The Updated Statewide Transition Plan Spring 2017 Background

The Updated Statewide Transition Plan Spring 2017 Background

The Updated Statewide Transition Plan Spring 2017 Background http://dds.dc.gov/page/waiver-amendmentinformation 2 HCBS Settings Rule 3 Title: Medicaid Program; State Plan Home and Community-Based Services, 5-Year Period for Waivers, Provider Payment Reassignment, and Home and CommunityBased Setting Requirements for Community First Choice (Section 1915(k) of the Act) and Home and Community-Based Services (HCBS) Waivers (Section 1915(c) of the Act)

or The Settings Rule Published in the Federal Register on 01/16/2014 Effective March 17, 2014 www.hcbsadvocacy.org HCBS Requirements The Home and Community-Based setting: Is integrated in and supports access to the greater community Provides opportunities to seek employment and work in competitive integrated settings, engage in community life, and control personal resources Ensures the individual receives services in the community to the same degree of access as individuals not receiving Medicaid home and community-based services 4

HCBS Requirements The Home and Community-Based setting: Is selected by the individual from among setting options, including non-disability specific settings and an option for a private unit in a residential setting Person-centered service plans document the options based on the individuals needs, preferences; and for residential settings, the individuals resources 5 HCBS Requirements The Home and Community-Based setting: Ensures an individuals rights of privacy, dignity, respect, and freedom from coercion and restraint Optimizes individual initiative, autonomy, and independence in making life choices Facilitates individual choice regarding services

and supports, and who provides them 6 District of Columbia Statewide Transition Plan http://dhcf.dc.gov/release/public-notice-revisions-statewide-tra nsition-plan-district-medicaid-programs-home-and https://dds.dc.gov/publication/public-notice-revisionsstatewide-transition-plan-medicaid-home-community-basedservices 7 Statewide Transition Plan All states were required to develop an HCBS transition plan, that provides a comprehensive assessment of potential gaps in compliance with the new regulation, as well as strategies, timelines, and milestones for becoming compliant with the rules requirements by March 2019. Filed an initial plan after public comment and received feedback from CMS.

Final statewide transition plan currently posted for public comment. 8 Statewide Transition Plan Final Statewide Transition Plan: Submit to CMS by 4/28/2017. Thirty day public comment period open through April 11, 2017. Update of data due to CMS September, 2017 and then annually or upon request by CMS. (Next data: HCBS IDD Residential Settings). 9 Assessments: Review of Systems and All Provider Locations 10

State Self-Assessment Worked with HCBS Settings Advisory Group to review and make recommendations for remediation, where needed, on: All HCBS waiver service definitions and provider requirements. All regulations governing HCBS. DDS/DDA Provider Certification Review (PCR) process.

DOH licensing requirements and regulations. All relevant DDS/DDA policies, procedures, and protocols, including Quality Management practices and tools. Provider training requirements. Human Care Agreements and rate methodologies. Information systems. State Self-Assessment 12 State Self-Assessment EPD Waiver Regulations-EPD & District regulations that include licensed residences where EPD Waiver participants live Mental Health Community Residence Facilities-DBH Assisted Living-DOH

LTSS Assessment process through Delmarva Relevant DHCF, DBH, and DOH policies & procedures Provider enrollment requirements-EPD (Assisted Living & Adult Day Health Program) 13 Provider Self-Assessments # Indicator CMS Recommended Assessment Question (a) The

home ensures a persons rights of privacy, dignity, respect and freedom from coercion and restraint . Prevalence in Provider Setting (Select 1-6, above )

Provide name and hyperlink, if available, for specific evidence of compliance. If no specific evidence is available, please indicate that. Comments & Feedback: Please use this section to help us identify systemic support and barriers to achieving compliance with the HCBS Settings Rule; areas in which training, technical assistance and capacity building would be helpful; explanations, if needed, of your self-assessment score; etc. The following PCR question(s) may be helpful in responding to this section: CQ.2- Is the persons right to privacy acknowledged and practiced? (for 1 & 4 below) CQ.3 Is the person and/or their representative aware of actions they can take if they feel they have been treated unfairly, have concerns or are displeased with the services being provided? (for 2 below)

CQ.25 Is the person and/or their representative able to communicate and/or demonstrate their rights as a consumer of waiver services? ( for 2 below) OO.CQ.20- Does the provider ensure proper handling of all consumer records including security, confidentiality, and retention in accordance with DDS and federal policies (for 3 below) 1 People are provided personal care assistance in private, as appropriate. 2 Information is provided to people on how to make an anonymous complaint.

3 Peoples health and other personal information (e.g., mealtime protocols, therapy schedules) are kept private. Provider Self-Assessments Aggregated for Day Habilitation Providers Question Category Average Score (a) The setting ensures a persons rights of privacy, dignity, respect and freedom from coercion and restraint. 4

(b) The setting optimizes a persons initiative, autonomy, and independence in making life choices. 3.25 (c) The setting facilitates individual choice regarding services and supports, and who provides them. 3.75 (d) The setting provides opportunities to seek employment and work in competitive integrated settings, engage in community life, and control personal resources. 4 (e) The setting is integrated and supports access to the greater community. (f) The setting provides opportunities to engage in community life. (g) The setting provides opportunities to control personal resources. 4.375 3 2.67 (h) The setting provides opportunities to receive services in the community to the same degree of

access as individuals not receiving Medicaid HCBS. 4.25 (i) The setting is selected by the person from among options including non-disability specific settings and a private unit in a residential setting. 3.25 (m) If provider-owned or controlled, the setting provides that each person has privacy in their sleeping or living space. 3.625 (n) If provider-owned or controlled, the setting provides units with lockable entrance doors, with appropriate staff having keys to doors as needed. 2.75 (q) If provider-owned or controlled, the setting provides people with the freedom and support to

control their schedules and activities and have access to food any time. 3.875 (r) If provider-owned or controlled, the setting allows people to have visitors at any time. 3.75 (s) If provider-owned or controlled, the setting is physically accessible to the person. 154.875 Provider Self-Assessments Self-Assessment Tool-Assisted Living & Community Residence Facilities HCBS Settings Domain Number of Indicators Choice of Roommates

3 Choice of Schedule 2 When & What to Eat 7 Private Phone/Text/Email 3 Isolation from Non-HCBS 6 Physical Environment

6 Access to Community 8 Privacy 8 Eviction Protection/Appeals 4 16 Provider Self-Assessments EPD Waiver Assisted Living (3 Facilities) Overall Compliance at 81%

Non-Medicaid Residential Facilities (3 Facilities-2 MH CRFs, 1 non-Medicaid AL) Overall Compliance at 76.5% Transition Plans DHCF will be working with providers to meet settings requirements through one-on-one technical assistance When a discovery and remediation are issued to an EPD Waiver provider, a Corrective Action Plan will be required 17 Provider Transition Plans Any areas in which their self-assessment identified noncompliance + a strategic plan to support people to: advance rights and choice; build and maintain relationships with and without people with disabilities; fully engage in self-determination and supported

decision-making; work in competitive, integrated employment or engage in community-based, integrated retirement activities; participate in a variety of community activities based upon their interests. These are incorporated into each providers Continuous Improvement Plan and followed through Provider Performance Review. 18 Provider Transition Plans Type of Setting Issue # of Sites Remedial Strategy

Lead Unit Target Date Ongoing Monitoring Residential Habilitation Access to Visitors 10 Issue policy Operations 11/1/2015 Train staff

Training 12/1/2015 Inform and educate people we support and their families Operations 12/1/2015 19 Quarterly review of visitor logs

and interviews with people who receive supports. Site by Site Assessments: Day Programs & Services Revised Provider Certification Review for all HCBS Settings to include all HCBS Indicators. 30 25 20 Day Habiitation Employment Readiness 15

Data as of December 2016 10 5 0 Compliant Non-compliant Total 7 of 25 day habilitation sites and 5 of 18 employment readiness sites are compliant. The remainders have plans of correction. 20 Site by Site Assessments:

Day Programs & Services All community-based day settings achieved compliance. Top issues resulting in non-compliance findings (more than 10% non-compliant responses across day providers): The program facilitates individual choice regarding services and supports, and who provides them 11% The program is integrated and supports access to the greater community 14% The program is selected by the person from among options including non-disability specific settings 18% If provider-owned or controlled, the program allows people to have visitors at any time -15% 21

Site by Site Assessments: Supported Living; Host Homes; Residential Habilitation Worked with our HCBS Settings Group, Project ACTION! members, and Support Development Associates (PersonCentered Thinking experts) to create a tool to ask people who receive supports about their experiences. Currently a standalone interview, but will be incorporated into regular Service Coordination Monitoring and the questions asked will align with the PCR tool. Completed 100% sample by July 2016 and working on 2 nd round now.

Updated data will be published Summer, 2017 for public comment. 22 Site by Site Assessments: Supported Living; Host Homes; Residential Habilitation 23 Results of Site by Site Assessments: Residential Will be Non-compliant Removed Total Compliant Supported Living

54 418 0 472 Residential Habilitation 2 34 2 38

Host Home 6 56 0 62 Data as of July 2016 24 PCR Residential Results Data as of December 2016 100% organizational assessment of providers 25% sample of sites with personal interview Finding of non-compliance leads to

TA, issues, and plans of correction PCR Residential Results Shows ongoing progress in providers achieving compliance with the rule. Top issues resulting in non-compliance findings (more than 10% non-compliant responses across residential providers): assisting a person to develop transportation skills a persons access to personal funds a persons ability to know which actions to take if treated unfairly landlord/tenant agreements Site by Site Assessments: Assisted Living-EPD DHCF tool mirrors Provider Self-Assessment Administered as part of on-going monitoring activities

100% completed in 2016 Overall compliance is at 86% DHCF will be working with providers to meet settings requirements through one-on-one technical assistance When a discovery and remediation are issued to an EPD Waiver provider, a Corrective Action Plan will be required 27 Site by Site Assessments: Community Residence Facilities & Non-EPD Assisted Living Administered as part of LTSS Assessment by Delmarva HCBS Settings Addendum to assessment Abbreviated version of provider self-assessment and DHCF assessment tools One assessment pending-expected completion April 2017

With data to date, overall compliance is at 90% DHCF will be working with providers to meet settings requirements through one-on-one technical assistance When a discovery and remediation are issued to an EPD Waiver provider, a Corrective Action Plan will be required 28 Heightened Scrutiny DHCF will submit one setting for heightened scrutiny to CMS because it does not meet one of the elemental HCBS Settings requirements The EPD-enrolled assisted living provider is on the grounds of or immediately adjacent to a public institution.

DHCF contends that the provider meets the HCBS settings requirements and will submit an evidentiary package demonstrating the facilitys HCBS characteristics with the updated plan on April 28, 2017. 29 Heightened Scrutiny No residential settings No community based day settings Facility-based day: Based upon the settings compliance with indicators of the HCBS Settings Rule, for which we believe that findings of non-compliance tend to indicate the effect of isolating individuals receiving Medicaid-funded HCBS from the broader community of individuals not receiving Medicaid-funded HCBS. 30

Heightened Scrutiny Any day provider that is not in compliance with two (2) or more of the indicators listed below after the next site-by-site assessment, which occurs as part of the regular PCR review, will either Be submitted to CMS for heightened scrutiny review; or DC will determine that the setting is not likely to meet the HCBS Settings Rule by March 17, 2019 and will begin to transition people to a new provider and ultimately eliminate the setting from the program. 31 Heightened Scrutiny Requirements of the HCBS Settings Rule Related to DCs Heightened Scrutiny Review for HCBS IDD Waiver Day Program Settings The following CMS Questions were used by DDS to determine which settings qualify for heightened scrutiny review:

(a) The setting ensures a persons rights of privacy, dignity, respect and freedom from coercion and restraint. (b) The setting optimizes a persons initiative, autonomy, and independence in making life choices. (c) The setting facilitates individual choice regarding services and supports, and who provides them. (d) The setting provides opportunities to seek employment and work in competitive integrated settings, engage in community life, and control personal resources. (e) The setting is integrated and supports access to the greater community. (f) The setting provides opportunities to engage in community life. (h) The setting provides opportunities to receive services in the community to the same degree of access as individuals not receiving Medicaid HCBS. (q) If provider-owned or controlled, the setting provides people with the freedom and support to control their schedules and activities and have access to food any time. (r) If provider-owned or controlled, the setting allows people to have visitors at any time. 32

Remediation: Proposed Waiver Amendments 33 Proposed Waiver Amendments Provider Qualifications for All HCBS Settings: Modify language in provider qualifications to require that any new settings must meet all requirements of the HCBS Settings Rule. Also applies to settings outside the natural home under the Elderly & persons with Physical Disabilities (EPD) Waiver, including Adult Day Health and Assisted Living. 34 Proposed Waiver Amendments Day Habilitation: Eligibility Limitations based on Level of Need for New Admissions

People who are 64 and younger and have Level of Need score of 1 or 2 would not be eligible to attend Day Habilitation programs, unless approved by DDS due to extenuating circumstances or barriers that are expected to be resolved within six months. People who are 64 and younger and have a Level of Need score of 3 would not be eligible to attend Day Habilitation programs, unless they have tried other day and employment options for one year first, or they were approved by DDS. No person may not attend Day Habilitation more than 24 hours per week. (Not-applicable to small group day habilitation.) Wrap around services are available. 35 Proposed Waiver Amendments Day Habilitation: Eligibility Limitations based on Level of Need for People Currently Receiving Supports: Within one year from the date of the approved waiver amendments, any person with a Level of Need score of 1

or 2 would no longer be eligible for Day Habilitation services must instead be offered employment services, either through the waiver, RSA, or other community based options. No person may not attend Day Habilitation more than 24 hours per week. (Not-applicable to small group day habilitation.) Wrap around service are available up to 40 hours/ week. Due process notice 36 Day Habilitation LON Distribution 37 Proposed Waiver Amendments Size Limitations for Day Habilitation & Employment Readiness Services

Current Day Habilitation and Employment Readiness settings that have a daily census under fifty people in the setting for more than 20% of the day, may only receive authorizations for services for new participants up to a daily census of fifty people in the setting. Current Day Habilitation settings that have a daily census of fifty people or more in the setting for more than 20% of the day will not be eligible for authorizations for services for new participants until their daily census is less than fifty people in the setting. (There are no current Employment Readiness settings that have a daily census 38 over 50 people Proposed Waiver Amendments Time Limitation for Employment Readiness Services For people who are not currently enrolled in Employment Readiness services, the service may only be authorized for up to one year, except that DDS may approve up to a one year extension if there is documentation that the person is making progress towards competitive integrated employment and would benefit from

extended services. If a person has exhausted Employment Readiness services and: (1) has had at least one year since the end of that service; (2) expresses an interest in employment; and (3) the support team has identified specific goals around building employment skills that are reflected in the ISP, then DDS may authorize Employment Readiness services one time, for up to one year. (Total of up to three years of Employment Readiness services.) For people currently receiving Employment Readiness services, the 39 time limitation would begin to run upon approval of the Waiver Amendments EPD Waiver

Includes HCBS setting requirements Assisted Living Adult Day Health Program Providers enrolling will meet HCBS setting requirements in keeping with DHCFs updated Provider Readiness Review process. Includes Statewide Transition Plan 40 Remediation: Changes to Regulations 41 Changes Made to General Provisions 1938 HOME AND COMMUNITY BASED SETTING REQUIREMENTS 1938.1 All HCBS Settings must:

Be chosen by the person; Ensure peoples right to privacy, dignity, and respect, and freedom from coercion and restraint; Be physically accessible to the person and allow the person access to all common areas; Support the persons community integration and inclusion, including relationship-building and maintenance, support for selfdetermination and self-advocacy; Provide opportunities for the person to seek employment and meaningful non-work activities in the community; Provide information on individual rights; Changes Made to General Provisions 1938 HOME AND COMMUNITY BASED SETTING REQUIREMENTS 1938.1 All HCBS Settings must: Optimize the persons initiative, autonomy and independence in making life choices including but not limited to, daily activities, physical environment, and with whom to interact;

Facilitate the persons choices regarding services and supports, and who provides them; Create individualized daily schedules for each person receiving supports, that includes activities that align with the persons goals, interests and preferences, as reflected in his or her ISP; Provide opportunities for the person to engage in community life; and Allow visitors at any time, with any exception based on the persons assessed need and justified in his or her person-centered Changes Made to General Provisions 1938 HOME AND COMMUNITY BASED SETTING REQUIREMENTS 1938.2 All Supported Living, Supported Living with Transportation, Host Home, Residential Habilitation, and Respite Daily, settings must: Be integrated in the community and support access to the greater community; Provide opportunities for the person to engage in community life;

Allow full access to the greater community; Be leased in the names of the people who are being supported. If this is not possible, then the provider must ensure that each person has a legally enforceable residency agreement or other written agreement that, at a minimum, provides the same responsibilities and protections from eviction that tenants have under relevant Changes Made to General Provisions 1938 HOME AND COMMUNITY BASED SETTING REQUIREMENTS 1938.2(e) All Supported Living, Supported Living with Transportation, Host Home, and Residential Habilitation settings must: Develop and adhere to policies which ensure that each person receiving services has the right to the following: Privacy in his or her personal space, including entrances that are lockable by the person (with staff having keys as needed); Freedom to furnish and decorate his or her personal space (with the exception of Respite Daily);

Control over his or her personal funds and bank accounts; Privacy for telephone calls, texts and/or emails; and Access to food at any time. Changes Made to General Provisions 1938 HOME AND COMMUNITY BASED SETTING REQUIREMENTS 1938.3 All Day Habilitation and Employment Readiness settings must develop and adhere to policies which ensure that each person receiving services has the right to the following: Privacy for personal care, including when using the bathroom; Access to snacks at any time; and Meals at the time and place of a persons choosing. Any deviations from the requirements must be supported by

a specific assessed need, justified in the persons personcentered Individualized Support Plan, and reviewed and 46 Changes Made to General Provisions 1911 INDIVIDUAL RIGHTS (New Additions) Each Waiver provider shall develop and adhere to policies which ensure that each person receiving services has the right to the following: Be informed orally and in writing of the following: Complaint and referral procedures including how to file an anonymous complaint; The telephone number of the DDS customer complaint line;

How to report an allegation of abuse, neglect and exploitation; For people receiving residential supports, the persons Changes Made to Day/ ER Regs Require development of Positive Personal Profile (Vocational Assessment) and a Job Search/ Community Participation Plan Day Habilitation must include activities to support community integration and inclusion. These must occur in the community in groups not to exceed 4 participants and must be based on peoples interests and preferences as reflected in their Individualized Support Plan and Person-Centered Thinking and Discovery tools.

Employment Readiness must include community-based employment preparation experiences that are related to the persons employment goals. Proposed Changes to Day/ ER Regs Require that people can choose whom they spend time with during the day; Providers must develop and adhere to policies which ensure that each person receiving services has the right to the following:

Safe and private place to store personal possessions (if locked, with staff having keys as needed); Control over his or her personal funds; and Opportunity for privacy for telephone calls, texts and/or emails; or any other form of electronic communication, e.g. FaceTime or Skype. DDS plans to update regulations to address the areas mentioned above by September, 2018 49 Changes to EPD Regulations HCBS Settings provisions included in general EPD Waiver regulation

Adult Day Health Program regulations published January 29, 2016 Must be compliant upon enrollment Proposed changes to MH Community Residence Facility regulation and Assisted Living legislation HCBS Settings provisions will be included for all licensed providers Maximizes residential options for EPD Waiver beneficiaries who choose licensed settings that are not enrolled in the waiver 50

Remediation: Changes to Policy & Practice 51 Changes Made to Policy New person centered Individual Support Plan policy requires vocational assessment; guided conversations around employment, most integrated day, and informed choice. Provider Performance Review includes regular review of compliance with HCBS Settings requirements. New Complaint policy providing ability to submit anonymous complaints. 52 Proposed Changes to Policy

Personal Funds: to ensure no barriers to a person controlling their own funds, while balancing protections Most Integrated Setting: to specifically include HCBS Settings requirements Human Rights/ Behavior Supports: to incorporate requirements around deviations from HCBS Settings Requirements (for example, how to handle a person cannot have access to food at any time) Contribution to Cost: process by which a person can contribute to costs of residential supports (rent, utilities, etc.) so that they can live in a place of their choosing; with roommates of their choice; or

by themselves. Will seek stakeholder input through HCBS Settings Advisory Group + Public Forums. Goal to publish all by September 31, 2018. 53 Proposed Changes to PolicyEPD Waiver Settings EPD Waiver policy and procedures for Assisted Living and Adult Day Health will address the HCBS Settings provisions.

EPD Waiver policy and procedures for Case Management will address the HCBS Settings provisions within the context of personcentered planning. Where applicable, DBH Community Residence Facility policy and procedure, and DOH Assisted Living Residence policy and procedure will address the HCBS provisions. 54 Remediation: Capacity Building 55 Capacity Building

Ongoing Person-Centered Thinking training (Phase 1 & 2) Supporting 5 Day Habilitation programs to become person centered organizations. Community Life Engagement Community of Practice Targeted TA & training based upon results of assessments. Discuss HCBS Settings Rule at every Provider Leadership meeting and Day & Employment Community of Practice

Offer quarterly training on Discovery Positive Personal Profiles and Job Search/ Community Participation Plans. Ongoing real time 1:1 TA by Service Coordination, Quality and PCR staff, based on results of monitoring, Provider Certification Review and Provider Performance Review. 56 Capacity Building New Community of Practice on Person-Centered Planning & Conflict-Free Case Management- Focus on training case managers

Targeted TA & training based upon results of assessments Discuss HCBS Settings Rule at monthly EPD/State Plan Provider meetings and Person-Centered Planning Community of Practice Ongoing real time 1:1 TA by Long Term Care and Policy staff, based on results of monitoring, self-assessments and Provider Readiness Reviews 57 For More Information Erin Leveton State Office of Disability Administration

DC Department on Disability Services (202) 730-1754 [email protected] http:// dds.dc.gov/page/waiver-amendmen For More Information Leyla Sarigol Long Term Care Administration DC Department of Health Care Finance (202) 442-5918 [email protected]

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