HCBS Statewide Transition Plan Training for Multiple Service Areas

HCBS Statewide Transition Plan Update

Aging Services, Medical Services, and Developmental Disabilities

November 16 & 17 2022

Agenda

A final rule by Centers for Medicare and Medicaid (CMS 2249F) was issued in January 2014 for home and community-based services (HCBS) provided through Medicaid waivers. The new regulations:

• • Provided requirements of a home and community-based setting
• • Defined person-centered planning requirements

• • Required states to develop transition plans for bringing all HCBS settings into compliance

• • Ensures that HCBS waiver participants can enjoy the benefits of living, working, and participating in the most integrated setting.

• • Settings are more about the nature and quality of individual’s experiences, not only about buildings where the services are being delivered.

• • People have maximum choice and control over their lives

• • Rights are respected and should be same as any citizen

Overview

Definition of Settings

• • Homes
• • Apartment Units
• • Day Programs

• • Work Locations
  HCBS Settings Include:

• • Nursing Facility

• • Institution for mental diseases

• • Intermediate care facility for individuals with intellectual disabilities (ICF/IID)

• • Hospital

• • Any setting that has “institutional” characteristics or isolates from the broader community

Cannot be Provided in:

HCBS Requirements are about:

Physical environment where people live & work

Individual experiences & preferences

People participate & live in the community

• • Full access & integrated

HCBS Requirements:

Settings selected by the person from among multiple setting options

• • Includes living options of people without disabilities

People have choice of services & supports

People choose their roommate(s)

People’s rights are respected & promoted

HCBS Requirements:

People make their own daily/life choices, develop their schedules, & have independence

People are free from restraint & not pressured into choices

People have privacy & dignity

People decorate & furnish their home as they wish

HCBS Requirements:

People have access to food & personal items at any time

People have visitors at any time

People control their own money & have opportunities  to get paid at least minimum wage

Provider Owned & Controlled Residential Settings

Person-Centered Planning Requirements

Person-Centered Planning Requirements

Community Integration

Consider local activities

1. - • Parades, farmer’s market, craft fairs, car shows, high school sporting events, church programs
   • • Participate in meal serving at a local event
   • • Attending an art class, petting zoo, go to the library to check out books, go to the coffee shop once per week
   • • Local schools often have plays, sporting events, fundraisers, craft fairs, and other activities people may enjoy
   • • Partner with what is already available in your community

Community Integration

What to do for those who become overstimulated or anxious in crowds:

1. - • Go to an event when it first opens, before it becomes crowded
   • • Meet 1:1 with an expert or another person that shares their interest
   • • Shop smaller stores
   • • Check for sensory friendly options in the community
   • • Join small group activities (e.g., animal shelters, food pantries, homeless shelters to serve meals, etc.)
   • • Bring calming items with
   • • Visit in smaller time increments

Community Integration

Community Integration

Examples

• • Only go into the community with a group as a “group trip” or outing
• • Entire day spent at day program location
• • All activities are scheduled by staff with out individual input
• • Can only shower on certain days or times
• • If chores not done, no other activities that day

• • Personal schedules are posted
  Do NOT Meet Requirements

• • Individualized activities in community based on personal interest

• • Activities also include social or volunteer activities in coffee shops, library, senior center, etc.

• • People are involved in choosing their activities

• • Can choose to shower when they want

• • May choose not to wash supper dishes that night, but still go out with friends

• • Personal schedules are kept in a binder or own private space/bedroom

Do Meet Requirements

Examples

• • Scheduled meal, bed, & waking times
• • Set menus & people are not part of the meal planning
• • No food in bedrooms
• • All checkbooks kept in staff office or locked

• • Home or room is already furnished & decorated
  Do NOT Meet Requirements

• • Choose when wake up, go to bed, have meals

• • If menus are developed people have input, based on food preferences, or other food choices available

• • Eat food in living room, or other areas & not confined to the kitchen

• • Keep their checkbooks & money in their private space

• • Can furnish home/room with personal items
  Do Meet Requirements

Examples

• • Does not have own key to bedroom/house
• • No area to make private phone calls or have to ask to use phone
• • Staff talking about you in front of others
• • House rules-where provider implement “blanket” procedures for everyone
• • Being told can only make plan changes at annual meeting

Do NOT Meet Requirements

• • Have own key, code, fab, etc. to use
• • Use of a cordless phone, option to have cell phone, ability to take phone to private area
• • Staff conduct conversations in a separate room or other private manners
• • Procedures are based on individual need or roommate discussion/agreement
• • Plans can be updated or requested anytime by the person & guardian

Do Meet Requirements

• • States were allowed some time to come into compliance. States had to assess provider settings and state policies, then develop a Statewide Transition Plan (STP) to describe how its programs meet the rules and how it will fix the areas that do not comply.

• • ND submitted their STP for all Medicaid Waivers

• • • HCBS Waiver (serves Aged and Disabled)
  • • Autism Spectrum Disorder (ASD) Waiver
  • • Children’s Hospice Waiver
  • • Medically Fragile Children’s Waiver
  • • Technology Dependent Waiver
  • • Traditional IID/DD HCBS Waiver

Statewide Transition Plan

States must ensure continued compliance with the requirements.

ND ensures this by:

• • Reviewing future settings
• • Monitoring person-centered service plans through quality reviews
• • Monitoring people’s experiences are consistent with those of the general public
• • Implementation of Policy and Procedures
• • Case Management oversight activities
• • Licensing requirements Ongoing Monitoring and Compliance

May 2022 CMS announced strategy for implementation of the HCBS requirements for states to continue to receive federal reimbursement

1. 1. All states must receive final Statewide Transition Plan by March 17, 2023
2. • • ND achieved final approval by CMS February 2019 https://www.hhs.nd.gov/sites/www/files/documents/DHS%20Legacy/nd-approved-statewide-transition-plan-ada.pdf

STP Update and CMS Expectations

1. By March 17, 2023: all states and providers must be in compliance with requirements not directly impacted by the COVID-19 PHE disruptions (includes workforce challenges)

2. • • Privacy, dignity, respect
   • • Freedom from coercion & restraint
   • • Control of personal resources
   • • Lease or other legally enforceable agreement (provider owned or controlled settings)
   • • Lockable doors (provider owned or controlled settings)
   • • Freedom to furnish or decorate their home
   • • Access to food & visitors at any time
   • • Physical accessibility of home
   • • Person-centered service plan documentation of modifications (right restrictions)

STP Update and CMS Expectations

STP Update and CMS Expectations

ND presumes that previously approved setting assessments continue to be in compliance with the setting requirements (listed in previous slide)

• • This is in anticipation of CMS completing future on-site visits

1. By December 1, 2022: States may submit time-limited corrective action plans (CAPs) to authorize additional time to achieve full compliance with requirements that are directly impacted by PHE disruptions

2. • • Access to the broader community
   • • Opportunities for employment
   • • Option for a private unit and/or choice of a roommate
   • • Choice of non-disability specific settings

STP Update and CMS Expectations

STP Update and CMS Expectations

ND Aging will be submitting a CAP for any providers who are not in compliance with community integration

1. By January 1, 2023: states must submit their process for waiver participants to notify the state of provider noncompliance

States can identify their processes through a variety of methods such as:

• • case management
• • call-in center
• • state administration, etc.

STP Update and CMS Expectations

• • Concerns with provider staff, provider performance, service delivery, people’s experiences, etc.
• • Person receiving services, legal decision maker, or any other interested person can submit
• • Can be submitted anytime
• • Submit to Case Manager/Program Manager or Administration at state office
• • Notification of right to submit a Grievance/Complaint initially & annually
• • Policy will identify process & contact information

Grievance/Complaint

Grievance/Complaint

• • Contact with other entities

• • • Human Service Centers or Zone
  • • P&A, VAPS, Child Protection Services
  • • Accreditation organization

• • Team meeting

• • Service plan revisions

• • Service or provider changes

Potential Actions or Resolutions

• • Review or investigation
• • On-site visit
• • Monitoring
• • Plan of Correction
• • Licensure status change

ND Information

https://www.hhs.nd.gov/human-services/hcbs

Federal Information

• • https://www.medicaid.gov/medicaid/home-community-based-services/index.html
• • https://www.medicaid.gov/medicaid/home-community-based-services/guidance/home-community-based-services-final-regulation/index.html

• • https://www.medicaid.gov/medicaid/home-community-based-services/guidance/home-community-based-settings-requirements-compliance-toolkit/index.html

• • This intensive is about 3 hours, but it does have a lot of good information:
  https://youtu.be/OYFarI7aVVY - CMS Intensive: Time is of the Essence: Countdown to Compliance with the HCBS Settings Rule

Resources