receiving services. The reimbursement rate shall be three hundred eighty-nine dollars and fifteen cents ($389.15) per day;
(h) Basic Support Level 2: Provides awake overnight support for a home with two (2) residents and a direct care staff support ratio of 1:2 for staff awake overnight and 1:2 during all awake hours when the resident is receiving services. The reimbursement rate shall be four hundred one dollars and ninety cents ($401.90) per day;
(i) Moderate Support Level 1: Provides awake overnight daily rate for a home with two (2) residents and a direct care staff support ratio of 2:2 for four (4) hours a day, 1:2 during remaining awake hours and 1:2 staff awake coverage overnight shall be four hundred sixty-five dollars and eighty-six cents ($465.86) per day;
(j) Moderate Support Level 2: Provides support in a home with two (2) residents and a direct care staff support ratio of 1:2 for staff awake overnight and 2:2 for eight (8) hours a day, 1:2 during remaining awake hours when residents are receiving services and adjusted for increased absenteeism from day and employment programs. The reimbursement rate shall be five hundred thirteen dollars and seventy-eight cents ($513.78) per day;
(k) Intensive Support Level 1: Provides support in a home with two (2) residents and a direct care staff support ratio of 1:2 for staff awake overnight and 2:2 for all awake hours when residents are receiving services and adjusted for increased absenteeism from day and employment programs. The reimbursement rate shall be five hundred eighty-eight dollars and ninety-nine ($588.99) per day;
(l) Supported Living periodic services, described under Subsection 1934.6, shall be authorized up to sixteen (16) hours per day. The hourly rate shall be twenty-seven dollars and eight cents ($27.08) per hour billable in quarter hour units of six dollars and seventy-seven cents ($6.77) per fifteen (15) minute unit; and
(m) There shall be a specialized service rate for supported living with skilled nursing services, described under Subsection 1934.5. The reimbursement rate is five hundred fifty- nine dollars and ten cents ($559.10) per day, when there are at least three (3) people living in the SLR and residing in a home that requires skilled nursing services and demonstrates extraordinary medical needs.
(n) There shall be a specialized service rate for twenty-four hour one-to-one supported living service for a person living in a single occupancy SLR, described under Subsection 1934.4. The reimbursement rate is seven hundred thirty five dollars and sixty-two cents ($735.62) for asleep overnight staff and seven hundred fifty-four dollars and seventy cents ($754.70) for one-to-one awake overnight staff.
1934.39 There shall be a specialized service rate for intensive individualized staffing to support a person or persons who have complex behaviors that involve a risk to the health, safety or well-being of the person or others or required by court order. The specialized service rate shall be determined by DDS on a case-by-case basis as appropriate to correspond with court-ordered staffing ratios.
1934.40 For purposes of staffing and determining the Medicaid reimbursement rates for supported living services, assume sixteen (16) awake hours of the day on weekends or holidays and assume ten (10) to twelve (12) awake hours for all other days based on the level of support.
1934.41 For purposes of staffing and determining the Medicaid reimbursement rates for supported living services, the overnight period is an eight (8) hour period of time.
1934.42 The billable unit of service for Medicaid reimbursable supported living services, excluding periodic supported living services, shall be one (1) day (i.e. twenty-four (24) hours).
1934.43 The Medicaid reimbursement rate assumes a ninety-five percent (95%) annual occupancy and includes any unanticipated absences due to illness from any day/vocational services.
1934.44 Each provider of Medicaid reimbursable supported living services shall maintain the staffing ratio, described under Subsections 1934.37 and 1934.38, associated with the approved acuity rate for the residence. The DDA Service Coordinator shall generate an incident report if it is discovered that the staffing ratio is not maintained during DDA’s quarterly visits to the SLR.
1934.45 The Medicaid provider shall notify the DDS Service Coordinator to schedule a meeting to address the cause of any unanticipated absences that may result in a less than ninety-five percent (95%) occupancy rate or a reduced staffing ratio.
1934.46 Medicaid reimbursable supported living periodic services are calculated based on the time the person is scheduled to be in their place of residence, except the provider may include the time the person is being transported by the provider to day programs, employment, professional appointments, community activities, and events.
Section 1999, DEFINITIONS, is amended by adding the following:
Couples - A couple refers to those married or unmarried persons in a relationship, including same-sex relationships.
Health Care Management Plan - A written document designed to evaluate a person's health care status and to provide recommendations regarding the treatment and amelioration of health care issues by identifying types of risk, interventions to manage identified risks, persons responsible for carrying out interventions, and persons responsible for providing an evaluation of outcomes and timeframes.
Supported Living Residence (SLR) - A residence owned or leased by the provider or a residence owned or leased by the person receiving services.
