Current through Register Vol. 50, No. 9, March 1, 2024
RELATES TO:
KRS
205.520(3),
205.5605,
205.5606,
205.5607,
205.635,
42 C.F.R.
440.180
NECESSITY, FUNCTION, AND CONFORMITY: The Cabinet for Health and
Family Services, Department for Medicaid Services has responsibility to
administer the Medicaid Program.
KRS
205.520(3) authorizes the
cabinet to comply with any requirement that may be imposed, or opportunity
presented, by federal law to qualify for federal Medicaid funds. This
administrative regulation establishes the coverage and reimbursement provisions
for Michelle P. waiver services.
Section
1. Definitions.
(1) "1915(c) home
and community based waiver services program" means a Kentucky Medicaid program
established pursuant to and in accordance with
42 U.S.C.
1396n(c).
(2) "ADHC" means adult day health
care.
(3) "ADHC center" means an
adult day health care center licensed in accordance with
902 KAR 20:066.
(4) "ADHC services" means health-related
services provided on a regularly-scheduled basis that ensure optimal
functioning of a participant who does not require twenty-four (24) hour care in
an institutional setting.
(5)
"Advanced practice registered nurse" or "APRN" means a person who acts within
his or her scope of practice and is licensed in accordance with
KRS
314.042.
(6) "Assessment team" means a team which:
(a) Conducts assessment or reassessment
services; and
(b) Consists of:
1. Two (2) registered nurses; or
2. One (1) registered nurse and one (1) of
the following:
a. A social worker;
b. A certified psychologist with autonomous
functioning;
c. A licensed
psychological practitioner;
d. A
licensed marriage and family therapist; or
e. A licensed professional clinical
counselor.
(7) "Behavior support specialist" means an
individual who has:
(a) A master's degree from
an accredited institution with formal graduate course work in a behavioral
science; and
(b) At least one (1)
year of experience in behavioral programming.
(8) "Blended services" means a nonduplicative
combination of Michelle P. waiver services identified in Section 6 of this
administrative regulation and participant-directed services identified in
Section 7 of this administrative regulation provided pursuant to a
participant's approved person-centered service plan.
(9) "Budget allowance" is defined by
KRS
205.5605(1).
(10) "Certified psychologist" means an
individual who is a certified psychologist in accordance with
KRS
319.056.
(11) "Covered services and supports" is
defined by KRS
205.5605(3).
(12) "DCBS" means the Department for
Community Based Services.
(13)
"Department" means the Department for Medicaid Services or its
designee.
(14) "Developmental
disability" means a severe, chronic disability that:
(a) Is attributable to:
1. Cerebral palsy or epilepsy; or
2. Any other condition, excluding mental
illness, closely related to an intellectual disability resulting in impairment
of general intellectual functioning or adaptive behavior similar to that of an
individual with an intellectual disability and which requires treatment or
services similar to those required by persons with an intellectual
disability;
(b) Is
manifested prior to the individual's 22nd birthday;
(c) Is likely to continue indefinitely;
and
(d) Results in substantial
functional limitations in three (3) or more of the following areas of major
life activity:
1. Self-care;
2. Understanding and use of
language;
3. Learning;
4. Mobility;
5. Self-direction; or
6. Capacity for independent living.
(15) "Direct care staff"
means an individual hired by a Michelle P. waiver provider to provide services
to the participant and who:
(a)
1.
a. Is
eighteen (18) years of age or older; and
b. Has a high school diploma or GED;
or
2.
a. Is twenty-one (21) years of age or older;
and
b. Is able to communicate with
a participant in a manner that the participant or participant's legal
representative or family member can understand;
(b) Has a valid Social Security number or
valid work permit if not a U.S. citizen;
(c) Can understand and carry out simple
instructions;
(d) Has the ability
to keep simple records; and
(e) Is
managed by the provider's supervisory staff.
(16) "Electronic signature" is defined by
KRS
369.102(8).
(17) "Federal financial participation" is
defined in 42 C.F.R.
400.203.
(18) "Home health agency" means an agency
that is:
(a) Licensed in accordance with
902 KAR 20:081; and
(b) Medicare and Medicaid
certified.
(19) "ICF-IID"
means an intermediate care facility for individuals with an intellectual
disability.
(20) "Intellectual
disability" means an individual has:
(a)
Significantly sub-average intellectual functioning;
(b) An intelligence quotient of seventy (70)
or below;
(c) Concurrent deficits
or impairments in present adaptive functioning in at least two (2) of the
following areas:
1. Communication;
2. Self-care;
3. Home living;
4. Social or interpersonal skills;
5. Use of community resources;
6. Self-direction;
7. Functional academic skills;
8. Work;
9. Leisure; or
10. Health and safety; and
(d) Had an onset prior to eighteen
(18) years of age.
(21)
"Intellectual disability professional" means an individual who:
(a) Has at least one (1) year of experience
working with individuals with an intellectual or developmental
disability;
(b) Meets the personnel
and training requirements established in Section 2 of this administrative
regulation; and
(c)
1. Is a doctor of medicine or
osteopathy;
2. Is a registered
nurse; or
3. Holds a bachelor's
degree from an accredited institution in a human services field.
(22) "Level of care
determination" means a determination that an individual meets the Michelle P.
waiver service level of care criteria established in Section 5 of this
administrative regulation.
(23)
"Licensed clinical social worker" means an individual who meets the licensed
clinical social worker requirements established in
KRS
335.100.
(24) "Licensed marriage and family therapist"
or "LMFT" is defined by
KRS
335.300(2).
(25) "Licensed practical nurse" or "LPN"
means a person who:
(a) Meets the definition
of KRS
314.011(9); and
(b) Works under the supervision of a
registered nurse.
(26)
"Licensed professional clinical counselor" or "LPCC" is defined by
KRS
335.500(3).
(27) "Licensed psychological associate" means
an individual who meets the requirements established in
KRS
319.064.
(28) "Licensed psychological practitioner"
means an individual who:
(a) Meets the
requirements established in
KRS
319.053; or
(b) Is a certified psychologist with
autonomous functioning.
(29) "Licensed psychologist" means an
individual who:
(a) Currently possesses a
licensed psychologist license in accordance with
KRS
319.010(6); and
(b) Meets the licensed psychologist
requirements established in 201 KAR Chapter 26.
(30) "MWMA" means the Kentucky Medicaid
Waiver Management Application internet portal located at
http://chfs.ky.gov/dms/mwma.htm.
(31) "Normal babysitting" means general care
provided to a child which includes custody, control, and supervision.
(32) "Occupational therapist" is defined by
KRS
319A.010(3).
(33) "Occupational therapy assistant" is
defined by KRS
319A.010(4).
(34) "Participant" means an individual who:
(a) Is a recipient as defined by
KRS
205.8451(9);
(b) Meets the Michelle P. waiver service
level of care criteria established in Section 5 of this administrative
regulation; and
(c) Meets the
eligibility criteria for Michelle P. waiver services established in Section 4
of this administrative regulation.
(35) "Participant-directed services" or "PDS"
means an option established by
KRS
205.5606 within the 1915(c) home and
community based waiver services programs that allows participants to receive
non-medical services in which the individual:
(a) Assists with the design of the
program;
(b) Chooses the providers
of services; and
(c) Directs the
delivery of services to meet his or her needs.
(36) "Patient liability" means the financial
amount an individual is required to contribute toward cost of care in order to
maintain Medicaid eligibility.
(37)
"Person-centered service plan" means a written individualized plan of services
for a participant that meets the requirements established in Section 8 of this
administrative regulation.
(38)
"Physical therapist" is defined by
KRS
327.010(2).
(39) "Physical therapist assistant" means a
skilled health care worker who:
(a) Is
certified by the Kentucky Board of Physical Therapy; and
(b) Performs physical therapy and related
duties as assigned by the supervising physical therapist.
(40) "Physician assistant" or "PA" is defined
by KRS
311.840(3).
(41) "Plan of treatment" means a care plan
used by an ADHC center.
(42)
"Psychologist with autonomous functioning" means an individual who is licensed
in accordance with KRS 319.056.
(43) "Qualified professional in the area of
intellectual disabilities" is defined by
KRS
202B.010(12).
(44) "Registered nurse" or "RN" means a
person who:
(a) Meets the definition
established in KRS
314.011(5); and
(b) Has at least one (1) year of experience
as a licensed practical nurse or a registered nurse.
(45) "Representative" is defined by
KRS
205.5605(6).
(46) "Sex crime" is defined by
KRS
17.165(1).
(47) "Social worker" means a person with a
bachelor's degree in social work, sociology, or a related field.
(48) "Speech-language pathologist" is defined
by KRS
334A.020(3).
(49) "State plan" is defined by
42 C.F.R.
400.203.
(50) "Supervisory staff" means an individual
employed by the Michelle P. waiver provider who shall manage direct care staff
and who:
(a)
1.
a. Is
eighteen (18) years of age or older; and
b. Has a high school diploma or GED;
or
2. Is twenty-one (21)
years of age or older;
(b) Has a minimum of one (1) year experience
in providing services to individuals with an intellectual or developmental
disability;
(c) Is able to
adequately communicate with the participants, staff, and family
members;
(d) Has a valid Social
Security number or valid work permit if not a U.S. citizen; and
(e) Has the ability to perform required
record keeping.
(51)
"Support broker" means an individual chosen by a participant from an agency
designated by the department to:
(a) Provide
training, technical assistance, and support to the participant; and
(b) Assist the participant in any other
aspects of PDS.
(52)
"Support spending plan" means a plan for a participant that identifies the:
(a) PDS requested;
(b) Employee name;
(c) Hourly wage;
(d) Hours per month;
(e) Monthly pay;
(f) Taxes;
(g) Budget allowance; and
(h) Twelve (12) month budget.
(53) "Violent crime" is defined by
KRS
17.165(3).
Section 2. Non-PDS Provider Participation
Requirements.
(1) In order to provide
Michelle P. waiver services, excluding participant-directed services, a
provider shall be:
(a) Licensed in accordance
with:
1.
902 KAR 20:066 if an adult day
health care provider;
2.
902 KAR 20:078 if a group
home;
3.
902 KAR 20:081 if a home health
agency; or
4.
902 KAR 20:091 if a community
mental health center; or
(b) Certified by the department in accordance
with 907 KAR 12:010 if the provider's
type is not listed in paragraph (a) of this subsection.
(2) A Michelle P. waiver provider shall:
(a) Comply with:
1.
907 KAR 1:671;
2.
907 KAR 1:672;
3.
907 KAR 1:673;
4. This administrative regulation;
5. The Health Insurance Portability and
Accountability Act, 42
U.S.C. 1320d-2, and
45 C.F.R. Parts
160,
162, and
164;
6.
42 U.S.C.
1320d to
1320d-8; and
7. The provider participation requirements
for SCL providers established in
907 KAR 12:010, Section
3;
(b) Not enroll a
participant for whom the provider is unequipped or unable to provide Michelle
P. waiver services; and
(c) Be
permitted to accept or not accept a participant.
(3) In order to provide a Michelle P. waiver
service in accordance with Section 4 of this administrative regulation, a
Michelle P. waiver service provider:
(a)
Shall, for a potential employee or volunteer, obtain the results of a Caregiver
Misconduct Registry check as described in
922 KAR 5:120 or an equivalent
out-of-state agency if the individual resided or worked outside of Kentucky
during the year prior to employment or volunteerism; and
(b) May use Kentucky's national background
check program established by
906 KAR 1:190 to satisfy the
background check requirements of paragraph (a) of this
subsection.
Section 4. Participant Eligibility
Determinations and Redeterminations.
(1) A
Michelle P. waiver service shall be provided to a Medicaid-eligible participant
who:
(a) Is determined by the department to
meet the Michelle P. waiver service level of care criteria in accordance with
Section 5 of this administrative regulation; and
(b) Would, without waiver services, be
admitted to an ICF-IID or a nursing facility.
(2) To apply for participation in the
program, an individual or individual's representative shall:
(a) Apply for 1915(c) home and community
based waiver services via the MWMA; and
(b) Complete and upload into the MWMA a MAP -
115 Application Intake - Participant Authorization.
(3) The department shall perform a Michelle
P. waiver service level of care determination for each participant at least
once every twelve (12) months or more often if necessary.
(4) A Michelle P. waiver service shall not be
provided to an individual who:
(a) Does not
require a service other than:
1. An
environmental and minor home adaptation;
2. Case management; or
3. An environmental and minor home adaptation
and case management;
(b)
Is an inpatient of:
1. A hospital;
2. A nursing facility; or
3. An ICF-IID;
(c) Is a resident of a licensed personal care
home; or
(d) Is receiving services
from another 1915(c) home and community based waiver services
program.
(5) A Michelle
P. waiver provider shall inform a participant or the participant's legal
representative of the choice to receive:
(a)
Michelle P. waiver services; or
(b)
Institutional services.
(6) An eligible participant or the
participant's legal representative shall select a participating Michelle P.
waiver provider from which the participant wishes to receive Michelle P. waiver
services.
(7) A Michelle P. waiver
provider shall notify the department in writing electronically or in print of a
participant's:
(a) Termination from the
Michelle P. waiver program;
(b)
Admission to an ICF-IID or nursing facility for less than sixty (60)
consecutive days;
(c) Return to the
Michelle P. waiver program from an ICF-IID or nursing facility within sixty
(60) consecutive days;
(d)
Admission to a hospital; or
(e)
Transfer to another waiver program within the department.
(8) Involuntary termination of a service to a
participant by a Michelle P. waiver provider shall require:
(a) Simultaneous notice in writing
electronically or in print to the participant or legal representative, the case
manager or support broker, and the department at least thirty (30) days prior
to the effective date of the action, which shall include:
1. A statement of the intended
action;
2. The basis for the
intended action;
3. The authority
by which the action is taken; and
4. The participant's right to appeal the
intended action through the provider's appeal or grievance process;
and
(b) The case manager
or support broker in conjunction with the provider to:
1. Provide the participant with the name,
address, and telephone number of each current provider in the state;
2. Provide assistance to the participant in
making contact with another provider;
3. Arrange transportation for a requested
visit to a provider site;
4.
Provide a copy of pertinent information to the participant or legal
representative;
5. Ensure the
health, safety, and welfare of the participant until an appropriate placement
is secured;
6. Continue to provide
supports until alternative services are secured; and
7. Provide assistance to ensure a safe and
effective service transition.
Section 5. Michelle P. Waiver Service Level
of Care Criteria.
(1) An individual shall be
determined to have met the Michelle P. waiver service level of care criteria if
the individual:
(a) Requires physical or
environmental management or rehabilitation and:
1. Has a developmental disability or
significantly sub-average intellectual functioning;
2. Requires a protected environment while
overcoming the effects of a developmental disability or sub-average
intellectual functioning while:
a. Learning
fundamental living skills;
b.
Obtaining educational experiences which will be useful in self-supporting
activities; or
c. Increasing
awareness of his or her environment; or
3. Has a primary psychiatric diagnosis if:
a. The individual possesses care needs listed
in subparagraph 1 or 2 of this paragraph;
b. The individual's mental care needs are
adequately handled in an ICF-IID; and
c. The individual does not require
psychiatric inpatient treatment; or
(b) Has a developmental disability and meets
the:
1. High-intensity nursing care patient
status criteria pursuant to
907 KAR 1:022, Section 4(2);
or
2. Low-intensity nursing care
patient status criteria pursuant to
907 KAR 1:022, Section
4(3).
(2) An
individual who does not require a planned program of active treatment to attain
or maintain an optimal level of functioning shall not meet the Michelle P.
waiver service level of care criteria.
(3) The department shall not determine that
an individual fails to meet the Michelle P. waiver service level of care
criteria solely due to the individual's age, length of stay in an institution,
or history of previous institutionalization if the individual meets the
criteria established in subsection (1) of this section.
Section 6. Covered Services.
(1) A Michelle P. waiver service shall:
(a) Be prior authorized by the department to
ensure that the service or modification of the service meets the needs of the
participant;
(b) Be provided
pursuant to a person-centered service plan or, for a PDS, pursuant to a
person-centered service plan and support spending plan;
(c) Except for a PDS, not be provided by a
member of the participant's family. A PDS may be provided by a participant's
family member; and
(d) Be accessed
within sixty (60) days of the date of prior authorization.
(2) To request prior authorization, a
provider shall submit to the department a:
(a)
Completed MAP 10, Waiver Services Physician's Recommendation that has been
signed and dated by:
1. A physician;
2. An advanced practice registered
nurse;
3. A physician assistant;
or
4. An intellectual disability
professional; and
(b)
Person-centered service plan and MAP 351, Medicaid Waiver Assessment.
(3) Covered Michelle P. waiver
services shall include:
(a) A comprehensive
assessment, which shall:
1. Be completed by
the department;
2. Identify a
participant's needs and the services the participant or the participant's
family cannot manage or arrange for on the participant's behalf;
3. Evaluate a participant's physical health,
mental health, social supports, and environment;
4. Be requested by an individual seeking
Michelle P. waiver services or the individual's family, legal representative,
physician, physician assistant, APRN, or intellectual disability
professional;
5. Be conducted by an
assessment team; and
6. Include at
least one (1) face-to-face home visit by a member of the assessment team with
the participant and, if appropriate, the participant's family;
(b) A reassessment service, which
shall:
1. Be completed by the
department;
2. Determine the
continuing need for Michelle P. waiver services and, if appropriate,
PDS;
3. Be performed at least every
twelve (12) months;
4. Be conducted
using the same procedures used in an assessment service; and
5. Not be retroactive;
(c) Case management, which shall meet the
requirements established in Section 9 of this administrative regulation, and
which shall:
1. Consist of coordinating the
delivery of direct and indirect services to a participant;
2. Be provided by a case manager who shall:
a. Arrange for a service but not provide a
service directly;
b. Contact the
participant monthly through a face-to-face visit at the participant's home, in
the ADHC center, or the adult day training provider's location; and
c. Assure that service delivery is in
accordance with a participant's person-centered service plan;
3. Not include a group
conference;
4. Include
documentation with a detailed monthly summary note in the MWMA, which includes:
a. The month, day, and year for the time
period each note covers;
b.
Progression, regression, and maintenance toward outcomes identified in the
person-centered service plan;
c.
The signature, date of signature, and title of the individual preparing the
note; and
d. Documentation of at
least one (1) face-to-face meeting between the case manager and participant,
family member, or legal representative;
5. Include requiring a participant or legal
representative to sign a MAP-350, Long Term Care Facilities and Home and
Community Based Program Certification Form at the time of application or
reapplication and at each recertification to document that the individual was
informed of the choice to receive Michelle P. waiver services or institutional
services; and
6. Not be provided to
a participant by an agency if the agency provides any other Michelle P. waiver
service to the participant;
(d) A homemaker service, which shall consist
of general household activities and shall:
1.
Be provided by direct care staff;
2. Be provided to a participant:
a. Who is functionally unable, but would
normally perform age-appropriate homemaker tasks; and
b. If the caregiver regularly responsible for
homemaker activities is temporarily absent or functionally unable to manage the
homemaking activities; and
3. Include documentation with a detailed note
in the MWMA, which shall include:
a. The
month, day, and year for the time period each note covers; and
b. The signature, date of signature, and
title of the individual preparing the note;
(e) A personal care service, which shall:
1. Be age appropriate;
2. Consist of assisting a participant with
eating, bathing, dressing, personal hygiene, or other activities of daily
living;
3. Be provided by direct
care staff;
4. Be provided to a
participant:
a. Who does not need highly
skilled or technical care;
b. For
whom services are essential to the participant's health and welfare and not for
the participant's family; and
c.
Who needs assistance with age-appropriate activities of daily living;
and
5. Include
documentation with a detailed note in the MWMA, which shall include:
a. The month, day, and year for the time
period each note covers;
b. The
signature, date of signature, and title of the individual preparing the note;
and
c. The beginning and ending
time of service;
(f) An attendant care service, which shall
consist of hands-on care that is:
1. Provided
by direct care staff to a participant who:
a.
Is medically stable but functionally dependent and requires care or supervision
twenty-four (24) hours per day; and
b. Has a family member or other primary
caretaker who is employed or attending school and is not able to provide care
during working hours;
2.
Not of a general housekeeping nature;
3. Not provided to a participant who is
receiving any of the following Michelle P. waiver services:
a. Personal care;
b. Homemaker;
c. ADHC;
d. Adult day training;
e. Community living supports; or
f. Supported employment; and
4. Include documentation with a
detailed note in the MWMA, which shall include:
a. The month, day, and year for the time
period each note covers;
b. The
signature, date of signature, and title of the individual preparing the note;
and
c. Beginning and ending time of
service;
(g) A
respite care service, which shall be short term care based on the absence or
need for relief of the primary caretaker and:
1. Be provided by direct care staff who
provide services at a level that appropriately and safely meets the medical
needs of the participant;
2. Be
provided to a participant who has care needs beyond normal
babysitting;
3. Be used no less
than every six (6) months; and
4.
Include documentation with a detailed note in the MWMA, which shall include:
a. The month, day, and year for the time
period each note covers;
b. The
signature, date of signature, and title of the individual preparing the note;
and
c. The beginning and ending
time of service;
(h) An environmental and minor home
adaptation service, which shall be a physical adaptation to a home that is
necessary to ensure the health, welfare, and safety of a participant and which
shall:
1. Meet all applicable safety and local
building codes;
2. Relate strictly
to the participant's disability and needs;
3. Exclude an adaptation or improvement to a
home that has no direct medical or remedial benefit to the
participant;
4. Be submitted on a
MAP 95 Request for Equipment Form that is uploaded into the MWMA for prior
authorization; and
5. Include
documentation with a detailed note in the MWMA, which shall include:
a. The month, day, and year for the time
period each note covers; and
b. The
signature, date of signature, and title of the individual preparing the
note;
(i)
Occupational therapy, which shall be:
1. A
physician ordered evaluation of a participant's level of functioning by
applying diagnostic and prognostic tests;
2. Physician-ordered services in a specified
amount and duration to guide a participant in the use of therapeutic, creative,
and self-care activities to assist the participant in obtaining the highest
possible level of functioning;
3.
Training of other Michelle P. waiver providers on improving the level of
functioning;
4. Exclusive of
maintenance or the prevention of regression;
5. Provided by an occupational therapist or
an occupational therapy assistant supervised by an occupational therapist in
accordance with
201 KAR 28:130; and
6. Documented with a detailed staff note in
the MWMA, which shall include:
a. The month,
day, and year for the time period each note covers;
b. Progression, regression, and maintenance
toward outcomes identified in the person-centered service plan; and
c. The signature, date of signature, and
title of the individual preparing the note;
(j) Physical therapy, which shall:
1. Be a physician-ordered evaluation of a
participant by applying muscle, joint, and functional ability tests;
2. Be physician-ordered treatment in a
specified amount and duration to assist a participant in obtaining the highest
possible level of functioning;
3.
Include training of other Michelle P. waiver providers on improving the level
of functioning;
4. Be exclusive of
maintenance or the prevention of regression;
5. Be provided by a physical therapist or a
physical therapist assistant supervised by a physical therapist in accordance
with 201 KAR 22:001 and
201 KAR 22:053; and
6. Be documented with a detailed monthly
summary note in the MWMA, which shall include:
a. The month, day, and year for the time
period each note covers;
b.
Progression or lack of progression toward outcomes identified in the
person-centered service plan; and
c. The signature, date of signature, and
title of the individual preparing the note;
(k) Speech language pathology services, which
shall:
1. Be a physician-ordered evaluation of
a participant with a speech or language disorder;
2. Be a physician-ordered habilitative
service in a specified amount and duration to assist a participant with a
speech and language disability in obtaining the highest possible level of
functioning;
3. Include training of
other Michelle P. waiver providers on improving the level of
functioning;
4. Be provided by a
speech-language pathologist; and
5.
Be documented with a detailed monthly summary note in the MWMA, which shall
include:
a. The month, day, and year for the
time period each note covers;
b.
Progression, regression, and maintenance toward outcomes identified in the
person-centered service plan; and
c. The signature, date of signature, and
title of the individual preparing the note;
(l) An adult day training service, which
shall:
1. Support the participant in daily,
meaningful routines in the community;
2. Stress training in:
a. The activities of daily living;
b. Self-advocacy;
c. Adaptive and social skills; and
d. Vocational skills;
3. Be provided in a community setting that
may:
a. Be a fixed location; or
b. Occur in public venues;
4. Not be diversional in
nature;
5. If provided on site:
a. Include facility-based services provided
on a regularly-scheduled basis;
b.
Lead to the acquisition of skills and abilities to prepare the participant for
work or community participation; or
c. Prepare the participant for transition
from school to work or adult support services;
6. If provided off site:
a. Include services provided in a variety of
community settings;
b. Provide
access to community-based activities that cannot be provided by natural or
other unpaid supports;
c. Be
designed to result in increased ability to access community resources without
paid supports;
d. Provide the
opportunity for the participant to be involved with other members of the
general population; and
e. Be
provided as:
(i) An enclave or group approach
to training in which participants work as a group or are dispersed individually
throughout an integrated work setting with people without
disabilities;
(ii) A mobile crew
performing work in a variety of community businesses or other community
settings with supervision by the provider; or
(iii) An entrepreneurial or group approach to
training for participants to work in a small business created specifically by
or for the participant or participants;
7. Ensure that any participant performing
productive work that benefits the organization is paid commensurate with
compensation to members of the general work force doing similar work;
8. Require that an adult day training service
provider conduct, at least annually, an orientation informing the participant
of supported employment and other competitive opportunities in the
community;
9. Be provided at a time
mutually agreed to by the participant and Michelle P. waiver
provider;
10.
a. Be provided to participants of age
twenty-two (22) years or older; or
b. Be provided to participants of age sixteen
(16) to twenty-one (21) years as a transition process from school to work or
adult support services; and
11. Be documented in the MWMA with:
a. A detailed monthly summary note, which
shall include:
(i) The month, day, and year
for the time period each note covers;
(ii) Progression, regression, and maintenance
toward outcomes identified in the person-centered service plan; and
(iii) The signature, date of signature, and
title of the individual preparing the note; and
b. A time and attendance record, which shall
include:
(i) The date of service;
(ii) The beginning and ending time of the
service;
(iii) The location of the
service; and
(iv) The signature,
date of signature, and title of the individual providing the
service;
(m) A supported employment service, which
shall:
1. Be intensive, ongoing support for a
participant to maintain paid employment in an environment in which an
individual without a disability is employed;
2. Include attending to a participant's
personal care needs;
3. Be provided
in a variety of settings;
4. Be
provided on a one-to-one basis;
5.
Be unavailable under a program funded by either 29 U.S.C. Chapter 16 or 34
C.F.R. Subtitle B, Chapter III (34 C.F.R. Parts 300 to
399), proof of which shall be
documented in the participant's file;
6. Exclude work performed directly for the
supported employment provider;
7.
Be provided by a staff person who has completed a supported employment training
curriculum conducted by staff of the cabinet or its designee;
8. Be documented in the MWMA by:
a. A detailed monthly summary note, which
shall include:
(i) The month, day, and year
for the time period each note covers;
(ii) Progression, regression, and maintenance
toward outcomes identified in the person-centered service plan; and
(iii) The signature, date of signature, and
title of the individual preparing the note; and
b. A time and attendance record, which shall
include:
(i) The date of service;
(ii) The beginning and ending time of the
service;
(iii) The location of the
service; and
(iv) The signature,
date of signature, and title of the individual providing the
service;
(n) A behavioral support service, which
shall:
1. Be the systematic application of
techniques and methods to influence or change a behavior in a desired
way;
2. Be provided to assist the
participant to learn new behaviors that are directly related to existing
challenging behaviors or functionally equivalent replacement behaviors for
identified challenging behaviors;
3. Include a functional assessment of the
participant's behavior, which shall include:
a. An analysis of the potential communicative
intent of the behavior;
b. The
history of reinforcement for the behavior;
c. Critical variables that preceded the
behavior;
d. Effects of different
situations on the behavior; and
e.
A hypothesis regarding the motivation, purpose, and factors that maintain the
behavior;
4. Include the
development of a behavioral support plan, which shall:
a. Be developed by the behavior support
specialist;
b. Be implemented by
Michelle P. waiver provider staff in all relevant environments and
activities;
c. Be revised as
necessary;
d. Define the techniques
and procedures used;
e. Be designed
to equip the participant to communicate his or her needs and to participate in
age-appropriate activities;
f.
Include the hierarchy of behavior interventions ranging from the least to the
most restrictive;
g. Reflect the
use of positive approaches; and
h.
Prohibit the use of restraints, seclusion, corporal punishment, verbal abuse,
and any procedure that denies private communication, requisite sleep, shelter,
bedding, food, drink, or use of a bathroom facility;
5. Include the provision of training to other
Michelle P. waiver providers concerning implementation of the behavioral
support plan;
6. Include the
monitoring of a participant's progress, which shall be accomplished by:
a. The analysis of data concerning the
frequency, intensity, and duration of a behavior; and
b. The reports of a Michelle P. waiver
provider involved in implementing the behavior support plan;
7. Provide for the design,
implementation, and evaluation of systematic environmental
modifications;
8. Be provided by a
behavior support specialist; and
9.
Be documented in the MWMA by a detailed staff note, which shall include:
a. The date of service;
b. The beginning and ending time;
and
c. The signature, date of
signature, and title of the behavior support specialist;
(o) An ADHC service, which shall:
1. Be provided to a participant who is at
least twenty-one (21) years of age;
2. Include the following basic services and
necessities provided to participants during the posted hours of operation:
a. Skilled nursing services provided by an RN
or LPN, including ostomy care, urinary catheter care, decubitus care, tube
feeding, venipuncture, insulin injections, tracheotomy care, or medical
monitoring;
b. Meal service
corresponding with hours of operation with a minimum of one (1) meal per day
and therapeutic diets as required;
c. Snacks;
d. Supervision by an RN;
e. Age and diagnosis appropriate daily
activities; and
f. Routine services
that meet the daily personal and health care needs of a participant, including:
(i) Monitoring of vital signs;
(ii) Assistance with activities of daily
living; and
(iii) Monitoring and
supervision of self-administered medications, therapeutic programs, and
incidental supplies and equipment needed for use by a participant;
3. Include
developing, implementing, and maintaining nursing policies for nursing or
medical procedures performed in the ADHC center;
4. Include respite care services pursuant to
paragraph (g) of this subsection;
5. Be provided to a participant by the health
team in an ADHC center, which may include:
a.
A physician;
b. A physician
assistant;
c. An APRN;
d. An RN;
e. An LPN;
f. An activities director;
g. A physical therapist;
h. A physical therapist assistant;
i. An occupational therapist;
j. An occupational therapy
assistant;
k. A speech-language
pathologist;
l. A social
worker;
m. A
nutritionist;
n. A health
aide;
o. An LPCC;
p. An LMFT;
q. A certified psychologist with autonomous
functioning; or
r. A licensed
psychological practitioner; and
6. Be provided pursuant to a plan of
treatment that shall:
a. Be developed and
signed by each member of the plan of treatment team, which shall include the
participant or a legal representative of the participant;
b. Include pertinent diagnoses, mental
status, services required, frequency of visits to the ADHC center, prognosis,
rehabilitation potential, functional limitation, activities permitted,
nutritional requirements, medication, treatment, safety measures to protect
against injury, instructions for timely discharge, and other pertinent
information; and
c. Be developed
annually from information on the MAP 351, Medicaid Waiver Assessment and
revised as needed; and
(p) Community living supports, which shall:
1. Be provided to facilitate independence and
promote integration into the community for a participant residing in his or her
own home or in his or her family's home;
2. Be supports and assistance that shall be
related to chosen outcomes, not be diversional in nature, and may include:
a. Routine household tasks and
maintenance;
b. Activities of daily
living;
c. Personal
hygiene;
d. Shopping;
e. Money management;
f. Medication management;
g. Socialization;
h. Relationship building;
i. Leisure choices;
j. Participation in community
activities;
k. Therapeutic goals;
or
l. Nonmedical care not requiring
nurse or physician intervention;
3. Not replace other work or day
activities;
4. Be provided on a
one-on-one basis;
5. Not be
provided at an adult day training or children's day habilitation
site;
6. Be documented in the MWMA
by:
a. A time and attendance record, which
shall include:
(i) The date of the
service;
(ii) The beginning and
ending time of the service; and
(iii) The signature, date of signature, and
title of the individual providing the service; and
b. A detailed monthly summary note, which
shall include:
(i) The month, day, and year
for the time period each note covers;
(ii) Progression, regression, and maintenance
toward outcomes identified in the person-centered service plan; and
(iii) The signature, date of signature, and
title of the individual preparing the summary note; and
7. Be limited to sixteen (16)
hours per day alone or in combination with adult day training and supported
employment.
Section 7. Participant-Directed Services.
(1) Covered services and supports provided to
a participant receiving PDS shall be nonmedical and include:
(a) A home and community support service,
which shall:
1. Be available only as
participant-directed services;
2.
Be provided in the participant's home or in the community;
3. Be based upon therapeutic goals and not be
diversional in nature;
4. Not be
provided to an individual if the same or similar service is being provided to
the individual via non-PDS Michelle P. waiver services; and
5. Include:
a. Assistance, support, or training in
activities including meal preparation, laundry, or routine household care or
maintenance;
b. Activities of daily
living including bathing, eating, dressing, personal hygiene, shopping, or the
use of money;
c. Reminding,
observing, or monitoring of medications;
d. Nonmedical care that does not require a
nurse or physician intervention;
e.
Respite; or
f. Socialization,
relationship building, leisure choice, or participation in generic community
activities;
(b)
Goods and services, which shall:
1. Be
individualized;
2. Be utilized to
reduce the need for personal care or to enhance independence within the home or
community of the participant;
3.
Not include experimental goods or services; and
4. Not include chemical or physical
restraints;
(c) A
community day support service, which shall:
1.
Be available only as participant-directed services;
2. Be provided in a community
setting;
3. Be tailored to the
participant's specific personal outcomes related to the acquisition,
improvement, and retention of skills and abilities to prepare and support the
participant for work or community activities, socialization, leisure, or
retirement activities;
4. Be based
upon therapeutic goals and not be diversional in nature; and
5. Not be provided to an individual if the
same or similar service is being provided to the individual via non-PDS
Michelle P. waiver services; or
(d) Financial management, which shall:
1. Include managing, directing, or dispersing
a participant's funds identified in the participant's approved PDS
budget;
2. Include payroll
processing associated with the individuals hired by a participant or
participant's representative;
3.
Include withholding local, state, and federal taxes and making payments to
appropriate tax authorities on behalf of a participant;
4. Be performed by an entity:
a. Enrolled as a Medicaid provider in
accordance with
907 KAR 1:672; and
b. With at least two (2) years of experience
working with individuals possessing the same or similar level of care needs as
those referenced in Section 5 of this administrative regulation;
5. Include preparing fiscal
accounting and expenditure reports for:
a. A
participant or participant's representative; and
b. The department.
(2) To be covered, a PDS
shall be specified in a person-centered service plan.
(3) Reimbursement for a PDS shall not exceed
the department's allowed reimbursement for the same or similar service provided
in a non-PDS Michelle P. waiver setting except that respite may be provided in
excess of the cap established in Section 14(2) of this administrative
regulation if:
(a) Necessary per the
participant's person-centered service plan; and
(b) Approved by the department in accordance
with subsection (13) of this section.
(4) A participant, including a married
participant, shall choose providers and a participant's choice shall be
reflected or documented in the person-centered service plan.
(5)
(a) A
participant may designate a representative to act on the participant's
behalf.
(b) The PDS representative
shall:
1. Be twenty-one (21) years of age or
older;
2. Not be monetarily
compensated for acting as the PDS representative or providing a PDS;
and
3. Be appointed by the
participant on a MAP-2000, Initiation/Termination of Consumer Directed Option
(CDO)/Participant Directed Services (PDS).
(6) A participant may voluntarily terminate
PDS by completing a MAP-2000, Initiation/Termination of Consumer Directed
Option (CDO)/Participant Directed Services (PDS) and submitting it to the
support broker.
(7) The department
shall immediately terminate a participant from PDS if:
(a) Imminent danger to the participant's
health, safety, or welfare exists;
(b) The participant fails to pay patient
liability;
(c) The participant's
person-centered service plan indicates he or she requires more hours of service
than the program can provide; thus, jeopardizing the participant's safety and
welfare due to being left alone without a caregiver present; or
(d) The participant, caregiver, family, or
guardian threatens or intimidates a support broker or other PDS
staff.
(8) The department
may terminate a participant from PDS if it determines that the participant's
PDS provider has not adhered to the person-centered service plan.
(9) Except for a termination required by
subsection (7) of this section, prior to a participant's termination from PDS,
the support broker shall:
(a) Notify the
assessment or reassessment service provider of potential termination;
(b) Assist the participant in developing a
resolution and prevention plan;
(c)
Allow at least thirty (30) but no more than ninety (90) days for the
participant to resolve the issue, develop and implement a prevention plan, or
designate a PDS representative;
(d)
Complete, and submit to the department, a MAP-2000, Initiation/Termination of
Consumer Directed Option (CDO)/Participant Directed Services (PDS) terminating
the participant from PDS if the participant fails to meet the requirements in
paragraph (c) of this subsection; and
(e) Assist the participant in transitioning
back to traditional Michelle P. waiver services.
(10) Upon an involuntary termination of PDS,
the department shall:
(a) Notify a participant
in writing of its decision to terminate the participant's PDS participation;
and
(b) Inform the participant of
the right to appeal the department's decision in accordance with Section 16 of
this administrative regulation.
(11) A PDS provider shall:
(a) Be selected by the participant;
(b) Submit a completed Kentucky Consumer
Directed Options/Participant Directed Services Employee/Provider Contract to
the support broker;
(c) Be eighteen
(18) years of age or older;
(d)
1. Be a citizen of the United States with a
valid Social Security number; or
2.
Possess a valid work permit if not a U.S. citizen;
(e) Be able to communicate effectively with
the participant, participant's representative, or family;
(f) Be able to understand and carry out
instructions;
(g) Be able to keep
records as required by the participant;
(h) Submit to a criminal background check
from the Kentucky Administrative Office of the Courts and equivalent
out-of-state agency if the individual resided or worked outside of Kentucky
during the twelve (12) months prior to being a PDS provider;
(i) Submit to a check of the:
1. Nurse Aide Abuse Registry maintained in
accordance with
906 KAR 1:100 and not be found on
the registry;
2. Caregiver
Misconduct Registry maintained in accordance with
922 KAR 5:120 and not be found on
the registry; and
3. Central
Registry maintained in accordance with
922 KAR 1:470 and not be found on
the registry;
(j) Not
have pled guilty or been convicted of committing a sex crime or violent
crime;
(k) Complete training on the
reporting of abuse, neglect, or exploitation in accordance with
KRS
209.030 or
620.030 and on the needs of the
participant;
(l) Be approved by the
department;
(m) Maintain and submit
timesheets documenting hours worked; and
(n) Be a friend, spouse, parent, family
member, other relative, employee of a provider agency, or other person hired by
the participant.
(12) A
parent, parents combined, or a spouse shall not provide more than forty (40)
hours of services in a calendar week (Sunday through Saturday) regardless of
the number of children who receive waiver services.
(13)
(a)
The department shall establish a twelve (12) month budget for a participant
based on the participant's person-centered service plan.
(b) A participant's twelve (12) month budget
shall not exceed $40,000 unless:
1. The
participant's support broker requests a budget adjustment to a level higher
than $40,000; and
2. The department
approves the adjustment.
(c) The department shall consider the
following factors in determining whether to grant a twelve (12) month budget
adjustment:
1. If the proposed services are
necessary to prevent imminent institutionalization;
2. The cost effectiveness of the proposed
services;
3. Protection of the
participant's health, safety, and welfare; and
4. If a significant change has occurred in
the participant's:
a. Physical condition,
resulting in additional loss of function or limitations to activities of daily
living and instrumental activities of daily living;
b. Natural support system; or
c. Environmental living arrangement,
resulting in the participant's relocation.
(d) A participant's twelve (12) month budget
may encompass a service or any combination of services listed in subsection (1)
of this section, if each service is established in the participant's
person-centered service plan and approved by the department.
(14) Unless approved by the
department pursuant to subsection (13)(a) through (c) of this section, if a PDS
is expanded to a point in which expansion necessitates a twelve (12) month
budget increase, the entire service shall only be covered via traditional
(non-PDS) waiver services.
(15) A
support broker shall:
(a) Provide needed
assistance to a participant with any aspect of PDS or blended
services;
(b) Be available to a
participant twenty-four (24) hours per day, seven (7) days per week;
(c) Comply with all applicable federal and
state laws and requirements;
(d)
Continually monitor a participant's health, safety, and welfare; and
(e) Complete or revise a person-centered
service plan in accordance with Section 8 of this administrative
regulation.
(16)
(a) A support broker or case manager may
conduct an assessment or reassessment for a PDS participant.
(b) A PDS assessment or reassessment
performed by a support broker shall comply with the assessment or reassessment
provisions established in this administrative regulation.
(17) Services provided by a support broker
shall meet the conflict free requirements established for case management in
Section 9(4)(f) and 9(5) of this administrative regulation.
Section 8. Person-centered Service
Plan Requirements.
(1) A person-centered
service plan shall be established:
(a) For
each participant; and
(b) By the
participant's person-centered team.
(2) A participant's person-centered service
plan shall:
(a) Be developed by:
1. The participant, the participant's
guardian, or the participant's representative;
2. The participant's case manager;
3. The participant's person-centered team;
and
4. Any other individual chosen
by the participant if the participant chooses any other individual to
participate in developing the person-centered service plan;
(b) Use a process that:
1. Provides the necessary information and
support to empower the participant, the participant's guardian, or
participant's legal representative to direct the planning process in a way that
empowers the participant to have the freedom and support to control the
participant's schedules and activities without coercion or restraint;
2. Is timely and occurs at times and
locations convenient for the participant;
3. Reflects cultural considerations of the
participant;
4. Provides
information:
a. Using plain language in
accordance with 42 C.F.R.
435.905(b); and
b. In a way that is accessible to an
individual with a disability or who has limited English proficiency;
5. Offers an informed choice
defined as a choice from options based on accurate and thorough knowledge and
understanding to the participant regarding the services and supports to be
received and from whom;
6. Includes
a method for the participant to request updates to the person-centered service
plan as needed;
7. Enables all
parties to understand how the participant:
a.
Learns;
b. Makes decisions;
and
c. Chooses to live and work in
the participant's community;
8. Discovers the participant's needs, likes,
and dislikes;
9. Empowers the
participant's person-centered team to create a person-centered service plan
that:
a. Is based on the participant's:
(i) Assessed clinical and support
needs;
(ii) Strengths;
(iii) Preferences; and
(iv) Ideas;
b. Encourages and supports the participant's:
(i) Rehabilitative needs;
(ii) Habilitative needs; and
(iii) Long term satisfaction;
c. Is based on reasonable
costs given the participant's support needs;
d. Includes:
(i) The participant's goals;
(ii) The participant's desired outcomes;
and
(iii) Matters important to the
participant;
e. Includes a
range of supports including funded, community, and natural supports that shall
assist the participant in achieving identified goals;
f. Includes:
(i) Information necessary to support the
participant during times of crisis; and
(ii) Risk factors and measures in place to
prevent crises from occurring;
g. Assists the participant in making informed
choices by facilitating knowledge of and access to services and
supports;
h. Records the
alternative home and community-based settings that were considered by the
participant;
i. Reflects that the
setting in which the participant resides was chosen by the
participant;
j. Is understandable
to the participant and to the individuals who are important in supporting the
participant;
k. Identifies the
individual or entity responsible for monitoring the person-centered service
plan;
l. Is finalized and agreed to
with the informed consent of the participant or participant's legal
representative in writing with signatures by each individual who will be
involved in implementing the person-centered service plan;
m. Shall be distributed to the individual and
other people involved in implementing the person-centered service
plan;
n. Includes those services
that the individual elects to self-direct; and
o. Prevents the provision of unnecessary or
inappropriate services and supports; and
(c) Include in all settings the ability for
the participant to:
1. Have access to make
private phone calls, texts, or emails at the participant's preference or
convenience;
2.
a. Choose when and what to eat;
b. Have access to food at any time;
c. Choose with whom to eat or whether to eat
alone; and
d. Choose appropriating
clothing according to the:
(i) Participant's
preference;
(ii) Weather;
and
(iii) Activities to be
performed.
(3) If a participant's person-centered
service plan includes ADHC services, the ADHC services plan of treatment shall
be addressed in the person-centered service plan.
(4)
(a) A
participant's person-centered service plan shall be:
1. Entered into the MWMA by the participant's
case manager; and
2. Updated in the
MWMA by the participant's case manager.
(b) A participant or participant's authorized
representative shall complete and upload into the MWMA a MAP - 116 Service Plan
- Participant Authorization prior to or at the time the person-centered service
plan is uploaded into the MWMA.
Section 9. Case Management Requirements.
(1) A case manager shall:
(a) Have a bachelor's degree from an
accredited institution in a human services field and be supervised by:
1. A qualified professional in the area of
intellectual disabilities who:
a. Has at least
one (1) year of experience working directly with individuals with an
intellectual disability or a developmental disability;
b. Meets the federal educational requirements
for a qualified intellectual disability professional established in
42 C.F.R.
483.430; and
c. Provides documentation of education and
experience;
2. A
registered nurse who has at least two (2) years of experience working with
individuals with an intellectual or a development disability;
3. An individual with a bachelor's degree in
a human service field who has at least two (2) years of experience working with
individuals with an intellectual or a developmental disability;
4. A licensed clinical social worker who has
at least two (2) years of experience working with individuals with an
intellectual or a developmental disability;
5. A licensed marriage and family therapist
who has at least two (2) years of experience working with individuals with an
intellectual or a developmental disability;
6. A licensed professional clinical counselor
who has at least two (2) years of experience working with individuals with an
intellectual or a developmental disability;
7. A certified psychologist or licensed
psychological associate who has at least two (2) years of experience working
with individuals with an intellectual or a developmental disability;
or
8. A licensed psychological
practitioner or certified psychologist with autonomous functioning who has at
least two (2) years of experience working with individuals with an intellectual
or a developmental disability;
(b) Be a registered nurse;
(c) Be a licensed practical nurse;
(d) Be a licensed clinical social
worker;
(e) Be a licensed marriage
and family therapist;
(f) Be a
licensed professional clinical counselor;
(g) Be a licensed psychologist; or
(h) Be a licensed psychological
practitioner.
(2) A case
manager shall:
(a) Communicate in a way that
ensures the best interest of the participant;
(b) Be able to identify and meet the needs of
the participant;
(c)
1. Be competent in the participant's language
either through personal knowledge of the language or through interpretation;
and
2. Demonstrate a heightened
awareness of the unique way in which the participant interacts with the world
around the participant;
(d) Ensure that:
1. The participant is educated in a way that
addresses the participant's:
a. Need for
knowledge of the case management process;
b. Personal rights; and
c. Risks and responsibilities as well as
awareness of available services; and
2. All individuals involved in implementing
the participant's person-centered service plan are informed of changes in the
scope of work related to the person-centered service plan as
applicable;
(e) Have a
code of ethics to guide the case manager in providing case management, which
shall address:
1. Advocating for standards
that promote outcomes of quality;
2. Ensuring that no harm is done;
3. Respecting the rights of others to make
their own decisions;
4. Treating
others fairly; and
5. Being
faithful and following through on promises and commitments;
(f)
1. Lead the person-centered service planning
team; and
2. Take charge of
coordinating services through team meetings with representatives of all
agencies involved in implementing a participant's person-centered service
plan;
(g)
1. Include the participant's participation or
legal representative's participation in the case management process;
and
2. Make the participant's
preferences and participation in decision making a priority;
(h) Document:
1. A participant's interactions and
communications with other agencies involved in implementing the participant's
person-centered service plan; and
2. Personal observations;
(i) Advocate for a participant
with service providers to ensure that services are delivered as established in
the participant's person-centered service plan;
(j) Be accountable to:
1. A participant to whom the case manager
provides case management in ensuring that the participant's needs are
met;
2. A participant's
person-centered team and provide leadership to the team and follow through on
commitments made; and
3. The case
manager's employer by following the employer's policies and
procedures;
(k) Stay
current regarding the practice of case management and case management
research;
(l) Assess the quality of
services, safety of services, and cost effectiveness of services being provided
to a participant in order to ensure that implementation of the participant's
person-centered service plan is successful and done so in a way that is
efficient regarding the participant's financial assets and benefits;
(m) Document services provided to a
participant by entering the following into the MWMA:
1. A monthly department approved
person-centered monitoring tool; and
2. A monthly entry, which shall include:
a. The month and year for the time period the
note covers;
b. An analysis of
progress toward the participant's outcome or outcomes;
c. Identification of barriers to achievement
of outcomes;
d. A projected plan to
achieve the next step in achievement of outcomes;
e. The signature and title of the case
manager completing the note; and
f.
The date the note was generated;
(n) Accurately reflect in the MWMA if a
participant is:
1. Terminated from the
Michelle P. waiver program;
2.
Admitted to an intermediate care facility for individuals with an intellectual
disability;
3. Admitted to a
hospital;
4. Admitted to a skilled
nursing facility;
5. Transferred to
another Medicaid 1915(c) home and community based waiver service program;
or
6. Relocated to a different
address; and
(o) Provide
information about participant-directed services to the participant or the
participant's guardian:
1. At the time the
initial person-centered service plan is developed;
2. At least annually thereafter;
and
3. Upon inquiry from the
participant or participant's guardian.
(3) If a participant:
(a) Voluntarily terminates participation in
the Michelle P. waiver program in order to be admitted to a hospital, to a
nursing facility, or to an intermediate care facility for individuals with an
intellectual disability, the participant's case manager shall enter the request
into the MWMA; or
(b) Is
transferred to another 1915(c) home and community based waiver services
program, the case manager shall enter the transfer request into the
MWMA.
(4) Case management
shall:
(a) Consist of coordinating the
delivery of direct and indirect services to a participant;
(b) Be provided by a case manager who shall:
1. Arrange for a service but not provide a
service directly;
2. Contact the
participant monthly through a face-to-face visit at the participant's home, in
the ADHC center, or at the adult day training provider's location;
3. Assure that service delivery is in
accordance with a participant's person-centered service plan; and
4. Meet the requirements of this
section;
(c) Not include
a group conference;
(d) Include
documenting:
1. The following regarding notes:
a. The signature of the individual preparing
the note;
b. The date of the
signature; and
c. The title of the
individual preparing the note; and
2. At least one (1) face-to-face meeting
between the case manager and participant, family member, or legal
representative;
(e)
Include requiring a participant or legal representative to sign a MAP-350, Long
Term Care Facilities and Home and Community Based Program Certification Form at
the time of application or reapplication and at each recertification to
document that the individual was informed of the choice to receive Michelle P.
waiver or institutional services; and
(f) Not be provided to a participant by an
agency if the agency provides any other Michelle P. waiver service to the
participant.
(5)
(a) Case management for any participant who
begins receiving Michelle P. waiver services after the effective date of this
administrative regulation shall be conflict free except as allowed in paragraph
(b) of this subsection.
(b)
1. Conflict free case management shall be a
scenario in which a provider including any subsidiary, partnership,
not-for-profit, or for-profit business entity that has a business interest in
the provider who renders case management to a participant shall not also
provide another 1915(c) home and community based waiver service to that same
participant unless the provider is the only willing and qualified Michelle P.
waiver provider within thirty (30) miles of the participant's
residence.
2. An exemption to the
conflict free case management requirement shall be granted if:
a. A participant requests the
exemption;
b. The participant's
case manager provides documentation of evidence to the department that there is
a lack of a qualified case manager within thirty (30) miles of the
participant's residence;
c. The
participant or participant's representative and case manager signs a completed
MAP - 531 Conflict-Free Case Management Exemption; and
d. The participant, participant's
representative, or case manager uploads the completed MAP - 531 Conflict-Free
Case Management Exemption into the MWMA.
3. If a case management service is approved
to be provided despite not being conflict free, the case management provider
shall:
a. Document conflict of interest
protections, separating case management and service provision functions within
the provider entity; and
b.
Demonstrate that the participant is provided with a clear and accessible
alternative dispute resolution process.
4. An exemption to the conflict free case
management requirement shall be requested upon reassessment or at least
annually.
(c) A
participant who receives Michelle P. waiver services prior to the effective
date of this administrative regulation shall transition to conflict free case
management when the participant's next level of care determination
occurs.
(d) During the transition
to conflict free case management, any case manager providing case management to
a participant shall educate the participant and members of the participant's
person-centered team of the conflict free case management requirement in order
to prepare the participant to decide, if necessary, to change the
participant's:
1. Case manager; or
2. Provider of non-case management Michelle
P. waiver services.
(6) Case management shall involve:
(a) A constant recognition of what is and is
not working regarding a participant; and
(b) Changing what is not working.
Section 11. Incident
Reporting Process.
(1)
(a) There shall be two (2) classes of
incidents.
(b) The following shall
be the two (2) classes of incidents:
1. An
incident; or
2. A critical
incident.
(2)
An incident shall be any occurrence that impacts the health, safety, welfare,
or lifestyle choice of a participant and includes:
(a) A minor injury;
(b) A medication error without a serious
outcome; or
(c) A behavior or
situation that is not a critical incident.
(3) A critical incident shall be an alleged,
suspected, or actual occurrence of an incident that:
(a) Can reasonably be expected to result in
harm to a participant; and
(b)
Shall include:
1. Abuse, neglect, or
exploitation;
2. A serious
medication error;
3.
Death;
4. A homicidal or suicidal
ideation;
5. A missing person;
or
6. Other action or event that
the provider determines may result in harm to the participant.
(4)
(a) If an incident occurs, the Michelle P.
waiver provider shall:
1. Report the incident
by making an entry into the MWMA that includes details regarding the incident;
and
2. Be immediately assessed for
potential abuse, neglect, or exploitation.
(b) If an assessment of an incident indicates
that the potential for abuse, neglect, or exploitation exists:
1. The incident shall immediately be
considered a critical incident;
2.
The critical incident procedures established in subsection (5) of this section
shall be followed; and
3. The
Michelle P. waiver provider shall report the incident to the participant's case
manager and participant's guardian, if the participant has a guardian, within
twenty-four (24) hours of discovery of the incident.
(5)
(a) If a critical incident occurs, the
individual who witnessed the critical incident or discovered the critical
incident shall immediately act to ensure the health, safety, and welfare of the
at-risk participant.
(b) If the
critical incident:
1. Requires reporting of
abuse, neglect, or exploitation, the critical incident shall be immediately
reported via the MWMA; or
2. Does
not require reporting of abuse, neglect, or exploitation, the critical incident
shall be reported via the MWMA within eight (8) hours of discovery.
(c) The Michelle P. waiver
provider shall:
1. Conduct an immediate
investigation and involve the participant's case manager in the investigation;
and
2. Prepare a report of the
investigation, which shall be recorded in the MWMA and shall include:
a. Identifying information of the participant
involved in the critical incident and the person reporting the critical
incident;
b. Details of the
critical incident; and
c. Relevant
participant information including:
(i) A
listing of recent medical concerns;
(ii) An analysis of causal factors;
and
(iii) Recommendations for
preventing future occurrences.
(6)
(a) Following a death of a participant
receiving Michelle P. waiver services from a Michelle P. waiver provider, the
Michelle P. waiver provider shall enter mortality data documentation into the
MWMA within fourteen (14) days of the death.
(b) Mortality data documentation shall
include:
1. The participant's person-centered
service plan at the time of death;
2. Any current assessment forms regarding the
participant;
3. The participant's
medication administration records from all service sites for the past three (3)
months along with a copy of each prescription, if applicable;
4. Progress notes regarding the participant
from all service elements for the past thirty (30) days, including case
management notes;
5. The results of
the participant's most recent physical exam, if available;
6. All incident reports, if any exist,
regarding the participant for the past six (6) months;
7. The most recent psychological evaluation
of the participant, if applicable and available;
8. A full life history and any
updates;
9. Emergency medical
services notes regarding the participant if available;
10. The police report if available;
11. A copy of:
a. The participant's advance directive,
medical order for scope of treatment, living will, or health care directive if
applicable; and
b. Any functional
assessment of behavior or positive behavior support plan regarding the
participant that has been in place over any part of the past twelve (12)
months; and
12. A record
of all medical appointments or emergency room visits by the participant within
the past twelve (12) months, if available.
(7) A Michelle P. waiver provider shall
document all medication error details on a medication error log retained on
file at the Michelle P. waiver provider site.
Section 12. Michelle P. Waiver Program
Waiting List.
(1)
(a) If a slot is not available for an
individual to enroll in the Michelle P. Waiver Program at the time of applying
for the program, the individual shall be placed on a statewide Michelle P.
Waiver Program waiting list:
1. In accordance
with subsection (2) of this section; and
2. Maintained by the department.
(b) Each slot for the Michelle P.
Waiver Program shall be contingent upon:
1.
Biennium budget funding;
2. Federal
financial participation; and
3.
Centers for Medicare and Medicaid Services approval.
(2) For an individual to be placed
on the Michelle P. Waiver Program waiting list, the individual or individual's
representative shall:
(a) Apply for 1915(c)
home and community based waiver services via the MWMA; and
(b) Complete and upload to the MWMA a MAP -
115 Application Intake - Participant Authorization.
(3) Individuals shall be placed on the
Michelle P. Waiver Program waiting list in the chronological order that each
application is received and validated by the department.
(4) The department shall send a written
notice of placement on the Michelle P. Waiver Program waiting list to the:
(a) Applicant; or
(b) Applicant's legal
representative.
(5) At
least annually, the department shall contact each individual, or individual's
legal representative, on the Michelle P. Waiver Program waiting list to:
(a) Verify the accuracy of the individual's
information; and
(b) Verify whether
the individual wishes to continue to pursue enrollment in the Michelle P.
Waiver Program.
(6) The
department shall remove an individual from the Michelle P. Waiver Program
waiting list if:
(a) The individual is
deceased;
(b) The department
notifies the individual or the individual's legal representative of potential
funding approved to enroll the individual in the Michelle P. Waiver Program and
the individual or individual's legal representative:
1. Declines the potential funding for
enrollment in the program; and
2.
Does not request to remain on the Michelle P. Waiver Program waiting list;
or
(c) Pursuant to
subsection (5) of this section, the individual elects to not continue to pursue
enrollment in the Michelle P. Waiver Program.
(7) If, after being notified by the
department of potential funding approved to enroll the individual in the
Michelle P. Waiver Program, the individual or individual's legal representative
declines the potential funding but requests to remain on the Michelle P. Waiver
Program waiting list, the individual shall:
(a) Lose his or her current position on the
waiting list; and
(b) Be moved to
the bottom of the waiting list.
(8) If the department removes an individual
from the Michelle P. Waiver Program waiting list pursuant to this section, the
department shall send written notice of the removal to:
(a) The individual or the individual's legal
representative; and
(b) The
individual's Michelle P. Waiver Program coordination provider if the individual
has a Michelle P. Waiver Program coordination provider.
(9) The removal of an individual from the
Michelle P. Waiver Program waiting list shall not preclude the individual from
applying for Michelle P. Waiver Program participation in the future.
(10)
(a) An
individual who is placed on the Michelle P. Waiver Program waiting list shall
be informed about and told how to apply for Medicaid state plan services for
which the individual might qualify.
(b) An individual who is under twenty-one
(21) years of age and who is placed on the Michelle P. Waiver Program waiting
list shall also be informed about Early and Periodic Screening, Diagnostic, and
Treatment services.
Section 14. Reimbursement.
(1) The following Michelle P. waiver
services, alone or in any combination, shall be limited to forty (40) hours per
calendar week:
(a) Homemaker;
(b) Personal care;
(c) Attendant care;
(d) Supported employment;
(e) Adult day health care;
(f) Adult day training;
(g) Community living supports;
(h) Physical therapy;
(i) Occupational therapy;
(j) Speech therapy; and
(k) Behavior supports.
(2) Respite services shall not exceed $4,000
per member, per calendar year.
(3)
Environmental and minor home adaptation services shall not exceed $500 per
member, per calendar year.
(4)
(a) The department shall reimburse for a
Michelle P. waiver service at the lesser of billed charges or the fixed upper
payment rate for each unit of service.
(b) The unit amounts, fixed upper payment
rate limits, and other limits established in the following table shall apply:
Service |
Fixed Upper Payment Rate Limit |
Unit of Service |
Case Management |
$50.00 |
15 minutes |
Respite |
$4,000 per calendar year |
15 minutes |
Homemaker |
$6.50 |
15 minutes |
Personal Care |
$7.50 |
15 minutes |
Attendant Care |
$2.90 |
15 minutes |
Supported Employment |
$5.54 |
15 minutes |
Adult Day Health Care |
$2.75 |
15 minutes |
Adult Day Training |
$2.75 |
15 minutes |
Community Living Supports |
$5.54 |
15 minutes |
Physical Therapy |
$22.17 |
15 minutes |
Occupational Therapy |
$22.17 |
15 minutes |
Speech Therapy |
$22.17 |
15 minutes |
Behavior Supports |
$33.25 |
15 minutes |
Environmental and Minor Home
Adaptation |
$500 per calendar year |
|
Financial Management |
$12.50 (not to exceed eight (8) units or $100.00 per
month) |
15 minutes |
Support Broker |
$265.00 |
One (1) month |
Section 18. Incorporation by Reference.
(1) The following material is incorporated by
reference:
(a) "MAP - 115 Application Intake -
Participant Authorization", May 2015;
(b) "MAP - 116 Service Plan - Participant
Authorization", May 2015;
(c) "MAP
- 531 Conflict-Free Case Management Exemption", October 2015;
(d) "MAP 95 Request for Equipment Form", June
2007;
(e) "MAP - 350, Long Term
Care Facilities and Home and Community Based Program Certification Form", June
2015;
(f) "MAP 351, Medicaid Waiver
Assessment", July 2015;
(g)
"MAP-2000, Initiation/Termination of Consumer Directed Option (CDO)/Participant
Directed Services (PDS)", June 2015;
(h) "MAP 10, Waiver Services Physician's
Recommendation", June 2015; and
(i)
"Kentucky Consumer Directed Options/Participant Directed Services
Employee/Provider Contract", June 2015.
(2) This material may be inspected, copied,
or obtained, subject to applicable copyright law:
(a) At the Department for Medicaid Services,
275 East Main Street, Frankfort, Kentucky 40621, Monday through Friday, 8 a.m.
to 4:30 p.m.; or
(b) Online at the
department's Web site at
http://www.chfs.ky.gov/dms/incorporated.htm.
STATUTORY AUTHORITY:
KRS
194A.030(2),
194A.050(1),
205.520(3),
205.5606,
42 C.F.R.
440.180,
42 U.S.C.
1396a,
1396b,
1396d,
1396n